Care home staffing levels
Insufficient numbers of suitably skilled and experienced staff deployed in care homes, impacting ability to meet resident needs.
713 items
10 sources
4 inquiries
Source spread
Where this theme appears
Care home staffing levels has been flagged across 10 independent accountability sources:
7 inquiry recs
161 PFD reports
23 committee recs
82 CQC actions
6 PPO recs
15 IMB reports
3 IMB recs
5 detention investigation recs
4 PHSO decisions
407 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (7)
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
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
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
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
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
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
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
PFD Reports (161) — showing 50 strongest matches
Mohammed Chaudhury
Concerns: The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.
Overdue
Terence O’Connell
Concerns: A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital clinical monitoring for two days.
Response (Gabbandco): The care home disputes that there was a communication breakdown between the care home, district nurses, and the out-of-hours GP service, asserting that communication breakdown was between district nurses and …
Response: The University Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for switchboard staff to record out-of-hours requests for District Nurses in greater detail.
Overdue
Henry McQuoid
Concerns: Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive it.
Overdue
Barbara White
Concerns: Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.
Overdue
Wayne Broad
Concerns: There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees also need alignment with best practice.
Response: The Secretary of State states that specialist substance misuse nurses may not be the most effective use of resources in all hospitals and that a specialist substance misuse nurse would …
Overdue
Pamela Bailey
Concerns: Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.
Overdue
John William Tugwell
Concerns: The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Overdue
Marjorie Evelyne Keogh
Concerns: The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments and non-compliant staircase furniture also posed safety issues.
Response (My Mil Limited): My Mil Ltd instructed a Structural Engineer to look into the balustrading at Syston Lodge and make recommendations to ensure they comply, which will be undertaken once the report is …
Response (CQC): CQC is reviewing its approach to registration, considering checks to confirm compliance with building regulations for new or altered locations where providers seek to accommodate people. They will share the …
Responded
Keith Barton
Concerns: There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident reports, hindering further specialist reviews.
Response (Life Style Care): Lifestyle Care booked dysphagia training for staff in February and March 2014 and a Nutrition and Hydration course in March 2014. They received confirmation from SALT that they will now …
Responded
Beryl French
Concerns: Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.
Response (Life Style Care): Life Style Care has provided updated training on DNACPR forms to staff across its remaining homes. An End of Life care plan has been piloted in 3 homes and is …
Responded
Ian Page
Concerns: Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for high-need patients contributed to risks.
Overdue
Barbara Cooke
Concerns: Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.
Overdue
John Bird
Concerns: The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, leading to an untrained carer inaccurately assessing a high-risk patient's mobility.
Overdue
Noreen Porter
Concerns: Care home staff failed to perform CPR, indicating a complete absence of processes or procedures for emergency resuscitation.
Response (Bupa): Bupa acknowledges that CPR was not carried out when it should have been. Following the incident, Ardenlea Grove Nursing Home has reappraised procedures and processes for life support, and has …
Responded
Alois Piska
Concerns: The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.
Response (Care Uk): Care UK disputes the coroner's concerns, stating that staffing levels at Harry Sotnick House were adequate and that staff are trained not to catch residents who fall to prevent injury. …
Overdue
Jane Robinson
Concerns: Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant healthcare professionals was also found.
Response (University Hospitals of Leicester NHS Trust): The Trust is implementing a competency assessment for HCAs by the end of October 2015 and moving towards electronic recording of observations with automatic EWS calculation and alerts. Clinical handover …
Responded
Rufjan Bibi
Concerns: Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite a critical GCS score were identified.
Response (Barts Health NHS Trust): The Trust implemented intentional rounding and documentation audits, and carries out observations of care. A doctor received training on obtaining consultant reviews, and the case was discussed at a morbidity …
Responded
John Lowe
Concerns: Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.
Overdue
Howell Fisher
Concerns: Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.
Overdue
Alison Draper
Concerns: A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for staff balancing hourly checks with more frequent observations.
Overdue
Phyllis Broomhead
Concerns: Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.
Response (Rotherham Borough Council): Rotherham Metropolitan Borough Council will provide a detailed action plan regarding recommendations made under Regulation 28, outlining actions taken, actions to be achieved, and timescales to conclude any uncompleted actions.
Responded
Doreen England
Concerns: The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward suffered from inadequate leadership and medical cover. RMN training also failed to cover pressure sores sufficiently.
Response: NHS England will oversee a specific action plan to address deficiencies in care, particularly regarding pressure sore risk assessment. The matter has been tabled for discussion in the Quality Surveillance …
Overdue
Eliza Simpson
Concerns: The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.
Overdue
May Hall
Concerns: Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, indicating a need for regular, confirmed training.
Overdue
Thomas Nicholls
Concerns: The report identifies care staff lacking training in PEG feeding, specifically regarding mobility and handling, and the failure to report a related incident, prompting a review of policies and training.
Overdue
Jean Gillespie
Concerns: Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.
Response (MMCG): Senior Care Assistants received further medication training and competency assessments, including a supervision after the inquest. The new manager introduced handover and medication count down sheets for improved communication and …
Responded
Elsie Brown
Concerns: Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety risks due to unclear staff responsibilities.
Overdue
Lee Rigby
Concerns: The report identifies potential risks in resident care, including support workers not having keys for timely access, adequacy of staffing levels, review of risk procedures and staff training.
Overdue
Leslie Murray
Concerns: Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.
Overdue
Edith Kirkham
Concerns: Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of proper handover from the hospital. Vital records were also unavailable.
Response: Illegible response.
Overdue
Margaret Metcalfe
Concerns: Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.
Response (Stockton on Tees Borough Council): Rosedale Centre implemented a new policy regarding Care Assist pagers, including staff responsibilities for checking equipment, documenting its use, responding to alerts, and reporting problems, with monthly audits by the …
Responded
Jane Bell
Concerns: Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy with other tasks, creating a risk of future deaths.
Response (Jane Bell): The hotel has implemented constant poolside supervision, including patrolling staff and CCTV monitoring, with head counts recorded every 30 minutes. They have also hired a leisure club manager with extensive …
Responded
Pamela Thurston
Concerns: The care home failed to update the care plan for a patient with a choking risk and left her unsupervised to eat after a 17-hour period without food, leading to choking and subsequent death.
Response (Thurston): A memorandum was sent to all Home Managers regarding timely meals, choking risk assessments, and SALT referrals. The Senior Manager Monthly Report was amended to monitor Homes' adherence to the …
Overdue
Lillian Hursell
Concerns: Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential head and neck injuries.
Response (Hursell): The care home has commenced retraining in first aid, moving and handling, and health and safety. They have introduced bedrail audits, re-educated staff in bed rail use, and advised staff …
Responded
Freda Cordy
Concerns: A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
Overdue
Olive Wilmott
Concerns: An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements due to insufficient night staff for residents' needs.
Overdue
Margaret Gleeson
Concerns: Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher training.
Response (Wrighton Wigan and Leigh NHS Trust): The Trust reviewed staffing levels, provided refresher training on the MEWS tool, and conducted sepsis training, including drop-in sessions and mandatory attendance at a Sepsis Study Day for nursing staff, …
Responded
Alan Stead
Concerns: Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Response (Care UK): Care UK implemented a training program for nurses and HCAs in phlebotomy at HMP Dovegate, completed in March 2016, to ensure timely blood tests. The Governance team also shared learning …
Responded
Daphne McCorkle
Concerns: A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither district nurses nor agency carers provide night visits.
Response (D McCorkle): The CCG has established a Community Pressure Ulcer Panel and an acute pressure ulcer panel to review pressure ulcers acquired in the community. They will monitor risk assessment of patients …
Overdue
Edwina Moses
Concerns: A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing levels, leaving frontline nurses unable to safely care for vulnerable patients.
Response: The University Health Board has reviewed the process around enhanced observation, including risk assessments and staffing level monitoring, and introduced an audit process to monitor adherence to increased nursing observation …
Overdue
Jean McHale
Concerns: Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded by an insufficient number of Tissue Viability Nurses in healthcare.
Response (SEPT): SEPT reports a service review has been undertaken, clear pathways are in place, and the provision of TVNs has increased. In addition community nurses have ongoing training, all category 3 …
Overdue
Jennifer Clark
Concerns: The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This severe lack of facilities poses a high risk to babies' lives.
Response (West Hertfordshire Hospitals NHS Trust): The Trust states that it has adequate neonatal facilities but acknowledges that the Neonatal Unit requires modernisation. The Trust Board approved a redevelopment plan including the NICU and the Strategic …
Responded
Etheline De-Gale
Concerns: Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Response (Response Ambassador House Home): Ambassador House Home reports that the care plan will stipulate that residents must not be left unattended when bedrails are lowered, and staff will carry gloves in their pockets at …
Responded
Daphne Cherry
Concerns: Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Response (Care UK): Care UK has taken actions including training the home manager, deputy, and unit leaders in early recognition of deteriorating patients, delivering training to all staff, introducing daily meetings and walkarounds …
Responded
Annette Krasinsky-Lloyd
Concerns: Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.
Overdue
Steven Amos
Concerns: Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.
Overdue
Janet Muller
Concerns: Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.
Response (Janet Muller): NHS England is implementing enhanced governance arrangements to monitor QVH's action plan, engaging with the Trust to promote networking with BSUH, and assessing the suitability of QVH for specialized services. …
Responded
Joseph Tarnowski
Concerns: A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.
Response (Hillbrook Grange): Following the inquest, Hillbrook Grange Residential Care Home immediately provided residents with call bells to be worn around their necks.
Responded
Beryl Goode
Concerns: Care home night staff, lacking medical training, failed to consider a head injury as the cause of a resident's confusion after a fall, indicating a need for improved awareness and assessment training.
Overdue
Helen Cannon
Concerns: Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to identify critical inaccuracies in risk assessment completion and staff understanding.
Response: Illegible response.
Overdue
Committee Recommendations (23)
#47 —
Recommendation: Many of these pressures on the social care sector—such as funding and workforce— are longstanding and must be resolved urgently. Pressures on the social care workforce are likely to be compounded this autumn by the mandate that people working in …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#47 —
Recommendation: Many of these pressures on the social care sector—such as funding and workforce— are longstanding and must be resolved urgently. Pressures on the social care workforce are likely to be compounded this autumn by the mandate that people working in …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#19 —
Recommendation: The Department told us numbers in the social care workforce were going in the right direction and that domiciliary care and care home workforces were expanding.70 However, written evidence sent to us by the National Care Forum highlights that, as …
Gov response: 3.9 The government disagrees with the Committee’s recommendation. 3.10 According to Skills for Care, the vacancy rate in independent care providers was 10.7% in 2021-22, increasing from 7.0% the previous year. The rate had been …
Not Accepted
#18 —
Recommendation: The social care workforce is in a similarly precarious position, against a wider backdrop of declining local authority resources.64 Despite the Department’s assurances that “the numbers are moving in the right direction”, vacancies in social care have been on an …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2025 3.2 Whilst the government agrees with the recommendation, the proposed timescales are too premature for any impacts to be measurable. The workforce …
Not Addressed
#46 —
Recommendation: Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#1 —
Recommendation: The covid-19 pandemic has had a severe impact on adult social care. People have received less care and often care workers have been compelled to deliver only the basics. More people are going without care and many people’s needs are …
Gov response: Throughout the pandemic the government made available over £2.9 billion in specific COVID-19 funding to support the adult social care sector, including £1.81 billion for infection prevention and control (IPC), £523 million for testing and …
Accepted
#3 —
Recommendation: The Department has started taking some action to address workforce challenges in social care, but vacancies have increased by 50% in the last year and the number of people working in social care fell in 2021/22 for the first time …
Gov response: The government disagrees with the Committee’s recommendation. According to Skills for Care, the vacancy rate in independent care providers was 10.7% in 2021-22, increasing from 7.0% the previous year. The rate had been around 7% …
Not Accepted
#19 —
Recommendation: The COVID-19 pandemic has had devastating consequences both for vulnerable people using social care, and for the committed professional workforce that provide that care. These challenges have been exacerbated by long-standing funding and workforce issues which need to be recognised …
Gov response: Details of the level of funding provided to the social care system during the COVID-19 pandemic and at the 2020 Spending Review can be found in the section; Preface: Adult Social Care Funding. 8.1 We …
Under Consideration
#16 —
Recommendation: The Home Office should—in partnership with the Department of Health and Social Care—conduct a full assessment of the potential impact of its planned changes to routes to settlement on the adult social care workforce, and on the stability of the …
Response Pending
#15 —
Recommendation: It is extremely hard to predict what impact these changes will have on the social care workforce. Given the level of overseas recruitment that has taken place, decisions about routes to settlement for social care workers are likely to affect …
Response Pending
#14 —
Recommendation: If the Government implements a 15-year qualifying period for adult social care workers, we recommend that it takes urgent action to support decent pay and conditions for this group. The Home Office should set out in response to this report …
Response Pending
#55 — Social care staff shortages severely impact the provision of good-quality care.
Recommendation: We have heard evidence that staff shortages are having an impact on the ability of social care staff to provide good-quality care to the people they support. Lara Bywater told us that in the 20 years she has been running …
Gov response: This is not a recommendation but the issues raised are covered in our responses below.
Not Addressed
#20 —
Recommendation: We believe that the starting point for the social care funding increase must be an additional £7bn per year by 2023–24 to cover demographic changes, uplift staff pay in line with the National Minimum Wage and to protect people who …
Gov response: Details of the level of funding provided to the social care system during the COVID-19 pandemic and at the 2020 Spending Review can be found in the section; Preface: Adult Social Care Funding. 8.1 We …
Under Consideration
#2 —
Recommendation: It is clear from the evidence we have heard that funding shortfalls are having a serious negative impact on the lives of those who use the social care system, as well impacting the pay levels of the workforce and threatening …
Gov response: Details of the level of funding provided to the social care system during the COVID-19 pandemic and at the 2020 Spending Review can be found in the section; Preface: Adult Social Care Funding. 4.1 As …
Under Consideration
#15 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Gov response: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access …
Under Consideration
#46 —
Recommendation: Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#15 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Gov response: The government accepts this recommendation. The NHS is committed to developing and publishing new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. NHS England and NHS Improvement published …
Under Consideration
#22 — Private providers significantly dominate the residential care market, owning 84% of all settings.
Recommendation: In 2024–25, 84% of residential care settings registered with Ofsted, including supported accommodation and children’s homes, were owned by private providers.57 The Department told us this accounts for 74% of residential care places, because privately-owned homes tend to offer fewer …
Gov response: 5. PAC conclusion: Despite private providers providing most care home places, the Department does not fully understand their financial position.
Response Pending
#181 —
Recommendation: The Health and Social Care Committee’s Reports on social care and the delivery of core NHS and care services during the pandemic also highlighted the impact of a lack of testing for social care staff in the initial wave of …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#181 —
Recommendation: The Health and Social Care Committee’s Reports on social care and the delivery of core NHS and care services during the pandemic also highlighted the impact of a lack of testing for social care staff in the initial wave of …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#6 —
Recommendation: As emphasised by Alzheimer’s Society and other key stakeholders, social care reform must be “rooted in the recognition of what good quality care looks like” and 20 Supporting people with dementia and their carers create a system where people with …
No Published Response
#17 — NHS Providers warn Hospital 2.0's 95% bed occupancy assumption is unsustainable and unsafe.
Recommendation: In written evidence to us, NHS Providers advised that the standardised design had to be sufficiently future-proofed to handle changes in demand, practice and public expectations. It was concerned that future planned bed occupancy levels should be safe, and warned …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The government agrees that it is vital that future hospitals are the right size and it will keep the assumptions on size of future hospitals under …
Accepted
#60 — Publish a fully costed plan for funding Level 5 diplomas for care home managers.
Recommendation: It is clear that some care home managers lack the training and support they need to stay in post. We welcome the Government’s commitment to fund Level 5 diplomas for those who need them, and we urge the Government to …
Gov response: The Government broadly agrees with recommendation 60 and has published plans for workforce reform in ‘People at the Heart of Care: adult social care reform white paper. We are continuing with our system reform programmes …
Not Addressed
CQC Inspection Actions (82) — showing 50 strongest matches
Chy Byghan Residential Home
The provider must ensure people who use services are protected against the risks associated with not having sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the service requirements.
Must Do
Ambleside - Luton
The provider must ensure that there are sufficient numbers of suitably qualified, skilled and experienced staff.
Must Do
Valewood House Nursing Home
There were insufficient numbers of suitably qualified, skilled and experienced staff to safeguard people’s health, safety and welfare.
Must Do
Pennsylvania House
The provider must ensure people who use services are protected against the risks of receiving unsafe or inappropriate care by basing staffing levels at night on people's assessed needs.
Must Do
Laurel Lodge Care Home
The provider must ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of people using the service.
Must Do
Highfield House Residential Home
The provider must ensure appropriate staffing.
Must Do
Chiltern View
The provider must ensure there are enough staff deployed throughout the home to ensure people's care and support needs are met safely.
Must Do
Cary Lodge
There were not sufficient numbers of skilled staff deployed to keep people safe. 18(1)(2)(a)
Must Do
Benthorn Lodge
The registered person has failed to ensure that sufficient numbers of suitably qualified, competent, skilled and experienced persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
Must Do
Walmer Lodge Residential Home
Sufficient numbers of suitably qualified, competent, skilled and experienced persons were not deployed. 18.1
Must Do
The Peter Gidney Neurodisability Centre
There was a lack of suitably qualified, experienced and skilled staff to meet people's needs.
Must Do
The Moat House
Sufficient numbers of staff were not always available to meet people's care and support needs.
Must Do
The Gateway
There were insufficient numbers of suitably qualified and experienced staff to consistently meet the needs of people who used the service.
Must Do
Slate House Residential Home
The provider must ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced staff.
Must Do
Shenstone Hall Nursing Home
The provider must ensure staffing levels are continuously reviewed and adapted based on people’s assessed needs to ensure they are sufficient to meet people’s needs at all times.
Must Do
Robin Hood House
The provider had failed to ensure there were sufficient numbers of suitably trained staff deployed at all times to meet people's needs safely.
Must Do
Palm Court Nursing Home
We recommend that the service considers using a tool to determine suitable staffing levels and reviews staffing levels regularly to ensure people receive safe care and support at all times.
Should Do
Newland House
The provider did not have a system in place to accurately determine the number of staff required.
Must Do
Newland House
The provider did not ensure sufficient numbers of suitably qualified staff were deployed to fully meet people's care needs. This had impacted on staff's ability to provide care in line with the fundamental standards of the Health and Social Care …
Must Do
Lincoln Lodge Residential Home for the Elderly
staffing levels should be reviewed.
Should Do
Keb House Residential Home
The registered provider failed to ensure sufficient numbers of suitably qualified, competent and skilled staff were deployed.
Must Do
Karenza Care Home
The provider had failed to ensure there were always adequate numbers of staff to meet people's needs.
Must Do
Holmesley Nursing Home
We recommend the provider keep staffing levels, people's dependency levels and the deployment of staff at the service under review.
Should Do
Holly House Residential Care Home
The provider must ensure there are sufficient staff to support people in a way that ensures their continued safety.
Must Do
Holly Court Care Home
We recommend a dependency tool is used to help determine appropriate staffing levels, based on the number of people living in the home and their changing needs.
Should Do
Highcliffe House Nursing Home
The manager agreed to reassess people's needs and to make any necessary changes to ensure there were sufficient staff.
Should Do
Fremington Manor Nursing and Residential Home
The provider had failed to ensure sufficient numbers of staff were consistently deployed to meet people's needs.
Must Do
Beech House - Basildon
The provider must ensure there are always enough staff on shift.
Must Do
Ashington Gardens
Regulation 18 HSCA RA Regulations 2014 Staffing
Must Do
We (Always) Care Under One Roof Limited
The provider must ensure sufficient staff are deployed.
Must Do
Walnut Villa
People were at risk of their needs not being met because there were insufficient staff provided and at times staff were not present in the home. Staff did not always have the relevant skills to meet people's care needs safely. …
Must Do
The Homestead (Crowthorne) Limited
The registered person failed to consistently ensure that sufficient numbers of staff are deployed to meet people's needs.
Must Do
Stepping Out
Staffing levels were not sufficient to ensure the safety of staff and service users.
Must Do
St Paul's Lodge
The registered person must ensure suitably qualified, skilled and experienced persons are deployed to meet people’s needs.
Must Do
Redcot Lodge Residential Care Home
The provider must ensure sufficient numbers of suitably competent and experienced staff are deployed.
Must Do
Precious Nursing & Residential Home
The provider must ensure people receive safe care by deploying sufficient trained staff to meet their needs.
Must Do
Park Grange Care Home
We concluded staffing levels and deployment of staff were not maintained to ensure people were not at risk of their care needs been met.
Must Do
Oaklands Care Home
The provider must ensure there are sufficient numbers of suitably skilled and experienced staff deployed at all times.
Must Do
JDK Limited (Glenholme Care)
There were not enough staff employed to deliver the service which was needed to meet people’s needs
Must Do
Elsinor Residential Home
Comply with Regulation 18 (Staffing)
Must Do
Eleanor House
The provider must take action to ensure there were sufficient numbers of suitably qualified, skilled and experienced staff available at all times. This was to ensure people who used the service were provided with appropriate meaningful opportunities for social interaction …
Must Do
Benthorn Lodge
The provider must ensure that staffing levels are sufficient to meet people's care and support needs safely.
Must Do
Attwood's Manor Care Home
The provider must ensure that staff are effectively deployed to meet people's needs.
Must Do
Ashmore House
The provider must ensure sufficient numbers of suitably qualified, skilled and experienced staff are deployed.
Must Do
Arthur House
The provider had failed to ensure there was sufficient numbers of suitably skilled and experienced staff to meet people's care needs.
Must Do
Archers Point Residential Home
The provider must ensure there are enough housekeeping staff deployed to keep the home clean throughout and establish a system to determine the required number of housekeeping staff to comply with infection control and COVID-19 protocols.
Must Do
Cygnet Bury Hudson
The provider should continue with its recruitment of permanent staff to ensure there is sufficient cover at weekends, and reduce the cancellation of section 17 leave and patient activities on the wards.
Should Do
Clare House Residential Home
The registered manager agreed to look at staffing levels.
Should Do
Chestnut Lodge Nursing Home
We recommend the provider introduces a suitable dependency tool in order to ensure appropriate staff levels are regularly in place to meet the changing needs of the people using the service.
Should Do
Charnwood
There were not sufficient staff at the service to support people in a timely and meaningful way which allowed for people to have time with staff outside of direct care tasks.
Must Do
PPO Death in Custody Recommendations (6)
The Head of Healthcare and Greater Manchester Mental Health Services
The Head of Healthcare and Greater Manchester Mental Health Services should consider what additional support can be put in place to address staffing shortages at Garth and consider how they can reasonably deliver a meaningful healthcare resource.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies in line with Prison Service Instruction (PSI) 03/2013. In particular, where there are serious concerns about the health of a prisoner, …
The Director
The Director should remind staff of their responsibilities in a medical emergency, including that they should radio the correct medical emergency code immediately.
The Governor of HMP Sudbury
The Governor should ensure that, in line with National Instructions, an ambulance is called immediately in an emergency medical situation and that ambulances have speedy access to prisoners in all parts of the prison.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, in particular that staff efficiently communicate the nature of a medical emergency using the appropriate code.
The Governor
The Governor should ensure that adequate supervision and support arrangements are in place for RSAs and issues they raise are discussed at the relevant social care MDT meeting.
IMB Annual Reports (15)
Warren Hill (2022)
Warren Hill maintained a safe environment despite Covid-19 constraints, effectively managing outbreaks and promoting positive staff-prisoner interactions. The IMB commends the prison's efforts in harmonising regimes and establishing on-site approved premises. However, persistent issues with food provision, the suspension of the ROTL pilot, and challenges related to prisoner property and in-cell telephony remain significant concerns, along with the impact of recent parole changes on prisoner morale and progression.
PRISON
Key concerns
The Verne (2022)
HMP The Verne, an adult training prison for men convicted of sexual offences, has largely restored its 'core day' regime following COVID-19, maintaining a safe environment with good staff-prisoner relationships and high-quality healthcare. However, the report highlights critical issues, particularly regarding the inadequate 24-hour social care and onsite hospital provision for its growing elderly and frail population. Significant understaffing in the Offender Management Unit continues to undermine resettlement efforts for the substantial number of prisoners released directly from this training prison, alongside concerns about low prisoner pay and a third of the population lacking purposeful activity.
PRISON
Key concerns
Low Newton (2023)
HMP/YOI Low Newton is a well-managed women's prison that successfully adapted its regime post-Covid. While praised for its safe environment, estate improvements, and dedicated staff, it is significantly hampered by staff shortages, impacting regime delivery and key worker scheme consistency. The Board highlights concerns regarding funding for essential facilities, the management of complex prisoners, and the need for improved transport arrangements and oversight of disciplinary processes.
PRISON
Key concerns
Feltham (2023)
Feltham, comprising a YOI (A side) and a Cat C prison (B side), faced significant challenges in the reporting year ending August 2023, primarily due to severe staff shortages impacting regime delivery, time out of cell, and purposeful activity. While staff were commended for their dedication, these shortages led to increased incidents on A side and curtailed essential services and rehabilitative programs across both sides. Key concerns also included the inadequate education provision for separated young people, safety in communal showers on B side, and the ongoing issue of lost prisoner property.
PRISON
Key concerns
Altcourse (2021)
HMP Altcourse was judged a safe prison during the reporting year, demonstrating low levels of self-harm and violence despite pandemic restrictions. The Board noted significant improvements in food quality and strong staff-prisoner relationships. Key concerns include the persistent delays in transferring seriously mentally ill prisoners, issues with property, and the uncertain future and low morale of the resettlement service following a contract change.
PRISON
Key concerns
Bristol (2021)
HMP Bristol successfully managed Covid-19, implementing strong infection control and a good vaccination programme. The prison saw significant improvements in accommodation and the general environment, alongside a reduction in self-harm and violence. However, the Board remains concerned about inconsistent key work delivery, staffing shortfalls, persistent issues with disability access, and the appropriate placement of vulnerable prisoners.
PRISON
Key concerns
Brixton (2021)
The reporting year at HMP Brixton was dominated by COVID-19, leading to severe restrictions on the prison regime, impacting prisoners' mental health and resettlement opportunities. Despite significant efforts by staff and healthcare to maintain services and well-being, concerns persisted regarding the suitability of the offender flow system, inadequate accommodation for older prisoners, and a lack of D-category prison places. While self-harm incidents slightly decreased, assaults on staff increased, and substance misuse remained a challenge, with the Board commending positive aspects like food quality, staff commitment, and progress in education.
PRISON
Key concerns
Preston (2023)
HMP Preston, a Category B reception prison, continues to face challenges common to Victorian establishments, including chronic overcrowding (670 population vs. 433 CNA). Staffing levels are effectively low due to sickness and training, impacting key worker provision and regime. While some areas like self-harm incidents have reduced and in-cell phones installed, significant concerns remain regarding reception facilities, prisoner property management, and adequate budget for essential equipment. The Board made several recommendations to address these and other issues related to regime, family engagement, and staffing.
PRISON
Key concerns
New Hall (2023)
HMP/YOI New Hall reported a population of 335 and an operational capacity of 381 for the year ending February 2023. The prison saw a significant reduction in self-harm incidents (609, down from 965) and use of force, alongside a good HMIP report and positive staff-prisoner relationships. Key concerns include underfunded trainee officer allocations, slow recruitment checks, the need to address OFSTED recommendations, and frustrating waiting lists for prisoner jobs.
PRISON
Key concerns
North Sea Camp (2024)
HMP North Sea Camp generally provides a safe and humane environment, with a strong emphasis on humane treatment and a wide range of release preparation programs. Positive developments include improved facilities management, a proactive safer community team, and good healthcare services that receive positive feedback from prisoners. Key concerns include persistent delays in offender management paperwork, the unresolved situation for IPP prisoners, and poor accommodation standards with no plans for replacement or conversion of dormitories. Additionally, issues with prisoner property transfers, lack of on-site end-of-life care, and difficulties for disabled prisoners accessing resettlement opportunities remain.
PRISON
Key concerns
Doncaster (2025)
HMP Doncaster was rated the top local prison nationally, demonstrating strong performance in areas like refurbishment and support services. Despite an improved regime and full staffing, significant challenges persist, including increased prisoner violence due to overcrowding, and persistent, prolonged delays in mental health transfers. The IMB highlights critical issues such as national probation staffing deficits, property management concerns, and unanswered cell bells, calling for urgent attention from government and prison management.
PRISON
Key concerns
Bristol (2020)
HMP Bristol, a Category B local prison, navigated the reporting year (August 2019 – July 2020) under significant COVID-19 restrictions, which impacted the daily regime but also led to a more settled environment and improved staff morale. Despite efforts, safety ratings remained low, with high levels of self-harm, violence, and increased use of force incidents. Challenges persisted with delayed mental health transfers, unsuitable Victorian accommodation for disabled prisoners, and resource issues affecting key work and healthcare.
PRISON
Key concerns
Highpoint (2021)
HMP Highpoint is a male Category C training and resettlement prison. The reporting year saw a positive reduction in self-harm and violence, with staff commended for humane Covid management. Key concerns include persistent issues with property transfers, under-resourcing in contracted services like mental health and education, poor maintenance by GFSL, and the ongoing security vulnerability from unrepaired netting.
PRISON
Key concerns
Humber (2024)
HMP Humber, a Category C resettlement prison, experienced significant challenges in 2024 due to high prisoner turnover and population pressures. While the Board commends management's efforts in maintaining safety and improving regime stability, issues persist concerning property loss, inadequate purposeful activity, and cell sharing. Healthcare provision is improving but faces space and recruitment challenges, while key worker schemes are compromised by staffing shortages.
PRISON
Key concerns
Cardiff IMB (2025)
Overall, HMP Cardiff has seen positive developments in safety, with significant reductions in self-harm and use of force incidents, and successful digital platform implementation. However, the prison continues to grapple with severe staffing shortages, particularly in healthcare, and the physical estate remains in poor condition, affecting prisoners with mobility issues and access to basic amenities. Concerns persist regarding delays in mental health transfers, lack of secure medication storage, and the underperformance of the key worker scheme.
PRISON
Key concerns
IMB Recommendations (3)
Springhill (2023)
OMU staffing problems being addressed to enable it to again achieve its 8-12 week targets for sentence plan and offender assessment system (OASys) processes to be completed (7.3.5 and 7.3.7 and 7.3.8).
Governor / Director
Channings Wood (2025)
Can HMPPS confirm what actions are to be taken to ensure staffing levels at HMP Channings Wood are restored and maintained?
HMPPS
Berwyn (2022)
As the prison population ages, the Board would like to see training for staff on recognising and dealing with dementia and other age-related needs.
Governor / Director
Detention Investigations (5)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R31
G4S and the SMT should ensure that the welfare team is adequately staffed at all times. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R6
The SMT should urgently ensure that Brook House is fully staffed. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R7
G4S managers should undertake a comprehensive review of matters affecting staff retention at Brook House including remuneration, shift patterns and working hours and G4S needs to develop plans to address the matters arising from such a review. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R32
G4S and the SMT should ensure that the welfare team has the technological and administrative support it needs. (To be completed within 6 months)
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 13
the question of staffing levels be reviewed to assess if future contracts should contain more prescriptive requirements in relation to staff numbers.
Immigration Detention
PHSO Casework Decisions (4)
P-002934 — Frimley Health NHS Foundation Trust
Mrs K complains about how the Trust cared for her mother. She says there was a delay in diagnosing a urinary tract infection and giving antibiotics to treat it, medication for Parkinson’s disease was not given at the right times and she was discharged despite for poor condition.
NHS in England
Sep 2024
P-003012 — St George's University Hospitals NHS Foundation Trust
Miss P complains her mother should not have been admitted to hospital and that she received poor nursing care. She also complains about poor communication and that she was not allowed to visit her mother.
NHS in England
Upheld
Oct 2024
P-003412 — Derbyshire Community Health Services NHS Foundation Trust
Mrs J complains about the service community nurses provided to her mother. She is concerned about the frequency of visits, advice given to care home staff, and the quality of nursing care when care home staff raised concerns about her mother.
NHS in England
Not Upheld
Mar 2025
P-004682 — A practice in the Leeds area
Mrs A complains about the care and treatment provided to her father, Mr R, by the Practice on 13 August 2024. She says Practice staff should have attended Mr R’s care home to provide him with a face-to-face consultation, and it failed to accurately diagnose and subsequently treat Mr R, …
NHS in England
Jan 2026
LGO / SPSO Decisions (407)
21-018-287 — Ideal Carehomes (Number One) Limited
Summary: Mr F complained that the care provider failed to provide proper care to his late mother, Mrs J, prior to her death. We found the care provider’s actions caused injustice to Mrs J and her family. The care provider should waive some of the fees to redress this injustice.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
23-020-780 — Willow Tower Opco 1 Limited
Summary: We will not investigate this complaint about adult social care at the end of life. The Care Provider failed to treat its resident with dignity and respect following death. The Care Provider has taken action to improve service and apologised to the family for their distress pursuing a complaint. …
LGO (Local Government & …
Adult Care Services
May 2024
NIPSO-16874 — Belfast Health and Social Care Trust
The Ombudsman has found that the Belfast Health and Social Care Trust made a concerted attempt to resolve a complainant’s concerns about the care and treatment provided to her father while he was the resident of a Belfast nursing home.
NIPSO (NI Public Service…
Health & Social Care
Mar 2018
25-012-341 — Bupa Care Homes (GL) Limited
LGO (Local Government & …
Adult Care Services
Upheld
PSOW-202104529 — A Care Home
Mr X complained about aspects of care provided to his late father Mr Z, by the Care Home between April 2020 and May 2021. The Ombudsman found that there was no failure to consider the interaction between trazadone (an antidepressant) and lamotrigine (epilepsy medication) and that it was, ultimately the …
PSOW (Public Services Om…
Upheld
Jun 2023
PSOW-202202308 — A Care Home
Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately …
PSOW (Public Services Om…
Upheld
Jan 2024
21-011-179 — Caring Homes Healthcare Group Limited
Summary: We will not investigate this complaint about the quality of residential care and the Care Provider’s response when Miss X raised concerns.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-012-003 — Kent County Council
Summary: We will not investigate this complaint about the Council’s actions regarding Mrs X’s father’s care needs. This is because it is unlikely we would find fault with the actions of the Council. The Council has also take action to refund care charges to cover an apparent deficit in care …
LGO (Local Government & …
Adult Care Services
Jan 2022
21-000-792 — Porthaven Care Homes No 3 Limited
Summary: Mr X complained Porthaven Care Homes No 3 Limited (the Care Provider) failed to provide adequate care to his wife, Mrs X during her respite stay for ten nights in the autumn of 2020. We found the Care Provider failed to identify an illness Mrs X was suffering from …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-000-200a — Amberley Lodge Care Home (21 000 200a)
Summary: We found fault by a care home acting on behalf of the Council regarding the care it provided to Mr X, an elderly man with complex care needs. We found the care home failed to support Mr X and his wife, Mrs X, to make an informed choice about …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-015-937 — Buckinghamshire Council
Summary: We will not investigate this complaint about the Council’s failure to place Mrs Y in a care home closer to Mr X. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. There is nothing further we …
LGO (Local Government & …
Adult Care Services
Mar 2022
21-004-728 — Care UK Community Partnerships Limited
Summary: There is no evidence of proper oral care for Mr X. Mr X incurred dental fees as a consequence which the care provider has reimbursed. There was poor maintenance of some fluid and hygiene records although their absence is mitigated by the detail in the daily records. Beyond the …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-005-332 — Fridhem Rest Home Limited
Summary: Mrs B complained about the care Mrs C received during the last few months of her life. She also complained about restrictions on visiting arrangements for the family. We found fault with some of the personal care Fridhem failed to provide. Fridhem apologised to Mrs B and her family …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-015-353 — Nottingham City Council
Summary: We will not investigate this complaint about jewellery that went missing when Mrs X was a resident in a care home. That is because there are other bodies better placed to deal with the matter and further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-001-178 — Salveo Care Ltd
Summary: Mrs X complained about the care given to her late mother by the Care Provider and that she did not have a face-to-face visit with her before she passed away. We find the Care Provider’s management of her mother’s weight loss, how it told Mrs X of her death …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-007-659 — Cumbria County Council
Summary: Mrs X complained about the level of care provided to her mother, Ms Y, in the last few days of her life by the care home. She also complained about the clearing of Ms Y’s room and the way her belongings were handled. There were failings in the care …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-018-066 — Saima Raja AKA Braemar Care Centre
Summary: We will not investigate this complaint about the Care Provider refusing to issue a refund. This is because the Care Provider has now issued the refund. This remedies the claimed injustice and an investigation could not achieve anything more.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
22-000-089 — Blanchworth Care Homes Limited
Summary: We will not investigate this complaint about missing items belonging to the complainant’s deceased mother. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. An investigation would be unlikely to add anything to the Care Provider’s …
LGO (Local Government & …
Adult Care Services
May 2022
21-018-231 — Four Seasons Mickleton Limited
Summary: We will not investigate this complaint about the residential care received by the complainant’s now deceased mother. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate.
LGO (Local Government & …
Adult Care Services
May 2022
21-002-687 — Bournemouth, Christchurch and Poole Council
Summary: The Council commissioned Mr Y’s care so it is at fault for the failings in that care. It is also at fault for the way it dealt with Ms X’s complaint about this.
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-013-890 — West Berkshire Council
Summary: The Council’s complaint responses should have explained the circumstances of Mrs Y’s fall in a care home it commissioned. This was fault causing avoidable distress. The Council will apologise for its poor complaint responses. There was no fault in placing Mrs Y in a care home in a different …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
22-001-875 — T L C Care & Support
Summary: We will not investigate this complaint about noise from a residential care home. This is because there is not enough evidence of fault by the Care Provider. If Mrs X thinks the noise from the care home is a statutory nuisance she can complain to the Council.
LGO (Local Government & …
Adult Care Services
May 2022
22-001-572 — East Riding of Yorkshire Council
Summary: We will not investigate Mrs X’s complaint about matters relating to her mother’s care home placement between late 2017 and early 2020. The complaint lies outside our jurisdiction because it is late and I see no good grounds to consider it now.
LGO (Local Government & …
Adult Care Services
Jun 2022
21-007-565 — Aegis Residential Care Homes Limited
Summary: The care provider did not provide sufficiently clear information about the fees or placement before Mr and Mrs X moved into the home. It should repay the deposit amount to Ms A.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-015-115 — City of Wolverhampton Council
Summary: Mrs B complained about the care provided to her mother Mrs C during a two week stay at a care home commissioned by the Council. We have not found fault with the Council.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2022
22-002-749 — Luton Borough Council
Summary: We will not investigate Mrs D’s complaint about the care Mrs E received from her former care provider. This is because further investigation by the Ombudsman could not add to the care provider’s response or make a finding of the kind Mrs D wants.
LGO (Local Government & …
Adult Care Services
Jun 2022
22-004-036 — Hill Care 3 Limited
Summary: We will not investigate Mrs X’s complaint the Care Home used a hoist to transfer her father, Mr Y whilst he was having respite. That is because there is insufficient of fault in the Care Home’s actions to justify our involvement. The Care Provider has already apologised to Mrs …
LGO (Local Government & …
Adult Care Services
Jul 2022
21-017-902 — Burlington Care (Yorkshire) Limited
Summary: The Care Provider failed to identify some upheld points of complaint as poor care. It also failed to properly acknowledge Ms X’s distress.
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-016-775 — Christchurch Fairmile Village LLP
Summary: We will not investigate this complaint about adult social care provision, because the injustice claimed is not serious enough to warrant our involvement and we could not add to the Care Provider’s investigation.
LGO (Local Government & …
Adult Care Services
Jul 2022
21-006-282 — Georgians (Boston) Limited(The)
Summary: Mrs X complained about several aspects of poor care she received while resident at The Georgians Nursing Home. We have identified some areas of fault including poor record keeping, uncertainty about care provision and complaint handling. To remedy the injustice caused, the Care Home has agreed to apologise, make …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-013-311 — Ideal Carehomes (Number One) Limited
Summary: Mrs X complained the care home failed to provide adequate care for an illness her mother Mrs Y was suffering from, during her respite stay. Mrs X said Mrs Y suffered unnecessarily during her stay and subsequently died. We do not find fault with the care providers actions.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-012-375 — West Sussex County Council
Summary: Mrs X complained, on behalf of her mother Mrs Y, about the poor standard of care provided to Mrs Y by a Care Home. We found the Council at fault. We recommended it apologise to Mrs X and Mrs Y, pay Mrs X £500 for distress, pay Mrs Y …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-018-453 — Care Line Homecare Limited
Summary: Mrs X complains about an allegation made against her son, the Care Provider’s failure to deal properly with her concerns and its decision to end its support. The Care Provider accepts it did not deal with her concerns properly and that if it had it should have been able …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-010-423 — Lancashire County Council
Summary: Mrs X complained that the Care Provider, acting on behalf of the Council, delayed advising family of the late Mrs Y’s fall. Also, that it unreasonably refused to allow her to return from hospital and did not deal with her complaint properly. Mrs X says Mrs Y was deeply …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-012-559 — London Borough of Hounslow
Summary: Ms X complained the Council failed to act in her husband, Mr Y’s, best interest when it obtained a deprivation of liberty authorisation to keep him at the Care Home which had previously found to have been providing him with poor care. There was no fault in how the …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-001-426 — Wood Green Nursing Home Ltd
Summary: We will not investigate this complaint about the residential care provided to the complainant’s aunt, the way the care provider responded to her and her uncle, and any unresolved dispute over standards and charges. This is because in different parts of the complaint there is either not enough evidence …
LGO (Local Government & …
Adult Care Services
Aug 2022
21-016-412 — Care UK Community Partnerships Limited
Summary: Mrs C complains the Care Provider was not transparent over care fees and failed to provide suitable care to Mr C which resulted in a decline in his health. The Care Provider is at fault for failing to keep full contemporaneous records about the support it provided Mr C …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-018-580 — Care UK Community Partnerships Limited
Summary: Mrs X complained about the care her father received and the accuracy of notes that were taken while he was resident in a care home. Mrs X said the poor care meant her father’s health deteriorated rapidly. We find the Care Provider at fault for failing to take and …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-017-241 — Monarch Healthcare Limited
Summary: Mrs X complained that Monarch Healthcare Limited failed to keep her mother, Mrs Y safe during her stay at Clifton Manor Residential Home in November 2021. The care home was not at fault for Mrs Y’s fall. However, the failure to return the unused milkshakes amounts to fault. This …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-017-570 — The Orders Of St. John Care Trust
Summary: We will not investigate this complaint about the Care Provider failing to manage Mr Y’s pain properly at the end of his life. We could not add to the investigation that has already taken place, and we could not provide a meaningful outcome for Ms X.
LGO (Local Government & …
Adult Care Services
Sep 2022
21-017-428 — Barchester Healthcare Homes Limited
Summary: Mrs C complains about the standard of care provided by the Care Provider. The Care Provider is at fault for failing to retain and record interventions which has caused uncertainty about whether it cared for Mrs C’s mother, Mrs D, properly. The Care Provider has accepted some fault, apologised, …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-001-337 — Bowbrook House
Summary: Mrs X has complained about the care her husband, Mr X, received from a care provider, causing him to deteriorate rapidly. Mrs X also complained the Care Provider was critical of the care she had provided him. We find the Care Provider at fault for failing to take and …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-017-118 — Brunelcare
Summary: Ms C complained about the care her (late) father received at his care home. We found there was fault with regards to some of the aspects of the support Mr F received at the care home. The care home has agreed to apologise for the distress this caused and …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
22-000-102 — Warwickshire County Council
Summary: The Council acknowledges Mrs X received poor care and treatment by the commissioned care provider. Mrs X suffered severe dehydration, often expressed pain which was not acted on and was not treated with dignity. The Council will now offer a sum in recognition of the harm caused to Mrs …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
22-001-843 — Saint Jude Residential Care Home Limited
Summary: there was no fault in the care provided by Saint Jude Residential Care Home Limited to the complainant’s mother or in its consideration of, or planning for, her care needs. However, its handling of Ms B’s complaint did not comply with its own policy on this and amounts to …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
22-000-034 — Pine View Care Homes Ltd
Summary: There was fault in the way the Home communicated with the family of a resident and its failure to respond to the family’s complaints. There was also fault in the Home’s record keeping. This has caused the family distress and we recommend that the Home apologises to the family …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-018-301 — Barchester Healthcare Homes Limited
Summary: We will not investigate Mr X’s complaint about the standard of care provided to his mother-in-law by her care home. This is because an investigation would not lead to any different findings or outcomes.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-017-162 — Your Health Ltd
Summary: We will not investigate this late complaint from Mr X about Mr Y’s transfer to an unsuitable room within his residential care home. There is not a good reason for the delay in bringing the matter to the Ombudsman. We also could not achieve the outcome Mr X seeks.
LGO (Local Government & …
Adult Care Services
Apr 2024
23-009-243 — Rotherwood Healthcare (St Georges Park) Limited
Summary: The care provider charged the fees for the notice period in accordance with the contract which Mrs X signed. The care provider acknowledges there were some inadequacies in the decoration of Mr X’s room and the operation of the call buzzer, and there are some discrepancies in the response …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-021-168 — Park Homes (UK) Limited
Summary: We cannot investigate this complaint about adult social care provided in Scotland.
LGO (Local Government & …
Adult Care Services
Apr 2024