Care home staffing levels
163 items
2 sources
Insufficient numbers of suitably skilled and experienced staff deployed in care homes, impacting ability to meet resident needs.
Cross-Source Insight
Care home staffing levels has been flagged across 2 independent accountability sources:
7 inquiry recs
156 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (7)
23 — Quarterly assessment of staffing levels against population needs
Recommendation: The Home Office and contractors operating immigration removal centres must ensure that there is ongoing assessment of staffing levels (at least on a quarterly basis), so that the level of staff present within each centre is appropriate for the size …
Gov response: A new staffing model has been implemented delivering a 'considerably healthier ratio of custodial staff per detained individual to nearly double what it was in 2017'. Contract reviews address safe staffing policies.
Accepted in Part
Delivered
25 — Ensure senior manager presence and accessibility to staff
Recommendation: Contractors operating immigration removal centres must ensure that senior managers are regularly present and visible within the immigration removal centre and are accessible to more junior detention staff.
Gov response: The government response addressed this under staffing and culture, with contractors required to ensure senior managers are regularly present and visible.
Accepted in Part
Delivered
FENN-80 — Ensure adequate staffing by suitably trained personnel in station operations rooms
Recommendation: Station operations rooms shall always be adequately staffed by suitably trained personnel.
Unknown
F163 — Safe staff numbers and skills
Recommendation: The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of available staff for the provision of training and to ensure …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F23 — Responsibility for regulating and monitoring compliance
Recommendation: The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F93 — NHS Litigation Authority Improvement of risk management
Recommendation: The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
R31 — Staffing and skills mix review
Recommendation: Health Boards should ensure that the staffing and skills mix is appropriate for each ward, and that it is reviewed in response to increases in the level of activity/patient acuity.
Gov response: Section 4.1 of the Scottish Government's response details the development and mandatory use of ground-breaking nursing and midwifery workload and workforce planning tools across all NHS boards. These tools help determine the number of nurses …
Accepted
PFD Reports (156) — showing 100 most recent
Elise Sebastian
Concerns: Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
Pending
Pamela George
Concerns: The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and documentation, despite patient needs exceeding capacity.
Pending
Patricia Walker
Concerns: Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.
Response: NHS England notes the concerns, stating some fall outside its usual remit and seeking clarification on 'TAG nursing care.' They report that Hull University Teaching Hospitals NHS Trust has presented …
Pending
George Ritchie
Concerns: The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.
Responded
George Ritchie
Concerns: The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.
Overdue
Peter Thompson
Concerns: Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.
Response: Bank Close House has strengthened documentation expectations for handovers and instructed staff to immediately request blood glucose tests from external professionals for ill diabetic residents. Blood glucose monitoring equipment is …
Responded
Ramona Harbott
Concerns: Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a high-risk patient.
Response: Barchester Healthcare has engaged a Clinical Development Nurse to provide weekly training on wound care and pressure ulcer prevention at Windmill Manor Care Home. They have also commenced implementing an …
Overdue
Dorothy Macdonald
Concerns: Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately refer to specialist falls teams.
Response: Springcare has revised falls risk assessment documentation, introduced new falls training for existing and new staff, and begun auditing assessments. Westwood Hall has also implemented a new policy to refer …
Responded
Debapriya Ghosh and David Ward
Concerns: Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to provide necessary enhanced nursing care.
Response: The Department for Health and Social Care acknowledges A&E staffing and demand concerns, highlighting actions already implemented by St George’s Trust. DHSC's own response outlines a 2025/26 Urgent and Emergency …
Responded
Marc Davies
Concerns: Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.
Response: Monmouthshire County Council and MJ Events have implemented a new three-tier training program for all Safe Guards, covering first aid, safeguarding, drug and alcohol awareness, naloxone administration, mental health awareness, …
Overdue
Pauline Stirling
Concerns: Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to poor patient safety and persistent record-keeping failures.
Response: Malhotra Group has implemented an electronic care recording system (Nourish) which now includes specific fields for positional tilts and enhanced wound management oversight. They have also updated their Position Change …
Overdue
Beatrice Smith
Concerns: No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a repeat of inadequate practices.
Response: Harbour Healthcare Limited completed a Serious Untoward Incident Root Cause Analysis, introduced daily safety huddles, implemented Wound Care Champions, and provided comprehensive staff training on wound management and safeguarding. They …
Overdue
Susan Barrett
Concerns: Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community hospitals, leading to inadequate care for pressure ulcers and an increased risk of future deaths.
Response: The Trust has confirmed funding for a 0.6wte Band 6 Tissue Viability CNS substantive post, with the establishment control form approved and active recruitment underway to embed a Tissue Viability …
Responded
Evelyn Chancellor
Concerns: Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
Responded
Margaret Douglas
Concerns: The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding of patient requirements.
Overdue
Colin Brooks
Concerns: Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues during cardiopulmonary bypass procedures.
Responded
Anthony Wood
Concerns: A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when two were required.
Overdue
Tina Doig
Concerns: The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and increasing the risk of future deaths.
Responded
Raihana Oluwadamilola Awolaja
Concerns: A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.
Responded
Peter Anzani
Concerns: Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting lists and prolonged patient waits for reviews are caused by staffing shortages and insufficient funding.
Responded
Allan Taylor
Concerns: Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as the patient's side room was too far. This lack of escalation and compliance likely contributed to an unwitnessed fall.
Responded
Philip Unwin
Concerns: Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with national guidance for patient-to-nurse ratios.
Responded
Margaret Rodgers
Concerns: Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to experience insufficient nursing staff levels for acutely ill patients.
Responded
Neville McKenzie
Concerns: Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from choking.
Responded
Diane Poole
Concerns: A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Responded
Susan Paley
Concerns: A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place for residents.
Responded
John Riley
Concerns: Observations were consistently late or not performed at required intervals, indicating a failure to adhere to vital patient monitoring protocols in the care home.
Responded
Sylvia Prichard
Concerns: The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.
Responded
Sally Mills
Concerns: There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being fully embedded or known.
Responded
Paul Batchelor
Concerns: A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.
Responded
Peter Dickens
Concerns: Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, and inadequate provision of funded support, compromised patient care.
Responded
Margaret Burman
Concerns: Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically stable patients awaiting community care, leading to an increased risk of falls.
Responded
Edith Alden
Concerns: Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were often unsupervised in communal areas or bedrooms, leading to preventable falls.
Responded
Ronald Jepson
Concerns: Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.
Pending
David Hemmings
Concerns: Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent fatal complications from surgical treatment.
Overdue
Julia Murphy
Concerns: The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for a resident with evolving dementia.
Overdue
Raymond Eggleton
Concerns: Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient supervision and preventable falls for vulnerable elderly patients in the hospital.
Responded
Norma Kyte
Concerns: Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small coverage area, risking undetected falls and potential non-compliance with manufacturer instructions.
Overdue
Linda Oldland
Concerns: Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, indicating policy and training deficiencies.
Responded
Julie Nolan
Concerns: Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive days.
Responded
Ben Shipley
Concerns: A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in A&E for hours, unable to be legally detained and without appropriate specialist care.
Overdue
Janet Smith
Concerns: Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.
Responded
Joseph Maunick
Concerns: National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures prevent adequate supervision and timely transfer, increasing their risk of harm.
Responded
John Stiff
Concerns: Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due to inadequate recognition and treatment of co-morbidities.
Overdue
Lugh Baker
Concerns: The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff to address residents with unusual presentations.
Responded
Gunapathyammah Ragnanathan
Concerns: An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an inexperienced carer who lacked sufficient training and supervision to provide safe assistance.
Responded
Peter Seaby
Concerns: Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack of post-incident review and management oversight.
Responded
Mary White
Concerns: Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in single-room environments.
Responded
Tina Allen
Concerns: Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective management oversight of care quality.
Responded
Frederick King
Concerns: The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.
Responded
Hazel Mayho
Concerns: Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks effective exit control or alert systems to prevent vulnerable residents from entering alone.
Responded
Carl Langdell
Concerns: A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding items prisoners can possess in their cells overnight, and a national proposal is underway to remove identified risks.
Overdue
Ernest Bacon
Concerns: Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be unrecognised and the sepsis policy to be un-followed. The failure to escalate concerns was unclear.
Responded
Cassian Curry
Concerns: Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.
Responded
Remi Koduah
Concerns: The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.
Overdue
Gary Ottway
Concerns: Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the sole junior doctor contributed to a critical delay.
Overdue
Joyce Dennis
Concerns: Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor documentation and communication within the care home created significant risks.
Overdue
Maziellie Mackenzie
Concerns: The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.
Responded
Charlie Todd
Concerns: A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU led to incomplete observations and a failure to ensure prisoner safety.
Responded
John Humphries
Concerns: Inadequate skin integrity assessments occurred in A&E for prolonged stays, and staff failed to seek external professional advice for managing patient resistance to turning.
Responded
Hazel Wiltshire
Concerns: Inadequate staffing, poor call bell response times, and a systemic failure to complete falls risk assessments for vulnerable patients compromise safety across hospital wards.
Responded
Peter Harte
Concerns: A systemic failure in a care home led to inadequate and unrecorded skin inspections for a frail resident over multiple days, posing a significant risk to vulnerable patients.
Responded
Roland Stannard
Concerns: Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This highlights a broader concern regarding the appropriate assessment for nursing care needs.
Responded
Albert Rowlands
Concerns: Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement also increased the risk of falls during toilet access.
Responded
Valmai West
Concerns: Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
Responded
Leonard Pritchard
Concerns: The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids is unmanaged and delayed.
Responded
William Rutherford
Concerns: Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate and inaccurate, despite prior concerns.
Responded
Geoffrey Hutton
Concerns: HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff training.
Responded
William Simons
Concerns: The hospital's tele-tracking system led to communication breakdown and confusion over patient transport, with porters unaware of fall risks and unclear roles regarding patient assistance.
Responded
Derek Russell
Concerns: A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of falls and fatal injuries, compromising staff's ability to provide safety.
Responded
Cecilia Edwards
Concerns: A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency staff without clear protocols, and nurse-carer visit coordination was inadequate.
Responded
Alan Jones
Concerns: There was a complete failure in falls prevention, with inadequate multidisciplinary management and insufficient supervision for a confused, agitated patient. Wards were dangerously understaffed, failing to provide required enhanced care levels.
Responded
Ruth Jones
Concerns: The care home could not adequately observe falls-risk residents during self-isolation due to staffing and lack of guidance. Vulnerable elderly patients sent to hospital alone faced significant communication barriers, hindering their care.
Responded
Joseph O’Neill
Concerns: Care staff failed to address a heating fault during a heatwave and ensure adequate rehydration, leading to the patient's deterioration being unrecognised.
Responded
Marion Glover
Concerns: Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.
Responded
Ann Stillwell
Concerns: The Commissioner failed to authorise essential 1:1 care for a patient at high risk of falls, despite it being the only identified method to mitigate her specific risks.
Responded
Eileen Pollard
Concerns: Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Overdue
Jake Lee
Concerns: The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, and performed incorrect resuscitation, demonstrating severe gaps in emergency response.
Overdue
Sidney Baker
Concerns: Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and poses risks to patient care and safety.
Responded
Andrew Hogg
Concerns: A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures or equipment to prevent repeated incidents.
Responded
Evha Jannath
Concerns: The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, poor signage, and no staff training or equipment for water rescue, alongside unclear emergency procedures.
Overdue
Harold Uzomechina
Concerns: Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.
Overdue
Edna Evans
Concerns: The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.
Overdue
Robert Lowe
Concerns: Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
Overdue
Barbara Humphreys
Concerns: Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, and delays in care plan completion. There was also a failure to inform families of medically relevant events.
Overdue
Charles Knapp
Concerns: Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere to care plan staffing requirements. The company's continued operation with inadequate care and record-keeping poses a significant risk of future deaths.
Overdue
James Delaney
Concerns: Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different homes created confusion and potential risks.
Overdue
James Francis
Concerns: Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical attention for deteriorating health and insufficient information provided to paramedics.
Responded
Frederick Brooker
Concerns: The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or reported, and patient safety was compromised by over-reliance on capacity.
Responded
Sophie Bennett
Concerns: The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
Overdue
John Duckenfield
Concerns: Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.
Responded
Allan Shepard
Concerns: Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient information was not passed to the third-party call centre.
Overdue
Simon Graham
Concerns: Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and unqualified staff conducting suicide risk assessments without training.
Overdue
Theresa Button
Concerns: Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in maintaining contemporaneous records.
Responded
Ruth Perkins
Concerns: A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.
Overdue
Alfred Meek
Concerns: Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages left vulnerable patients at risk of falls.
Responded
George Goldby
Concerns: Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.
Responded
John Wherlock
Concerns: Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still ongoing despite being criticised.
Overdue
John Edwards
Concerns: The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.
Overdue
Ronald Farrington
Concerns: The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.
Overdue