Ineffective Staff Deployment
Failure to effectively deploy staff to meet service users' needs, coupled with unclear or inadequate training and induction records.
28 items
1 source
10 inquiries
Source spread
Where this theme appears
Ineffective Staff Deployment has been flagged across 1 independent accountability source:
28 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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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 (28)
MAI-93 — 24-hour qualified command structure rostering
Recommendation: The College of Policing and His Majesty's Inspectorate of Constabulary and Fire and Rescue Services should ensure that each police service has in place a system that means appropriately qualified and experienced personnel are rostered 24 hours each day so …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-82 — Allocate best-trained operators to Major Incident roles
Recommendation: North West Fire Control should review how it allocates the best-trained and most suitable Control Room Operators to roles during a Major Incident. It should consider whether it is beneficial to allocate a Control Room Operator to monitor communications on …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-76 — Review HART mobilisation policies
Recommendation: North West Ambulance Service should review its policies for mobilising the Hazardous Area Response Team resource, to ensure that this team is available as soon as possible for an emergency where its specialist skills are required.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-72 — Review NWAS Tactical Advisor rostering coverage
Recommendation: North West Ambulance Service should review how it rosters Tactical Advisors and National Interagency Liaison Officers so as to ensure that there is adequate geographical coverage enabling those on duty to arrive promptly at the scene of any Major Incident.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-6 — Ensure Airwave Tactical Advisors availability
Recommendation: All police services should ensure that they have made adequate provision for Airwave Tactical Advisors, in particular that an identified Airwave Tactical Advisor is either on duty or on call at all times.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
R69 — Needs-based staffing with acuity measures
Recommendation: Staffing should be based on service user needs rather than a fixed budget, using daily acuity measures designed specifically for units caring for people with learning disabilities. These should include enhanced supervision requirements, personal care support and therapeutic activities. Service …
Response Pending
R9 — Integrated workforce plans
Recommendation: Each facility or service should have an integrated workforce plan that includes all allied health professionals (AHPs) and all staff involved in patient care. This should be based upon the assessed needs of the service user and must include protected …
Response Pending
R13 — Clear nursing responsibility line
Recommendation: Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.
Gov response: Section 2.2 of the Scottish Government's response addresses leadership and management structures. It highlights the strengthened role of senior charge nurses through the Leading Better Care initiative, which provides a template for developing their role …
Accepted
ETI-3 — Staffing Guidance
Recommendation: Guidance should address: circumstances for civil servant transfers within government; which positions may use agency staff; and whether temporary contracts suit positions unfillable by permanent staff.
Gov response: Transport Secretary's Statement to Scottish Parliament, 2 November 2023: "We are working through all of these recommendations, but I can report that additional guidance similar to that suggested is already in development with reference to …
Accepted in Part
No update 2+ yrs
9 — Improve joint working between hospital sites
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify an approach to developing better joint working between its main hospital sites, including the development and operation of common policies, systems and standards. Whilst we do not believe that …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
5 — Promote effective multidisciplinary team-working
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and develop measures that will promote effective multidisciplinary team-working, in particular between paediatricians, obstetricians, midwives and neonatal staff. These measures should include, but not be limited to, joint training …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
MAI-10 — Resolve paramedic-driver shortage in mass casualties
Recommendation: A significant issue in a mass casualty situation is that all of those paramedics who have arrived in ambulances may be required for the treatment of casualties, so that no paramedic is available to drive patients to hospital. The Department …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
FENN-96 — Allocate physically suitable staff to roles, ensuring station safety balance
Recommendation: London Underground shall only allocate staff to a role for which they are physically suitable. In the cause of safety, a proper balance must be ensured at each station.
Unknown
FENN-92 — Appoint only qualified relief supervisory staff to stations
Recommendation: Relief supervisory staff shall only be appointed to a station for which they are qualified.
Unknown
FENN-91 — Appoint and train station 'landlords' with total management responsibility
Recommendation: A station 'landlord' shall be appointed and trained to have total management responsibility at each major station or group of smaller stations.
Unknown
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
FLIX-210 (i) — Exercise special care when making decisions during important post vacancies
Recommendation: That when an important post is vacant special care should be exercised when decisions have to be taken which would normally be taken by or on the advice of the holder of the vacant post. This, in the present instance, …
Unknown
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
R17 — Ward admission responsibility
Recommendation: Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility for admission of patients to the ward or bay.
Gov response: Section 2.1 of the Scottish Government's response details the Standard Infection Control Precautions (SICP) which are basic infection prevention and control measures. One of the ten SICPs is "Patient placement in wards and bays," directly …
Accepted
R8 — Reorganisation management structure
Recommendation: In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable management structure is in place.
Gov response: Section 2.2 of the Scottish Government's response emphasizes that leaders and managers at all levels are responsible for quality of care and that investment is needed in leadership and management. Work is ongoing locally and …
Accepted
ETI-19 — Collaborative Delivery
Recommendation: At all stages of the project there should be a collaborative approach to delivering it, including co-location of representatives from each organisation relevant to the particular stage, enabling issues to be addressed and resolved at the earliest opportunity, minimising risk …
Gov response: The Inquiry Report describes some of the damaging behaviours adopted during project delivery by various parties. The advantage of co-locating representatives having an interest in project completion is understood and indeed was successfully adopted on …
Accepted
No update 2+ yrs
ETI-18 — Effective Communication and Reporting
Recommendation: There should be effective communication and reporting at all stages of the project, including accurate progress reports to councillors and stakeholders, with clear escalation procedures for issues that may affect cost, programme or scope.
Gov response: While this Recommendation is for third parties who may undertake a readiness review or audit of a publicly funded project in future, it is recommended that the Council agrees to support any such review or …
Accepted
No update 2+ yrs
RHI-24 — Staff Move Sequencing
Recommendation: Senior managers in the Civil Service must take responsibility for guiding and, where necessary, sequencing the timing of staff moves so that continuity of business is secured. This includes allowing sufficient time for transferring staff to hand over, and discuss …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
No update 2+ yrs
BAHA-41 — Detention Sergeant Role
Recommendation: On operations where CPErS may be taken there should be a Senior Non-Commissioned Officer (NCO) who acts as the 'Detention Sergeant' who has responsibility for the administrative aspects of CPErS handling. In most cases, it would be appropriate for the …
Gov response: The Secretary of State for Defence accepted this recommendation in principle. Statement to Parliament, 8 September 2011: 'I am accepting in principle all of [Sir William's] recommendations with one reservation.'
Accepted
BAHA-40 — Battlegroup Detention Officer
Recommendation: Each Battlegroup should have a 'Detention Officer' being a commissioned officer within Battlegroup Headquarters. The role should encompass coordination and management of CPErS; acting as a focus on CPErS matters during mission specific training; ensuring correct handling of CPErS; assisting …
Gov response: The Secretary of State for Defence accepted this recommendation in principle. Statement to Parliament, 8 September 2011: 'I am accepting in principle all of [Sir William's] recommendations with one reservation.'
Accepted
JB-15.14 — Require trained CMP manager for covert monitoring posts
Recommendation: CMPs should not be established without the appointment of a properly trained CMP manager, whose responsibility it should be to appoint a team of CMOs, once satisfied from proper assessment as to their qualifications and ability.
Gov response: MPS formally responded on 28 October 2022 (paras 24-25). Guidance issued reaffirming Surveillance MoS 2021 position: only trained officers may perform CMP roles; no CMP without accredited CMP Manager.
Accepted
14 — Review clinical leadership arrangements
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with appropriate skills and support. The Trust has implemented change at …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted