Complaint record keeping failures
Failures in maintaining accurate and procedural records for managing complaints in residential care homes.
10,594 items
17 sources
21 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
90match
L20 - Compliance Record Keeping
The Board should have both the power and a duty to ensure that all breaches of the standards code that it considers are recorded as such and that proper data is kept that records the extent to which complaints have been made and their outcome; this information should be made available to the public in a way that...
Matched on
terms: complaint, keeping, record
PFD report
81match
Philip Smith
Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.
Matched on
terms: failure, keeping, record
PFD report
81match
John Duckenfield
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.
Matched on
terms: failure, record
PFD report
81match
Peter Ross
A CT scan was misreported, and a reviewing surgeon failed to escalate a noticed abnormality. Repeated communication failures among clinical staff and poor record-keeping led to serious patient harm.
Matched on
terms: failure, keeping, record
LGO / SPSO decision
80match
21-011-711d - CSH Surrey (21 011 711d)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track NHS continuing healthcare. Those faults caused Mrs P’s...
Matched on
terms: complaint, keeping, record
LGO / SPSO decision
80match
21-011-711c - Woking and Sam Beare Hospice and Wellbeing Care (21 011 711c)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track NHS continuing healthcare. Those faults caused Mrs P’s...
Matched on
terms: complaint, keeping, record
Inquiry recommendation
78match
RHI-28 - Record Keeping Culture and Audit
The culture and practice of record keeping and access to records within the Northern Ireland Civil Service needs to change so that staff responsible for a given area of work have easy access to the analysis and decisions underpinning the policy or initiative on which they are engaged. Regular audits of record keeping should be undertaken so as...
Matched on
terms: keeping, record
PFD report
77match
William Tolen
Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.
Matched on
terms: failure, keeping
PFD report
77match
Margaret Greenacre
The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's understanding of resident needs.
Matched on
terms: keeping, record
LGO / SPSO decision
76match
21-014-433 - London Borough of Lewisham
Summary: The Council failed to provide evidence of compliance with a remedy it previously agreed with the Ombudsman. In the original complaint, we found the Council failed to investigate Mr B’s complaint The Council agreed to make a financial payment to recognise the impact of its fault. The Council was at fault for not paying Mr B or...
Matched on
terms: complaint, keeping, record
LGO / SPSO decision
76match
21-004-840 - London Borough of Waltham Forest
Summary: Mr X complained he was excluded from the Council’s Rapid Employment Service. He also complained the Council’s investigation of his complaint was flawed. The Ombudsman found no evidence the Council excluded Mr X from its service. The Ombudsman did find fault in the Council’s record keeping and in the complaint process. It agreed to apologise to Mr...
Matched on
terms: complaint, keeping, record
LGO / SPSO decision
76match
21-000-037 - Sheffield City Council
Summary: The Ombudsman found fault by the Council on Ms J’s complaint about its failure to take enforcement action against noisy neighbours. It failed to provide us with complete records, show it considered and reached a decision on her acoustic report, and failed to show whether officers properly considered and reviewed the case after witnessing two breaches of...
Matched on
terms: complaint, failure, record
LGO / SPSO decision
76match
21-018-132 - Surrey County Council
Summary: Mrs X complains the Council has not completed some of the agreed remedy actions after it upheld her complaints following an investigation under the children’s statutory complaints procedure. The Council is at fault. It has not completed some of the actions agreed. There was also poor record keeping which has caused uncertainty about how the decision to...
Matched on
terms: complaint, keeping, record
Committee recommendation
74match
#21 - Analyse complaint data to identify systemic issues and report quarterly on service improvements.
Users of such a service must receive assurance that information about complaints and failures is being aggregated and used proactively to improve systems and services, not just to effect redress to the individual. In order to achieve this, the Department should: • analyse information gathered through this mechanism both to hold operators to account for resolving specific problems...
Matched on
terms: complaint, failure
Committee recommendation
74match
#15 - Clarify commission complaint procedures for maladministration and Police Ombudsman's investigative powers over state actors.
The Joint Framework and Troubles Bill partially fill the gap in commission accountability left by the Legacy Act. It is still unclear, however, what procedure there is to complain about maladministration or service failure by the commission. The Government must also clarify whether the powers of the Police Ombudsman for Northern Ireland to investigate a relevant offence apply...
Matched on
terms: complaint, failure
PFD report
73match
Marian Dale
The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and had no protocol for their retrieval after death.
Matched on
terms: keeping, record
PFD report
73match
Tina Tait
Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.
Matched on
terms: keeping, record
PFD report
73match
Sidney Baker
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.
Matched on
terms: keeping, record
Inquiry recommendation
73match
BRIS-36 - Establish independent, swift, and thorough complaints handling with advocacy for patients
Complaints should be dealt with swiftly and thoroughly, keeping the patient (and carer) informed. There should be a strong independent element, not part of the trust’s management or board, in any body considering serious complaints which require formal investigation. An independent advocacy service should be established to assist patients (and carers).
Matched on
terms: complaint, keeping
Inquiry recommendation
73match
31 - Fundamental review of NHS complaints system
The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the operation of the NHS complaints system nationally, both the nature of the failures and persistent comment from elsewhere lead us to suppose that this is not unique to...
Matched on
terms: complaint, failure
CQC action
73match
Park Grange Care Home
There was not an effective system in place to ensure concerns and complaints were recorded and responded to appropriately.
Matched on
terms: complaint, record
CQC action
73match
B&H Care Ltd
The provider must ensure people's complaints and concerns are managed effectively to promote their health, safety and wellbeing, including having a system for independent investigation of complaints and maintaining records of complaints.
Matched on
terms: complaint, record
CQC action
72match
Rosecroft Residential Care Home
The provider should ensure that complaints are appropriately recorded and maintained.
Matched on
terms: complaint, record
LGO / SPSO decision
72match
201103592 - Grampian NHS Board
Ms C was injured when there was an accident involving the stair lift on which she was being transported by a member of the Scottish Ambulance Service (the Service) to a hospital appointment. She complained that, following the accident, she reported the matter to the receptionist at the clinic and was told that someone (apparently the lead nurse...
Matched on
terms: complaint, failure
CQC action
72match
Roland Residential Care Homes - 27 Bush Hill
We recommend the provider reviews its processes for managing complaints to ensure records are kept in line with their procedure.
Matched on
terms: complaint, record
ICIBI recommendation
72match
An inspection of the Home Office’s use of sanctions and penalties
2. (Without waiting to complete any more comprehensive reviews), ensure that the quality and extent of record-keeping and data collection are sufficient to provide clear insights into the efficiency and effectiveness of the processes supporting each sanction and penalty currently in use and, where this is not the case, take whatever actions are necessary to fix this in...
Matched on
terms: complaint, keeping, record
PFD report
69match
Kimberley Lindfield
Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping practices.
Matched on
terms: keeping, record
PFD report
69match
Sean Plumstead
Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.
Matched on
terms: keeping, record
PFD report
69match
Peter Lawrence
An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially endangering future patients.
Matched on
terms: keeping, record
PFD report
69match
Alexander Blewitt
The coroner notes concerns about the lack of reliable recording of intravenous fluids in the emergency department, missed points during triage, and a failure to record a major presenting symptom by the treating doctor; the Incident Investigation Report was also found to be of a poor standard.
Matched on
terms: failure, record
PFD report
69match
Emily Corfield
An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long waiting times.
Matched on
terms: keeping, record
Inquiry recommendation
69match
WATE-(4) - Define specific duties for Children's Complaints Officers, prioritising child's best interests
Amongst the duties of the Children's Complaints Officer should be: (a) to act in the best interests of the child; (b) on receiving a complaint, to see the affected child and the complainant, if it is not the affected child; (c) thereafter to notify and consult with appropriate line managers about the further handling of the complaint, including:...
Matched on
terms: complaint, record
IOPC learning recommendation
69match
Complaints made against a senior Lancashire police officer by two retired senior police officers - Lancashire Police, June...
The IOPC recommends that Lancashire Police should ensure all policy decisions and rationales should be documented appropriately during the course of its investigations to record strategic decisions, operational priorities, and strategic, critical and investigative issues. This follows an independent IOPC investigation into a Misconduct Investigation carried out by Lancashire Police in 2015. Our investigation found that no-one involved...
Matched on
terms: complaint, record
CQC action
69match
Kingfishers Nursing Home
The registered person failed to establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and others in relation to the carrying on of the regulated activity.
Matched on
terms: complaint, record
CQC action
69match
Heritage Healthcare-Middlesbrough
The provider must ensure complaints are investigated appropriately and dealt with effectively, with proper records maintained.
Matched on
terms: complaint, record
CQC action
69match
Kingsley Nursing Home
The registered manager and provider failed to: 2. have an effective system to receive, record, investigate or respond to complaints. 16 (2)
Matched on
terms: complaint, record
CQC action
69match
Barton Park Nursing Home
Complaints were not being recorded or responded to in line with the registered providers complaints policy.
Matched on
terms: complaint, record
Inquiry recommendation
69match
CLAR-3 - Remind agencies to keep detailed, accurate records, especially mortuary documentation
We would like to remind all agencies of the importance of keeping detailed and accurate records. Particular attention should be given to the correct documentation of proceedings in the mortuary.
Matched on
terms: keeping, record
CQC action
68match
Etherley Lodge
The provider must ensure that record-keeping arrangements are in place which protect people, including maintaining accurate, fit-for-purpose, and securely stored personal and staff records, and ensuring staff supervision records are comprehensive and accessible.
Matched on
terms: keeping, record
Inquiry recommendation
66match
F121 - Learning and information from complaints
The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints and the detail underlying them.
Matched on
terms: complaint
Inquiry recommendation
66match
F118 - Learning and information from complaints
Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, refuses to agree, or for some other reason publication of an upheld, clinically related complaint is not possible,...
Matched on
terms: complaint
Committee recommendation
66match
#26 - AIRE service lacks follow-up mechanisms, creating accountability gap for complaints
Migrant Help is not contracted to follow up on or monitor issues and does not have sight of the response from providers and the Home Office. This creates a significant gap in accountability. We recognise the value of enabling asylum seekers to raise concerns separately from accommodation providers and the Home Office itself. However, to ensure that concerns...
Matched on
terms: complaint
PFD report
65match
Clive Clinton
A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of harm.
Matched on
terms: complaint
Committee recommendation
65match
#27 - First Report - The Regulation of Social Housing
The introduction of the Housing Ombudsman’s complaint handling code and complaint handling failure orders must drive improvement and consistency in the way providers respond to complaints. We are pleased therefore that the Government is legislating through the Social Housing (Regulation) Bill to place the power to establish such a code on a statutory footing. It is not clear,...
Matched on
terms: complaint, failure
CQC action
65match
Winterton House
The registered person did not operate an effective system for identifying, receiving, recording, handling or responding to complaints.
Matched on
terms: complaint, record
CQC action
65match
Ashmore House
The provider must establish and operate an accessible system for identifying, receiving, recording, handling and responding to complaints.
Matched on
terms: complaint, record
CQC action
65match
Ashbourne House - Torquay
The provider did not effectively record, handle and respond to complaints.
Matched on
terms: complaint, record
Committee recommendation
64match
#9 - Seventeenth Report - Government’s contracts with Randox Laboratories Ltd
In addition to the wider efforts to improve basic documentation, the Department told us that it had introduced measures such as spot checks by the principal private secretary to reinforce the importance of proper record-keeping in private offices. The Department explained that the measures were designed to ensure staff in private offices and policy teams always kept records...
Matched on
terms: keeping, record
CQC action
64match
The Homestead (Crowthorne) Limited
The registered person failed to operate an effective and accessible system for identifying, receiving, recording, handling and responding to complaints.
Matched on
terms: complaint, record
LGO / SPSO decision
64match
21-004-999 - Bristol City Council
Summary: The Ombudsman found fault by the Council on Mrs Q’s complaint of it failing to act against a neighbouring allotment tenant after upholding her complaint and failing to respond to her correspondence. It failed to keep proper records, could not show it did what it said it would do, delayed responding to her formal complaint, and delayed...
Matched on
terms: complaint, record