Informal user feedback
Informal and insufficient processes for providing feedback to service users, leading to a lack of clarity and accountability.
203 items
9 sources
5 inquiries
Source spread
Where this theme appears
Informal user feedback has been flagged across 9 independent accountability sources:
15 inquiry recs
11 PFD reports
17 committee recs
50 CQC actions
4 NAO recs
33 IMB recs
2 detention investigation recs
70 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 (15)
IHRD-64 — Parental Involvement in Training
Recommendation: Parents should be involved in the preparation and provision of any such training programme.
Gov response: Parents involved in development of relevant training programmes.
Accepted
No update 2+ yrs
IHRD-63 — Evaluation of Parental Involvement
Recommendation: The practice of involving parents in care and the experience of parents and families should be routinely evaluated and the information used to inform training and improvement.
Gov response: Parental involvement evaluation mechanisms established.
Accepted
No update 2+ yrs
F256 — Follow up of patients
Recommendation: A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a wider range of responses and feedback on their care.
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
F255 — Using patient feedback
Recommendation: Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" as possible, even if later adjustments have to be made.
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
F254 — Access for public and patient comments
Recommendation: While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, it would be helpful for there to be consistency across the country in methods of access, and for …
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
BRIS-166 — PCTs must involve public in commissioning hospital services and gather feedback
Recommendation: Primary care trusts (and groups), given their capacity to influence the quality of care in hospitals, must involve patients and the public, for example through each PCG/T’s Patient and Advocacy Liaison Service. They must make efforts systematically to gather views …
Unknown
BRIS-165 — NHS Modernisation Agency to advise on achieving widest public and patient involvement
Recommendation: The involvement of the public, particularly of patients, should not be limited to the representatives of patients’ groups, or to those representing the interests of patients with a particular illness or condition: the NHS Modernisation Agency should advise the NHS …
Unknown
BRIS-164 — Provide financial resources to support public involvement, covering costs like childcare
Recommendation: Financial resources must be made available to enable members of the public to become involved in NHS organisations: this should include provision for payments to cover, for example, the costs of childcare, or loss of earnings.
Unknown
BRIS-163 — Provide training and guidance to properly support public involvement processes
Recommendation: The process of public involvement must be properly supported, through for example, the provision of training and guidance.
Unknown
R58 — Lay representation on IPC committee
Recommendation: Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy on public involvement.
Gov response: Section 2.1 of the Scottish Government's response outlines several initiatives to ensure patient and public involvement, including the National Health Service Reform (Scotland) Act 2004, which requires NHS boards to involve the public in service …
Accepted
F289 — Experience on the front line
Recommendation: Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who have suffered poor experiences. The Department of Health could also be assisted in its work by involving patient/service …
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
F233 — For joint action Profile
Recommendation: While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that patients and other service users are made aware at the point of service provision of their existence, their …
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
F230 — Profile
Recommendation: The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable source of information about the conduct of nurses. All patients should be informed, by those providing treatment or …
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
LADB-60 — Conduct market research on safety measures to include informed passenger views
Recommendation: Comprehensive market research in regard to safety related measures should be carried out in order to take account of the views of informed passengers (para 13.20).
Unknown
IHRD-89 — Patient Concern Organisation
Recommendation: The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.
Gov response: Under consideration as part of broader patient engagement strategy.
Accepted
No update 2+ yrs
PFD Reports (11)
Joshua Brown
Concerns: The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him and verify information accuracy.
Response (Department of Health): The Department of Health references existing guidance regarding information sharing with family members and mental capacity assessments in cases of suicide risk, but does not outline any new action being …
Overdue
Lorraine Youngs
Concerns: A vulnerable service user's agreed care package was not implemented or followed up, as there was no system in place to track the progress of care package implementation.
Response (Lorraine Youngs): Norfolk County Council changed its social care support arrangements to wards at Hellesdon Hospital in May 2015, establishing a dedicated Hospital Discharge Social Care Team and other measures to ensure …
Responded
Dorota Kijowska
Concerns: The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to a lack of clarity.
Overdue
Dennis Oldland
Concerns: Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns due to insufficient interaction time with vulnerable service users.
Overdue
Simon Barber
Concerns: Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.
Response (Nottingham City Council): Nottingham City Council has reviewed its Ramping policy to explicitly consider two ramped points of access where there are significant risks or increased fire risk. A commitment has been made …
Responded
Geraint Hughes
Concerns: Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans and risk assessments, a critical oversight not identified by supervisory reviews.
Response (Cornwall Partnership NHS Trust): The Trust is working to embed the Triangle of Care standards and has joined the Triangle of Care membership scheme committing to changing the culture of the organisation to one …
Responded
Ailsa Stewart
Concerns: A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to continuity of care.
Response (Department of Health Social Care): North West Ambulance Services (NWAS) has introduced an additional question to prevent a journey until confirmation is received that a care package is either not required or is in place. …
Responded
Beryl Simcock
Concerns: The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant incidents or deprivation of liberty.
Response (Radcliffe Manor House): Radcliffe Manor House plans to introduce a digital care planning system and an online total quality system by the end of the year. They have implemented changes to the falls …
Response (Swift Management services): Swift Management Services conducted a clinical governance review of Radcliffe Manor House and recommended improvements including investment in an electronic care planning system and training for staff and trustees on …
Responded
Thomas Godderidge
Concerns: Inadequate liaison between Adult Social Care and care providers regarding service-users' fluctuating capacity risks missed care opportunities for vulnerable individuals.
Response (Cumberland Council): Cumberland Council will deliver a 7-minute briefing on fluctuating capacity for managers to deliver in team meetings and individual staff supervisions, targeted for completion by 29th March 2024. A rolling …
Responded
Owen Gardner
Concerns: A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules or short-notice changes, risking future adverse health outcomes.
Response (Norfolk and Suffolk NHS): The Trust is working to improve support for people with cognitive deficits, including a policy to identify and communicate with families/carers, and documentation of next of kin. They have launched …
Responded
Janet Brown Townend
Concerns: Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate EWS recording and neglect to reassess capacity for unwise decisions.
Response (CQC): CQC received an action plan from the provider addressing their systems for monitoring people’s health effectively within the staff team, and staff understanding of the mental capacity act; CQC intends …
Response (East Riding of Yorkshire Council): The Prevention of Future Deaths report will be included in the application which will be considered by the Safeguarding Adults Review Group, who follow a decision-making framework which also ensures …
Overdue
Committee Recommendations (17)
#5 — Develop and publish a comprehensive stakeholder engagement framework for marine decision-making by January 2025.
Recommendation: We recommend that the Department for Environment, Food and Rural Affairs (DEFRA) develops a comprehensive framework for engaging a diverse range of stakeholders, particularly coastal communities and underrepresented voices, early-on in marine decision-making and outline the responsible organisation for leading …
Gov response: Stakeholder engagement is highly valued by the Department, its Arms-Length Bodies (ALBs) and Ministers. It is a central part of policy delivery and implementation. In tandem, Defra fully recognises the importance of being clear about …
Partially Accepted
#4 — Strengthen stakeholder engagement across all marine policy areas within Defra.
Recommendation: Engaging stakeholders in a meaningful way is essential to ensure that decisions are inclusive, transparent, and responsive to both environmental and societal needs. For engagement to be effective, it must occur through appropriate forums, begin early in the decision-making process, …
Gov response: Stakeholder engagement is highly valued by the Department, its Arms-Length Bodies (ALBs) and Ministers. It is a central part of policy delivery and implementation. In tandem, Defra fully recognises the importance of being clear about …
Partially Accepted
#4 — Ensure care-experienced young people's full engagement and involvement in social care accountability mechanisms.
Recommendation: The Department should ensure that it is engaging with care-experienced young people in all areas of its work on children’s social care and should encourage local authorities to do the same. The Department for Education, 82 Ofsted and the Care …
Gov response: The Department draws on the lived experience and knowledge of its care experienced staff through the Children and Young People Board run by the National Children’s Bureau on behalf of the department. The board has …
Accepted
#3 — Streamlined, transparent marine governance and stakeholder engagement are crucial for protection commitments.
Recommendation: A more streamlined and transparent approach to marine governance, underpinned by effective stakeholder engagement, is essential for the Government to meet its marine protection commitments and to ensure a balanced approach to managing the economic, social, and environmental demands placed …
Gov response: Stakeholder engagement is highly valued by the Department, its Arms-Length Bodies (ALBs) and Ministers. It is a central part of policy delivery and implementation. In tandem, Defra fully recognises the importance of being clear about …
Not Addressed
#52 — Introduce opt-out independent advocacy for all children in care, including disabled children.
Recommendation: The Department for Education must take forward the recommendation of the Independent Review of Children’s Social Care to introduce an opt-out model of independent advocacy for all children in care. It must also act 90 on the Child Safeguarding Practice …
Gov response: We will introduce new National Standards for Advocacy for Children and Young People and revised statutory guidance on Providing Effective Advocacy for Children and Young People Making a Complaint under the Children Act 1989 in …
Accepted
#51 — Too few children, especially disabled, access entitled independent advocacy support in care.
Recommendation: It is essential that children in care have a voice when important decisions are being made about their lives. Currently, too few children are accessing the advocacy support they are entitled to, with an average referral rate of just 5% …
Gov response: We will introduce new National Standards for Advocacy for Children and Young People and revised statutory guidance on Providing Effective Advocacy for Children and Young People Making a Complaint under the Children Act 1989 in …
Accepted
#3 — Care-experienced young people's voices vital and require broader inclusion across government levels.
Recommendation: We were privileged to hear powerful and insightful evidence from care-experienced young people in this inquiry, and their voices have informed many of the conclusions and recommendations in this report. We are pleased that the Department is regularly hearing from …
Gov response: The Department draws on the lived experience and knowledge of its care experienced staff through the Children and Young People Board run by the National Children’s Bureau on behalf of the department. The board has …
Accepted
#23 — Engage parents of SEND children during area inspections on local inclusive practices
Recommendation: Area SEND inspections should engage with parents across the locality to gather the perspective of parents of children with SEND on the admissions policies and inclusive practices of local authorities, schools and multi- academy trusts in the area. (Recommendation, Paragraph …
Gov response: A new SEND inspection framework launched in January 2023, with all local areas to be inspected by 2027 to improve outcomes for children and young people with SEND. This inspection covers the role of the …
Accepted
#16 — Meaningful parental involvement is crucial for successful SEND system outcomes and trust
Recommendation: Parents and carers of children and young people with SEND often feel excluded from the processes that affect their children’s education and support. However, meaningful and collaborative parental involvement is essential to the success of the SEND system. When parents …
Gov response: Shared. Education, health and care services should work in partnership with one another, local government, families, teachers, experts and representative bodies to deliver better experiences and outcomes for all our children. The Ministerial team and …
Accepted
#28 —
Recommendation: HS2 Ltd told us that the nature of the High Speed 2 programme means that the work required for it will be disruptive. HS2 Ltd estimated it had handled 124,000 queries over the past three years and interacted with over …
Gov response: 6: PAC conclusion: We are already concerned about the volume of complaints on disruption from the programme which does not bode well for the future as more communities will be impacted as construction progresses. 6: …
Under Consideration
#19 —
Recommendation: We believe the Electoral Commission should be sensitive to the role of volunteers in campaigns and the potential for inadvertent reporting errors to occur. We welcome the Electoral Commission’s proposed changes to the Political Finance Online platform to support individuals …
Gov response: 4 Cabinet Office, Corporate report – “Government response to ‘Regulating Election Finance’ ”, 15 September 2021 (last accessed 9 January 2023) 5 Public Administration and Constitutional Affairs Committee, Written evidence, Electoral Commission, TEC0051, pp.4–5 6 …
Accepted
#13 —
Recommendation: We received written evidence from stakeholders representing asylum seekers who told us that they needed information on the contracts’ performance to help them better support people. The Refugee Council told us that they needed greater transparency over service standards and …
Gov response: 5.2 The department agrees that stakeholders should have greater transparency on the performance of the service and has been making progress on providing that transparency. Working within Cabinet Office guidance and commercial confidentiality, summary performance …
Not Addressed
#5 — Require IREF to set higher fan engagement licensing conditions independently of existing standards.
Recommendation: IREF, beginning in shadow form, should ensure that its licencing conditions regarding fan engagement are set independently of the current Premier League Fan Engagement Standard. Unless there is immediate and significant change from leagues and clubs, we expect that IREF …
Gov response: The Government agrees that the Regulator should set its standards for fan engagement independently from the Premier League Fan Engagement Standard, and from the football industry more broadly. The Government welcomes the industry’s measures which …
Accepted
#4 — IREF presents a significant opportunity to accelerate and strengthen fan engagement in football.
Recommendation: The introduction of IREF remains a great opportunity to increase the pace of the important work that is already underway at football clubs consulting and engaging with their fans. Whilst clubs should be encouraged to exceed fan engagement standards and …
Gov response: The Government welcomes the industry’s ongoing efforts to improve transparency and its commitments to practices which seek to provide equity and fair opportunities for all. For example, since the publication of the Fan-Led Review, the …
Under Consideration
#3 — Premier League fan engagement standards are inadequate for consistent high-quality club interaction.
Recommendation: We welcome the Premier League’s fan engagement standard and commend the Premier League for acting prior to the publication of the White Paper. However, the level of fan engagement from Premier League and EFL clubs still varies wildly and we …
Gov response: The Government agrees that the Regulator should set its standards for fan engagement independently from the Premier League Fan Engagement Standard, and from the football industry more broadly. The Government welcomes the industry’s measures which …
Accepted
#9 — Require energy companies to use contact empathy as a measure of customer service success.
Recommendation: We recommend that contact empathy be used as a measure of success in customer service provision by energy companies. This would help to rebuild trust in the sector.
Gov response: 2022–23 And Recommendations 10/11 Ofgem and energy companies need to adopt a more proactive culture in improving industry consumer standards. Energy companies should not wait to be enforced to certain standards by Ofgem but should …
Accepted
#23 — Update tenant satisfaction measures to include shared owners' satisfaction with repairs and maintenance.
Recommendation: We welcome the Government’s confirmation that the Regulator is preparing to introduce a new, proactive consumer regulation regime. However, for the next round of tenant satisfaction data collection, the Regulator must update the measures to include satisfaction with repairs and …
Gov response: 61. The Regulator’s TSMs contain a series of indicators relating to repairs and maintenance services carried out by registered providers. The three main measures – TP02 – Satisfaction with repairs; TP03 – Satisfaction with time …
Not Accepted
CQC Inspection Actions (50)
Clova House Residential Care Home
The provider said they would record conversations with people about their views of the service and their care in future, and the manager also said they would record the discussions about care plans with people in future to ensure they …
Must Do
Prospects for People with Learning Disabilities - 3 Norwich Road
It is good practice to seek regular feedback from people who use the service and any other people involved in the service, such as, relatives, friends and professionals. This gives the provider information about what the service does well and …
Should Do
Holly House Residential Care Home
The provider should ensure the complaints system is effective and that people feel comfortable complaining and that their concerns are listened to and dealt with.
Should Do
Valewood House Nursing Home
We recommend that that manager considers a structured approach to gathering people’s views to ensure that they have regular opportunities to share concernsor ideas.
Should Do
Benthorn Lodge
The registered person had failed to ensure suitable systems were in place so that people could be supported to voice their opinions or raise concerns about their care and treatment.
Must Do
St Albans House
The provider must ensure that the systems in place to quality assure and check the care being provided are effective. The provider must actively seek the views of people living at the service to ensure the continuous improvement of the …
Must Do
Ranyard at Mulberry House
Systems were not established to seek and act on feedback from relevant persons on the services provided for the purposes of continually evaluating and improving the services.
Must Do
Ranyard at Dowe House
We recommend that the service find ways to consult and gather the feedback of people about the service provided.
Should Do
Pheonix Healthcare
The registered person must effectively act on feedback from relevant persons and other persons on the services provided, for the purposes of continually evaluating and improving the services.
Must Do
Oak Tree Manor
However, we noted that the notes for these meetings did not include a record of discussion or staff voice. This was an area that needed to be developed to ensure all feedback and ideas were captured.
Should Do
Holly Court Care Home
We noted the complaints process was laminated and taped to the wall in a corridor on one of the units. We discussed the effectiveness and appropriateness of this with the deputy manager, who assured us it would be removed.
Should Do
Darenth Grange Residential Home
The provider should gather feedback and suggestions from relatives about the development of the service, including through questionnaires and exploring social media channels.
Should Do
Darenth Grange Residential Home
The provider should fully support people to contribute to the development of the service, ensuring regular residents' meetings are held and consultations with individuals are well-developed, recorded, and effective.
Should Do
Caremax Support Services Ltd
We recommend the provider consider their approach to supporting people to give feedback about the service and take action to improve their practice accordingly.
Should Do
Valewood House Nursing Home
The manager should consider a structured approach to gathering people’s views to ensure that they have regular opportunities to share concerns or ideas.
Should Do
Rosecroft Residential Care Home
The provider should ensure that action plans or records are in place to show how people's feedback from resident meetings and other sources has been consistently addressed.
Should Do
Chatting Independently Limited - Orchard View
The provider must ensure people who use the service could be assured that any complaints would be acted on investigated and resolved to their satisfaction.
Must Do
Ashmore House
The provider must establish and operate effective systems to seek and act on feedback from relevant persons to continually improve the service.
Must Do
Linda Lodge
The registered manager told us they would be chasing up these groups to encourage a fuller return of feedback information. They said the intention was to ensure that any areas identified that needed improvement will form part of an action …
Should Do
Sobell Medical Centre
Establish an active Patient Participation Group.
Should Do
Oak Tree Manor
We discussed with the management team the need to capture people's voice within the notes from the meeting to demonstrate suggestions were considered and acted upon.
Should Do
Oak Tree Manor
The service may benefit from having this [complaints process] in an easy read, more accessible place for people who may not look in the folders.
Should Do
No. 3
The provider should consider more formal mechanisms to enable staff to give feedback about the service.
Should Do
Lotus Home Care Worksop
The provider should contact people on a regular basis to make sure they are happy with the service offered.
Should Do
Linden Road Surgery
Take steps to acknowledge and respond to complaints in a timely way.
Should Do
Lambeth and Southwark Mencap
The provider had not taken sufficient steps to ensure that people and their relatives were involved in the development of the service. The provider told us they would take steps to seek feedback from people.
Should Do
Cotton Exchange
Theprovidershouldensureitclearlydisplaysinformationonhowtoraiseacomplaintandsignpostappropriatelyto theIndependentSectorComplaintsAdjudicationService(ISCAS).
Should Do
Cherished Moments
The service should ensure information on how to complain is readily available and accessible to women who use the service and learning from complaints is shared with staff.
Should Do
Camphill Health Centre
Continuetotakeactionstoimprovepatientsatisfaction.
Should Do
Bracken House
People and relatives told us the management team could be more visible in the home.
Should Do
Assisted Lives (Birmingham)
Improvements could be made to the questions asked in these reviews to get a more in-depth view of people's view of their care.
Should Do
Winterton House
The registered person did not operate an effective system for identifying, receiving, recording, handling or responding to complaints.
Must Do
Etherley Lodge
The provider must ensure effective systems are in place for assessing and monitoring the quality of service provision, including addressing cleaning issues, assessing health risks in the kitchen, and routinely gathering feedback from people and visitors to inform improvements.
Must Do
Elizabeth Street Surgery
Establish a patient participation group.
Should Do
Barton Park Nursing Home
Complaints were not being recorded or responded to in line with the registered providers complaints policy.
Must Do
Archers Point Residential Home
The provider should hold regular relatives meetings to provide opportunities for feedback and drive improvements.
Should Do
Affinity Trust Specialist Support Division North
The provider uses feedback from staff, people and relatives to inform improvement within the service.
Should Do
Cygnet Bury Hudson
The provider must ensure that feedback from patients is recorded, looked into and responded to in a timely manner.
Must Do
Clare House Residential Home
The registered manager agreed to put the complaint and feedback forms into an accessible format and ensure care plans and menus were accessible to people using the service.
Should Do
Bousfield Surgery
Takeactiontoimprovepatient’sexperienceofbeingabletogetthroughtothepracticebytelephone.
Should Do
Westwood Care Home
Further work was required to ensure formal feedback from relatives was collected and used to improve the quality of the service.
Should Do
Standon House
The care manager told us they were looking at ways to make these conversations more formal and to provide more feedback to people.
Should Do
St Albans House
The provider should ensure the complaints policy is in a prominent place and in a format that is easy to read.
Should Do
Spindrift Care Home Limited
The provider was not effectively operating systems designed to assess, monitor and improve the quality of the service provided. The provider had not maintained an accurate, complete and up to date record of the care people received. The provider had …
Must Do
Nanny Care Services Ltd
The registered person must establish an effective system to enable them to ensure compliance with their legal obligations and the regulations. The registered person must assess, monitor and mitigate the risks relating to the health, safety and welfare of service …
Must Do
Home Comfort Care
The provider should include a question in future surveys asking people if staff turned up on time for their calls.
Should Do
The Croft
The staff told us they did attend staff meetings where they were able to discuss issues about the service and discuss where improvements were needed; however there was no record of these meetings taking place. The registered manager confirmed the …
Should Do
St Gabriel's House - Apartments
The provider must assess, monitor and improve the quality of the service and seek and act on feedback from relevant persons.
Must Do
Rosecroft Residential Care Home
The provider should ensure that staff meetings are held and recorded on a regular basis to maintain good communication and oversight.
Should Do
Aarondale House
The provider had failed to assess, monitor and improve the quality and safety of the service, They provider had failed to assess monitor and mitigate risks relating to the health and safety of others. The provider had failed to maintain …
Must Do
NAO Audit Recommendations (4)
Regulating the financial sustainability of higher education providers in England
e) set out how it will secure provider and stakeholder views of its work;
Accepted
Department for Work and Pensions Annual Report and Accounts 2020-21
Ensure that behavioural insights are used extensively in the design of controls to drive claimants towards more compliant behaviours. The Department should seek to understand how claimants respond to the interactions that they have with the Department and tweak controls …
Accepted
Department for Work and Pensions Annual Report and Accounts 2020-21
• improve the way it uses information from quality checks and explore how it can better use claimant and pensioner contact to identify systemic issues affecting payment accuracy.
Accepted
DWP Report on Account 2022/23
i DWP should collect information to provide assurance over the quality of customer service and report on this in its 2023-24 Annual Report and Accounts.
Partially accepted
IMB Recommendations (33)
Heathrow Immigration Removal Centre (2020)
As soon as practically possible the Detainee Consultative Committee meeting should be resumed at scale to take account of the concerns of all detainees on both sites. These meetings are helpful in ensuring that detainees’ views are heard and their needs are met.
Governor / Director
Erlestoke (2025)
What urgent action will be taken to establish the new format of the prison council, so that prisoners can have an appropriate outlet for their concerns?
Governor / Director
Bedford (2020)
Request that the healthcare team provides the Board and prison managers with monthly data regarding patient satisfaction for both the healthcare team and the mental health team.
Governor / Director
Gatwick IRC/RSTHF (2022)
Establish a robust, repeatable mechanism for collecting and analysing views of the detained men about their perception of safety in the Gatwick centres (sections 4, 4.3).
Home Office
Wayland (2023)
Prison management should seek to discover why there has been this significant reduction [in the perceived utility of Prisoner Forums].
Governor / Director
Wayland (2023)
Perhaps, considering how much digital communication is now relied upon, prison management should seek to discover why there has been this significant reduction [in perceived utility of Prisoner Forums].
Governor / Director
Gatwick IRC (2021)
Home Office and Serco should consider how the perceptions of the detained men about their safety can be collected consistently through the year and used as a meaningful tool for improving the centres' management (section 4.3).
Home Office
Norwich (2022)
The Board asks the Governor to provide information on plans for ensuring that Prisoner representatives have time allocated in order to support their fellow prisoners.
Governor / Director
Norwich (2022)
The Board asks the Governor to provide information on plans for ensuring that scheduled forums take place and minutes are readily available for prisoners to see.
Governor / Director
Lindholme (2022)
We would urge that this initiative is reinforced in order to further reduce the dissatisfaction that arises amongst prisoners.
Governor / Director
Gatwick IRC/RSTHF (2022)
Establish a robust, repeatable mechanism for collecting and analysing views of the detained men about their perception of safety in the Gatwick centres (sections 4, 4.3).
Governor / Director
Feltham (2022)
What can the Prison Service do to raise the profile of the IMB within the new online resources available to prisoners via their prison-issued laptops? Could individual Boards have support to construct their own page specific to its particular presence in an establishment? Additionally, there is no online encouragement for prisoners to speak directly to IMB members about their experience …
HMPPS
Littlehey (2023)
The Board has been pleased to see the re-introduction of prisoner forums during this reporting year and the willingness of the prison to engage with the prisoner population to improve their lived experience. The Board has also heard the frustrations of prisoners who feel that these forums can be talking shops rather than action orientated. The Board would like to …
Governor / Director
Bronzefield (2023)
What plans are in place to re-introduce User Voice or a similar provision?
Governor / Director
Wayland (2024)
strongly recommend to all areas of the prison’s management, that further consultative investigation is done with prisoners to unpack the reasons behind this result, and, if justified, consider strategies to respond to the findings revealed.
Governor / Director
Durham (2020)
How can focus groups be introduced and sustained?
Governor / Director
Bedford (2020)
Build on the work already undertaken to create a more collaborative culture (for example, joint monitoring and planning meetings) aimed at giving prisoners a real role in helping to monitor and improve the prison regime.
Governor / Director
Bedford (2020)
Develop methods for evaluating the key worker scheme.
Governor / Director
Parc (2021)
It was identified that a proportion of prisoners were positive about the Purple Visits service, and it is hoped that this will continue to be fully funded, with improved software to avoid random disconnections in the service.
HMPPS
Thorn Cross (2024)
To make the Prison council a more effective means of consultation and communication.
Governor / Director
Dartmoor (2020)
The Board understands that it is now planned to bring facilitators to every wing under the Dialogue Road Mapping (DRM) scheme. However, the nature of DRM means that not much is heard about it, except by word of mouth. Can ways be found of raising its profile in the prison?
Governor / Director
Bedford (2020)
Consider if it might be useful to investigate how the current incentives and earned privileges (IEP) scheme could be modified to be more effective in incentivising prisoners.
Governor / Director
Bedford (2020)
Consider an evaluation of the ACCT process which takes into account the feelings of the prisoners involved regarding their safety and wellbeing.
Governor / Director
Coldingley (2021)
The Board also hopes that the option of video calls will be maintained once social visits return to full capacity as many relatives, particularly those with young children, find it difficult to access the prison.
Governor / Director
North and Midlands Short Term Holding Facilities (2022)
Continue the constructive engagement with the Board and continue to attend the monthly meetings.
Other
North and Midlands Short Term Holding Facilities (2022)
Continue the constructive engagement with the Board and continue to attend the monthly meetings.
Home Office
Maidstone (2022)
Restart governor wing surgeries as soon as possible.
Governor / Director
Maidstone (2022)
Continue to seek ways to enhance the role of the community council.
Governor / Director
Ashfield (2022)
Can the Director share the survey’s findings, as well as the official prison statistics, with prisoners for transparency?
Governor / Director
Thorn Cross (2025)
Are the current arrangements for prisoner consultation through consultative committees and the Queensland meeting as effective as they could be? (5.3.2)
Governor / Director
Styal (2025)
How does the prison intend to improve opportunities for prisoner voice to be regularly heard and acted upon?
Governor / Director
Bronzefield (2025)
How does the prison plan to address the concerns raised by reception peer workers, as outlined in the fourth paragraph of section 4.1?
Governor / Director
Ashfield (2022)
Can the Director consider the resumption of the prisoner advice and liaison service (PALS)?
Governor / Director
Detention Investigations (2)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R48
The safeguarding team should survey staff at Brook House regularly to ascertain their experience of and perspective on violence and bullying and its causes. (To be completed within 6 months)
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 41
In general, I believe that Boards in IRCs (as in prisons) need to develop a range of techniques for taking the temperature of an institution in addition to formal applications and walking the site. I think the idea of regular 'surgeries' could also be added to the list above, and …
Immigration Detention
LGO / SPSO Decisions (70)
21-017-107 — Bristol City Council
Summary: Miss X complains the Council incorrectly advised her to submit a non-material amendment (NMA) application for changes to existing planning permission which it then rejected, after it deemed the changes as material, incurring a £234.00 fee. There was no fault in the initial advice the case officer gave Miss …
LGO (Local Government & …
Planning
Upheld
Jun 2022
21-005-727 — Wakefield City Council
Summary: Mrs X complained the Council ignored her request for a reasonable adjustment leaving her unable to access the Council’s complaint process, causing her frustration and additional costs. We found the Council was at fault for not properly considering Mrs X’s request for a reasonable adjustment. We recommended the Council …
LGO (Local Government & …
Other Categories
Upheld
Mar 2022
21-014-987 — Derbyshire County Council
Mr X complained the Council failed to adequately consult with him and other residents around its decision to approve a cycling and walking scheme in his area.
LGO (Local Government & …
Transport And Highways
Upheld
May 2022
22-002-449 — Bath and North East Somerset Council
Summary: The Council gave Ms B confusing information about whether she could make a formal objection to a neighbourhood improvement scheme, and it did not always correctly handle its communication with her. However, I am persuaded that the Council has taken Ms B’s needs into account within its consultation process, …
LGO (Local Government & …
Transport And Highways
Upheld
Dec 2022
22-002-694 — London Borough of Hounslow
Summary: We will not investigate this complaint about allotment fees because part of the complaint is late and because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Other Categories
Jun 2022
22-004-305 — Reading Borough Council
Summary: We will not investigate Mrs X’s complaint about a storytelling event due to be held at the Council’s library. This is because the matter has not caused Mrs X a significant personal injustice.
LGO (Local Government & …
Other Categories
Jul 2022
23-019-467 — Westminster City Council
Summary: Mr X complains the Council is failing to provide him with enough support to meet his care needs. There was a period in 2023 when the Council did not respond to Mr X’s e-mails because they were going to a junk folder. The Council needs to apologise for the …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
23-015-068 — West Lindsey District Council
Summary: The Council properly investigated Mrs B’s reports of noise from her neighbours and problems with building work. The Council’s website was not clear that it has powers to tackle noise from premises under antisocial behaviour (ASB) legislation. This has not impacted on Mrs B as it is unlikely the …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2024
25-000-516 — Durham County Council
Summary: We will not investigate Ms X’s complaint about the Council’s response to a service request. The Council has already upheld Ms X’s complaint, apologised and taken steps to rectify its service delivery. Because these actions are appropriate and there are no wider public interest issues, it is not proportionate …
LGO (Local Government & …
Other Categories
Upheld
Apr 2025
24-021-182 — Brighton & Hove City Council
Summary: We will not investigate Ms X’s complaint about the Council’s handling of her complaint about antisocial behaviour from a neighbour. It is unlikely an investigation would lead to a different outcome or achieve what Ms X wants.
LGO (Local Government & …
Environment And Regulation
Jun 2025
201904682 — Fife Council
C complained about how the council handled and assessed a planning application. The planning application related to a proposal for an extension to an existing business premises and was approved by the council. C's own business premises are located nearby and C raised concerns about how the extension would impact …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
May 2021
25-011-216 — Ashfield District Council
Summary: We will not investigate this complaint about the way the Council carried out a public consultation. We have not seen enough evidence of fault in the Council’s actions.
LGO (Local Government & …
Other Categories
Dec 2025
201903741 — Scottish Water
C operated a bed and breakfast business from their home (the premises) and a number of years ago was identified as a gap site (a property where commercial activity is being conducted and should, therefore, be liable for commercial water charges, but that has not yet been registered for commercial …
SPSO (Scottish Public Se…
Water
Not Upheld
Oct 2021
25-012-768 — Darlington Borough Council
LGO (Local Government & …
Other Categories
25-012-722 — Calderdale Metropolitan Borough Council
LGO (Local Government & …
Other Categories
25-012-648 — City of York Council
LGO (Local Government & …
Other Categories
25-015-563 — New Forest District Council
LGO (Local Government & …
Other Categories
Upheld
21-009-014 — Buckinghamshire Council
Summary: Mrs X complained the Council refuse crew failed to return her garden waste bin to the collection point after emptying it. Mrs X says the Council’s actions cause her strain in retrieving the bin given her age. The Ombudsman found fault with the Council. The Council has already made …
LGO (Local Government & …
Environment And Regulation
Upheld
Mar 2022
22-000-115 — Tameside Metropolitan Borough Council
Summary: We will not investigate this complaint about changes the Council has made to its waste management strategy. This is because it is an issue that has affected all or most of the people in the Council’s area. We are unlikely to find fault in how the Council consulted about …
LGO (Local Government & …
Environment And Regulation
Apr 2022
22-001-975 — Birmingham City Council
We will not exercise discretion to investigate this complaint about Mr X’s complaint about the Council failing to help him evict a tenant whom it referred to him under a previous scheme. The complaint was received outside the normal 12-month period for investigating complaints. There is no evidence to suggest …
LGO (Local Government & …
Housing
May 2022
22-001-945 — Transport for London
Summary: We will not investigate this complaint about the outcome of a test the complainant took as part of his application for a private hire driver’s licence. This is because there is insufficient evidence of fault by the Authority, and he could bring his concerns about access to information to …
LGO (Local Government & …
Environment And Regulation
May 2022
22-001-767 — City of Bradford Metropolitan District Council
Summary: We will not investigate this complaint about Mr X’s business rates. The argument about how much business rates Mr X should pay could reasonably be raised in court. We cannot consider what happened in court.
LGO (Local Government & …
Benefits And Tax
May 2022
22-001-673 — London Borough of Croydon
Summary: We will not investigate this complaint about incorrect council tax bills. This is because the problem has been resolved and there is insufficient evidence of injustice. In addition, we cannot investigate a council when it is operating as a landlord.
LGO (Local Government & …
Benefits And Tax
May 2022
22-001-632 — London Borough of Haringey
Summary: We will not investigate this complaint about the handling of Mrs X’s housing application. The evidence suggests the Council properly reached its decision, so we cannot criticise the decision.
LGO (Local Government & …
Housing
May 2022
22-002-128 — Dorset Council
Summary: We will not investigate Mr X’s complaint about the Council’s handling of an alcohol licence application. This is because he had available appeal rights to the Magistrates’ Court to challenge the Council’s decision on the application which places the complaint outside our jurisdiction.
LGO (Local Government & …
Environment And Regulation
May 2022
22-002-302 — Northumberland County Council
Summary: We will not investigate this complaint about the Council’s decision to continue to treat Mr X as a vexatious complainant. This is because we are unlikely to find evidence of fault by the Council or injustice caused to Mr X sufficient to warrant an investigation.
LGO (Local Government & …
Other Categories
May 2022
22-002-205 — Swale Borough Council
Summary: We will not investigate this complaint about how the Council dealt with Mr X’s representations about a penalty charge notice as it would not be in the public interest to do so.
LGO (Local Government & …
Transport And Highways
May 2022
22-001-360 — London Borough of Merton
Summary: We will not investigate Ms X’s complaint the Council’s electoral register is not showing the date she moved into her property or first applied for the register thereby harming her credit rating. The Council has not caused Ms X an injustice and we cannot achieve the outcome Ms X …
LGO (Local Government & …
Other Categories
May 2022
22-001-345 — Bournemouth, Christchurch and Poole Council
Summary: We will not investigate this complaint that security guards at the recycling centre do not display their ID badges. This is because there is insufficient evidence of fault by the Council and insufficient evidence of injustice.
LGO (Local Government & …
Environment And Regulation
May 2022
22-000-928 — Cotswold District Council
Summary: We will not investigate Mr X’s complaint about the actions of refuse operatives and the Council in dealing with the issue as there is not enough evidence of injustice caused by fault to warrant investigation.
LGO (Local Government & …
Environment And Regulation
May 2022
21-016-303 — London Borough of Hounslow
Summary: We will not investigate this complaint about the Council’s refusal to approve Mr X’s application for a vehicle crossing. There is insufficient evidence of fault which would warrant an investigation.
LGO (Local Government & …
Transport And Highways
May 2022
21-015-761 — Leeds City Council
Summary: Ms X complained the Council failed to properly investigate her concerns about the allotment committee’s decision to evict her from her plot causing her to lose out financially and be the subject of harassment. The Ombudsman does not find fault with the Council.
LGO (Local Government & …
Other Categories
Not Upheld
Jun 2022
22-004-808 — Burnley Borough Council
Summary: We will not investigate this complaint about how the Council worked with a community group to create a new park. This is because the events happened too long ago and I see no reason why the complaint could not have been made sooner.
LGO (Local Government & …
Other Categories
Jul 2022
21-012-376 — Bolton Metropolitan Borough Council
Summary: Mr X complained the Council failed to maintain a hedge that backs onto his property. Mr X said the Council also misled him about its responsibilities. Mr X says this has caused him considerable upset and distress. We do not find fault with the Council’s approach to determining liability …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
22-006-973 — Havant Borough Council
Summary: We will not investigate Mrs X’s complaint about the Council missing some of her paid-for garden waste collections. There has been fault by the Council in it not completing all planned collections and it has offered a partial refund of the fee. There is not enough remaining injustice to …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
21-017-094 — Leeds City Council
Summary: Mr X complained that the Council repeatedly failed to collect his bins which were registered for an assisted collection. The Council accepts fault and has suggested a way forward. We have made recommendations to acknowledge the distress the Council’s fault has caused Mr X.
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
22-007-896 — Cheshire East Council
Summary: We will not investigate this complaint about the Council’s failure to respond to the complainant’s request for faded dog fouling stickers where he lives to be replaced. The Council has apologised for the delay to respond and offered to send replacement stickers for the complainant to put up.
LGO (Local Government & …
Environment And Regulation
Nov 2022
22-001-557 — Tamworth Borough Council
Summary: Ms S complains about the Council’s inaction in dealing with her reports of her neighbour making low frequency noise to annoy her. She also complains the Council decided to restrict her contact with it. The Ombudsman’s view is the Council has taken appropriate action to deal with Ms S’s …
LGO (Local Government & …
Environment And Regulation
Upheld
Nov 2022
24-001-381 — Kent County Council
Summary: Mr X complained about a Parking Charge Notice that a private enforcement agency, which the Council employs, issued. He says he paid for his parking, but it was not properly registered because of a faulty machine, and the Council has refused to resolve this. We have decided to end …
LGO (Local Government & …
Transport And Highways
Not Upheld
Sep 2024
23-000-466 — Rotherham Metropolitan Borough Council
Summary: X complained the Council failed to take effective action to protect them from noise and dust caused by construction work. We did not investigate this complaint further because it was unlikely to result in a finding of fault, a remedy for X or any other meaningful outcome.
LGO (Local Government & …
Planning
Not Upheld
Sep 2024
24-007-349 — Manchester City Council
Summary: We will not investigate Mr X’s complaint about a refuse operative being verbally abusive to him and his wife. We could not add to the Council’s investigation or achieve anything more.
LGO (Local Government & …
Environment And Regulation
Sep 2024
24-009-116 — Transport for London
Summary: We cannot investigate Mr X’s complaint about two penalty charge notices issued by Transport for London. This is because Mr X has used his right of appeal to London Tribunals.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-008-711 — Transport for London
Summary: We will not investigate Mr X’s complaint about Transport for London’s handling of his representations against a penalty charge notice. This is because it would have been reasonable for Mr X to appeal to London Tribunals. We will not investigate TfL’s escalation of the case as it did not …
LGO (Local Government & …
Transport And Highways
Sep 2024
24-008-654 — London Borough of Southwark
Summary: We will not investigate Ms X’s complaint about the Council’s decision she is not eligible for a parking permit. This is because there is no sign of fault by the Council.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-007-974 — London Borough of Haringey
Summary: We will not investigate this complaint about a Penalty Charge Notice. It was reasonable for Mr X to use his statutory right of appeal to a tribunal.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-009-134 — Transport for London
Summary: We will not investigate Mr X’s complaint about a penalty charge notice issued by Transport for London. This is because Transport for London has accepted Mr X’s representations and cancelled the penalty charge notice and investigation would not achieve anything more for him.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-008-854 — London Borough of Redbridge
Summary: We will not investigate Mr X’s complaint about a penalty charge notice issued by the Council. This is because the amount of the penalty charge paid is not significant enough to warrant investigation. Mr X also had a right of appeal to London Tribunals which it would have been …
LGO (Local Government & …
Transport And Highways
Sep 2024
24-007-197 — London Borough of Islington
Summary: We will not investigate this complaint about the Council’s failure to take enforcement action over a reported noise and neighbour nuisance. There is insufficient evidence of fault which would warrant an investigation.
LGO (Local Government & …
Environment And Regulation
Sep 2024
24-005-964 — Swale Borough Council
Summary: We will not investigate Miss X’s complaint about parking issues relating to her property. The complaint lies outside our jurisdiction because it is late and there are no good grounds to exercise discretion to consider it now.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-007-861 — Cheshire East Council
Summary: We will not investigate Mr X’s complaint about charges for a replacement bin. There is not enough evidence of fault by the Council.
LGO (Local Government & …
Environment And Regulation
Sep 2024