Quality and safety oversight
Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.
1,292 items
15 sources
18 inquiries
Source spread
Where this theme appears
Quality and safety oversight has been flagged across 15 independent accountability sources:
381 inquiry recs
76 PFD reports
260 committee recs
467 CQC actions
8 ICIBI recs
6 PPO recs
2 IOPC recs
16 NAO recs
5 PHSO recs
2 IMB reports
8 IMB recs
12 detention investigation recs
8 PHSO decisions
35 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 (381) — showing 50 strongest matches
MACP-5 — Apply OFSTED-like standards to Police Service inspections for improved quality and reporting
Recommendation: That principles and standards similar to those of the Office for Standards in Education (OFSTED) be applied to inspections of Police Services, in order to improve standards of achievement and quality of policing through regular inspection, public reporting, and informed …
Unknown
MACP-3 — Grant Her Majesty's Inspectors full powers to inspect all Police Services.
Recommendation: That Her Majesty's Inspectors of Constabulary (HMIC) be granted full and unfettered powers and duties to inspect all parts of Police Services including the Metropolitan Police Service.
Unknown
BRIS-73 — Grant Council powers to enforce good regulation principles and consistent professional body behaviour
Recommendation: The Council for the Regulation of Healthcare Professionals should have formal powers to require bodies which regulate the separate groups of healthcare professionals to conform to principles of good regulation. It should act as a source of guidance and of …
Unknown
BRIS-72 — Prioritise establishing statutory Council for Regulation of Healthcare Professionals with broad membership
Recommendation: The Council for the Regulation of Healthcare Professionals should be established as a matter of priority. It should have a statutory basis. It should report to Parliament. It should have a broadly-based membership, consisting of representatives of the bodies which …
Unknown
BRIS-71 — Establish a single body to coordinate all healthcare professional regulatory bodies
Recommendation: In addition, a single body should be charged with the overall co-ordination of the various professional bodies and with integrating the various systems of regulation. It should be called the Council for the Regulation of Healthcare Professionals. (In effect, this …
Unknown
BRIS-70 — Establish single regulatory bodies for each distinct healthcare professional group
Recommendation: For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine, and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and …
Unknown
HIDD-39 — Urgently introduce independent monitoring and auditing for all safety-related work
Recommendation: BR shall introduce monitoring and independent auditing systems in all safety-related aspects of work, in particular the S&T Departments, with the greatest urgency, in advance of Total Quality Management as an aid to good management.
Unknown
HIDD-38 — Urgently use outside consultants to review safety management and communication issues
Recommendation: The Court endorses the use of outside consultants to review safety management issues within BR and recommends that the consultants proceed with their programme with the greatest urgency looking particularly at problems of communication up and down the organisation.
Unknown
P2-71 — New Chief Inspector regulatory regime for deceased
Recommendation: The UK government should establish an independent statutory regulatory regime, headed by a Chief Inspector, for those who store and care for deceased people. The purpose of the regulatory regime should be to ensure that the security and dignity of …
Gov response: This recommendation is under consideration.
Response Unclear
P2-61 — Statutory regulation of funeral directors
Recommendation: The UK government should establish an independent statutory regulatory regime for funeral directors in England as a matter of urgency in order to safeguard the security and dignity of the deceased. This regime should include a licensing scheme, mandatory standards …
Gov response: This recommendation is under consideration.
Response Unclear
P2-59 — Local authority contractor governance assurance
Recommendation: Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee the services they provide. This should include Standard Operating Procedures that protect the security and dignity of the …
Gov response: This recommendation is under consideration.
Response Unclear
F72 — Assessment process for authorisation
Recommendation: The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas as well as all wards to determine whether it is compliant with fundamental safety and quality standards.
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
F69 — Focus on compliance with fundamental standards
Recommendation: The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality standards at the same time as complying with the financial and corporate governance requirements of a foundation trust.
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
F31 — Interim measures
Recommendation: Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place policies which ensure that they constantly review whether the need to protect patients requires use of their own …
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
F30 — Interim measures
Recommendation: The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach of fundamental standards, even if it has yet to reach a concluded view or acquire all the evidence. …
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
F29 — Sanctions and interventions for non-compliance
Recommendation: It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory requirements, or, in any other case of breach, where a warning notice in respect of the breach has …
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
F28 — Sanctions and interventions for non-compliance
Recommendation: Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable to an organisation in the case of a system failure and to individual accountability where individual professionals are …
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
F27 — Responsibility for regulating and monitoring compliance
Recommendation: The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental standards; and allowing no place for favourable assumptions, unless there is evidence showing that suspicions are ill-founded 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
F26 — Responsibility for regulating and monitoring compliance
Recommendation: In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and protocols. The regulatory system should retain the capacity to undertake …
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
F22 — Responsibility for regulating and monitoring compliance
Recommendation: The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical means of compliance, and indicators by which compliance with both fundamental and enhanced standards can be measured. These …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F21 — Responsibility for regulating and monitoring compliance
Recommendation: The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. The regulator must be willing to consider individual cases of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F20 — Responsibility for regulating and monitoring compliance
Recommendation: The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the indicators by which it intends to monitor compliance with those standards. It should be responsible not for directly …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F19 — Gaps between the understood functions of separate regulators
Recommendation: There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards for all trusts.
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" …
Not Accepted
MAI-126 — Assess quality of first responder training
Recommendation: The Home Office and the College of Policing should regularly assess and appraise the training on first responder interventions provided by each police service to ensure that it is of an appropriate quality and that adequate time is allocated to …
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-121 — Consequences for breaching event healthcare standards
Recommendation: The Department of Health and Social Care together with the Care Quality Commission should consider what the consequences of breaching the appropriate standard should be. That should include consideration of whether the sanction should be criminal in nature.
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 Part
In progress
MAI-89 — CQC regulation of event healthcare standards
Recommendation: That standard needs to be regulated and enforced. The Care Quality Commission is the appropriate body to provide regulation and enforcement. The Department of Health and Social Care should give urgent consideration to making the necessary changes in the law …
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-63 — Monitor LRF attendance and flag concerns
Recommendation: Local resilience forums should monitor attendance and participation at their meetings, and flag promptly any concerns about attendance by members to the leadership of the organisation concerned. The Home Office should ensure that this is being done by local resilience …
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-62 — LRF oversight of lessons from exercises and incidents
Recommendation: Local resilience forums should establish procedures to ensure that they oversee the process of identifying the lessons to be learned from major exercises, or serious incidents, in their areas, and that they are responsible for overseeing the debriefing of those …
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-61 — Independent inspection regime for LRFs
Recommendation: Local resilience forums have a vital role in the preparation for the response to any Major Incident. The Cabinet Office and the Home Office should consider implementing an independent inspection regime for local resilience forums.
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-51 — Address Showsec failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made by Showsec to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
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-50 — Address Arena failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made at the Arena to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
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-18 — Address BTP systemic failings from Volume 1
Recommendation: BTP should address the systemic failings identified in Volume 1, so as to ensure that they are not repeated.
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
WATE-(53) — Require agency to present annual report on work and constraints
Recommendation: The agency referred to in recommendation (47) should present an annual report on all aspects of its work, including any constraints upon that work and any shortfall in fulfilling its obligations.
Unknown
LADB-89 — HSC to review compliance with recommendations and publish review outcomes.
Recommendation: A review of compliance with the above recommendations should be conducted on behalf of the HSC within six months of publication of this report, and further reviews should be put in hand as necessary thereafter. The HSC should publish the …
Unknown
LADB-32 — Integrate signal sighting committee recommendations into Railtrack's safety management system
Recommendation: It should form part of Railtrack’s safety management system that it is the responsibility of senior Zone operating and signal engineering management to decide whether the recommendations of a signal sighting committee under the Group Standard on SPADs are to …
Unknown
LADB-20 — Strengthen safety audit processes and improve communication quality during audits
Recommendation: The safety audit process should be strengthened, and the quality of communication during the process should be improved (para 9.44).
Unknown
BRIS-162 — Routinely evaluate NHS public involvement mechanisms based on evidence of effectiveness
Recommendation: The mechanisms for the involvement of the public in the NHS should be routinely evaluated. These mechanisms should draw on the evidence of what works.
Unknown
BRIS-161 — Ensure Patients' Forums and Councils include wider public, not just patient groups
Recommendation: Proposals to establish Patients’ Forums and Patients’ Councils must allow for the involvement of the wider public and not be limited only to patients or to patients’ groups. They must be seen as an addition to the process of involving …
Unknown
BRIS-160 — Focus public involvement on NHS service development, delivery, safety, and quality regulation
Recommendation: The public’s involvement in the NHS should particularly be focused on the development and planning of healthcare services and on the operation and delivery of healthcare services, including the regulation of safety and quality, the competence of healthcare professionals, and …
Unknown
BRIS-159 — Ensure transparent public involvement processes in NHS organisations, reported annually
Recommendation: The processes for involving patients and the public in organisations in the NHS must be transparent and open to scrutiny: the annual report of every organisation in the NHS should include a section setting out how the public has been …
Unknown
BRIS-158 — Require non-NHS regulatory bodies to involve the public in healthcare decisions
Recommendation: Organisations which are not part of the NHS but have an impact on it, such as Royal Colleges, the GMC, the Nursing and Midwifery Council and the body responsible for regulating the professions allied to medicine, must involve the public …
Unknown
BRIS-157 — Embed public and patient perspectives into all NHS healthcare decision-making structures
Recommendation: The involvement of the public in the NHS must be embedded in its structures: the perspectives of patients and of the public must be heard and taken into account wherever decisions affecting the provision of healthcare are made.
Unknown
BRIS-156 — Require trust boards to publicly report compliance with national clinical standards
Recommendation: As part of their Annual Reports trust boards should be required to report on the extent of their compliance with the national clinical standards. These reports should be made public and be made available to CHI.
Unknown
BRIS-155 — Ensure patients and public can access trust and consultant unit performance information
Recommendation: Patients and the public must be able to obtain information as to the relative performance of the trust and the services and consultant units within the trust.
Unknown
BRIS-153 — Develop clear, high-quality national healthcare performance indicators comprehensible to the public
Recommendation: At national level, the indicators of performance should be comprehensible to the public as well as to healthcare professionals. They should be fewer and of high quality, rather than numerous but of questionable or variable quality.
Unknown
BRIS-147 — New Office to co-ordinate national audits and provide early performance surveillance
Recommendation: The Office for Information on Healthcare Performance should supplant the current fragmentation of approach through a programme of activities involving the co-ordination of the various national audits. In addition to its other responsibilities, the new system should provide a mechanism …
Unknown
BRIS-146 — Consolidate national clinical performance monitoring into a new CHI Office
Recommendation: The monitoring of clinical performance at a national level should be brought together and co-ordinated in one body: an independent Office for Information on Healthcare Performance. This Office should be part of CHI.
Unknown
BRIS-145 — Make clinical audit compulsory for all healthcare professionals and part of contracts
Recommendation: Clinical audit should be compulsory for all healthcare professionals providing clinical care and the requirement to participate in it should be included as part of the contract of employment.
Unknown
BRIS-144 — Trusts must fully support clinical audit with resources and a central co-ordinating office
Recommendation: Clinical audit must be fully supported by trusts. They should ensure that healthcare professionals have access to the necessary time, facilities, advice and expertise in order to conduct audit effectively. All trusts should have a central clinical audit office which …
Unknown
BRIS-143 — Establish multidisciplinary clinical audit as the core of local performance monitoring
Recommendation: The process of clinical audit, which is now widely practised within trusts, should be at the core of a system of local monitoring of performance. Clinical audit should be multidisciplinary.
Unknown
PFD Reports (76) — showing 50 strongest matches
Walter Gordon Powley
Concerns: Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Response (CQC): The CQC acknowledges the incident and will share the report's findings within the organisation. They are exploring ways to work more closely with the HSE and ensuring their new inspection …
Response (Health Safety Executive): HSE will raise concerns about assessing risks from hot surfaces and pipe-work at the next GB Social Care Partners Forum meeting, scheduled for February 2014. They will also share the …
Response (RNHA): The RNHA acknowledges the risk and states they regularly advise members of their responsibilities under the Health & Safety at Work Act, particularly regarding covering radiator pipes. They will continue …
Responded
Kathleen Rosemary Dixon
Concerns: Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Response (Department of Health): The Department of Health acknowledges the concerns raised about mental health assessments at Cumbria Partnership NHS Foundation Trust and outlines existing measures and guidance in place to improve patient safety …
Overdue
Mary Waldron
Concerns: Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
Overdue
Derrick Rivers
Concerns: The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Overdue
Clive Clinton
Concerns: 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.
Overdue
Peter White
Concerns: Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.
Overdue
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
Concerns: Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.
Response (NHS England): NHS England is reviewing service specifications, establishing a national expert group for oncology, enhancing reporting to the BSBMT registry, and commissioning its quality surveillance team to assure changes in governance.
Responded
Edwin Thompson
Concerns: A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.
Overdue
Huseyin Erdogan
Concerns: Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.
Overdue
Maurice Cowling
Concerns: Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.
Response (Northern Lincolnshire Goole NHS Trust): The Trust conducted a patient safety review of three cases and concluded that the complications were managed appropriately and existing arrangements are adequate. They state no further specific actions have …
Responded
Kathleen Neville
Concerns: The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
Overdue
Amanda Ellams
Concerns: Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone system collectively contributed to significant care failures.
Response (Response Alexandra Hospital): The hospital-wide completion of training on documentation and legal aspects for patient records was 95%, and further documentation training has been scheduled; nursing staff will be notified that nursing notes …
Overdue
Adrian Smith
Concerns: A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to ensure specialist advice is implemented.
Response: The Trust will change the communication process for specialist radiological investigation queries by having the consultant radiologist speak directly with the senior neurosurgeon. A standard operating procedure (SOP) will be …
Overdue
Angela Brealey
Concerns: The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.
Response (South Staffordshire and Shropshire Healthcare NHS Trust): The Trust has reviewed and amended its Serious Incident Review process and now employs a full-time Serious Incident Review Co-ordinator and Administrator. Reports now go through an additional governance process, …
Overdue
Harry Gill
Concerns: The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Response (NHS England): NHS Pathways has amended the vomiting questions to be more specific, focusing on the nature of the vomit and the presence of coffee ground-like material. They have also enhanced the …
Responded
Martyn Watkins
Concerns: Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.
Response (CQC): The Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward, though details of changes not provided in this extract.
Overdue
Norman Beard
Concerns: Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Overdue
Barry Thompson
Concerns: The patient's high-priority triage was not followed by timely review by a doctor or antibiotic administration per national standards, the NEWS score was not actioned, and there were issues managing a diabetic patient's monitoring and basic needs, along with inaccurate and incomplete record-keeping.
Overdue
Helen Millard
Concerns: The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.
Overdue
Doreen Willis
Concerns: Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light of these findings.
Response (Torbay and South Devon NHS Trust): The trust summarises the key learning outcomes from the agency review, pertaining to medicine management policies and processes for care homes. It references NICE guidance and the Electronic Transfer of …
Responded
Sam Crick
Concerns: Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR …
Response (CQC): The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend …
Response (NHS England): NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next …
Responded
David Lindsey
Concerns: The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, and that the trust did not follow its own policies and guidelines.
Overdue
Brian Betterton
Concerns: Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log installation locations or end-user details.
Response (Department for Business Energy Industrial Strategy): The Department for Business, Energy & Industrial Strategy set up the Working Group on Product Recalls and Safety in October 2016, which published recommendations on improving recalls and reducing fires …
Responded
Sarah Kiff
Concerns: GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.
Response (Stonefield Street Surgery): The practice has produced annual audit reports around new cancer diagnoses for several years; the practice has a new written policy around methodology for undertaking HVS and the recording of …
Responded
Elaine Bradbrook
Concerns: Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.
Response (United Lincolnshire Hospitals NHS Trust): United Lincolnshire Hospitals NHS Trust acknowledges communication issues and historical problems with their Serious Incident (SI) process. They have made significant improvements to the SI process in the last 12 …
Responded
David Sketchley
Concerns: The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Response: The CQC is gathering evidence into this matter with a view to deciding whether there has been a failure by BUPA and/or the Registered Manager to comply with the Health …
Overdue
Neville Welton
Concerns: The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.
Response: The Health Board is establishing weekly meetings for senior staff to review incidents, track progress of investigations, and ensure timely action plan implementation, commencing July 12th, 2018. They will also …
Overdue
Lewis Colgan
Concerns: Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and an incomplete Root Cause Analysis further raised concerns.
Overdue
Ester Wood
Concerns: Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
Overdue
Margaret Evans
Concerns: Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Overdue
Ruth Whitmore
Concerns: Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which failed to thoroughly interview staff or analyse events.
Overdue
Sophie Bennett
Concerns: The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
Overdue
Tom Cribley
Concerns: Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.
Overdue
Jean Cutler
Concerns: The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.
Response (Cole Valley Nursing Home): New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed, considering internal and external risk factors. A new competent, experienced and dynamic manager who will provide …
Responded
Kathleen Smith
Concerns: Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
Response (Coed Duon Care Home): Coed Duon Care Home has implemented several changes, including SALT training for staff, designation of two Dysphagia champions, creation of a diets and fluids consistency file for each resident in …
Responded
Daniel Williams
Concerns: Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial care failures on the transferring ward.
Response (Guys and St Thomas NHS Trust): The Trust's C-diff Action Group reviewed the Trust's C-diff investigation process and revised it to include a stage to check whether the mandatory infection control data forms need to be …
Responded
Ben Haddon-Cave
Concerns: Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.
Response (Network Rail): • A National Safety Bulletin will be issued to all Off Track teams, which are the Network Rail maintenance teams that carry out boundary inspections. • The National Safety Bulletin …
Responded
Pamela Evans
Concerns: Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.
Response (Bedford Hospital NHS Trust): Bedford Hospital NHS Trust will ensure assessments and patient observations are carried out. The post falls protocols and level of escalation will be reviewed and there will be Shared learning …
Responded
Evelyn Swift
Concerns: The medical group lacked safe procedures for triaging patients, allocating home visits, providing urgent clinical advice, documenting calls, and ensuring sufficient clinical capacity; they also lacked processes to review significant events and learn from them.
Overdue
Gillian McKinlay
Concerns: There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.
Overdue
Frank Medley
Concerns: The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
Response (Royal Blackburn Teaching Hospital): Royal Blackburn Teaching Hospital has established a core group to oversee implementation of an action plan addressing concerns regarding detection of adverse outcomes, review of the case, and radiology practices, …
Responded
Elizabeth Robinson
Concerns: Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.
Response (Aneurin Bevan University Health Board): Aneurin Bevan University Health Board has established a Ysbyty Ystrad Fawr (YYF) Health Care Support Worker (HCSW) pool in September 2020 to support enhanced care levels. The Corporate Serious Incident …
Responded
Rachel Johnston
Concerns: The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Response (Holmleigh Care Homes Ltd): Following a death, the care home introduced training for all nurses and reviewed its policies. They have since implemented the Staff Retention policy to ensure agency workers under investigation do …
Overdue
Pauline Brumfitt
Concerns: The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Response (Anchor Hanover Group): Anchor Hanover Group has reviewed and updated training, policies and procedures, introduced more formal triage arrangements, additional handover guidance, and improvements to Care Quality Indicators.
Overdue
Kyle Hurst
Concerns: The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.
Response (BCUHB): BCUHB is considering adopting the SNAP protocol for paracetamol overdose treatment but requires local review and approval. The Health Board is reviewing historic action plans from serious incident investigations and …
Responded
Susan Merton
Concerns: The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.
Response (BCUHB): BCUHB changed its serious incident process in April 2021, requiring all investigation reports to be submitted for scrutiny and approval at an Incident Learning Panel. The Health Board is tracking …
Overdue
Philip Ellis
Concerns: The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.
Response (Free the Way): Free the Way has introduced measures including escorting clients returning from relapse to collect belongings, searching all property, and restricting unaccompanied leave. Clients entering treatment will be monitored closely and …
Responded
Emma Burbury
Concerns: There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.
Response (Cornwall Partnership): The Trust is contributing to the implementation of a system-wide Dual Diagnosis policy and will explore improvements to information sharing between partner organisations. Community Mental Health transformation work is underway …
Response (NHS Kernow Clinical Commissioning Group): NHS Kernow will provide funding for read-only access to We Are With You (WAWY) notes for CMHT staff at CFT. They are engaging with CFT regarding discharge processes and will …
Responded
Darrell Devlin
Concerns: Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or polydrug exposure.
Response (Humankinds): Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of …
Response (Greater Manchester Mental Health NHS Foundation Trust): Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, …
Responded
Rebecca Begg
Concerns: The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated time for staff to read care plans.
Response (Heathcotes Group): Full incident reviews are implemented and the Clinical team now has involvement to understand the root cause and offer different support methods. The internal governance and quality assurance procedures have …
Overdue
Committee Recommendations (260) — showing 50 strongest matches
#19 — Home Office contracts for migrant accommodation lack specified penalties for safeguarding failures.
Recommendation: 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 …
Gov response: 3.12 The government agrees with the Committee’s recommendation. Target implementation date: October 2024 for the previous quarter, continuing quarterly. 3.13 Asylum, Accommodation Support Contracts (AASC) provide a mechanism for application of service credits if provider …
Accepted
#42 — Women's health hubs require national evaluation to ensure benefits and multi-service provision.
Recommendation: It is positive to hear that many of the leaders in the ICBs are focusing their hubs on disadvantaged groups. While local ownership, management and decentralisation of the hubs is important to meet local needs, regular national-level evaluations are also …
Gov response: We are committed to moving towards a neighbourhood health service, with more care delivered in local communities, to identify and address problems earlier and closer to home. Women’s health hubs are an example of this …
Not Addressed
#40 — Commission NICE to develop and disseminate comprehensive guidelines for all reproductive health conditions, monitoring adherence.
Recommendation: The Department of Health and Social Care and NHS England should commission NICE to develop comprehensive guidelines for all reproductive health conditions. Those guidelines should be communicated to GPs and made accessible to patients through the NHS website to allow …
Gov response: We agree that reproductive health is an important area for the development of clinical guidelines. NICE has identified women’s and reproductive health as a priority area for guideline development, and already has an extensive portfolio …
Partially Accepted
#35 — Strengthen annual GP appraisal with performance indicator on women's reproductive health diagnosis and treatment.
Recommendation: The annual GP appraisal process should be strengthened to include a specific performance indicator on the diagnosis and treatment of women’s reproductive health conditions, including intersectional considerations. That indicator should include patient experience.
Gov response: Primary care is often the first point of contact for women seeking help with their reproductive health and so it’s vital that GPs are well supported to care for reproductive health conditions. Doctors must regularly …
Not Accepted
#9 — Summarise findings and outcomes of MOD complaints policy review in report response.
Recommendation: We understand that MOD were conducting a review of the complaints policy and process, and of the quality of contractors’ responses to complaints to improve the customer experience. We trust that work on this review is now complete and ask …
Gov response: The MOD agrees with the conclusion and accepts recommendations 8 and 9 which is critical for enhancing the customer experience for Service Personnel and their families. In this context, the role and responsibilities of Housing …
Accepted
#8 — Ensure Pinnacle's housing officers effectively resolve issues and complaints with partners.
Recommendation: If the housing officer role is to continue being undertaken by Pinnacle, then Pinnacle’s representatives must be more effective at resolving outstanding issues and complaints, working collaboratively with their contract partners. (Conclusion, Paragraph 59)
Gov response: The MOD agrees with the conclusion and accepts recommendations 8 and 9 which is critical for enhancing the customer experience for Service Personnel and their families. In this context, the role and responsibilities of Housing …
Accepted
#5 — MOD's performance recovery claims demand demonstrable improvement in customer experience and trust.
Recommendation: The MOD’s claims of a recovery in performance need to be borne out in a demonstrable improvement in the customer experience and markedly increased customer satisfaction. Service families’ trust has been affected and the DIO and service providers need to …
Gov response: The MOD accepts the recommendation and agrees with the conclusion set out in 4 and 5. The DIO is working closely with its IPs, Families Federations and Service Personnel and their families to identify performance …
Accepted
#4 — Outline assurance processes and review performance measures for service families' satisfaction.
Recommendation: The DIO and its contractors should outline the assurance processes they have in place to ensure maintenance and repairs meet the needs of service families. The DIO should also review the performance measures in the RAMS and NAMS contracts to …
Gov response: The MOD accepts the recommendation and agrees with the conclusion set out in 4 and 5. The DIO is working closely with its IPs, Families Federations and Service Personnel and their families to identify performance …
Accepted
#38 — Lack of clear standards for supported housing licensing schemes risks inconsistency.
Recommendation: We suggested that the licensing schemes that local authorities were considering would turn out to be very different from each other, unless there was a clear standard to be followed. We were concerned about evidence that, in the absence of …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2026 7.2 A consultation on the implementation of measures in the Supported Housing (Regulatory Oversight) Act was published on 20 February 2025 and …
Accepted
#37 — MHCLG to consult on supported housing regulations and licensing scheme in early 2025.
Recommendation: We asked MHCLG what progress it had made in implementing the Act. It replied that it would issue a consultation on the regulations and a licensing scheme for supported housing landlords early in 2025. It would seek to make the …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2026 7.2 A consultation on the implementation of measures in the Supported Housing (Regulatory Oversight) Act was published on 20 February 2025 and …
Accepted
#7 — Implement the provisions of the Supported Housing (Regulatory Oversight) Act as quickly as possible.
Recommendation: Despite legislation designed to tackle well-established problems and gaps in regulation, MHCLG has made no progress in improving the oversight of the supported housing sector. Supported housing can provide much-needed homes for people transitioning from homelessness, or may stop people …
Gov response: The government agrees with the Committee’s recommendation. (Regulatory Oversight) Act was published on 20 February 2025 and is open for 12 weeks. This sets out proposals on a locally led licensing regime for supported housing …
Accepted
#29 — Review roles of transport accessibility enforcement bodies and legislate for consistent, sufficient powers.
Recommendation: The Department should within 12 months review the roles of enforcement bodies with responsibilities for transport accessibility and prepare to legislate where necessary: • to ensure that all have consistent and sufficient powers at their disposal, and have both the …
Gov response: 31. The Department agrees that there should be no ambiguity about the importance of all relevant parties fulfilling their duties on accessibility. The Department sets the policy framework for transport accessibility, which regulators enforce. As …
Not Addressed
#28 — Mandate regulators with resources to proactively enforce accessibility laws and publish breach data.
Recommendation: The Secretary of State should immediately give regulators an explicit mandate, backed by the necessary resources, to be far more proactive within the scope of their current powers in identifying and enforcing against breaches of accessibility law and regulations by …
Gov response: 31. The Department agrees that there should be no ambiguity about the importance of all relevant parties fulfilling their duties on accessibility. The Department sets the policy framework for transport accessibility, which regulators enforce. As …
Not Addressed
#27 — Effective enforcement routes for street environment accessibility are absent and insufficient.
Recommendation: There appears to be no effective or easily available enforcement route for accessibility in the street environment in particular. There is instead a reliance on upstream measures such as local authorities following good practice, consulting effectively and having “due regard” …
Gov response: 31. The Department agrees that there should be no ambiguity about the importance of all relevant parties fulfilling their duties on accessibility. The Department sets the policy framework for transport accessibility, which regulators enforce. As …
Not Addressed
#26 — Informal enforcement methods by regulators prove insufficient for addressing systemic accessibility failures.
Recommendation: The confidence that regulators evince in informal methods of enforcement and its deterrent effect on other operators is not justified by the experience of travellers. We recognise that reputational incentives such as performance rankings have a part to play, as …
Gov response: 31. The Department agrees that there should be no ambiguity about the importance of all relevant parties fulfilling their duties on accessibility. The Department sets the policy framework for transport accessibility, which regulators enforce. As …
Not Addressed
#9 — Embed accountability for accessibility failures and collect comprehensive data on occurrences.
Recommendation: The Government’s new strategy for inclusive transport should set out what practical measures it will take to embed the principle that every instance of not meeting accessibility obligations constitutes a serious failure for which operators and service providers will be …
Gov response: 17. The Department accepts that our strategic approach to consideration of accessibility can be improved. Accessibility must be a golden thread that runs through the design, implementation and operation of our transport system – this …
Accepted
#8 — Routine rail assistance failures are unacceptable and must become vanishingly rare occurrences.
Recommendation: The seemingly routine, everyday nature of assistance failures on the rail network is unacceptable. Accessibility must not be viewed through the same lens as customer service, where less than 100 per cent performance is considered normal. Accessibility failures should be …
Gov response: 17. The Department accepts that our strategic approach to consideration of accessibility can be improved. Accessibility must be a golden thread that runs through the design, implementation and operation of our transport system – this …
Accepted
#43 — Require creative industries under CIISA's remit to commit to unconditional funding.
Recommendation: All parts of the creative industries under CIISA’s remit should commit to unconditional, long-term funding within six months. In the meantime, the Government should explore all options for funding CIISA in case the industry does not deliver a voluntary solution. …
Gov response: The government stands strongly against bullying, harassment and discrimination in any sector. We expect industry to continue to tackle this behaviour, including through strong, cross-industry support for the Creative Industries Independent Standards Authority (CIISA). We …
Not Accepted
#42 — Lack of industry support undermines Creative Industries Independent Standards Authority.
Recommendation: It is in the film and HETV industry’s interests to tackle bullying and harassment through effective self-regulation. Yet for the Creative Industries Independent Standards Authority (CIISA) to operate effectively, the industry must see supporting it financially and ideologically to be …
Gov response: The government stands strongly against bullying, harassment and discrimination in any sector. We expect industry to continue to tackle this behaviour, including through strong, cross-industry support for the Creative Industries Independent Standards Authority (CIISA). We …
Accepted
#29 — ScreenSkills remains inadequate in addressing urgent film and HETV skills challenges.
Recommendation: We are not convinced ScreenSkills is up to the challenge of delivering meaningful action on skills and training. It has been slow to grasp the urgency of the situation, to identify its priorities and performance indicators and ultimately to tackle …
Gov response: The government agrees that public funding for ScreenSkills must be linked to their effective delivery. ScreenSkills is primarily funded through voluntary industry contributions through their Skills Investment Funds. In 2025/26, ScreenSkills is receiving grant funding …
Accepted
#31 — Seriously improve the Energy Company Obligation policy to clarify installer accountability for poor quality retrofit work.
Recommendation: We found it incredible that the Residential Property Surveyors Association has reported that around 250,000 homes could be un-mortgageable due to spray foam insulation and that the accountability to remedy things remains unclear. We recommend that the Energy Company Obligation, …
Gov response: The government has worked with industry and inspection protocols were published to allow the proper assessment of spray foam installations. Recent indications are that most mortgage lenders no longer have blanket policies on spray foam …
Partially Accepted
#30 — Introduce national workforce accreditation and contractor licensing schemes for all retrofit work, ensuring consumer redress.
Recommendation: We recommend that the Government introduces a national workforce accreditation scheme and a national contractor licensing scheme as a prerequisite for carrying out any retrofit work. These should be granted powers to revoke licenses or impose financial penalties for poor …
Gov response: In January 2025, Ministers announced their intention to conduct a sweeping overhaul of the system of standards, oversight and consumer protections for retrofit. The Department is exploring a full range of options to determine a …
Partially Accepted
#29 — Consumer protection gaps and lacking standards permit rogue traders in non-grant retrofit work.
Recommendation: We are especially concerned about the lack of consumer protections and mandatory standards for retrofit work not covered by government grants. This is allowing rogue traders to operate unimpeded. We believe that those who fail certification to carry out government-funded …
Gov response: In January 2025, Ministers announced their intention to conduct a sweeping overhaul of the system of standards, oversight and consumer protections for retrofit. The Department is exploring a full range of options to determine a …
Not Addressed
#28 — Complicated consumer protection and accreditation landscapes undermine trust in home retrofit sector.
Recommendation: The consumer protections and workforce accreditation landscapes are excessively complicated, which makes it challenging for consumers to know who to trust. Many consumers are simply unaware of which schemes they can rely upon and what avenues for redress they have …
Gov response: In January 2025, Ministers announced their intention to conduct a sweeping overhaul of the system of standards, oversight and consumer protections for retrofit. The Department is exploring a full range of options to determine a …
Accepted
#10 — Sellafield Ltd consistently underperforms against strategic waste processing targets, impacting wider site cleanup plans.
Recommendation: Sellafield Ltd has–in conjunction with the NDA and the Office for Nuclear Regulation–set a ‘strategic tolerance’ for completing key activities. It described this to us as the date “we really want to hit”, to ensure that the site is fully …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: March 2027 2.2 Currently there are mission-length plans spanning 100+ years for each Operating Company (OpCo) within the NDA group. These reflect the best …
Accepted
#8 — Sellafield Ltd consistently misses waste retrieval and vitrification targets since 2020 due to various issues.
Recommendation: Since 2020, Sellafield Ltd has missed most of its operational targets for retrieving waste, and turning liquid waste into a glass–like substance (both of which reduce the hazard the waste poses).12 It told us that the COVID–19 pandemic had had …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: March 2027 Currently there are mission-length plans spanning 100+ years for each Operating Company (OpCo) within the NDA group. These reflect the best estimate of …
Accepted
#16 — Government's 2019-24 AMR action plan targets largely unmet with slow progress.
Recommendation: The government achieved only one of the five quantitative domestic targets it set as part of the 2019–24 NAP–reducing the use of antibiotics in food-producing animals.41 The 2019–24 NAP also set 128 commitments for DHSC and Defra which related to …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: Winter 2025 2.2 Progress against NAP human health targets is closely monitored, using data to assess effectiveness, guide future action, and ensure alignment with …
Not Addressed
#15 — Past animal health AMR targets were unchallenging; new plan lacks targets amid rising usage
Recommendation: We asked VMD whether the targets set for animal health in the 2019–24 NAP were challenging enough given that they were successfully achieved. VMD acknowledged that while reaching the targets was a big success, it also considered that this was …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: Winter 2025 2.2 Progress against NAP human health targets is closely monitored, using data to assess effectiveness, guide future action, and ensure alignment with …
Accepted
#13 — New 2024-29 AMR Action Plan targets are less ambitious and potentially insufficient
Recommendation: The 2024–29 National Action Plan (NAP) includes new targets which are less stretching than the targets in the 2019–24 NAP. While the government previously set targets for reductions of 50% in Gram-negative bloodstream infections and 10% in drug-resistant infections, the …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: Winter 2025 2.2 Progress against NAP human health targets is closely monitored, using data to assess effectiveness, guide future action, and ensure alignment with …
Partially Accepted
#12 — Most domestic targets in 2019-24 AMR National Action Plan remained unachieved
Recommendation: As part of its 2019–24 National Action Plan for AMR, the third UK plan of its kind, the government set five domestic targets. These related to levels of drug-resistant and Gram-negative bloodstream infections (named after a bacteria-testing method and are …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: Winter 2025 2.2 Progress against NAP human health targets is closely monitored, using data to assess effectiveness, guide future action, and ensure alignment with …
Not Addressed
#2 — Mandate DHSC and Defra to review and increase ambition of AMR targets regularly.
Recommendation: Government has missed most of the targets in the 2019–24 National Action Plan (NAP) and the ambition of the new targets is much more modest. While the government previously set targets for reductions of 50% in Gram-negative bloodstream infections1 and …
Gov response: The government agrees with the Committee’s recommendation. effectiveness, guide future action, and ensure alignment with broader public health objectives. The government conducts formal reporting on these targets biannually. Additionally, targets are subject to annual review …
Accepted
#26 — Require the Water Commission to assess new consumer protection standards and consider statutory standards.
Recommendation: The Independent Water Commission should assess whether Ofwat’s new customer-focussed licence condition, and the new Guaranteed Standards of Service, are sufficient to improve protective services for consumers during and after high-impact events. The Commission and Defra must address the issues …
Response Pending
#25 — Many water companies fail to adequately protect and compensate consumers during high-impact incidents.
Recommendation: Evidence suggests that some water companies are not sufficiently protecting or compensating their consumers before, during or after high impact incidents such as supply interruptions and sewer flooding. Regulatory steps are being taken to address most of these concerns, although …
Response Pending
#23 — Current regulatory system fails to encourage long-term thinking and coherent resilience standards.
Recommendation: The current regulatory system does not encourage long-term thinking, as already acknowledged by the Commission. This affects both short-term resilience against asset failures and long-term water security. Improved finances may help, but part of the problem is, like in many …
Response Pending
#22 — Assess regulator effectiveness, ensure open data access, and overhaul water company self-reporting system.
Recommendation: The Independent Water Commission should assess how effectively the regulators audit companies, monitor the water environment, and enforce breaches of licences and permits. It should consider whether regulators are leveraging enough fees from the sector to ensure robust, fair and …
Response Pending
#21 — Under-equipped and underfunded regulators lead to insufficient monitoring and enforcement of water companies.
Recommendation: We support the Commission’s focus on creating a better regulatory framework, however a good framework is nothing without well-equipped regulators to act against bad actors and poor behaviours. Without clearer information and standards, it is difficult to have faith that …
Response Pending
#20 — Reform regulatory frameworks to ensure effective environmental protection is a priority for companies.
Recommendation: The Independent Water Commission should look at potential reforms of the regulatory frameworks and regulators that govern the water sector to ensure that environmental protection is effective and a priority for water companies. It is vital that the reforms the …
Response Pending
#19 — Prioritise environmental regulation and safe water delivery for water companies and regulators.
Recommendation: Environmental regulation and the delivery of a reliable and safe water must be the first priorities of water companies and regulators. Effective regulation, strongly prioritised towards environmental and customer targets, is needed to make these a core part of the …
Response Pending
#18 — Reshape the price review system to create a culture of improvement through effective incentives.
Recommendation: The Independent Water Commission’s proposals should ensure that the price review system is reshaped so that its system of incentives creates a culture of improvement. The price review should contain a comprehensive but straightforward set of performance metrics that matches …
Response Pending
#17 — Ofwat's incentive system is too complicated, misaligned with public expectations, and ineffective.
Recommendation: The incentives that Ofwat puts in place for companies are too complicated, fail to match public expectations, and in many cases are not bringing about a culture of improvement. Despite public consultation, there are too many to provide a clear …
Response Pending
#15 — Irresponsible culture among all actors led to unsustainably low water bills and insufficient investment.
Recommendation: Customers should be protected from paying more than is necessary for maintaining national water infrastructure, and the price review is an important part of doing this. Some evidence suggests that previous determinations have not been sufficient, at least for some …
Response Pending
#13 — Efficacy of special administration versus continued debt for failing companies is unclear
Recommendation: Special administration should be a last resort. However, it is unclear whether allowing a failing company to struggle on and accumulate progressively more debt is a better outcome than assuming temporary national control more quickly, with the associated costs that …
Response Pending
#12 — Establish stable regulatory environment for water companies, linking dividends to performance and outcomes
Recommendation: The Independent Water Commission must determine whether equity investment has been value for money for customers. If it is advisable to continue with a totally privatised model, the Commission needs to create a comprehensive but stable regulatory environment for water …
Response Pending
#11 — Excessive dividends reflect profit prioritisation over performance and customer duties
Recommendation: There clearly have been examples of excessive dividends, particularly when poor performance or finances are taken into account, symptomatic of a culture of prioritising profit over duties to regulators and customers. However, dividends for other companies have been in line …
Response Pending
#10 — Implement new measures to regulate water sector debt, allowing regulator intervention
Recommendation: The Independent Water Commission should determine new measures to regulate the accumulation and management of debt in the water sector. These measures should allow the economic regulator to intervene when irresponsible debt management is taking place. Any new powers should …
Response Pending
#8 — Improve regulator oversight of debt levels and simplify water company financial structures
Recommendation: The Independent Water Commission should determine how regulators can have better oversight over debt levels in regulated entities and other connected companies. Its proposals should actively require companies to simplify structures to allow for greater regulation and oversight of any …
Response Pending
#4 — Mandate greater Ofwat oversight and clearer criteria for water company senior bonuses
Recommendation: The Independent Water Commission should consider what other reforms are necessary to ensure that the right people are put into senior positions and the appropriate bonuses are paid to them. This should include greater oversight or approval from Ofwat before …
Response Pending
#3 — Current incremental measures are insufficient to improve water company culture and performance.
Recommendation: Given the wide array of performance issues across the sector, more responsible leadership is clearly needed for better stewardship of our natural water resources. Incremental steps have been taken to improve governance, increase consumer representation and influence bonus cultures in …
Response Pending
#27 — Inconsistent monitoring and evaluation evident across Department's industry support programmes.
Recommendation: We asked the Department about gaps in its monitoring and evaluation of support programmes.54 Of the Department’s Business Group’s 32 initiatives to support sectors, it provided monitoring and evaluation evidence for just 11.55 The Department told us there is a …
Not Addressed
#9 — Department struggles monitoring sector engagement with inaccessible digital systems and inconsistent records
Recommendation: We asked the Department about its ability to monitor its engagement with economic sectors, given that officials do not consistently record their interactions with companies, and its digital system — DataHub — is not accessible across the whole of Whitehall.17 …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 The department developed the whole of the Industrial Strategy in partnership with other departments, with Sector Plans led by relevant departments. This ongoing programme …
Accepted
CQC Inspection Actions (467) — showing 50 strongest matches
Cygnet Bury Hudson
The provider must ensure that systems and processes operate effectively to assess, monitor and improve the quality and safety of the services provided:
Must Do
Cotton Exchange
The provider must have systems and processes such as regular audits of the service and must assess, monitor and improve the quality and safety of the service.
Must Do
Cottesmore House
Systems or processes were not established and operated effectively to ensure compliance with the requirements in this Part.
Must Do
Continuity Healthcare Services Private Limited
The provider had not ensured that systems or processes operated effectively to assess, monitor and improve the quality of the service and mitigate the risks relating to the health, safety and welfare of service users. The provider had not maintained …
Must Do
Clare House Residential Home
The provider failed to ensure that their systems and processes were effective in monitoring the quality and safety of the services being provided.
Must Do
Chatham House
The provider must have effective systems in place to regularly assess, monitor and improve the quality of the service and act on feedback provided by people using the service.
Must Do
Chandos Lodge Nursing Home
The provider did not ensure their quality assurance processes were effective. Regulatory requirements were not always understood.
Must Do
Brook House Residential Home
Improve quality monitoring systems to identify and address areas requiring improvement, including gaps in decision-making processes, medicine administration timings, and environmental challenges.
Must Do
Billet Lane Medical Practice
Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcareandtreatment.
Must Do
Baby Bump Limited
The service must have effective governance systems or processes to ensure the safe and effective delivery of care. Systems and processes must be regularly audited.
Must Do
Assured Care Formby
Governance processes were knot established or operated effectively.
Must Do
Agnes House 81
Quality monitoring systems were not robust. There was a lack of evidence that the provider was continually evaluating the service and making the required improvements.
Must Do
Aaron Abbey Care Services Limited
The registered person must ensure that systems or processes are established and operated effectively to ensure compliance with the requirements of regulations 8 to 20A of the HSCA 2008 (Regulated Activities) regulations 2014.
Must Do
Woodlands
Regulation 17 HSCA RA Regulations 2014 Good governance
Must Do
Winterton House
Systems or processes were not established and operated effectively. Systems or processes did not enable the registered person to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity. The …
Must Do
Victoriana Care Home
There was a lack of effective systems to ensure quality safe care was always provided.
Must Do
Verve Health
The service must ensure governance systems and processes are in place to assess, monitor and improve the quality and safety of the service.
Must Do
Valewood House Nursing Home
People were not protected against the risks of inappropriate or unsafe care and treatment by means of the effective operation of systems designed to regularly assess and monitor the quality of the services provided and to identify assess and manager …
Must Do
Universal Care - Beaconsfield
The provider failed to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services). The provider failed …
Must Do
Taplow Manor
The service must ensure that there are effective and robust governance procedures in place to ensure that young people always receives safe care and treatment.
Must Do
Southwinds
The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service.
Must Do
Serenity House
There was a lack of effective systems and processes in place for monitoring quality of the service.
Must Do
Reside at Southwood
The provider must ensure that effective systems and processes are established to assess, monitor and drive improvement in the quality and safety of services provided and that accurate records are maintained.
Must Do
Nower House
The failure to ensure consistent management oversight of the service and respond to shortfalls in a timely manner was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Nicholas House
The culture of the service did not promote high-quality care and support. Quality assurance systems were not robust enough to demonstrate the service was effectively managed.
Must Do
Laurel Lodge Care Home
The provider must ensure that effective governance systems are established and operated to monitor the quality of the service, identify risks to the health and safety of people, and drive continuous improvement.
Must Do
Kingsleigh Residential
The provider failed to operate effective systems to monitor the safety and quality of the service.
Must Do
Highfield House Residential Home
The provider must ensure good governance.
Must Do
Havilah Office
Systems or processes were not established and operated effectively to assess, monitor and improve the quality and safety of the services provided. Regulation 17 (1) (2) (a)(b)(c)
Must Do
Haisthorpe House
The provider must ensure people who used services are protected against the risks of inappropriate or unsafe care and treatment, by means of the effective operation of systems designed to enable the registered person to regularly assess and monitor the …
Must Do
Gledhow Lodge
Quality assurance processes were not robust or effective in identifying areas of improvement and analysing records for trends and themes. Records were not always managed effectively.
Must Do
Dr French Memorial Home Limited
Systems were either not in place or robust enough to demonstrate that the services were of good quality and safety was effectively managed. Reg 17 (1)
Must Do
Chiltern View
The provider must ensure quality monitoring systems are used to identify and address shortfalls in the quality of the service, and that management oversight is effective.
Must Do
Cedar House
Management oversight processes in place failed to establish and operate systems to ensure compliance, assess, monitor and improve the quality and safety of the service.
Must Do
Cary Lodge
Systems and processes had failed to adequately assess, monitor and improve the quality and safety of people. Records were not always accurate. 17(1)(2)(a)(b)(c)
Must Do
Brushwood
The provider's governance and quality assurance systems were not always effective.
Must Do
Benthorn Lodge
The registered person did not have an effective system in place to monitor the quality of care provided to people or to manage risks of unsafe or inappropriate treatment. There was a lack of management and leadership at the service.
Must Do
Benedict House Nursing Home
The provider put in place effective systems to monitor the quality and safety of the service that people receive.
Should Do
Ashcroft House - Leeds
The provider had not ensured systems and processes operated effectively to assess, monitor and mitigate the risks relating to the health, safety and welfare of people and to improve the quality and safety of the service provided.
Must Do
Arthur House
The provider did not have robust, consistent and adequate systems in place to monitor the quality of the service.
Must Do
Archers Point Residential Home
There were not effective systems in place to assess and monitor the quality of the service provided.
Must Do
Yanah Care
The provider must ensure effective systems and processes are in place to assess, monitor and improve the quality and safety of the services provided to people.
Must Do
Woodview House Nursing Home
Systems and processes to ensure monitoring and oversight of the quality and safety of the service were not operating effectively.
Must Do
Woodbridge Lodge Residential Home
The governance systems in place were not robust enough to identify shortfalls and address them.
Must Do
Wishingwell Residential Care Home
The provider had not established and operated effectively systems and processes to assess, monitor and improve the quality and safety of the service and to mitigate risks. Regulation 17(1).
Must Do
Willow Court
The lack of robust quality assurance meant people were at risk of receiving poor quality care.
Must Do
Widnes Hall
The provider must operate effective systems to ensure the safety and quality of the service.
Must Do
Westwood Care Home
The provider had failed to ensure governance systems were effective in monitoring service quality, responding to poor quality and driving improvement.
Must Do
Westacre Nursing Home
We found no evidence that people had been harmed however, there was a failure to operate effective systems to assess, monitor and improve the service.
Must Do
West Farm House
Shortfalls in the service were not being identified and addressed.
Must Do
ICIBI Immigration Recommendations (8)
An inspection of illegal working enforcement (August – October 2023)
In relation to assurance: (a) as a matter of priority, re-introduce a formal first-line assurance process. (b) ensure that second-line assurance covers all operational areas, including planning activity. (c) review …
An inspection of asylum casework (August 2020 – May 2021)
Ensure all first line quality assurance takes place before asylum decisions are served. Ensure that trends in Second Pair of Eyes (SPoE) feedback are identified and analysed, and that the …
An inspection of asylum casework (June - October 2023)
Ensure all first line quality assurance takes place before asylum decisions are served. Ensure that trends in Second Pair of Eyes (SPoE) feedback are identified and analysed, and that the …
An inspection of asylum casework (August 2020 – May 2021)
Introduce Calibre assurance assessments for screening interviews
A further inspection of the EU Settlement Scheme July 2020 – March …
Recommendation 5 Review the robustness of the quality assurance regimes in place for EU Settlement Scheme (EUSS) caseworkers and Settlement Resolution Centre (SRC) staff, in the process explaining to staff …
An inspection of visit visa operations December 2022 to January 2023
Improve the existing first-line assurance regime to cover all operational grades and processes, with a focus on routing and decision quality
An inspection of asylum casework (June - October 2023)
Introduce Calibre assurance assessments for screening interviews
An inspection of Border Force practice and procedures in relation to firearms …
Review the current Border Force Assurance Expectations, to ensure that all risks in relation to firearms identification, handling, storage, and transport are subject to adequate first and second-line assurance.
PPO Death in Custody Recommendations (6)
Manx Care
Manx Care should have a dedicated clinical governance lead responsible for prison healthcare at Isle of Man Prison to ensure practice is compliant and underpinned by national guidance, legislation and evidence-based practice.
The Chief Executive of NHS Wales
The Chief Executive of NHS Wales should ensure that prison dental surgeries in Wales are subjected to the same level of scrutiny and inspection as community dental surgeries.
The Governor
The Governor should review whether the quality assurance process for escort risk assessments is sufficiently robust and consider introducing SLT review of a random sample to identify any ongoing issues.
The HMPPS Executive Director for Custodial Contracts
The HMPPS Executive Director for Custodial Contracts should write to the Ombudsman setting out what he has done to satisfy himself that healthcare services at Rye Hill, including the contract for GP services, meet the needs of the prison’s population.
The Director
a robust quality assurance process is implemented to check that these measures are in place and effective.
The Governor
The Governor should review the quality and compliance with policy of ACCT management in the previous 12 months, identify any improvements required, and devise a plan to deliver those improvements.
IOPC Learning Recommendations (2)
Investigation into recruitment irregularities and the actions of a civilian staff member …
The IOPC recommends that British Transport Police reviews the current practice of passing investigations between different teams within the Professional Standards Department and different appropriate authority delegates and sets out clear roles and responsibilities for all those involved in carrying …
Investigation into recruitment irregularities and the actions of a civilian staff member …
The IOPC recommends that British Transport Police considers working practices in the Professional Standards Department to consider and take action to address any issues with: During our investigation we found that there were various issues with the processes followed in …
NAO Audit Recommendations (16)
NHSE's management of elective care transformation programmes
NHSE plans to reset its central oversight arrangements for elective recovery. As it establishes its new national level oversight board for the transformation programmes it should: ? ensure that performance information reported to the board is prioritised, clear and consistent …
Accepted
Financial sustainability of colleges in England
d) Evaluate, and take action to improve, the effectiveness of the early and formal intervention regimes in improving colleges’ financial sustainability. At a time of significant funding and cost pressures, intervening successfully is particularly challenging. However, it is important for …
Accepted
Resilience to animal disease
b support APHA to improve its systems and processes in ways that will ensure more efficient and effective responses to outbreaks; this could include providing ongoing support for APHA?s Delivering Sustainable Future programme;
Accepted
NHSE's management of elective care transformation programmes
NHSE should do more to secure buy-in from clinicians across its programmes. It should achieve this by: ? continuing to build support and endorsement nationally by strengthening its work with Royal Colleges and through national clinical directors embedded in the …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 5: NHSE should revisit internal quality assurance arrangements for existing models when they are used for a new purpose, such as the models used to provide input data for the workforce modelling, and ensure independent scrutiny is evidenced accordingly.
Accepted
Progress in improving mental health services in England
e) As mental health services will need to remain the focus of sustained improvement and in the light of national and local reorganisation of health bodies, DHSC and NHSE should set out the future approach to leading, monitoring and assuring …
Accepted
Progress in improving mental health services in England
c) NHSE, working with local ICBs and providers, should improve its data and analysis to better understand the relative cost and cost-effectiveness of different services, and provide a more robust basis to decide future priorities.
Accepted
Introducing Integrated Care Systems: joining up local services to improve health outcomes
d) by April 2023, NHSE should fully align its oversight of ICBs with the strategic objectives for ICSs. Specifically, it should: ? agree with ICBs what they can realistically deliver against each of the four purposes, taking account of individual …
Accepted
NHS financial management and sustainability
NHSE&I should put in place a regulatory and oversight system that aligns with the responsibilities placed upon individual NHS bodies and their role within non-statutory sustainability and transformation partnerships and integrated care systems. This should clearly set out how roles …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 7: Modelling of this kind requires gathering assumptions about the future of the NHS in one place. This presents an opportunity to expose those assumptions widely to scrutiny and challenge, both internally and externally. Assumptions should be generated in …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 4: NHSE should ensure quality assurance practices take place in a timely manner, so analysts have sufficient time to respond accordingly.
Accepted
Progress in improving mental health services in England
d) NHSE, working with ICBs, should develop and issue guidance in 2023 on how the system will gain more transparency over capacity, activity, performance and outcomes in community mental health services, including improvements required to implement the proposed new clinical …
Accepted
Government Shared Services
f) Departments working together as clusters should complete individual ?declarations? that set out agreed ways of working and reaffirm their commitment to the Shared Services Strategy. This should be signed by each departmental accounting officer.
Accepted
Government Shared Services
c) The Cabinet Office should streamline its central governance arrangements so that they avoid duplication and unnecessary work for departments.
Accepted
Government Shared Services
e) Departments should establish cluster-level governance arrangements to avoid duplication in decision-making and to embed the cluster model. It should no longer use existing departmental governance routes to approve high-level strategy decisions.
Accepted
Introducing Integrated Care Systems: joining up local services to improve health outcomes
e) NHSE should evaluate whether it can draw lessons from the simplified system of commissioning and contracting arrangements put in place for the NHS during 2020-21 and 2021-22, and streamline the requests made to front-line providers while retaining the information …
Accepted
PHSO Ombudsman Recommendations (5)
Ignoring the alarms: How NHS eating disorder services are failing patients
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Ignoring the alarms: How NHS eating disorder services are failing patients
NICE should consider including coordination as an element of their new Quality Standard for Eating Disorders.
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.
Broken trust: making patient safety more than just a promise
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local …
Broken trust: making patient safety more than just a promise
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is …
IMB Annual Reports (2)
Hull (2021)
During the reporting year dominated by COVID-19, HMP Hull remained a safe prison with reduced violence and aggression, despite two self-inflicted deaths. Staff and prisoners collaborated well, and new communication and education methods supported coping. However, pandemic restrictions severely limited prisoners' time out of cells to approximately one hour daily, highlighting issues with shared Victorian cells. While healthcare provision was maintained under pressure, the Board raised concerns about the management oversight of the external provider (CHCP) and the complexity of the complaints system.
PRISON
Key concerns
Exeter (2022)
HMP Exeter, a Category B local and resettlement prison, experienced persistent high levels of violence and self-harm, alongside challenges with staffing instability and extensive refurbishment work in 2022. While healthcare provision was generally satisfactory, access to psychological therapies remained limited, and living conditions were often impacted by overcrowding and restricted regimes. Progress towards successful resettlement was hindered by short sentences, lack of work opportunities, and staff shortages.
PRISON
Key concerns
IMB Recommendations (8)
Winchester (2024)
What can be done to further hold to account Practice Plus Group's activities for the purposes of monitoring delivery of healthcare services under terms of contract and PSO1700?
HMPPS
Elmley (2024)
Address the inconsistency in the quality of ACCT documents through effective quality assurance.
Governor / Director
Humber (2023)
The Board acknowledges the 12 key concerns identified by HMIP in its recent report and agrees they should be progressed during the coming reporting year, subject to the necessary resources being available. The Board will endeavour to structure its monitoring to reflect these concerns and the progress made in addressing them.
Governor / Director
Thorn Cross (2024)
To provide the Board with regular and timely evaluation of all aspects of the prison’s performance.
Governor / Director
Leicester (2022)
The Board would like to draw the minister’s attention to its continued concerns about the service provided (5.1.2).
Ministry of Justice
Gartree (2022)
Therefore, can the Minister confirm to the Board that all services being provided to Gartree by outside organisations (e.g. healthcare, maintenance and education) are achieving all quality and performance targets for the services they have been commissioned to provide?
Ministry of Justice
Hollesley Bay (2024)
The Board is pleased to acknowledge the very positive result of the unannounced HMIP inspection in April. It also notes the positive comments by the Chief Inspector.
Governor / Director
Wakefield (2022)
We ask the minister and his/her officials to explain how the ministry perceives the performance of prisoner healthcare at HMP Wakefield when compared against the performance specification in the contract.
Ministry of Justice
Health Investigations (6)
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1c
Urgent prioritisation of the national Beacon dashboard, with routine use embedded to support whole system learning and improvement, and regular public reporting. A real-time safety signals dashboard, overseen by a clinically and academically informed subgroup of the national oversight group to enable early identification of risk and timely intervention.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1b
A National Strategic Oversight Board should include all relevant national stakeholders with responsibility for perinatal services, the national perinatal team, and a service user representative, with the aim of providing comprehensive oversight and shared accountability. The Board should meet regularly to provide a single, coordinated mechanism for monitoring and acting …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1a
The appointment of national Clinical Directors or leads in obstetrics, neonatology, neonatal nursing and obstetric anaesthetics. These roles should form a National Perinatal Team, working alongside the Chief Midwifery Officer to advise the Welsh Government, drive policy development and implementation, and provide strengthened clinical oversight and accountability of Health Boards …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1d
A comprehensive, accessible governance map, accompanied by a clear narrative explanation of roles, responsibilities, decision-making routes and escalation pathways, should be developed and published within six months of the publication of this report.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bii
The assurance assessment panel has benefited significantly from advice and challenge provided by a wider stakeholder group. We recommend this group is formally retained, meeting quarterly with clear terms of reference to inform the national strategic oversight Board, and that its membership is expanded to include educators, researchers and student …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bi
We recommend that the planned National Maternity and Neonatal Voices Panel also includes representatives from community advocacy organisations representing populations at increased risk of poorer experiences and outcomes in perinatal services, and that it elects a representative to sit on the national strategic oversight Board.
wales
Accepted
Detention Investigations (12)
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
Assessment of government progress in implementing the report on the … — Rec 42
The Home Offce should strengthen its own assurance processes to examine adherence to professional standards and staff culture in IRCs on a regular basis.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 46
I recommend that IND gives urgent consideration to contract monitoring in relation to all holding rooms.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 43
The computerised monitoring schedule needs to be redesigned to make it more flexible and adaptable in monitoring and recording non-commercial aspects of the contract; A training analysis should be conducted across monitoring teams to ascertain the levels of understanding surrounding issues of passive discrimination. The above recommendations should be applied …
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 42
I recommend that IND and the National Council of IMBs take steps to provide IMB scrutiny of all areas (that is, vans and holding areas) where detainees are held.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 40
I recommend that the IMB carry out more frequent, unannounced visits between 9:00pm and 9:00am in order to assess the centre during all its hours of operation.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 50
I also recommend that the performance of the RFU – in terms both of facilitating removals and forestalling problems between the contractor and the detainee – is monitored with a view to introducing a RFU at other ports.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 47
I recommend that IND considers the advantages and practicality of contract monitors carrying out investigations into allegations against staff in other centres.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R10
The SMT should undertake unannounced observation of training sessions as part of the evaluation and quality assurance of training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R9
The SMT and G4S managers should undertake regular and systematic evaluation and quality assurance of the training provided at Gatwick IRCs to ensure that staff receive training of a consistently high standard; that it meets the operational needs of the IRCs, trains and develops staff appropriately and promotes appropriate values. …
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 47
IND reviews and clarifies its role in overseeing the operation of removal centres, notwithstanding principles pertaining to transfer of risk.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 39
I recommend that Oakington’s IMB members be offered refresher training in relation to their powers and how to ensure maximum effectiveness.
Immigration Detention
PHSO Casework Decisions (8)
P-003058 — Care Quality Commission
Mr and Mrs B complain the Care Quality Commission failed to properly inspect the Nursing Home. The also say It failed to act on intelligence it received about the Nursing Home before the inspection and it did not take account of relevant evidence during the inspection. They also complain about …
UK Government
Partly Upheld
Oct 2024
P-003045 — Care Quality Commission
Dr C explains that after the coroner’s inquest concluded, more information came to light and she raised concerns with the CQC about her foster son’s care. She complains it has not correctly addressed the issues she raised or taken any enforcement action.
UK Government
Upheld
Aug 2024
P-003539 — Care Quality Commission
Mrs O says the CQC failed to act against her daughter’s college. She complains it failed to take appropriate action after inspections in January and February 2023 and to prosecute the college after she gave it evidence in 2023 and 2024.
UK Government
May 2025
P-003487 — Care Quality Commission
Mrs X complains on behalf of staff at the hospice, about the attitude and behaviour of a CQC Inspector, during an inspection.
UK Government
Apr 2025
P-004114 — Care Quality Commission
Miss A is unhappy with the CQC's handling of her applications to register her new health business. In addition she complains about complaint handling.
UK Government
Sep 2025
P-003503 — Hertfordshire and West Essex Integrated Care Board
Ms K complains Hertfordshire and West Essex Integrated Care Board did not oversee and respond appropriately to the concerns she raised in September 2022 about the care being provided to her father whilst resident in a care home.
NHS in England
Apr 2025
P-003511 — NHS England
Dr R complains that NHSE independent review panel (IRP) upheld the ICB’s decision that his mother was not eligible for NHS CHC when it assessed her care needs on 10 May 2022.
NHS in England
Apr 2025
P-003683 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Miss A complains York & Scarborough Teaching Hospitals Trust failed to investigate suspicious findings when Mrs C underwent a hysterectomy.
NHS in England
Partly Upheld
Jul 2025
LGO / SPSO Decisions (35)
201400244 — Care Inspectorate
Ms C owns a childcare business. She initially set the business up with her daughter (Miss A) and registered the partnership with the Care Inspectorate. Miss A subsequently left the business and Ms C's son (Mr A) joined as her partner. This partnership change came to light during a routine …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Dec 2015
201202561 — Care Inspectorate
Miss C's mother had received care services through her local council for a number of years, but these were suddenly withdrawn. Miss C complained to the council and also asked the Care Inspectorate to investigate. The Care Inspectorate investigated four complaints about the council's termination of Miss C's mother's care …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Sep 2013
25-004-224 — Danforth Care No. 1 Limited
Summary: Ms X complained about poor service during her respite stay at Heatherton House, and the care provider’s failure to escalate her concerns. She left early due to the undue distress caused. Ms X received a partial refund for the unused days since making the complaint to us. The evidence …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
PSOW-202103154 — Meddyg Care Porthmadog
Mr A, through his Community Health Council Advocate, complained about the care and treatment his father, Mr B, received at the Care Home. Mr B’s care needs meant he was in receipt of NHS Continuing Health Care (“NHSCHC”) from the Health Board who were responsible for monitoring the care provided …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
PSOW-202408904 — Welsh Government - Care Inspectorate Wales
Ms C complained that Care Inspectorate Wales had not acted impartially when it investigated and responded to her complaint. The Ombudsman decided that the Body’s investigation did not lack impartiality, but the response had not fully considered that there had been a breakdown in communication regarding the availability of training, …
PSOW (Public Services Om…
Mar 2025
21-009-703 — London Residential Healthcare Limited
Summary: The Care Provider acknowledged the care provided to Mrs Y was below an acceptable standard before the involvement of this office, but it did not offer an appropriate remedy for the injustice caused.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
24-019-026 — The Fremantle Trust
Summary: We will not investigate this complaint about the quality of care provided in a care home. This is because any injustice is insufficient to justify our involvement.
LGO (Local Government & …
Adult Care Services
Apr 2025
24-015-590 — North East Lincolnshire Council
Summary: We will not investigate this complaint about the quality of domiciliary care. The Council has refunded the cost of Mrs Y’s care and apologised to her daughter, Mrs X. Further investigation by us is unlikely to achieve anything more meaningful.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
202106302 — East Dunbartonshire Health and Social Care Partnership
C complained about the care provided to their elderly parent (A). A had to remain in bed to allow several pressure sores to be treated. To assist with moving A out of bed and changing A's position, a manual handling assessment was requested. C felt that there was an unreasonable …
SPSO (Scottish Public Se…
Health and Social Care
Upheld
Aug 2023
PSOW-202200031 — Plas Gwyn Nursing Home
Mrs X complained that she was unable to visit the Care Provider and had not received a response to her complaint. The Ombudsman was concerned that Mrs X had yet to receive a response to her concerns and contacted the Care Provider. As an alternative to an investigation, the Care …
PSOW (Public Services Om…
Health
Apr 2022
PSOW-202102997 — Betsi Cadwaladr University Health Board
Mr A, through his Community Health Council Advocate, complained about the care and treatment his father, Mr B, received at the Care Home. Mr B’s care needs meant he was in receipt of NHS Continuing Health Care (“NHSCHC”) from the Health Board who were responsible for monitoring the care provided …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
22-008-440 — Jubilee Court Care Ltd
Summary: We will not investigate this complaint about adult social care provision because the injustice claimed is not serious enough to warrant our involvement and the use of public money.
LGO (Local Government & …
Adult Care Services
Oct 2022
23-011-659 — Barchester Healthcare Homes Limited
Summary: Mrs X complains, on behalf of her father, Mr Y, Barchester Healthcare Homes Limited mishandled the pre-admission process and failed to ask relevant questions before her father moved into in the home. She says the Care Provider failed to engage with her or social services to complete a re-assessment. …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2024
201508742 — Care Inspectorate
Mr C complained to us that the Care Inspectorate had published an inspection report on his nursery that was inaccurate. He stated that there were a large number of errors in both the draft report and the final published report. We found that although there had been errors in the …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
May 2017
25-011-335 — Care UK Care Services Limited
Summary: We will not investigate Ms X’s complaint about the residential care provided to her mother Ms Y.
LGO (Local Government & …
Adult Care Services
Jan 2026
24-023-387 — Sheffield City Council
Summary: I find fault in the care provided by a care provider acting on behalf of the Council. The Council has agreed to provide a remedy.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
25-010-204 — Green Lane Care Centre
Summary: We cannot investigate this complaint as it is outside our jurisdiction. Mr X’s care was arranged and funded by the NHS and so the complaint can be investigated by the Health Services Ombudsman.
LGO (Local Government & …
Adult Care Services
Jan 2026
PSOW-202205658 — Cwm Taf Morgannwg University Health Board
Mr E complained about Cwm Taf Morgannwg University Health Board’s handling of his complaint about the care provided to his mother. The Ombudsman decided that the Health Board had failed to provide regular and meaningful updates and had not issued a complaint response to Mr E. She said that this …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202206173 — Cwm Taf Morgannwg University Health Board
Ms D complained that Cwm Taf Morgannwg University Health Board had failed to provide a complaint response to correspondence she sent to it in February 2022. The Ombudsman found that the Health Board had acknowledged Ms D’s letter but had failed to respond to it. She said that this caused …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202206233 — Betsi Cadwaladr University Health Board
Mrs A complained that the Health Board had failed to issue a complaint response to her in accordance with an agreement it had previously reached with the Ombudsman’s office (ref: 202204472). The complaint response should have been issued to Mrs A by 30 November 2022. The Ombudsman contacted the Health …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202105999 — Cwm Taf Morgannwg University Health Board
Miss A’s complaint related to the care and treatment that she received during her admission to Prince Charles Hospital in April 2021. Specifically, Miss A complained that she was inappropriately discharged on 22 April as she was not properly examined, such as with a speculum or an ultrasound, following the …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2022
PSOW-202108104 — Swansea Bay University Health Board
Mr A’s complaint centred on his care and management at Morriston Hospital (“the Hospital”). He complained that the Swansea Bay University Health Board (“the Health Board”) failed to accurately diagnose giant cell arteritis (“GCA” – inflammation in the lining of the arteries especially in the temple) and provide timely treatment …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
PSOW-202206156 — Cardiff and Vale University Health Board
Mr C complained that Cardiff and Vale University Health Board had failed to adequately address his concerns about the care and treatment provided to his late father. The Ombudsman found that whilst the Health Board had issued a complaint response it had delayed making further contact with Mr C about …
PSOW (Public Services Om…
Health
Feb 2023
PSOW-202402334 — Estyn
Mr W complained about whether Estyn’s investigation into his complaint at Stage 2 of its complaints procedure was completed reasonably and in accordance with its ‘Complaint Handling Procedure 2021’. The Ombudsman found that Mr W’s complaint was not investigated in accordance with Estyn’s Complaint Handling Procedure 2021 which states that …
PSOW (Public Services Om…
Upheld
Jun 2025
22-002-226 — Liberty House Clinic Limited
Summary: We will not investigate this complaint about a Private Care Provider. This is because there is insufficient injustice caused to warrant our intervention. Also, some actions complained of fall outside of our jurisdiction as they do not relate to the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Jun 2022
22-003-864 — Sunderland City Council
Summary: We will not investigate this complaint about the standard of care Mrs Y received in a nursing home. That is because further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Jul 2022
23-014-133a — Maria Mallaband Care Group Ltd (23 014 133a)
Summary: Mrs X complained about the treatment and care provided to her late grandmother, Mrs Y while she was living in a nursing home. We will not investigate Mrs X’s complaint because it is unlikely we could add to the responses she has already received from the organisations she complains …
LGO (Local Government & …
Health
May 2024
23-014-029 — Yourlife Management Services Limited
Summary: Ms X complains YourLife (Droitwich) failed to meet her father’s (Mr Y’s) needs when he went to live in Horton Mill Court in July 2021 and told his family he had to leave, resulting in him having to live in a care home and incurring losses selling his flat. …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
201103809 — Tayside NHS Board
Mr C complained that the board did not provide pelvic support girdles, which he considered his partner needed because of pelvic pain in pregnancy. We explained to him that our role in such complaints is limited because it is not for us to tell the NHS how to use their …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2012
201102661 — A Medical Practice in the Fife NHS Board …
Mr C complained that his GP practice decided to restrict the number of diabetic testing strips he could have, and then stopped providing them. He said that this was unfair and did not take into consideration his personal circumstances. Mr C said that self monitoring of his diabetes cannot be …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2012
201102066 — Care Inspectorate
Ms C, a childminder, complained about the Care Inspectorate’s decision to uphold a complaint that she did not have a safety net on a trampoline used by the children in her care. She said that this had not been pointed out on previous inspections. The law says that we cannot …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Jul 2012
201407618 — Care Inspectorate
Ms C complained to the Care Inspectorate about the care home her father was staying in. She complained about a range of issues, including how often bedding was changed, concerns about electric reclining chairs, and the lack of a care plan for her father. The Care Inspectorate responded to her …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
Aug 2015
PSOW-202308118 — Liberty Care Ltd
Mrs C complained about Aneurin Bevan University Health Board (“the Health Board”) and a registered Residential Care Provider (“the Care Provider”) which the Health Board had commissioned to provide care to her son, Mr A. The investigation looked at whether between November 2021 and October 2022, the Health Board failed …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2025
21-010-477 — Sheffield City Council
Summary: I have ended our investigation into this complaint because the Council has recently begun an independent review of the care provider and service Ms X complained about. Further investigation by us could achieve nothing more.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-018-997 — Assini Limited
Summary: We cannot investigate this complaint about the actions of a Private Care Provider. This is because the actions complained of fall outside of our jurisdiction to investigate as they do not relate to the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Apr 2022