Staff policy awareness
Absence of a system to confirm that all staff have read and understood existing, updated, or new policies, procedures, and guidance documents.
917 items
16 sources
15 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
77match
Seweryn Glowinski
Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Matched on
terms: awarenes, staff
PFD report
77match
Mary Chapman
The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.
Matched on
terms: policy, staff
PFD report
73match
Rosalind Flett
Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting thorough searches and potentially missing concealed items.
Matched on
terms: policy, staff
PFD report
73match
Michael Dent-Jones
National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.
Matched on
terms: staff
PFD report
73match
Liridon Saliuka
There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Matched on
terms: awarenes, staff
PFD report
69match
Theresa Robertson
The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.
Matched on
terms: policy
PFD report
69match
Shirley Froggett
New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
Matched on
terms: staff
PFD report
69match
William Savory
There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.
Matched on
terms: awarenes, staff
PFD report
69match
Cariss Stone
Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.
Matched on
terms: policy, staff
PFD report
69match
Jada Monoja
An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.
Matched on
terms: policy
Detention investigation recommendation
68match
Independent Investigation into Concerns about Brook House Immigration Removal Centre - Rec R47
The SMT should undertake a programme of awareness-raising among staff to improve their understanding and use of the anti-bullying policy. (To be completed within 3 months)
Matched on
terms: awarenes, policy, staff
CQC action
66match
The Newcastle Clinic
The service should have a system in place to confirm all staff have read existing, updated or new polices, procedure and guidance documents.
Matched on
terms: staff
PFD report
65match
Rajesh Parkash
Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Matched on
terms: staff
PFD report
65match
Arthur Fry
A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.
Matched on
terms: staff
PFD report
65match
Maureen Flynn
A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.
Matched on
terms: staff
PFD report
65match
Wayne Cornlouer
An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion and proper use.
Matched on
terms: staff
PFD report
65match
Henry Holcombe
The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Matched on
terms: staff
PFD report
65match
Cpl Ryan Lovatt
The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks formalization and clear communication.
Matched on
terms: policy
HMICFRS recommendation
64match
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • improve how it engages with its staff to gain their commitment to the service’s values and associated behaviours;...
Matched on
terms: staff
Detention investigation recommendation
63match
Independent Investigation into Concerns about Brook House Immigration Removal Centre - Rec R49
The SMT with the violence reduction manager should undertake a development programme with staff to: • develop their confidence and skills in dealing with disruptive detainees; and • improve their awareness and understanding of the anti-disruption policy and how it should be implemented. (To be completed within 3 months)
Matched on
terms: awarenes, policy, staff
Committee recommendation
62match
#26 - Code of Practice for resident communication during remediation shows inconsistent practice and limited awareness
In 2023, MHCLG launched a Code of Practice to support improved communications during remediation. The HBF and the NHF told us that developers and social housing providers had agreed to follow the code. EOCS told us the code was “a long time coming” and had been heavily revised at the last minute. It told us that information on...
Matched on
terms: awarenes
PFD report
61match
Ryan Chapman
Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.
Matched on
terms: staff
PFD report
61match
Doris Taylor
The coroner noted that staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such. The door-closers on all doors should be in a safe working condition.
Matched on
terms: staff
PFD report
61match
John Lowe
Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.
Matched on
terms: staff
PFD report
61match
Mark Groombridge
There was no direct communication between the local offender manager and the clinician responsible for the patient's care before the recall paperwork was issued, and there was confusion about the recall process among probation staff.
Matched on
terms: staff
PFD report
61match
Valmai West
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
Matched on
terms: staff
PFD report
61match
Khalid Abiaz
A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.
Matched on
terms: policy
PFD report
61match
Ash Bannister
Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.
Matched on
terms: policy
PFD report
61match
Susan Edwards
A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a risk to patients requiring this treatment.
Matched on
terms: staff
CQC action
60match
Elizabeth Street Surgery
Make all policies and procedures accessible to staff.
Matched on
terms: staff
HMICFRS recommendation
60match
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve understanding and awareness of the importance of equality, diversity and inclusion (EDI) and remove barriers to embedding EDI in the service. Recommendation: By 28 February 2022 the service should develop an action plan to engage with its staff to develop clear EDI objectives and...
Matched on
terms: awarenes, staff
PPO recommendation
60match
The Head of Healthcare
The Head of Healthcare should ensure that staff are aware of their responsibilities under the food refusal policy, including sharing information with prison staff and completing an incident report.
Matched on
terms: policy, staff
IMB recommendation
60match
Berwyn (2020)
There is a need to ensure that systems and policies are consistent and fully understood both by prisoners and staff.
Matched on
terms: staff
NAO recommendation
60match
Bank of England: Managing legal, ethical and staff compliance risks
The Bank should review whether there are material differences in awareness, understanding and perception of risk and compliance between different groups of staff ? for example, based on role, seniority or length of service ? in order to identify ways to target further improvements.
Matched on
terms: awarenes, staff
CQC action
60match
Percys Travel
The service should ensure that Control of Substances Hazardous to Health (COSHH) documents are available and accessible to staff so that products can be used safely and in line with service policy.
Matched on
terms: policy, staff
PPO recommendation
60match
The Governor
The Governor should ensure that staff understand local policy around covered observation panels, that prisoners are appropriately challenged, and blockages removed, and that there is not a culture in which prisoners routinely cover observation panels.
Matched on
terms: policy, staff
LGO / SPSO decision
59match
24-020-460 - Rother District Council
Summary: We will not investigate this complaint about a lack of policy and procedures for staff carrying out planning enforcement investigations and actions. This is a matter which affects all or most of the people in the Council’s area and is therefore outside our jurisdiction.
Matched on
terms: policy, staff
LGO / SPSO decision
59match
201403970 - West Lothian Council
Mr C complained that his son's school had introduced a new policy on excursions that impacted unfairly on his son, who had a disability. Mr C said the school failed to consult him about the new policy and failed to take into account his son's needs and the Equality Act in developing the policy. Mr C also said...
Matched on
terms: policy, staff
PFD report
57match
Bruce Longden
The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
Matched on
terms: awarenes
PFD report
57match
Lee Gaunt
The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed employee after a colleague's death, indicating a general lack of support for staff in stressful situations.
Matched on
terms: staff
PFD report
57match
Agnes Lambert
Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
Matched on
terms: staff
PFD report
57match
Austin Thomas
Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was inadequate, with no random testing despite evidence of an employee's drug use.
Matched on
terms: policy
PFD report
57match
Giuseppe Tabone and Andrew Evans
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
Matched on
terms: staff
PFD report
57match
Donna Smith
A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous delays.
Matched on
classifier match
PFD report
57match
Clara Winter
Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to resource issues, nor is it compulsory, leaving a significant learning gap.
Matched on
terms: staff
IOPC learning recommendation
57match
Recommendation - Metropolitan Police, February 2021
The IOPC recommends that the Metropolitan Police Service formally reviews their internal processes to provide for appropriate monitoring of outstanding calls and that sufficient controls are in place to ensure that policies and procedures are followed, and then takes any necessary action identified as a result of the review. We also recommend that as part of the new...
Matched on
terms: policy
LGO / SPSO decision
57match
201103108 - Scottish Prison Service
Mr C complained that the prison governor failed to properly investigate his complaint about prison staff referring to him by his surname and not including his title. The governor had responded by asking one of the managers to raise this with staff. We confirmed with the SPS that the manager had indeed raised the issue at a subsequent...
Matched on
terms: staff
LGO / SPSO decision
57match
201204540 - Lothian NHS Board
Ms C's late mother (Mrs A) was treated in hospital as an in-patient for illnesses that included pneumonia and chronic heart failure. Ms C complained that during that time the hospital communicated inadequately with her and other family members about Mrs A's medical condition. In particular Ms C said that she and family members were not made aware...
Matched on
terms: staff
Inquiry recommendation
57match
F9 - Fundamental standards of behaviour
The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers.
Matched on
terms: staff
Inquiry recommendation
57match
F7 - Clarity of values and principles
All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts of employment.
Matched on
terms: staff