Care safeguarding systems
Absence of effective systems to protect people from abuse and avoidable harm, including failures in reporting suspected abuse.
3,661 items
16 sources
7 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
92match
Charmes Care
The registered persons failed to protect people from abuse and improper treatment and to have effective systems and processes in place to prevent abuse of people
Matched on
terms: care, system
CQC action
90match
Yanah Care
The provider must ensure effective systems and processes are in place to protect people from abuse and improper treatment.
Matched on
terms: care, system
Committee recommendation
88match
#4 - Thirty-Seventh Report - Support for vulnerable adolescents
It is not clear how lessons and learning from changing threats, serious case reviews and child safeguarding review panels are embedded in day-to-day practice. Time and again reviews into child deaths highlight poor coordination between services, including insufficient joined-up leadership and a lack of appropriate and timely information-sharing around cases, as a contributing factor in the death. Adolescents...
Matched on
terms: care, safeguarding, system
CQC action
86match
Ivydene Care Home
Systems to protect people from allegations of or actual abuse were not always followed. Regulation 13 (3).
Matched on
terms: care, system
PFD report
85match
Arthur Adley
Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Matched on
terms: care, safeguarding, system
CQC action
82match
Continuity Healthcare Services Private Limited
The provider did not ensure systems and processes were in place to prevent people from abuse or to investigate immediately on becoming aware of an allegation of abuse.
Matched on
terms: care, system
CQC action
82match
Ash Court Care Centre - Camden
The registered person had not ensured that systems and processes had been established and operated effectively to prevent abuse of service users. Regulation 13 (1) (2) (3)
Matched on
terms: care, system
CQC action
82match
Multicare Services - Maylands Building
The provider had not always identified and effectively investigated safeguarding concerns to people.
Matched on
terms: care, safeguarding
CQC action
82match
Heritage Healthcare-Middlesbrough
The provider must ensure service users are safeguarded from abuse and improper treatment, including raising safeguarding alerts and ensuring staff understanding and training in safeguarding.
Matched on
terms: care, safeguarding
PFD report
81match
Barbara Cooke
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.
Matched on
terms: care, safeguarding, system
PFD report
81match
Phyllis Broomhead
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.
Matched on
terms: care, safeguarding, system
Inquiry recommendation
81match
WATE-(22) - Conduct inter-agency review of child abuse investigation procedures to issue guidance
In the light of the recent experience gained in both England and Wales in major investigations of alleged wide ranging abuse of children in care/looked after children, an inter-agency review of the procedures followed and personnel employed in those investigations should now be arranged with a view to issuing practical procedural guidance for the future. In any event...
Matched on
terms: care, safeguarding
CQC action
81match
Winterton House
People were not always protected from abuse and improper treatment. Systems and processes were not established and operated effectively to prevent abuse of service users. People were deprived of their liberty for the purpose of receiving care or treatment without lawful authority.
Matched on
terms: care, system
Inquiry recommendation
78match
LAMI-81 - Implement systems to record, complete, and check actions for deliberate harm cases.
Hospital chief executives must introduce systems to ensure that actions agreed in relation to the care of a child about whom there are concerns of deliberate harm are recorded, carried through and checked for completion.
Matched on
terms: care, system
Inquiry recommendation
78match
LAMI-71 - Require documented future care plan for discharging children with protection concerns.
Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. Hospital chief executives must introduce systems to monitor compliance with this recommendation.
Matched on
terms: care, system
CQC action
78match
TerraBlu Homecare
The failure to protect people from abuse and improper treatment was a breach of Regulation 13 (1)(2)
Matched on
terms: care
CQC action
78match
Ave Maria Care (Edgbaston)
The provider's safeguarding procedures were not effective and safeguarding concerns had not been consistently reported to the relevant agencies.
Matched on
terms: care, safeguarding
Committee recommendation
77match
#16 - Thirty-Seventh Report - Support for vulnerable adolescents
The national Child Safeguarding Practice Review Panel, set up to commission reviews of serious child safeguarding cases, has consistently highlighted cases in which poor coordination between services, including insufficient joined-up leadership and a lack of appropriate and timely information-sharing around cases, were a contributing factor.40 The Department for Education told us that the Panel publish the findings from...
Matched on
terms: care, safeguarding
CQC action
77match
Wrottesley House
The provider must ensure they have robust safeguarding systems in place to protect people from potential harm.
Matched on
terms: safeguarding, system
CQC action
77match
Leopold Muller Home
Systems in place to safeguard people were not effectively being used so placed them at risk of potential abuse and restrictive practices. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Matched on
terms: care, system
Committee recommendation
74match
#64 - Rising child neglect linked to poverty lacks clear DfE strategy and social care response.
Neglect is sadly on the rise in England and is clearly linked to poverty and poor parental mental health. The Department for Education does not appear to have a clear strategy for addressing neglect and there are concerns that the social care system is not set up well to respond to neglect referrals. (Conclusion, Paragraph 160)
Matched on
terms: care, system
Committee recommendation
74match
#62 - Establish clear processes for reviewing and escalating multi-agency child safeguarding disagreements.
Multi-agency working is crucial in child safeguarding processes. Where there is disagreement between children’s social care and other agencies such as health, police and education on a safeguarding matter, there must be clear processes in place to review and escalate concerns providing a clear line of accountability and decision-making. (Recommendation, Paragraph 155)
Matched on
terms: care, safeguarding
Committee recommendation
74match
#46 - Serious recruitment and retention problems in children's social care workforce require wholesale review.
There is a serious problem with recruitment and retention in the social care workforce. High turnover and overstretched staff are exacerbating the instability experienced by children in care and increase the risk of 89 safeguarding concerns being overlooked. The Department for Education has begun to address this with the planned induction programme and regulations on the use of...
Matched on
terms: care, safeguarding
Committee recommendation
74match
#1 - Children’s social care problems persist and worsen without comprehensive reform following the Independent Review.
Evidence given to the Committee during our inquiry indicates that many of the problems highlighted by the Independent Review of Children’s Social Care in 2022 persist, and in a significant number of cases have worsened since the Review. Increases in need coupled with stretched budgets and a lack of serious attention to reform have resulted in a system...
Matched on
terms: care, system
Committee recommendation
74match
#29 - Significant safeguarding failings persist in asylum accommodation with inadequate oversight
We are deeply concerned by the volume of evidence indicating significant safeguarding failings in asylum accommodation. While there are evidently pockets of localised good practice, the response to safeguarding concerns is inconsistent and often inadequate, leaving vulnerable people at risk of harm. We are particularly concerned that the Home Office does not currently have adequate understanding and oversight...
Matched on
terms: safeguarding
CQC action
74match
Redcot Lodge Residential Care Home
The provider must protect people from abuse and improper treatment.
Matched on
terms: care
PFD report
73match
June Winterbottom
Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking accountability, and having no safety net for emergency medical assistance.
Matched on
terms: care, system
Inquiry recommendation
73match
LAMI-73 - Require inquiry and review of previous hospital admissions for suspected deliberate harm.
When a child is admitted to hospital and deliberate harm is suspected, the doctor or nurse admitting the child must inquire about previous admissions to hospital. In the event of a positive response, information concerning the previous admissions must be obtained from the other hospitals. The consultant in charge of the case must review this information when making...
Matched on
terms: care, system
Committee recommendation
73match
#3 - Thirty-Seventh Report - Support for vulnerable adolescents
Critical local multi-agency safeguarding partnerships are still not working well enough, which risks those vulnerable adolescents that need support and help falling through the gaps. While in some places multi-agency safeguarding partnerships may work well, in other places, sadly, they do not. In May 2022 the Child Safeguarding Practice Review Panel found multi-agency safeguarding arrangements “are not yet...
Matched on
terms: care, safeguarding
LGO / SPSO decision
73match
21-000-348 - Brighton & Hove City Council
Summary: Dr B complained ESC Council and the NHS Trust failed to properly safeguard her when it undertook an investigation into allegations of physical assault when she lived in a care home jointly funded by the CCG and BHC Council. She also complained about the home’s investigation and its decision to serve notice to end the placement. We...
Matched on
terms: care, safeguarding
LGO / SPSO decision
73match
20-012-369 - London Borough of Newham
Summary: Ms Z, on behalf of her mother Ms X, complained about the Council’s action in respect of her finances. There is fault by the Council in failing to start a safeguarding investigation at the appropriate time; delay in progressing a safeguarding investigation and failure to ensure Ms X's needs were met when it suspected her son was...
Matched on
terms: care, safeguarding
Committee recommendation
70match
#19 - Home Office contracts for migrant accommodation lack specified penalties for safeguarding failures.
The Home Office told us that health and welfare of migrants was “baked into” the way that it runs the sites and the contracts with suppliers. It said there were clear key performance indicators (KPIs) on accommodation being safe and habitable and that the providers have welfare teams on site. However, the National Audit Office reported that the...
Matched on
terms: safeguarding
CQC action
70match
Ave Maria Care (Wolverhampton)
The provider did not mitigates risks to keep people safe from abuse
Matched on
terms: care
CQC action
70match
The Hollies Care Home
The registered person had not made suitable arrangements to ensure that people were safeguarded against abuse.
Matched on
terms: care
PFD report
69match
Sidney Barnett
The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff statements.
Matched on
terms: care, safeguarding
PFD report
69match
Anne Scott
Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.
Matched on
terms: care, safeguarding
PFD report
69match
Ahmedreza Fathi
Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a safeguarding opportunity.
Matched on
terms: care, safeguarding
PFD report
69match
Carol Leesley
A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.
Matched on
terms: safeguarding, system
PFD report
69match
Dorothy Seekings
Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.
Matched on
terms: care, safeguarding
PFD report
69match
Charlotte Duffield
Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and sending a letter, without making any physical visit to a vulnerable individual.
Matched on
terms: care, safeguarding
Inquiry recommendation
69match
LAMI-70 - Require consultant or paediatrician permission for discharging children with protection concerns.
Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician above the grade of senior house officer. Hospital chief executives must introduce systems to monitor compliance with this...
Matched on
terms: care, system
Committee recommendation
69match
#13 - Thirty-Seventh Report - Support for vulnerable adolescents
We asked the Department for Education what is being done to review multi-agency safeguarding partnerships to ensure they work better and to stop horrific events, such as the cases of Star Hobson and Arthur Labinjo-Hughes from recurring. The Department for Education said there are 135 safeguarding partnerships across the country covering 151 local authority areas. It is looking...
Matched on
terms: care, safeguarding
Committee recommendation
69match
#32 - Improve age dispute identification in asylum accommodation, ensuring staff training and compliance monitoring
The Home Office should review and make improvements to arrangements for identifying and responding to age dispute cases in adult asylum accommodation and ensure that there is clear guidance for accommodation providers. To protect the welfare of children in the asylum system the department must ensure that provider staff have adequate training to respond appropriately to such cases,...
Matched on
terms: safeguarding, system
CQC action
69match
Woodlands
Effective systems were not fully in place to protect people from the risk of abuse.
Matched on
terms: system
CQC action
69match
Kingsley Nursing Home
The registered manager and provider failed to 1. report safeguarding concerns or have effective systems to investigate allegations. 13 (2 & 3)
Matched on
terms: safeguarding, system
CQC action
69match
Fairglen Residential Home
The provider must operate an effective safeguarding system that reports and investigates concerns.
Matched on
terms: safeguarding, system
LGO / SPSO decision
69match
21-009-157 - London Borough of Sutton
Summary: Ms X complained the Council failed to arrange a follow up safeguarding meeting as agreed, in relation to concerns a care home failed to call an ambulance in response to her mother’s seizures. The Council’s failure to communicate clearly with Ms X amounts to fault. This fault has caused Ms X distress and uncertainty and put her...
Matched on
terms: care, safeguarding
LGO / SPSO decision
69match
21-006-495 - Hertfordshire County Council
Summary: We have not found fault in the way the Council made its decisions regarding safeguarding enquiries, but there was a delay in its completion of the assessments and there was fault in the way the Council communicated with Dr C about the powers of the attorney and the requirement to apply to the Court of Protection. The...
Matched on
terms: care, safeguarding
LGO / SPSO decision
69match
21-007-224 - Suffolk County Council
Summary: Mr X complains about the care the late Mr Y received in Highfield House Care Home and the safeguarding enquiry it undertook. Mr X says Mr Y was subject to incidents of abuse from care workers and although he was told the Council was investigating with Police, he heard nothing. We find the Council was at fault...
Matched on
terms: care, safeguarding
LGO / SPSO decision
69match
21-016-608 - Dudley Metropolitan Borough Council
Summary: The Council is not at fault in considering safeguarding referrals made by Ms Z and viewing camera footage as part of its enquiries. The Council is not at fault for considering Mrs Y’s care options including residential care. The Council is at fault for not considering Mr X’s complaint about the safeguarding process but this did not...
Matched on
terms: care, safeguarding