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
Source spread
Where this theme appears
Staff policy awareness has been flagged across 16 independent accountability sources:
61 inquiry recs
68 PFD reports
113 committee recs
21 CQC actions
102 HMICFRS recs
1 ICIBI rec
23 PPO recs
12 IOPC recs
2 NAO recs
12 IMB reports
233 IMB recs
3 Article 2 learning points
34 detention investigation recs
2 PHSO decisions
224 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 (61) — showing 50 strongest matches
F9 — Fundamental standards of behaviour
Recommendation: 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.
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
F7 — Clarity of values and principles
Recommendation: 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.
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
POH-11 — Apply best offer principle equally in GLOS
Recommendation: The "best offer" principle which will apply in HSSA, as explained in response to Recommendation 10, shall be equally applicable in GLOS.
Gov response: Department for Business and Trade accepts this recommendation. The "best offer" principle applies equally across GLO, HSSA, and HCRS schemes at all panel stages. This has been in effect since 12 August. DBT will retrospectively …
Accepted
WATE-(21) — Remind personnel of suspension guidelines: child's best interests, neutral, avoid long periods
Recommendation: Personnel departments and other persons responsible for disciplinary proceedings within local authorities should be reminded that: (a) in deciding whether or not a member of staff should be suspended following an allegation of abuse to a looked after child, first …
Unknown
F12 — Fundamental standards of behaviour
Recommendation: Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report …
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
F8 — Clarity of values and principles
Recommendation: Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for these purposes do so as well. These requirements could be included in the terms on which providers 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
WATE-(61) — Make willingness to visit children's homes pre-condition for committee appointment
Recommendation: The willingness of councillors to visit children's homes should be a pre-condition of appointment to the committee responsible for the homes and the importance of fulfilling the duty to visit and to report on visits conscientiously should be emphasised to …
Unknown
WATE-(9) — Make failure to report child abuse by staff an explicit disciplinary offence.
Recommendation: Consideration should be given to requiring failure by a member of staff to report actual or suspected physical or sexual abuse of a child by another member of staff or other person having contact with the child to be made …
Unknown
FENN-105 — Ensure London Underground written communications are plain, presented well, and followed.
Recommendation: London Underground shall make sure that all its written communications are in plain English and properly presented. They must check that instructions are being followed.
Unknown
BRIS-57 — Prioritise non-clinical skills in healthcare professional education and development
Recommendation: Greater priority than at present should be given to non-clinical aspects of care in six key areas in the education, training and continuing professional development of healthcare professionals: (cid:2) skills in communicating with patients and with colleagues; (cid:2) education about …
Unknown
R57 — IPC committee minutes reporting
Recommendation: Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to the level above in the hierarchy.
Gov response: Section 4.2 of the Scottish Government's response details that registered health professionals must meet professional standards on record-keeping established by their regulatory bodies, and the Scottish Government has its own Records Management: NHS code of …
Accepted
R56 — Regular IPC group meetings
Recommendation: Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through the management structure.
Gov response: Section 2.2 of the Scottish Government's response notes the recommendation that NHS boards should ensure infection prevention and control is explicitly considered at all clinical governance committee meetings. Section 2.1 describes the national HAI Taskforce, …
Accepted
R51 — ICT functions as team
Recommendation: Health Boards should ensure that any Infection Control Team functions as a team, with clear lines of communication and regular meetings.
Gov response: Section 2.1 of the Scottish Government's response highlights the role of the national HAI Taskforce, which coordinates, implements, and monitors actions across NHS Scotland to reduce HAIs, working with local teams and existing structures. The …
Accepted
R46 — ICM direct responsibility
Recommendation: Health Boards should ensure that the Infection Control Manager has direct responsibility for the infection prevention control service and its staff.
Gov response: Section 2.2 of the Scottish Government's response clearly states that the Infection Control Manager (ICM) has overall responsibility for coordinating prevention and control of infection throughout the NHS board area and delivering the board-approved infection …
Accepted
R45 — Manager IPC job description
Recommendation: Health Boards should ensure that where a manager has responsibility for oversight of infection prevention control, this is specified in the job description.
Gov response: Section 2.2 of the Scottish Government's response details the specific responsibilities of the Infection Control Manager (ICM), including overall responsibility for coordinating prevention and control of infection throughout the NHS board area and delivering the …
Accepted
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
IHRD-90 — Clinical Guidance Dissemination Protocol
Recommendation: The Department should develop protocol for the dissemination and implementation of important clinical guidance, to include: (i) The naming of specific individuals fixed with responsibility for implementation and audit to ensure accountability. (ii) The identification of specific training requirements necessary …
Gov response: Protocol development for clinical guidance dissemination progressing.
Accepted
No update 2+ yrs
IHRD-74 — Professional Codes in Employment Contracts
Recommendation: Likewise, professional codes governing nurses and other healthcare professionals should be incorporated into contracts of employment.
Gov response: Professional code requirements incorporated into healthcare professional employment contracts.
Accepted
IHRD-73 — GMC Code in Employment Contracts
Recommendation: General Medical Council ('GMC') 'Good Medical Practice' Code requirements should be incorporated into contracts of employment for doctors.
Gov response: GMC Good Medical Practice requirements incorporated into doctor employment contracts.
Accepted
F180 — Candour about incidents
Recommendation: Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.
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
F178 — Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and …
Recommendation: The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly …
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
F11 — Fundamental standards of behaviour
Recommendation: Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their employees comply with these requirements. Staff members affected by professional …
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
F10 — Fundamental standards of behaviour
Recommendation: The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as those produced by the National Institute for Health and Clinical Excellence and, where relevant, the Care Quality Commission, …
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
BAHA-2 — Standard Orders Prohibiting Five Techniques
Recommendation: Joint Doctrine Publication (JDP) 1-10 should include the requirement for standard orders to be issued for each operation prohibiting the use of the five techniques.
Gov response: Accepted. JDP 1-10 has been updated to require standard orders prohibiting the five techniques for each operation.
Accepted
WATE-(60) — Clearly define purpose and scope of visits to children's homes
Recommendation: The purpose and scope of visits to children's homes, whether by councillors or by senior and intermediate managers, should be clearly defined and made known to all such visitors.
Unknown
WATE-(20) — Expedite disciplinary proceedings for child abuse, independent of police investigations
Recommendation: Any disciplinary proceedings that are necessary following a complaint of abuse to a child should be conducted with the greatest possible expedition and should not automatically await the outcome of parallel investigations by the police or the report on any …
Unknown
SHEE-55 — Emphasise clear orders, strict discipline, and effective communication for ship safety
Recommendation: This Court need say no more than stress the need for: (a) Clear and concise orders. (b) Strict discipline. (c) Attention at all times to all matters affecting the safety of the ship and those on board. There must be …
Unknown
BRIS-98 — Regulatory bodies to vary professional duties for full-time managers without patient care
Recommendation: The relevant professional regulatory bodies should make rules varying the professional duties of those professionals, whose registration they hold, who are in full-time managerial roles, so as to take account of the fact that, while occupying such roles, they do …
Unknown
BRIS-46 — Incorporate professional codes of practice into contracts for nurses, allied professions, managers
Recommendation: The relevant codes of practice for nurses, for professions allied to medicine and for managers should be incorporated into their contracts of employment with hospital trusts or primary care trusts.
Unknown
BRIS-45 — Incorporate doctors' professional practice code into employment contracts and GP terms
Recommendation: The doctors’ Code of Professional Practice, as set down in the GMC’s ‘Good Medical Practice’, should be incorporated into the contract of employment between doctors and trusts. In the case of GPs, the terms of service should be amended to …
Unknown
R32 — Staffing concerns escalation
Recommendation: Health Boards should ensure that there is straightforward and timely escalation process for nurses to report concerns about staffing numbers/skill mix.
Gov response: Section 4.1 of the Scottish Government's response highlights that the NMC code requires registered nurses and midwives to escalate concerns regarding patient safety or the level of care. To support this, a national whistleblowing policy, …
Accepted
P2-69 — Formalise multi-organisation arrangements
Recommendation: Where organisations work together to care for people after death, the arrangements should be formalised through contracts or service level agreements. This should include joint Standard Operating Procedures. The parties to the contracts or service level agreements should ensure that …
Gov response: This recommendation is under consideration.
Response Unclear
P2-58 — Contractual incident notification requirement
Recommendation: There must be a contractual requirement to formally notify the contract manager and senior local authority officers of any incidents involving the deceased, as well as the outcome of inspections or other action by the Human Tissue Authority or others …
Gov response: This recommendation is under consideration.
Response Unclear
P2-57 — Local authority review third-party contracts
Recommendation: Local authorities must review all contractual arrangements and agreements with third-party providers of services that care for and transport the deceased. This must include consideration of assurance mechanisms, such as key performance indicators, regular reporting, formal contract review meetings, site …
Gov response: This recommendation is under consideration.
Response Unclear
P2-6 — Security breaches reviewed by expert with action plans
Recommendation: All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be reviewed by a security expert who is able to identify any systemic security issues associated with the incident. …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
IHRD-52 — Inquest Duties Protocol
Recommendation: Protocol should detail the duties and obligations of all healthcare employees in relation to healthcare related inquests.
Gov response: Protocols developed detailing employee duties in relation to healthcare inquests.
Accepted
F240 — Hygiene
Recommendation: All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of 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
F219 — A regulator as an alternative
Recommendation: An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up an independent professional regulator. The need for this would be greater if it were thought appropriate to extend …
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
F218 — Enforcement of standards and accountability
Recommendation: Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be fit and proper persons to hold such positions by a …
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
F217 — Common selection criteria
Recommendation: A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn could inform a list of competences a leader would be expected to have.
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
F216 — Leadership framework
Recommendation: The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health service. This could be done by, for example, creating a separate domain for managing safety, or by defining …
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
F215 — Shared code of ethics
Recommendation: A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the code and their employers to enforce it.
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
IHRD-5 — Employment Contracts and Duty of Candour
Recommendation: Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.
Gov response: Prototypes to determine the most appropriate way to operate such a service are progressing. Learning will inform proposals for an IME service in Northern Ireland.
Accepted
No update 2+ yrs
IHRD-4 — Trust Awareness of Duty of Candour
Recommendation: Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of healthcare.
Gov response: Being Open Framework implemented across Trusts. Training provided to staff on duty of candour principles.
Accepted
No update 2+ yrs
BAHA-23 — Ban Harsh Approach in Tactical Questioning
Recommendation: The harsh approach should no longer have a place in tactical questioning. The MoD should forbid tactical questioners from using what is currently known as the harsh approach and this should be made clear in the tactical questioning policy and …
Gov response: Not accepted. The Defence Secretary decided not to accept this recommendation. The MoD retained the ability to use the harsh approach in tactical questioning, subject to strict parameters and safeguards.
Not Accepted
BAHA-18 — Whistleblower Protection
Recommendation: JDP 1-10 should address the protection that will be afforded to service personnel who make complaints or allegations in good faith of the mistreatment of CPErS. It should give guidance as to those who can be approached when service personnel …
Gov response: Accepted. Guidance on protection for those reporting mistreatment and appropriate contacts has been included.
Accepted
SHEE-58 — Enlarge regulation to include all potentially hazardous occurrences on board ships
Recommendation: Consideration should be given to enlarging that regulation to include every occurrence which is potentially hazardous to the ship or to any person on board.
Unknown
SHEE-57 — Require entry of departure draughts in log books with strict enforcement
Recommendation: There should be a requirement that the departure draughts must be entered in the deck log book as well as the Official Log book. The only practical way of enforcing such a rule would be for the Department to initiate …
Unknown
LADB-34 — Reconsider the use of "disregard" in the SPAD Group Standard
Recommendation: The use of the word “disregard” in the Group Standard on SPADs and its associated documentation should be reconsidered (para 11.29).
Unknown
BRIS-47 — Enable trusts to independently address healthcare professional code breaches
Recommendation: Trusts should be able to deal as employers with breaches of the relevant professional code by a healthcare professional, independently of any action which the relevant professional body may take.
Unknown
PFD Reports (68) — showing 50 strongest matches
Ryan Chapman
Concerns: Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.
Overdue
Kevin Pearson
Concerns: The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions for specialized activities.
Overdue
Doris Taylor
Concerns: 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.
Overdue
Rajesh Parkash
Concerns: Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Overdue
Seweryn Glowinski
Concerns: 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.
Overdue
John Lowe
Concerns: 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.
Overdue
Austen Harrison
Concerns: Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional audits, led to undetected hazards like an unsafe mirror.
Response (Hugo Boss): Hugo Boss appointed a new Health and Safety Manager who undertook a detailed review of health and safety training, relaunched enhanced training for store and general managers via a workshop, …
Responded
Mark Groombridge
Concerns: 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.
Response (HM Prison and Probation Service): While the Director of Probation believes existing guidance on offender recall is clear, Deputy Directors will ensure probation staff are reminded of procedures by 31 August. The Public Protection Casework …
Responded
Bruce Longden
Concerns: The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
Responded
Gail Prentice
Concerns: There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.
Overdue
Arthur Fry
Concerns: 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.
Response (University Hospitals North Midalnds NHS Trust): University Hospitals of North Midlands NHS Trust is incorporating a phrase into the MRI safety questionnaire about MRI compatibility. The Department of Imaging has applied for transformation funding for Imaging …
Responded
Douglas Birch
Concerns: Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. They also did not consistently receive or read crucial Prison Service Orders.
Response (HM Prison and Probation Service): HMP Swaleside issued a notice to staff on 10 August 2015 setting out local procedure for welfare checks and requiring staff to sign to confirm checks have taken place. NOMS …
Responded
Lee Gaunt
Concerns: 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.
Response (Lee Gaunt): GMFRS has amended its procedures to allow employees to self-refer for counselling via its occupational health provider. It has also been piloting a system known as Trauma Risk Management (TRiM) …
Responded
Maureen Flynn
Concerns: 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.
Response (Stockport NHS Trust): The Trust has completed actions detailed in an updated Patient Safety Investigation report, including an audit of falls risk assessments, enhanced falls sensors, and sharing investigation findings via ward newsletters, …
Responded
Warren Sampson
Concerns: Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Response (Care UK): Discipline staff now email healthcare each day with the ACCT reviews they are intending to hold and invite the appropriate healthcare professional to input into the process. A Second Health …
Overdue
Wayne Cornlouer
Concerns: 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.
Response (HM Prison and Probation Service): A notice to staff was re-issued on 28 September 2016 reminding staff about emergency codes and ambulance requests; the local emergency code protocol has been distributed and displayed. The induction …
Responded
John Williams
Concerns: Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies and a need for improved referral systems.
Response (Care UK): Care UK has reminded the nurse involved about giving evidence at an inquest and provided further support. The First Reception Health Screen template has been changed to include a mandatory …
Overdue
Dominic White
Concerns: A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental health professional showed a lack of recognition regarding the absconding risk when allowing a detained patient leave.
Response (Whittington Hospital NHS2 Trust): Whittington Health NHS Trust, Camden & Islington NHS Foundation Trust, and Barnet, Enfield and Haringey Mental Health NHS Trust have created a joint protocol to improve mental health observations in …
Overdue
Charlotte Agnew
Concerns: The report describes failures in the transfer of care, suicide risk assessment, care planning, medication management, and response to a request for urgent assessment; the coroner remains concerned that these failings could recur.
Overdue
Rosalind Flett
Concerns: 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.
Overdue
Agnes Lambert
Concerns: 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.
Response (Camden and Islington NHS Trust): The Trust is rolling out 'vital conversations' training for managers and reviewing its disciplinary policy to include clearer criteria for investigations. A specially-trained staff member will review cases to challenge …
Responded
Austin Thomas
Concerns: 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.
Overdue
Mary Chapman
Concerns: 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.
Response (Nuffield Health): Nuffield Health has implemented a new national discharge policy, provided additional training, and improved communication protocols. They are extending consultant pharmacist support across all 31 locations and are standardising discharge …
Responded
Ricky Barcock
Concerns: The client wellbeing check protocol during sleep needs review to ensure effective physical checks and rousing clients, especially drug users, to properly monitor their wellbeing.
Response (Oasis Recovery Communities): Oasis Bradford has reviewed and updated its Observation and Client Wellbeing Checks Policy December 2019 and plans to provide staff training to ensure working practice is safe and effective and …
Overdue
Theresa Robertson
Concerns: 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.
Overdue
Michael Dent-Jones
Concerns: 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.
Response (HM Prison and Probation Service): The national Safe Working Practice document for Approved Premises is being re-issued on April 30th 2021 and all staff must read the updated SWP and sign a register to confirm …
Responded
Shirley Froggett
Concerns: New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
Overdue
Valmai West
Concerns: 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.
Response (Aneurin Bevan University Health Board): The Health Board reviewed nurse staffing levels which they state were adequate at the time of the incident. They have also commissioned an in-depth review of nurse staffing levels for …
Responded
Henry Holcombe
Concerns: The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Response (Sussex Partnership NHS Trust): The Trust has strengthened internal monitoring, enhanced training (including for agency/bank staff), and now reviews policy compliance weekly by the Ward Manager and monthly by the Matron. They are also …
Responded
Cpl Ryan Lovatt
Concerns: 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.
Response (Ministry of Defence): The Ministry of Defence has amended its Sharkwatch policy to include written orders for the nominated sober individual, requiring them to keep the group together, ensure safe return, and report …
Responded
Robert Hammond
Concerns: The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, resulting in an unsatisfactory care plan.
Response (Coventry and Warwickshire Partnership NHS Trust): Coventry and Warwickshire Partnership NHS Trust is undertaking a project to improve risk assessment and management, including reviewing best practices, auditing current practices, commissioning a staff survey, and conducting observational …
Responded
Kyle Nel
Concerns: The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers between units.
Response (HM Prison and Probation Service): HMPPS replaced the Custodial Violence Management Model with the Challenge, Support and Intervention Plan (CSIP), a violence reduction case management model, and HMP Guys Marsh has a dedicated drug strategy …
Responded
Mark Castley
Concerns: The coroner suggests the risks of recurrent impulsive self-harm were not fully assessed in light of the circumstances, specifically concerning the period after sentencing, and that a notification form might have been completed had the risks been fully considered.
Response (HM Courts and Tribunals Service): HMCTS is updating Security and Safety Operating Procedure 4b across all crime courts by the end of May, including publicising random searches and implementing a new Safeguarding policy with training …
Response (HM Prison and Probation Service): The 'Working with Suicide & Self-Harm' guide was reviewed, changing a question about suicide risk, and the Probation EQUiP process map was updated for court staff; all London probation staff …
Responded
Jake Cahill
Concerns: Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Response (Youth Justice Board for England and Wales): The Youth Justice Board has updated national guidance to support practitioners in using self-assessment tools appropriately when engaging with children. The updated guidance covers topics such as bail, custody, family …
Responded
William Savory
Concerns: 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.
Overdue
Khalid Abiaz
Concerns: 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.
Response (HM Prison Probation Service): HM Prison and Probation Service rolled out ACCT version 6 across the prison estate and has produced and delivered training materials to support staff understanding. Fifteen staff members received the …
Response (Swansea Bay University Hospital): Swansea Bay University Hospital will ringfence two slots per ACCT training session for Health Board staff and will roster health staff to attend ACCT Awareness training as a priority. Health …
Responded
Liridon Saliuka
Concerns: 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.
Response (Oxleas NHS Foundation Trust): Oxleas NHS Foundation Trust will now document adjustments required for a patient's disability on the Prison Nomis (P-Nomis) system, accessible by prison staff, healthcare, and social services. A fortnightly meeting …
Response (HM Prison and Probation Services): HMP Belmarsh will be holding monthly training sessions throughout 2023, alongside Oxleas NHS Trust and RGB, for all operational staff. These sessions will focus on encouraging staff to think differently …
Responded
Doris Smith
Concerns: Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.
Response (Essex Partnership University): The Trust has implemented practice changes including a 24-hour falls risk assessment, mandatory physiotherapy referrals, and guidelines to address copying and pasting in records. They have also produced a video …
Responded
Gillian Baumgardt
Concerns: There is no system requiring radiographers to use pre-exposure markers or for radiologists to investigate inconsistencies in injury site between x-ray images, risking wrong-site surgery.
Response (North Bristol NHS Trust): The Trust acknowledges concerns about radiographer marker placement and radiologist review of image inconsistencies. They are implementing a revised Standard Operating Procedure with checks and communication protocols, awaiting sign-off at …
Responded
Daniel Tucker
Concerns: Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective named nurse sessions was also inadequate.
Response (NHS England): NHS England detailed updates to overdose guidance, implemented in November 2023, to include callers who reach a Category 5 disposition. Additionally, TOXBASE is to be viewed for each overdose/accidental ingestion …
Response (Ofcom): Ofcom acknowledges the concerns and outlines its plans to implement the Online Safety Act, including consulting on draft codes of practice and taking enforcement action against non-compliant services regarding harmful …
Response (Nottinghamshire Healthcare NHS Foundation Trust): Nottinghamshire Healthcare NHS Foundation Trust stated that care plans and risk assessments are individualised and updated, with monthly audits to ensure compliance. They have also invested in additional self-harm and …
Response (Department of Health and Social Care): The Department of Health and Social Care references actions taken to address harmful online content such as the Online Safety Act and states that the multi-sector and cross-government suicide prevention …
Responded
Giuseppe Tabone and Andrew Evans
Concerns: Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
Response (HM Prison and Probation Service): HMP Lewes investigated and disciplined staff who failed to carry out roll checks, and has planned further 'bite size' training sessions on roll checks with support from the standards coaching …
Responded
Cariss Stone
Concerns: 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.
Response (Somerset NHS Foundation Trust): The Trust has revised its policy on patient observation (most recently in May 2024) and implemented a new audit process for observation compliance. Additional training on ligature management is being …
Responded
Ash Bannister
Concerns: 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.
Response (United Childrens Services): The response consists of the organisation's name only.
Responded
Neville Abbott
Concerns: A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care practitioners, leading to missed multi-agency risk management opportunities.
Response (BCP Council): BCP Council has made changes to the way in which they support people who find it difficult to engage with support services. A deep dive audit will be undertaken in …
Responded
Samantha Angel
Concerns: Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. The system failed to accelerate the process despite the evident harm.
Response (Portsmouth Hospitals): Portsmouth Hospitals has made improvements to HR investigations, including wellbeing support, training for managers, and prompt signposting to Occupational Health. They are also reinforcing data protection policies to prevent disclosure …
Responded
Sean O’Connor
Concerns: The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into routine worker briefings increased the risk of harm.
Response (Canary Wharf Management): Canary Wharf Management will trial a new feature for work authorisations involving lone working, including a mandatory prompt for welfare checks, to be conducted and recorded by CWML staff if …
Responded
Donna Smith
Concerns: 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.
Response (West Mercia Police): West Mercia Police has withdrawn Airwave Radio from CCTV rooms, now receiving all contact from them via telephony which automatically creates a Contact Record for triage and decision-making, addressing a …
Response (Wychavon District Council): Wychavon District Council CCTV operators will now call 999 for specified incidents, requesting a reference log/number which will create a Contact Record; no further action is expected from CCTV operators …
Responded
Jada Monoja
Concerns: 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.
Response (NHS England): NHS England highlights the Suicide Prevention Strategy and guidance to improve the culture of care for mental health inpatient services. Oxleas has designed a clinical risk training workshop, and participates …
Response (Department of Health and Social Care): The Department acknowledges concerns about the use of risk assessment tools and refers to NICE guidance and the 5-year Suicide Prevention Strategy for England. It highlights NHS England's work to …
Response (South London and Maudsley NHS Trust): The Trust will issue a blue light bulletin reminding clinical staff to update risk assessment documents, and will audit risk assessments using the 'Tendable' system. The Trust will also work …
Responded
Clara Winter
Concerns: 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.
Response (Cwm Taf Morgannwg University Health Board): Cwm Taf Morgannwg UHB has provided training to staff on surgical wards in PCH to recognise and manage acutely unwell patients, with nearly all staff trained or booked for training …
Responded
Susan Edwards
Concerns: 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.
Response (Worcestershire Acute Hospitals NHS Trust): The Trust has focused on educating staff and will implement a 'Lesson of the Week' around mechanical prophylaxis. Anti-coagulation nurses will provide teaching to junior doctors and ward nurses. Checks …
Responded
Committee Recommendations (113) — showing 50 strongest matches
#26 — Code of Practice for resident communication during remediation shows inconsistent practice and limited awareness
Recommendation: 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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2025 3.2 The government will write to the Committee annually from Summer 2025, until Summer 2029 when, in alignment with the RAP, all …
Not Addressed
#14 —
Recommendation: In 2021, the Department acknowledged publicly concerns about excessive levels of noise and vibration on the Ajax vehicles. The Department admitted that because of shortcomings with its safety processes, which made it complicated to raise issues, it had injured some …
Gov response: The department has accepted all the recommendations in the King Report relating to safety and armoured vehicle procurement. Some have already been implemented and the remainder are being progressed. The independent Ajax Lessons Learned Review …
Accepted
#3 —
Recommendation: The failure to escalate and address noise and vibration issues in a timely manner shows that the Department must simplify its over-complex safety processes and change behaviours. The Department acknowledges that it has injured some soldiers, which it rightly describes …
Gov response: 3.1 The government agrees with the Committee’s recommendation Target implementation date: December 2022 3.2 The department has accepted all the recommendations in the King Report relating to safety and armoured vehicle procurement. Some have already …
Accepted
#83 — Publish joint statutory guidance on safe delegation of healthcare responsibilities in schools and trusts.
Recommendation: The Department for Education and the Department of Health and Social Care should issue joint statutory guidance clarifying how and when healthcare responsibilities can safely be delegated in schools and multi- academy trusts. This should be produced in collaboration with …
Gov response: The Government is grateful to the Education Select Committee for its inquiry report into Solving the SEND Crisis and we welcome the opportunity to respond to the Committee. Every child should have a childhood rich …
Not Addressed
#82 — Guidance on delegating healthcare responsibilities within schools remains weak and unclear.
Recommendation: Guidance on the delegation of healthcare responsibilities within schools and multi-academy trusts remains weak. There is insufficient clarity on how and when healthcare tasks can be appropriately and safely assigned to school or multi-academy trust staff, what training and safeguards …
Gov response: The Government is grateful to the Education Select Committee for its inquiry report into Solving the SEND Crisis and we welcome the opportunity to respond to the Committee. Every child should have a childhood rich …
Not Addressed
#80 — Utilise NICE expertise to produce new evidence-led SEND guidelines and intervention pathways.
Recommendation: Bringing education and health more closely together should be supported by an evidence led approach, drawing on the role of NICE (National Institute for Health and Care Excellence) to produce new SEND guidelines and intervention pathways. (Recommendation, Paragraph 277)
Gov response: Effective. Reforms should be grounded in evidence, ensuring all education settings know where to go to find effective practice that has excellent long-term outcomes for children. As set out in the 10 Year Health Plan, …
Partially Accepted
#51 — Provide comprehensive training within ITT and clear guidance for inclusive education practices.
Recommendation: The Department should provide comprehensive training within ITT and clear guidance for schools, multi-academy trusts and education staff on delivering inclusive education practice. This will ensure that all settings understand their legal obligations and are equipped to make the necessary …
Gov response: In schools, we want to make sure teachers can access high quality professional development that supports them to deliver the best teaching for all pupils, including those with SEND. We are considering how we can …
Partially Accepted
#9 — Inconsistent SEN support and provision leads to inequitable experiences for children with SEND.
Recommendation: The current inconsistency in SEN support and ordinarily available provision across England is unacceptable and results in deeply inequitable experiences for children and young people with SEND. The lack of consistent good practice in SEN support, driven by insufficiently clear …
Gov response: Fair. Every school should be resourced and able to meet common and predictable needs, including as they change over time, without parents having to fight to get support for their children. Where specialist provision is …
Partially Accepted
#30 — Ensure schools implement clear policies and teacher training to tackle anti-Muslim hate.
Recommendation: The Government should ensure that schools have clear policies in place for tackling anti-Muslim hate. This needs to include specific training for teachers on the ways in which gendered Islamophobia manifests in society to ensure that teachers are equipped to …
Gov response: 80. Muslim students and staff should be able to receive an education without the threat of harassment or racial abuse, and we welcome the Committee’s recommendation here. There is no place for hate or prejudice …
No Published Response
#14 — Afghan relocation unit reported 49 data breaches between 2021 and 2025.
Recommendation: In August 2025, the Department reported that there had been 49 separate data breaches between 2021 and 2025 at the unit handling applications from Afghan citizens to relocate to the UK. Of these, the Department assessed that seven met the …
Under Consideration
#180 — Inconsistent deployment of security measures undermines their effectiveness against criminal networks
Recommendation: Our observations confirmed that existing security measures, such as sniffer dogs, are often deployed in an inconsistent manner. For example, drug detection dogs being used for only a few instances in a day in some prisons, rather than as part …
Gov response: Disrupting the illicit economy within prisons is critical to maintaining safety and security, and financial intelligence plays a key role in this effort. HMPPS already has a Financial Investigation Unit (FIU) with both investigation and …
Partially Accepted
#18 —
Recommendation: Demands on the civil servants working on the Covid-19 pandemic response and/or EU Exit have been high at a time when many are having to adjust to new ways of remote working.48 The Cabinet Office believes that morale across staff …
Gov response: 3. 1 The government disagrees with this recommendation. 3.2 Please refer to the department’s response to recommendation 4.
Not Addressed
#17 —
Recommendation: The Department said that Ajax’s safety problems had highlighted broader issues around noise-induced hearing loss, which formed the largest number of claims in the armed forces compensation scheme. It has commissioned the vice-chief of the defence staff and the second …
Gov response: The department has accepted all the recommendations in the King Report relating to safety and armoured vehicle procurement. Some have already been implemented and the remainder are being progressed. The independent Ajax Lessons Learned Review …
Not Addressed
#15 —
Recommendation: In June 2021 the Department commissioned David King, its Director Health, Safety and Environmental Protection, to assess whether correct health and safety procedures had been followed. His report, published in December 2021, concluded that collective failings enabled activity to continue …
Gov response: 3.2 The department has accepted all the recommendations in the King Report relating to safety and armoured vehicle procurement. Some have already been implemented and the remainder are being progressed. The independent Ajax Lessons Learned …
Accepted
#40 —
Recommendation: Following the House administrations being three months late sharing information about a recent asbestos incident, the Clerk of the House acknowledged staff should have been notified earlier.108 We heard relevant trade union representatives were informed on 15 February, five days …
Gov response: The Clerk of the House and the Clerk of the Parliaments agree with the Committee’s recommendation. Target implementation date: the revised safety escalation protocols were implemented on 6 April 2022. A further review of their …
Accepted
#21 —
Recommendation: The incident was formally reported to the Health and Safety Executive on 10 February 2022, with relevant trade unions informed on 15 February. The Clerk of the House of Commons acknowledged that the staff affected should have been contacted with …
Gov response: Fourth bullet – safety escalation and reporting protocols The Clerk of the House and the Clerk of the Parliaments agree with the Committee’s recommendation. Target implementation date: the revised safety escalation protocols were implemented on …
Accepted
#20 —
Recommendation: The Clerk of the House of Commons explained the House administrations stood down all works on the parliamentary estate on 9 February, in part to check whether the right protocols were in place and understood by the relevant staff.50 He …
Gov response: Fourth bullet – safety escalation and reporting protocols The Clerk of the House and the Clerk of the Parliaments agree with the Committee’s recommendation. Target implementation date: the revised safety escalation protocols were implemented on …
Accepted
#5 —
Recommendation: To date, there has been a failure of transparency and accountability over work to restore and renew the Palace. This includes: the House administrations being three months late sharing, in line with expected standards, information on a recent asbestos incident …
Gov response: To maintain effective transparency over the Programme: • Measures should be put in place by the Programme’s Accounting Officers to ensure the programme sponsor reports regularly to Parliament on progress, including information on the potential …
Accepted
#8 —
Recommendation: We recommend that the Government, in consultation with the Menopause Ambassador, produces model menopause policies to assist employers. The model policies should cover, as a minimum: how to request reasonable adjustments and other support; advice on flexible working; sick leave …
Gov response: Whilst supporting the ambition, the government does not accept this recommendation, as we do not believe a model menopause policy is necessary at this moment. The government agrees with the Committee that there is much …
Not Accepted
#4 —
Recommendation: If Mr Thompson’s assertion is correct—namely, that there are errors in applying company policy at Royal Mail—then these would appear to be widespread, and we can only conclude that the level of management oversight at Royal Mail is negligent and …
Gov response: As has previously been said to the Committee, it is not our policy to prioritise parcels over letters. It is clearly important that our policies are implemented consistently across Royal Mail, so where there are …
Under Consideration
#3 —
Recommendation: Mr Thompson asserts that the evidence we presented to him was due to failures to apply company policy. However, we do not believe that such widespread errors in applying company policy could happen without the direct or indirect approval of …
Gov response: As has previously been said to the Committee, it is not our policy to prioritise parcels over letters. It is clearly important that our policies are implemented consistently across Royal Mail, so where there are …
Under Consideration
#65 — Improve local authority staff training on SEND law and parent engagement for better relationships
Recommendation: Local authority staff require improved training on child development, SEND law, parent engagement and mediation, alongside changes in practice that strengthen accountability and foster more constructive relationships with parents and carers. This should include meaningful parental involvement at every stage …
Gov response: We appreciate the Committee’s careful consideration of these issues and will respond to their recommendations on improving local authority accountability, including in relation to the SEND tribunal. Almost 95% of education, health and care plans …
Not Addressed
#62 — Issue guidance on TA-to-pupil ratios and develop comprehensive recruitment and retention strategy
Recommendation: The Department should issue guidance on teaching assistant-to-pupil ratios and urgently address the worsening crisis in recruiting and retaining TAs and learning support assistants to ensure these ratios can be met. These professionals are vital to the delivery of inclusive …
Gov response: Teaching Assistants (TAs) play an important role in supporting pupils with SEND. We recognise that training and career progression opportunities for TAs help schools have the skilled staff they need. This Government values and recognises …
Partially Accepted
#9 — FCDO prioritises estate safety, compliance, and security as its paramount strategic goal for staff welfare.
Recommendation: FCDO’s first strategic goal for its estate is for it to be safe, compliant with all relevant health and safety standards, and for it to be as secure as possible.19 The Permanent Under-Secretary told us that his most important duty …
Gov response: The government agrees with the Committee’s recommendation. requested by the Committee, noting that the negotiations for a Sanitary and Phytosanitary (SPS) agreement with the EU, and timescales involved, will need to be integrated into development …
Accepted
#15 —
Recommendation: We are concerned that lower qualified social care workers and those without qualifications at all are not eligible for the new NHS visa, not least because it undermines parity of esteem between the health and social care sectors. The Government …
Gov response: 7.28 Within the social care workforce, nurses, occupational therapists and social workers are eligible for the Health and Care Visa. Additionally, we are reviewing the list of eligible occupations since the launch of the expanded …
Under Consideration
#14 —
Recommendation: The Government must ensure that transitional arrangements are in place to ensure that social care workers can continue to be recruited from overseas for as long as it takes to build sufficient resilience in the domestic supply of social care …
Gov response: 7.24 We recognise the end of free movement between the UK and the EU means the majority of roles in adult social care will not be eligible for a sponsored work visa. Currently, 7% of …
Under Consideration
#9 —
Recommendation: We welcome the Government’s commitment to bringing forward a long-term solution to low pay in social care. It is essential that this solution provides a sustainable basis for continued rises in pay above and beyond increases to the National Minimum …
Gov response: Details of the level of funding provided to the social care system during the COVID-19 pandemic and at the 2020 Spending Review can be found in the preface to these responses. 7.1 We recognise the …
Under Consideration
#8 —
Recommendation: Improving the level of recognition afforded to social care workers must be a key focus for the Government to safeguard the future of the social care workforce. Not to do so would be to fail the many thousands of care …
Gov response: 7.20 The social care workforce has demonstrated compassion and dedication in responding to the COVID-19 pandemic. They have worked at the front line, supporting people at the heart of their communities. We want to increase …
Under Consideration
#8 —
Recommendation: We acknowledge there are staffing issues for the health and social care sector and that the Migration Advisory Committee did not have enough information when making the decisions about the Shortage Occupation List for Scotland. We welcome the recent development …
Gov response: The UK Government welcomes the recommendations of the Migration Advisory Committee (MAC) on the Shortage Occupation List (SOL). The Home Secretary wrote to the Chair, Professor Brian Bell, on 22 October 2020 to thank him …
Under Consideration
#17 —
Recommendation: There has been high turnover among staff working on EU Exit, particularly at senior levels. DExEU has had three Permanent Secretaries, the Border Delivery Group has had three Director-Generals, and there have been changes at Permanent Secretary grade in key …
Gov response: 4: PAC conclusion: EU Exit preparations involved more than 22,000 civil servants at the peak and have cost at least £4.4 billion. 4: PAC recommendation: The Cabinet Office should conduct a formal review, including seeking …
Not Addressed
#16 —
Recommendation: At the peak, more than 22,000 civil servants worked on EU Exit, and at present the Cabinet Office reports that the number is around 15,000.43 The civil service responded to this demand by moving staff between departments. In particular two …
Gov response: 4: PAC conclusion: EU Exit preparations involved more than 22,000 civil servants at the peak and have cost at least £4.4 billion. 4: PAC recommendation: The Cabinet Office should conduct a formal review, including seeking …
Not Addressed
#27 —
Recommendation: By October 2020, employers had reported 8,152 diagnosed cases of COVID-19 and 126 deaths as being linked to occupational exposure among health and care workers.45 The British Medical Association and Unison asserted that the Department should investigate whether PPE shortages …
Gov response: 5.5 There are mechanisms in place to investigate the deaths of health and care workers which involve coroners and the Health and Safety Executive (HSE). Medical examiners also have a role in scrutinising deaths of …
Not Addressed
#4 —
Recommendation: We welcome the additional support provided to health and care staff during the pandemic. However, we conclude that such additional support will need to be maintained during the recovery period and beyond to stop further staff from leaving. Furthermore simply …
Gov response: Recommendation 3 and 4 have been grouped together for an overarching response to the committee. NHS and social care staff have undoubtedly been through a very challenging period and they have been dedicated to providing …
Under Consideration
#3 —
Recommendation: We further recommend that the NHS Staff Survey and any social care equivalent includes an overall staff wellbeing measure, so that employers and national bodies can better understand staff wellbeing and take action based on that understanding. The Staff Survey …
Gov response: Recommendation 1 and 2 have been grouped together for an overarching response to the committee. The government agrees with the committee that monitoring staff wellbeing is essential both to better understand the various factors that …
Under Consideration
#20 —
Recommendation: General Dynamics has proposed modifications to vehicles that seek to reduce the impact of noise and vibration on crews and include, for example, the damping of hand controllers and seating, and changes to improve body posture. However, the Department said …
Gov response: The department is focussed on identifying the root causes of the noise and vibration issues to develop long-term solutions to ensure Ajax operates as required by the Army. The Written Ministerial Statement laid out in …
Not Addressed
#19 —
Recommendation: The Department told us that its contract with General Dynamics was to produce vehicles at an acceptable level of noise using existing headsets. It asserted that those headsets performed as it had assumed they would when the contract was let, …
Gov response: The department is focussed on identifying the root causes of the noise and vibration issues to develop long-term solutions to ensure Ajax operates as required by the Army. The Written Ministerial Statement laid out in …
Not Addressed
#18 —
Recommendation: Under the terms of the contract, General Dynamics is responsible for ensuring that Ajax vehicles are safe by design. The Department oversees and monitors this, conducting trials to ensure the vehicles are safe to use.35 The two parties disagreed on …
Gov response: The department is focussed on identifying the root causes of the noise and vibration issues to develop long-term solutions to ensure Ajax operates as required by the Army. The Written Ministerial Statement laid out in …
Not Addressed
#16 —
Recommendation: The Army told us it now placed greater emphasis on safety and looking after its personnel and that it had made “huge strides”. However, it acknowledged that it continued to be on a learning curve and that it still had …
Gov response: 3.2 The department has accepted all the recommendations in the King Report relating to safety and armoured vehicle procurement. Some have already been implemented and the remainder are being progressed. The independent Ajax Lessons Learned …
Not Addressed
#4 —
Recommendation: Nearly two years after identifying injuries to soldiers, the Department still does not know how to fix the noise and vibration problems. General Dynamics must produce vehicles that are safe and has proposed modifications to reduce noise and vibration levels. …
Gov response: 4.1 The government agrees with the Committee’s recommendation Target implementation date: December 2022 4.2 The department is focussed on identifying the root causes of the noise and vibration issues to develop long-term solutions to ensure …
Not Addressed
#9 —
Recommendation: In addition to the wider efforts to improve basic documentation, the Department told us that it had introduced measures such as spot checks by the principal private secretary to reinforce the importance of proper record-keeping in private offices. The Department …
Gov response: 1: PAC conclusion: Woefully inadequate record-keeping by the Department makes it impossible to have confidence that all its contracts with Randox were awarded properly. 1: PAC recommendation: The Department should write to us within two …
Accepted
#11 —
Recommendation: Neither the Health and Safety Executive (HSE) nor the Equality and Human Rights Commission (EHRC) provides any advice on menopause on its website. This should be rectified. The HSE and EHRC should publish guidance on the legal considerations when supporting …
Gov response: 84. The government accepts this recommendation in part. 85. The government is developing strengthened guidance that will give a set of clear and simple ‘principles’ that employers would be expected to apply, to support disabled …
Partially Accepted
#9 —
Recommendation: Menopause symptoms can have a significant and sometimes debilitating impact on women at work. The Government should work with a large public sector employer 48 Menopause and the workplace with a strong public profile to develop and pilot a specific …
Gov response: The government does not accept this recommendation. Within the Civil Service, we are focusing our efforts on developing and promoting good practice and adoption across the Civil Service. As set out in our response to …
Not Accepted
#7 —
Recommendation: The Government has a key strategic role in helping businesses and should lead the way in developing and disseminating good practice. The Government should appoint a Menopause Ambassador to work with stakeholders from business (including small to medium enterprises), unions, …
Gov response: 57. The government accepts this recommendation in principle. 58. This recommendation is in line with the recent government response18 to the independent menopause and the workplace report19 commissioned by the then Minister for Employment through …
Accepted
#6 —
Recommendation: Menopause is a workplace issue. There is a legal, economic, and social imperative to address the needs of menopausal employees. We are not persuaded that a legal requirement for every workplace to have a menopause policy would embed meaningful change. …
Gov response: 62. Whilst supporting the ambition, the government does not accept this recommendation, as we do not believe a model menopause policy is necessary at this moment. The government agrees with the Committee that there is …
Not Accepted
#20 —
Recommendation: Although ultimate responsibility must lie with the Prime Minister and Foreign Secretary, Ambassadors and other UK Heads of Mission should have a central role in preventing atrocities in the countries where they work. That role should be explicitly articulated in …
Gov response: 39. Sustainable Development Goal 16 is a priority for the UK Government. This commitment is reaffirmed in the 2022 International Development Strategy (IDS), which states: ‘Our approach to international development will be as a patient …
Under Consideration
#10 —
Recommendation: We are in little doubt that the blanket approach by Royal Mail in not paying sick pay during periods of strike action will have been unduly harsh on those who were genuinely unfit for work and who may, through no …
Under Consideration
#2 —
Recommendation: We acknowledge that there may be a case for Royal Mail to use PDA data to achieve consistent and effective performance, as long as it is undertaken within the terms of established policies and following consultation with the workforce.
Gov response: As has previously been said to the Committee, it is not our policy to prioritise parcels over letters. It is clearly important that our policies are implemented consistently across Royal Mail, so where there are …
Under Consideration
#25 —
Recommendation: The PHSO should provide an update in its response to this Report regarding what tools and infrastructure have been upgraded to support hybrid working, as mentioned in the Business Plan for 2022–23. The Committee would also appreciate information on what …
Gov response: Following the decision to maintain hybrid working, we have made some updates to systems to maximise productivity. We have integrated telephone and ICT systems to remove the need for call forwarding to mobiles and reduce …
Accepted
#11 —
Recommendation: Despite existing guidance on protecting vulnerable workers on the Health and Safety Executive website and Working Safely guidance on GOV.UK, many pregnant women still report health and safety concerns at work. Adhering to this guidance should not be seen by …
Gov response: Throughout the pandemic, the Health and Safety Executive (HSE) has supported Great Britain’s public health response in the workplace, by adopting a risk-based approach. HSE have used health and safety at work legislation, government guidance, …
Accepted
#10 — Recent asbestos incidents highlight ongoing contractor reporting failures and necessitate procedural review
Recommendation: Since then, there have been two further asbestos incidents, one of which the Clerks accepted had not been handled appropriately. In September 2022 a contractor did not inform the Clerks of an asbestos incident or limit the dangers as quickly …
Gov response: The Clerk of the House and Clerk of the Parliaments agree with this recommendation. The Clerks fully recognise the need to reiterate the importance of excellent health and safety performance, including the timeliness and accuracy …
Accepted
CQC Inspection Actions (21)
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.
Should Do
Elizabeth Street Surgery
Make all policies and procedures accessible to staff.
Should Do
Charlton House Medical Centre
developingarangeofsuitablepoliciesandprocedurestoensureclinicalandnon-clinicalstaffworkedtoappropriate standardstomeettheneedsofthepatientpopulation;
Must Do
Universal Care - Beaconsfield
We recommend the provider seek guidance from a reputable source to ensure the duty of candour requirements are fully understood by all staff.
Should Do
Laurel Lodge Care Home
The provider must ensure that persons employed in the provision of a regulated activity receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
Must Do
Attwood's Manor Care Home
We recommend that the provider review the current induction processes of new staff and ensure it is more robust and links in with the care certificate for new staff.
Should Do
The Newcastle Clinic
The service should have a system in place to ensure all MRI safety records and Gadolinium contrast consent forms are signed by radiographers.
Should Do
Prospects for People with Learning Disabilities - 3 Norwich Road
Staff who worked on an as and when basis did not receive any regular formal supervision despite the fact they worked at the home a couple of times a week.
Should Do
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.
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure sufficient and appropriately supported staff, including proper induction, supervision, appraisals, and training.
Must Do
Badger House
The provider finds out more about staff supervisions and takes action to update their practice accordingly.
Should Do
Winterton House
Staff did not always have sufficient skills and knowledge to enable them to support people living with dementia. Persons employed by the service provider in the provision of a regulated activity did not receive appropriate support, training, professional development, supervision …
Must Do
Universal Care - Beaconsfield
the provider sought guidance from a reputable source to ensure the duty of candour requirements were fully understood by all staff.
Should Do
The Croft
Staff files contained little evidence of discussion between the registered manager and staff about what they were doing well or what support they needed for their personal development. We found supervision records contained very basic information, which was mostly cut …
Should Do
Goldenley Care Home
The provider must ensure that persons employed receive appropriate support, training, professional development, supervision, and appraisal necessary to perform their duties.
Must Do
Ashbourne House - Torquay
People were not protected by infection control practices. The staff and provider did not have up to date knowledge in respect of infection control practices.
Must Do
Ashbourne House - Torquay
Service users were not protected from abuse because there were ineffective systems in place to implement safeguarding recommendations. There was a limited understanding from staff about safeguarding procedures.
Must Do
The Newcastle Clinic
The service should have a documented lone working policy or agreement.
Should Do
Ashcroft House - Leeds
We recommend that instructions received by external healthcare professionals be written into care planning and that staff are made aware of these instructions so they can be fully implemented.
Should Do
Affinity Trust Specialist Support Division North
The provider to immediately review their practice and act accordingly.
Should Do
Clare House Residential Home
The registered manager agreed to implement these policies immediately after the inspection.
Should Do
HMICFRS Recommendations (102) — showing 50 strongest matches
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS’s staff sometimes act in ways that go against its core values. This is leading to bullying in the workplace. Recommendation: The service should ensure that staff act in line with its values and are …
Recommendation
FRS 2021-22 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve how staff understand and display its expected values and behaviours. Recommendation: By 31 August 2022, the service should develop an action plan to ensure that staff …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service isn’t taking a proportionate approach to promoting equality, diversity and inclusion (EDI) in the workplace. Recommendation: By 31 August 2021, the service should make sure that senior leaders respond appropriately and quickly to EDI feedback …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2023-25 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since our last inspection to improve equality, diversity and inclusion. Recommendation: The service should improve equality, diversity and inclusion (EDI) by: • making improvements to the way it collects equality data …
Recommendation
FRS 2021-22 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since the last inspection to improve EDI. Recommendation: By 31 August 2022, the service should develop an action plan to: • make improvements to the way it collects equality data to …
Recommendation
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade has shown a clear intent to improve the culture of the brigade, with some staff reporting improvements under the new commissioner. However, more needs to be done. We found evidence of behaviours that are not …
Recommendation
FRS 2023-25 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: Since our last inspection, the service has made enough improvement to address two of our previous recommendations. But it still needs to improve equality, diversity and inclusion. The following recommendations remain in place. Recommendation: Within 28 days, …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve its EDI. Recommendation: By 30 September 2021, the service should improve how it works with its staff and provides feedback in relation to EDI issues.
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS has no strategy, visible leadership and limited training on equality, diversity and inclusion. This is affecting watch culture and undermining positives steps to attract new entrants from diverse backgrounds. Recommendation: By 31 December 2019, …
Recommendation
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: • …
Recommendation
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: • …
Recommendation
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: • …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to make sure …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to improve how …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to establish effective …
Recommendation
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 …
Recommendation
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 …
Recommendation
FRS 2018-19 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: There is a clear intent from senior officers to improve the culture of the service, and many staff reported improvements under the new chief fire officer. However, more needs to be done. We are concerned to have …
Recommendation
FRS 2018-19 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: There is a clear intent from senior officers to improve the culture of the service, and many staff reported improvements under the new chief fire officer. However, more needs to be done. We are concerned to have …
Recommendation
FRS 2023-25 CoC Recommendations: Dorset and Wiltshire Fire and Rescue Service
Cause of concern: The service needs to do more to ensure that its staff routinely demonstrate behaviours in line with its values. We found strong evidence of behaviours that weren’t in line with service values. We were told about cultures …
Recommendation
FRS 2023-25 CoC Recommendations: Dorset and Wiltshire Fire and Rescue Service
Cause of concern: The service needs to do more to ensure that its staff routinely demonstrate behaviours in line with its values. We found strong evidence of behaviours that weren’t in line with service values. We were told about cultures …
Recommendation
FRS 2018-19 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: We acknowledge Avon FRS has recently carried out a cultural review and has a plan in place to improve its organisational culture. But it should act immediately to change staff behaviours. It should also make sure all …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn’t engage with or seek feedback from staff to understand their needs. We found this to especially be the case with some under-represented groups. When staff raise issues and concerns, the service doesn’t respond …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn’t engage with or seek feedback from staff to understand their needs. We found this to especially be the case with some under-represented groups. When staff raise issues and concerns, the service doesn’t respond …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS’s staff sometimes act in ways that go against its core values. This is leading to bullying in the workplace. Recommendation: The service should clearly and effectively communicate its core values to staff. This should …
Recommendation
FRS 2021-22 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve how staff understand and display its expected values and behaviours. Recommendation: By 31 August 2022 the service should provide an updated action plan to:- improve how …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2021-22 CoC Recommendations: Northumberland Fire and Rescue Service
Cause of concern: The management of dual contracts, for staff working on-call and wholetime in the service, must be improved. Recommendation: By 31 March 2022, the service should:- make sure staff take appropriate breaks between on-call and wholetime commitments for …
Recommendation
FRS 2021-22 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since the last inspection to improve EDI. Recommendation: By 31 August 2022, the service should develop an action plan to: • support staff and managers to confidently challenge and manage inappropriate …
Recommendation
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade has shown a clear intent to improve the culture of the brigade, with some staff reporting improvements under the new commissioner. However, more needs to be done. We found evidence of behaviours that are not …
Recommendation
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade has shown a clear intent to improve the culture of the brigade, with some staff reporting improvements under the new commissioner. However, more needs to be done. We found evidence of behaviours that are not …
Recommendation
FRS 2023-25 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: Since our last inspection, the service has made enough improvement to address two of our previous recommendations. But it still needs to improve equality, diversity and inclusion. The following recommendations remain in place. Recommendation: Within 28 days, …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve its EDI. Recommendation: By 30 September 2021, the service should give greater priority to how it increases awareness of EDI across the organisation.
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS has no strategy, visible leadership and limited training on equality, diversity and inclusion. This is affecting watch culture and undermining positives steps to attract new entrants from diverse backgrounds. Recommendation: By 31 December 2019, …
Recommendation
FRS 2018-19 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: GRFS values are tarnished and are not credible with staff. The service needs to introduce its new values and service structure to allow staff and managers to understand the priorities for the future. Recommendation: The service should …
Recommendation
ICIBI Immigration Recommendations (1)
PPO Death in Custody Recommendations (23)
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.
The Governor
The Governor should ensure that all managers follow the national instructions for dealing with a death in custody or serious incident, including that all staff directly involved in an incident complete Incident Report Forms as soon as possible.
The Governor
The Governor should ensure that the staff named in this report are given the opportunity to read this initial report in line with paragraph 1.11 of PSI 58/2010.
The Director
The Director should ensure that when a cell door is unlocked, staff satisfy themselves of the safety of the prisoner by obtaining a response in line with local instructions.
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.
The Director of HMP Peterborough
The Director of HMP Peterborough should identify an effective means to ensure all staff understand their responsibilities to check the welfare of prisoners when unlocking cells.
The Director General of Operations of HM Prisons and Probation …
The Director General of Operations of HM Prisons and Probation Service should remind staff of the requirement to adhere to the Civil Service Code and for sensitive and responsible use of social media.
The Head of Healthcare
The Head of Healthcare should ensure that clinical checks on prisoners who are refusing food and/or fluids are carried out and recorded appropriately to ensure risks are managed.
The Governor
The Governor should implement a process for monitoring food collection, to ensure follow up action can be taken where necessary.
The Governor
The Governor should remind staff to switch on their body-worn cameras during reportable incidents and ensure that control room operators prompt staff to do so during an incident.
The Governor of HMP Sudbury
The Governor should ensure that all ROTL board reviews and decisions are made in or following a discussion or meeting between the board members and any other relevant individuals;
The Governor
The Governor should review staff compliance with local roll check procedures and identify any improvements to practice required.
The Governor
The Governor should ensure that staff operate their body-worn video cameras in line with national guidance.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • All necessary paperwork explaining the decision to segregate is appropriately completed, stored, and made available in the event of a PPO investigation.
The Director
The Director should share this report with PCO A and PCO B and ensure that a senior manager discusses the Ombudsman’s findings with them.
The Governor of HMP Birmingham
The Governor should introduce a robust quality assurance process to ensure that staff conduct routine roll checks and welfare checks in line with local and national guidelines.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should all remind staff that it is not appropriate to request or expect prisoners to collect medical equipment in medical emergencies.
The Governor
The Governor should ensure that any decision to move a prisoner while they are attending court is authorised by a wing manager, with the reasons for any move recorded in the prisoner’s records.
The Governor
The Governor should ensure that staff offer reasonable funeral expenses, in addition to repatriation costs, if a deceased foreign national prisoner is repatriated.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff follow local and national instructions regarding body scanners including that body scans are recorded appropriately, and decisions taken following scans are in adherence to the policy and clearly recorded.
The Governor
The Governor should ensure that all staff understand and follow the safeguarding policy, particularly with regard to the division of responsibilities for action to be taken.
The Governor of Holme House
The Governor of Holme House should remind all staff of the importance of completing information reports (IRs) when they receive information about threats of violence and bullying.
The Governor
The Governor should investigate the circumstances that led to Mr Stewart being sacked from his job to establish whether standard protocol was followed.
IOPC Learning Recommendations (12)
Recommendations - Greater Manchester Police, December 2020
The IOPC recommends that the Police Staff Council strengthen the Standards of Professional Behaviour (September 2008) in respect of ‘Authority, Respect and Courtesy’ to make it explicit to police staff that they should not establish or pursue an improper sexual …
Recommendations - Greater Manchester Police, December 2020
The IOPC recommends that GMP ensure that officers and staff working with children in any capacity are aware of the appropriate communications channels and that contact with a child via social media is never appropriate. This follows an IOPC investigation …
Recommendations - Greater Manchester Police, December 2020
The IOPC recommends that GMP update their policies on the use of personal social media to reinforce to officers and staff that using personal social media to contact members of the public they have met through their work or duties …
Recommendations - Northumbria Police, March 2021
The IOPC recommends that Northumbria Police take steps to ensure all officers and the wider organisation conform to the expectations of their behaviour under section 26 of the Equality Act 2010, whilst on and off duty, and promote a safe …
Recommendations - Northumbria Police, March 2021
The IOPC recommends that Northumbria Police take steps to ensure all officers and staff are complying with the Association of Chief Police Officers’ Guidelines on the Safe use of the Internet and Social Media by Police Officers and Police Staff …
Recommendations - Northumbria Police, March 2021
The IOPC recommends that Northumbria Police take steps to ensure all officers and the wider organisation conform to the expectations of their behaviour under the Code of Ethics, whilst on and off duty, and promote a safe and open culture, …
Recommendation - Essex Police, March 2021
The IOPC recommends that Essex Police take steps to ensure that supervising officers and staff in community policing departments are made aware of policies around the use of police cadets in community policing, including considerations around safeguarding, and are updated …
Recommendations - North Wales Police, January 2025
The IOPC recommends that North Wales Police review, and where necessary amend, their practice, guidance and policies surrounding the managing and recording of employees’ disabilities and provision of reasonable adjustments for disabled employees. This learning recommendation has arisen following an …
Recommendations - West Yorkshire Police, February 2021
The IOPC recommends that West Yorkshire Police (WYP) takes steps to review its use of the Central Logging of Intelligence Operations (CLIO) in Armed Policing Operations ensuring that command decisions are recorded by all relevant officers in compliance with national …
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 …
Investigation into police response to a call from a woman reporting assault …
The IOPC recommends that Cumbria Constabulary should clarify the process for when victims and witnesses should be provided with an information leaflet following a statement being taken, and how this should be recorded. This follows an IOPC investigation where Cumbria …
Recommendation - Surrey Police, April 2022
The IOPC recommends that Surrey Police updates relevant force policies relating to complaint handling [and body worn video (BWV) if appropriate] to include searching for BWV footage relevant to a complaint received and marking it as evidential as part of …
NAO Audit Recommendations (2)
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 …
Accepted
The BBC’s implementation of Across the UK
e set out a revised communications and engagement strategy. Building on its learning from phase one, the BBC should set out plans for sustaining culture change from ATUK. As it moves into phases two and three, it needs to collect …
Accepted
IMB Annual Reports (12)
Brinsford (2025)
HMP/YOI Brinsford, a YOI and Category C resettlement prison, held an average of 545 prisoners during the reporting year. While the environment is generally considered safe and healthcare provision good, the Board has significant concerns regarding the persistent delays in mental health transfers, the poor condition of the estate, and inadequate education and purposeful activity. Key worker compliance is low due to staffing issues, and violence between prisoners increased to 528 incidents.
PRISON
Key concerns
Brixton (2025)
HMP Brixton operated as an overcrowded Category C resettlement prison during the reporting year, with a population of 697 against a CNA of 530. The year was marked by preparations for a delayed re-role to Category B, which disrupted rehabilitation efforts. Positive developments included a reduction in self-harm, improved induction processes, and good staff-prisoner relations, alongside high-quality food provision. However, significant concerns persisted regarding drug availability, property loss, unlawful detentions, and the impact of the re-role on resettlement and purposeful activity.
PRISON
Key concerns
Chelmsford (2025)
HMP Chelmsford, a Category B local prison, reported three deaths in custody and a 4% reduction in self-harm incidents, though the total of 848 remains high. Operational capacity was 660, with 71% of the population being unsentenced, and overcrowding remains a significant concern, especially in the older Victorian wings. The prison saw a decrease in prisoner-on-staff violence but an increase in prisoner-on-prisoner violence and consistently high use of force incidents. Challenges persist with mental health provision due to a lack of specialist beds, property safeguarding, and staff conduct, while the Launchpad platform and improved dentistry services were positive developments.
PRISON
Key concerns
Wayland (2025)
The Wayland IMB's 2025 prisoner attitudes survey reveals a concerning decline in prisoner safety and trust, alongside persistent issues with basic decency standards in accommodation. While some improvements were noted in literacy support and property reception, significant challenges remain in staff-prisoner relationships, access to healthcare appointments, and the overall restrictiveness of the regime. The report highlights high levels of loneliness and a substantial drop in family visits, urging management to address these core concerns to improve prisoner welfare and prepare them for release.
PRISON
Key concerns
Brinsford (2021)
Despite a severely restricted Covid-19 regime, HMP/YOI Brinsford is deemed a safe prison where prisoners are treated fairly. While incidents of violence, self-harm, and substance misuse have reduced due to lockdown, persistent issues include delays in transferring prisoners with mental health needs and an education contract that largely failed to meet prisoner requirements for much of the reporting period.
PRISON
Key concerns
Thorn Cross (2022)
HMP/YOI Thorn Cross experienced a challenging year due to the pandemic and staffing issues but maintained a safe and humane environment. The Board found the prison's rehabilitative culture and healthcare provision to be strong, with positive staff-prisoner relationships. Key concerns include budget pressures, delays in high-risk transfers, persistent property issues, and the need to improve data collection on protected characteristics and reduce absconds.
PRISON
Key concerns
Swinfen Hall (2022)
HMP/YOI Swinfen Hall, a YOI and Category C training prison, held 583 prisoners during the reporting year. The Board noted positive progress in safety initiatives and equality, diversity, and inclusion. However, significant concerns remain regarding slow responses to prisoner property and complaints, insufficient purposeful activity places, and delays in offender management. Healthcare provision, particularly night cover and mental health staffing, also raises concerns.
PRISON
Key concerns
The Verne (2025)
HMP The Verne is a Category C training prison for men convicted of sexual offences, housing 645 prisoners at the end of the reporting period. The Board found it generally safe and humane, commending healthcare, key worker improvements, and the new Building Choices program. Key concerns include staffing uncertainty, lack of 24-hour clinical cover, and the impact of budget cuts on education and purposeful activity.
PRISON
Key concerns
Ford (2025)
HMP Ford, a Category D open prison, continues its focus on rehabilitation and resettlement amidst significant challenges. The prison has seen a rise in high-risk prisoners and increased population churn, while facing persistent issues with failing infrastructure and substantial cuts to the education and training budget. Despite these hurdles, the IMB commends the prison for its generally safe environment, excellent healthcare provision, and ensuring all released prisoners secure accommodation.
PRISON
Key concerns
Hatfield (2025)
HMP Hatfield, a Category D open men's prison and YOI, maintains a generally safe environment with no self-harm, assaults, deaths, or use of force incidents reported in the year. The IMB commends the prison's strong focus on resettlement, evidenced by high rates of employment (62.85%) and accommodation (99.75%) upon release. While facilities are improving through capital maintenance and healthcare provision is well-managed, concerns remain regarding the negative impact of prison population pressures on the Category D ethos, maintenance issues at the Lakes site, and the suitability assessment process for new prisoners.
PRISON
Key concerns
East Sutton Park (2025)
HMP/YOI East Sutton Park is an open female prison praised for its safety, healthcare, and resettlement efforts, with no deaths in custody during the reporting period. Key concerns include ongoing issues with property transfers, inconsistent responses to bullying, and delays in ROTL progression. The Board also highlights accessibility challenges in the old building and spatial constraints in healthcare facilities.
PRISON
Key concerns
Usk and Prescoed (2025)
HMP Usk and Prescoed are generally well-managed establishments with strong leadership, where prisoners report feeling safe and experience positive staff relations. However, the Board raises significant concerns regarding the welfare and progression of specific prisoner groups, particularly IPP prisoners, and elderly/disabled individuals requiring social care. Challenges related to staffing, the impact of early release schemes on rehabilitation, and delays in Release on Temporary Licence (ROTL) are highlighted as key areas needing intervention from both the Minister and HMPPS.
PRISON
Key concerns
IMB Recommendations (233) — showing 50 strongest matches
Berwyn (2020)
There is a need to ensure that systems and policies are consistent and fully understood both by prisoners and staff.
Governor / Director
Durham (2024)
How will you ensure that staff fully understand the eligibility and process for clothing parcels to be handed in/delivered to the prison so that consistent guidance is given to prisoners?
Governor / Director
Portland (2022)
What efforts will the Governor make to ensure that all staff comply with the new regulations concerning the wearing of BWC?
Governor / Director
Norwich (2022)
The Board asks the Governor to provide information on plans for making sure that all communications especially Governor's notices to prisoners (GNTPs) are distributed to, seen and understood by all prisoners including those who do not read/speak English This concern was highlighted in the 2020-21 annual report but the Board does not see any improvement.
Governor / Director
Downview (2023)
A lack of consistency in the application of prison rules by staff is frequently mentioned by prisoners during our monitoring. This may be exacerbated by staff inexperience and the ongoing regular staff redeployment. Staff tell us they feel undermined and less confident in maintaining safety, and prisoners cite frustration at perceived unfairness when senior managers overrule decision-making (sections 5.3, 5.6).
Governor / Director
Lancaster Farms (2025)
What steps will the Governor take to ensure that all prison officers wear and switch on their body worn video cameras?
Governor / Director
Five Wells (2025)
When will the policy be enforced on the use of vapes for both staff and prisoners?
Governor / Director
Five Wells (2025)
When will the policy be enforced on the use of vapes for both staff and prisoners?
Governor / Director
Lancaster Farms (2022)
To ensure that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA, deaths in custody and/or the use of the special cell, are implemented. In addition, to ensure that the appointment to the vacant position of Board clerk is prioritised, with a clear remit for that person to support …
Governor / Director
Low Newton (2020)
Can the equality and diversity policy be displayed on all wings and also in areas where there is a high volume of resident activity?
Governor / Director
High Down (2020)
What actions does the governor intend to take to ensure that welfare checks are done in a timely manner and are adequately recorded?
Governor / Director
Ford (2020)
For the second year running the Board comments on your service’s apparent lack of understanding of Category D open prisons. The Prisons National Framework response to COVID-19 including the coloured Levels/Stages diagram and supporting text failed to mention ROTL, even at Levels 1 or 2 where it might be expected. The Board understands that the number one priority was the …
HMPPS
Exeter (2020)
Will the Governor undertake to improve staff “buy in” and commitment to CSIP and monitor compliance and case management? (See paragraph 4.4).
Governor / Director
Charter Flight (2020)
The escorts must be instructed to explain the contents of the individual information packs to all returnees, with assistance, where needed, from interpreters (see paragraph 4.3.5).
Other
Charter Flight (2020)
Continued use of restraint and the reasons for this were rarely noted in the PER, despite the routine instruction to escorts during the staff muster to record (paragraph 3.8.8). This should be standard practice.
Other
Hewell (2021)
Maintain culture change pressure to have a consistent standard of staff behaviour towards prisoners.
Governor / Director
Gartree (2021)
Will the Governor ensure that all custodial managers are aware of the occasion when the Board needs to be notified of incidents, deaths in custody, use of force and all other routine notifications which are outlined in the memorandum of understanding between HMPPS and the Management Board for the IMB, dated December 2019?
Governor / Director
Wakefield (2022)
Key workers – there is some evidence of staff referring prisoners to the IMB rather than dealing with matters themselves. Keywork provides an opportunity for staff to engage with prisoners and resolve issues without the need to access the IMB. Our data (see ‘the work of the Board’) suggests that the present level of applications received by the board is …
Governor / Director
Oakwood (2022)
The Board continues to be concerned about prisoners in the servery not wearing the appropriate personal protective equipment (PPE) and clothing. Notwithstanding that Aramark provided continuity of a balanced menu and two cooked meals a day, the Board is still concerned about the quality, quantity and variety of the food provided and the ensuing waste that results, and that the …
Governor / Director
Isis (2022)
Having published a Prisoners’ Property Policy Framework, ensure that it is fully implemented and adhered to.
HMPPS
Swaleside (2023)
Facilities for female officers are inadequate and it is not acceptable that they have to share locker rooms with male staff. This needs to be addressed, especially as there are now many female officers working in the prison.
Governor / Director
Oakwood (2023)
Can the Director take steps to address the standard of hygiene on the serveries? Issues of dirty or incomplete Personal Protective Equipment (PPE) are regularly reported on the Board’s Rota Report, as are concerns about missing or broken equipment. Repairs to broken kitchen equipment are often prolonged.
Governor / Director
Foston Hall (2023)
Staffing issues have had an impact on the implementation of key working, as intended in the offender management in custody (OMiC) model. What action will you be taking to improve staff availability?
Governor / Director
Bronzefield (2023)
How does the prison plan to ensure that complaints are handled in line with the Prisoner Complaints Policy Framework?
Governor / Director
Norwich (2024)
There would still appear to be a problem with the circulation and comprehension of communications released to prisoners, especially Governor’s notices to prisoners (GNTP). Of the prisoners who responded to the IMB’s 2023-2024 questionnaire, only 33% found them easy to access and only 48% understood their content. What steps could be taken to improve the situation?
Governor / Director
London STHF (2024)
During inductions, detained people should be reminded that they have the right not to disclose certain information, such as marital status and religion in line with Rule 21 of STHF rules.
Other
Feltham (2024)
Will you ensure that the shortfall between planned hours of education and delivered hours continues to be monitored and reduced?
Governor / Director
Feltham (2024)
What further steps will be taken to reduce staff absence, particularly during school holiday periods?
Governor / Director
Bristol (2024)
Key working is focused on the high-risk cohorts of prisoners. Will key working be available for all prisoners in the coming year?
Governor / Director
Thorn Cross (2025)
What plans are there to ensure there are adequate numbers of skilled cleaners? (5.1.4)
Governor / Director
Rochester (2025)
The Board understands and supports the reasoning for the re-rolling of the top site at Rochester as a prison for PCoSos, but it was rushed through and creates significant logistical issues for the prison, which will take time to bed down. The Board believes a period of stability is required, without further changes to leadership and functions.
HMPPS
Portland (2025)
The Governor should undertake steps to ensure that key work continues to increase so all prisoners benefit on a regular basis.
Governor / Director
Lancaster Farms (2025)
When will the Governor increase the effective use of key working at the prison, with demonstrable targets and outcomes?
Governor / Director
Erlestoke (2025)
What can be done to reduce the pressure on the Offender Management Unit (OMU), enabling offender managers to manage more consistently their caseload, particularly given the likelihood of further changes to sentence and release criteria?
Governor / Director
East Sutton Park (2025)
Could the Prison Service implement an effective system for managing prisoners’ property and transfers? The ESP Board notes that a related key performance indicator (KPI) once existed but was discontinued. Could this KPI be reinstated?
HMPPS
Durham (2025)
How will you ensure that staff fully understand the eligibility and process for clothing parcels to be handed in/delivered to the prison so that consistent guidance is given to prisoners? (5.8.4)
Governor / Director
Doncaster (2025)
Internal property issues remain a concern for the Board and cause great frustration for prisoners. Will the Director commit to making the resolution of this issue a top priority in the coming year?
Governor / Director
Cardiff IMB (2025)
Sut bydd y trafodaethau hyn yn cael eu datrys ddechrau 2026 i gefnogi system gweithwyr allweddol gwell yng Ngharchar Caerdydd.
Governor / Director
Cardiff (2025)
The Board acknowledges the attempts made to introduce a revised staffing profile during the reporting period. How will these negotiations be resolved early in 2026 to support an improved key worker system in HMP Cardiff.
Governor / Director
Birmingham (2025)
What will the governor do to resolve the ongoing issue relating to shortages of kit?
Governor / Director
Berwyn (2025)
We are still receiving reports from prisoners saying that they do not know who their key worker is.
Governor / Director
Wealstun (2020)
Ensure that all relevant paperwork and witnesses are available for all adjudications, especially for those to be heard by the independent adjudicator (see paragraph 5.2.14).
Governor / Director
Swinfen Hall (2020)
The key worker programme has been inadequately implemented, averaging only 52% of expected contact time (see paragraph 5.3(b)). Similarly, the key worker clothing parcels initiative was poorly executed (although hugely welcomed by prisoners) and plagued by administrative difficulties (see paragraph 5.3(c)]. How will these programmes deliver expectation in a self-regulating and sustained way?
Governor / Director
Pentonville (2020)
Will the recording and scrutiny of use of force incidents be prioritised?
Governor / Director
Norwich (2020)
What plans does the Prison Service have to rationalise and streamline reporting information and assurance? Mandatory paperwork is excessive for staff and the SMT, cutting down their time for hands-on management and interaction with prisoners.
HMPPS
Oakwood (2020)
Following concerns expressed in last year’s AR, the Director should consider again, how to ensure that staff enforce the use of Personal Protective Equipment (PPE) across all houseblocks and ensure the regular availability of appropriate cleaning materials so that the serveries are maintained to a more consistent standard of hygiene and cleanliness.
Governor / Director
North Sea Camp (2020)
Ensure that any future wages changes are fully understood by all residents before implementation.
Governor / Director
Isis (2020)
deliver the ‘prisoners’ property policy framework’ that the minister stated in response to previous annual reports that HMPPS was planning to publish (see section 5.8)
HMPPS
Foston Hall (2020)
The variable operation of the personal officer scheme (see paragraph 5.3.3).
Governor / Director
Foston Hall (2020)
The induction pack is out-of-date and is not provided in other languages. (see paragraph 4.1.1).
Governor / Director
Health Investigations (6)
Investigation into matters relating to Jimmy Savile at Wythenshawe Hospital — Rec a.
That all policies identified as having passed their formal review date should be reviewed and ratified.
University Hospital of South Manchester NHS Foundation Trust
north_west
Investigation into matters relating to Jimmy Savile at Wythenshawe Hospital — Rec b.
A specific, stand-alone policy for Volunteers and Visitors to the Trust should be developed to consolidate current processes, protocols and guidance.
University Hospital of South Manchester NHS Foundation Trust
north_west
Themes and lessons learnt from NHS investigations into matters relating … — Rec R8
The Department of Health and NHS England should devise and put in place an action plan for raising and maintaining NHS employers’ awareness of their obligations to make referrals to the local authority designated officer (LADO) and to the Disclosure and Barring Service.
national
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 8b
Improve how the experiences and views of staff are heard and acted upon by implementing meaningful involvement approaches that are co-produced with staff groups.
wales
Accepted
Themes and lessons learnt from NHS investigations into matters relating … — Rec R9
All NHS hospital trusts should devise a robust trust-wide policy setting out how access by patients and visitors to the internet, to social networks and other social media activities such as blogs and Twitter is managed and where necessary restricted. Such policy should be widely publicised to staff, patients and …
national
Accepted
Themes and lessons learnt from NHS investigations into matters relating … — Rec R1
All NHS hospital trusts should develop a policy for agreeing to and managing visits by celebrities, VIPs and other official visitors. The policy should apply to all such visits without exception.
national
Accepted
Article 2 Learning Points (3)
— LP 5
Methods of translating Formal Policy Documents into accessible and simplified instructions for Prison Officers using skills-based training methods should be developed.
HMPPS
— LP 19
We recommend that officers’ attendance at ward rounds is embedded as a norm on HMP Pentonville’s Healthcare unit, if this is not already the case. This should help further improve understanding and promote a sense of collegiate working among discipline and clinical staff.
PPG
Accepted
— LP 1
At an organisational and cultural level, we recommend that further measures are taken to close the perceived gap between the main prison and the Healthcare unit at HMP Pentonville. This should help create a greater sense that HMP Pentonville is functioning as one organisation, comprised of staff and managers working …
HMPPS
Accepted
Detention Investigations (34)
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)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R37
The age dispute policy should be amended to make explicit that it is the duty of staff members who have any cause to believe that a detainee is under age to report it to a manager or ensure that it has been reported. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R26
G4S managers and the SMT should: • improve the environment in the reception area at Brook House and make it more welcoming; • consider how all new arrivals can be interviewed in privacy; and • agree with the Home Office how they will provide showers for new arrivals. (To be …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R25
Residential DCMs and wing staff should ensure that all detainees have access to cleaning products to clean their rooms, including washbasins and toilets. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R24
Residential DCMs must hold staff to account for ensuring wings are maintained at an acceptable standard cleanliness. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R23
The SMT must resolve the issue of the inadequate cleaning of the wings either by agreeing with that it will undertake the cleaning of wings or by ensuring that wing orderlies keep wings to an acceptable standard of cleanliness throughout the day, that they are properly supervised and allowed access …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R21
The SMT and staff must enforce the ban on smoking inside Brook House. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R30
The SMT and DCMs must ensure continued adherence to the induction policy. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R22
The SMT and residential DCMs must ensure that adequate numbers of staff are on duty throughout the service of meals to ensure orderly queues and service of meals. (To be completed within 3 months)
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 51
I recommend that contract monitors be instructed personally to investigate all allegations against members of staff.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 45
I recommend that clear guidelines are produced for contract monitors.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 34
I recommend that Securicor requires staff to take regular meal-breaks.
Immigration Detention
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)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R39
The SMT, in consultation with the local safeguarding boards, should review and redraft the safeguarding policy to ensure that it: • has a clear and easy-to-follow scheme and does not contain errors in drafting and meaning; • makes clear to staff their principle duties and responsibilities in relation to safeguarding, …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R1
The SMT should be more present in the centre and should consider how they can better engage with staff. (To be completed as a matter of urgency)
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 59
IND consults upon the merits of incentives schemes and the terms of a single national framework - to reflect a consistent set of principles and processes - within which schemes could operate.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R46
The SMT and safeguarding team should ensure that all incidents of violence and bullying at Brook House are investigated in a timely way. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R27
G4S should amend its induction policy to make it clear that a detainee posing a risk of any significant violence to others will be justification for accommodating the detainee in a single occupancy room. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R17
The SMT must design and implement as a matter of urgency purposeful and better-resourced education, activities and entertainments programmes. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R4
The SMT at Gatwick IRCs must review arrangements for providing care and support to staff and ensure that they have ready access to a care service they trust. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R51
The SMT and G4S managers should review the policy and arrangements for raising concerns and their own handling of such matters to ensure that they encourage and support staff to report wrongdoing or misconduct or inappropriate behaviour by colleagues and managers. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R48
The safeguarding team should survey staff at Brook House regularly to ascertain their experience of and perspective on violence and bullying and its causes. (To be completed within 6 months)
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 41
contract monitors regularly check that the Detention Centre Rules and operating standards are readily available to detainees.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 29
IND issues instructions to Immigration Service staff in removal centres governing effective engagement with detainees.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 27
when a new centre opens, the relevant Project Board issues specific instructions to DEPMU about population build up.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 49
I recommend that a formal protocol is drawn up between the contractor and the Immigration Service setting out the circumstances in which attempts at removal could be abandoned.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 38
I recommend that IND and its contractors jointly review the shift patterns worked by staff in the immigration detention arena.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 35
I recommend that IND and Securicor review the logistics of escorted removals to minimise the time that staff and detainees spend waiting at airports.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 14
I also recommend that a new term be chosen that reflects the positive nature of the arrangements.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R6
Managers should review the centre’s policies, its recruitment, training and appraisal arrangements and the regime at the centre to ensure they are consistent with its mission, role and purpose.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R5
Managers at Yarl’s Wood should put in place a programme of organisational development work involving all staff, to develop a clearer and better shared understanding of the centre’s mission, role and purpose, and the cultures and arrangements, including staffing arrangements, that will ensure the appropriate care of Yarl’s Wood’s residents. …
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 54
IND arranges for the weight of each contract monitor post to be assessed to determine both the appropriate grade of the contract monitor and the level of support he/she should have.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 16
GSL reviews its fire signage at all its centres and carries out regular management checks to ensure all fire safety measures are complied with.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 20
Alongside the contractors, I recommend IND considers establishing a zero-tolerance campaign across the detention estate, with appropriate posters and literature, to remind staff of the expected standards of conduct.
Immigration Detention
PHSO Casework Decisions (2)
P-002414 — An independent provider in the Hackney area
Mrs E complains the Service could not identify the staff member who said her husband’s nails were going blue and it gave her husband midazolam which made his condition worse.
NHS in England
Jan 2024
P-002549 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs Q complains that Trust staff did not drain her husband's collection bag soon enough.
NHS in England
Partly Upheld
Apr 2024
LGO / SPSO Decisions (224)
22-001-289 — Stoke-on-Trent City Council
Summary: Mrs X complained about the Council’s application of its home to school transport policy. There was fault in the way the Council conducted its stage 2 appeal which caused Mrs X uncertainty. There was also delay holding the panel. The Council has agreed to apologise to Mrs X, reconvene …
LGO (Local Government & …
Education
Upheld
Oct 2022
22-000-526a — Akari Care (22 000 526a)
Summary: Mr B complained about the actions of a Care Provider because he says his late mother’s rings went missing in one of its nursing homes. He also said the Council did not do enough to investigate the matter. We did not find fault by the Council. The Care Provider …
LGO (Local Government & …
Health
Upheld
Oct 2022
22-011-627 — London Borough of Brent
Summary: We will not investigate this complaint about a Council Officer’s use of the incorrect pronoun when writing to the complainant. We are satisfied the Council’s response was a proportionate to the issues raised.
LGO (Local Government & …
Other Categories
Upheld
Dec 2022
24-003-887 — London Borough of Hackney
Mrs D complained the Council refused to renew her Blue Badge. Our investigation has found fault in the advice given to staff who work at the Council’s assessment centre and assess Blue Badge applications.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
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.
LGO (Local Government & …
Planning
Apr 2025
24-015-681 — Bournemouth, Christchurch and Poole Council
Summary: Mx X complained the Council failed to adhere to reasonable adjustments agreed for their disability between August 2023 and December 2024. There was no fault in how the Council adhered to the agreed reasonable adjustments. There was fault in the Council’s communication and record keeping about the reasonable adjustments. …
LGO (Local Government & …
Other Categories
Upheld
Aug 2025
24-019-309 — St Albans City Council
Summary: Mr B complained that the Council had not followed its own policy when it banned him from trading at one of its markets. We found the Council did not follow its policy on giving warnings, but this did not cause Mr B injustice as he had been allowed to …
LGO (Local Government & …
Other Categories
Upheld
Sep 2025
24-003-010 — Medway Council
Summary: There was fault by the Council in failing to seek confirmation of whether a pupil had previously hit staff on school transport before reaching a decision about the nature of transport required. The Council will apologise, provide a payment to remedy injustice and make service improvements. The complaint is …
LGO (Local Government & …
Education
Upheld
Nov 2024
201103124 — Scottish Prison Service
Mr C complained because he said his parole information was not delivered to him in the normal way - it was hand delivered by a unit manager instead of being sent in an envelope. Mr C also said he was not given enough time to submit his representations to the …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Mar 2012
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 …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Apr 2012
201203348 — Scottish Prison Service
Mr C complained about the way he was treated by a prison officer in the reception area of a prison he was visiting. He was unhappy with the prison's complaints handling, and in particular, felt the prison failed to investigate his complaint appropriately. He was also unhappy because the prison …
SPSO (Scottish Public Se…
Prisons
Upheld
Jun 2013
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 …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
24-001-211 — Dorset Council
Summary: We will not investigate this complaint about how the Council dealt with a report that health and safety procedures were not being followed at a workplace. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-005-075 — London Borough of Tower Hamlets
Summary: There was fault in the way the Council responded to the complainant’s reports of anti-social behaviour (ASB) in her building. The Council did not give proper consideration to the complainant’s needs or to its full toolkit of powers for tackling ASB, did not follow its own ASB policy as …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2025
24-020-673 — Thurrock Council
Summary: Mr D complains the Council failed to fully consider relocating communal waste bins. I do not have contemporaneous evidence of how the Council assessed the site and considered Mr D’s request. I have upheld the complaint and asked the Council to carry out a new assessment, which it should …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2025
24-015-859 — Dacorum Borough Council
Summary: We have no grounds to criticise the Council’s decision that a noise does not amount to a statutory nuisance. However, there was fault by the Council, because it has considered irrelevant factors as part of its decision-making. This did not cause an injustice to the complainant, but the Council …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2025
23-016-869 — Surrey County Council
Summary: Miss X complained about how the Council administers school transport applications for children in her village. We do not find fault with how the Council assesses these applications. We find the Council at fault for delays in considering Miss X’s appeal, and for providing incorrect information but we find …
LGO (Local Government & …
Education
Upheld
Nov 2024
201200240 — A Medical Practice in the Ayrshire and Arran …
Miss C had her tonsils removed. After the procedure, she was in a great deal of pain and unable to eat and drink. Five days after the procedure, she went to see her GP about these symptoms. Miss C said that her GP just looked at the back of her …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2012
201300417 — South Ayrshire Council
Mr and Miss C complained that a neighbour had constructed an entranceway that extended along the road verge to the entrance of a field that Mr and Miss C rent. They complained that this in effect increased the level of the verge, making it difficult to access the field with …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Nov 2013
201203255 — An NHS Board
Ms C is a transgender woman undergoing gender reassigment (a process of changing from man to a woman). She complained that the assessment process for acceptance for gender reassignment surgery took too long and was unreasonably delayed. She started going to the relevant clinic, attending regularly over the following three …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2013
201100497 — Dumfries and Galloway Council
The council had approved a planning application for a new house on a site close to Mr C's home, although the application was subject to certain planning conditions. Mr C complained that since then the council had failed to enforce a condition about a landscaping scheme. He also complained that …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Nov 2013
201301789 — South Lanarkshire Council
Mr C complained about the council's decision to reschedule road resurfacing work. He complained that they had not recorded the feedback on which their decision was based, or recorded the decision. Our investigation, however, found no evidence that the council had any obligation to record every piece of feedback received …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Dec 2013
201300737 — Renfrewshire Council
Mr C complained about the way the council handled his claim for compensation after he damaged his suit on a protruding screw in a council-owned building. He also complained about their decision to limit the sum they agreed to pay him to the cost of replacing his jacket, rather than …
SPSO (Scottish Public Se…
Local Government
Upheld
Dec 2013
201300574 — Business Stream
Mr C leased and operated a pub that shared its water supply with a residential property. He complained that Business Stream unreasonably delayed in issuing their initial invoice he had run the pub since 2007 and only received an invoice in 2010 and that when it arrived it …
SPSO (Scottish Public Se…
Water
Partly Upheld
Jan 2014
201405793 — Scottish Prison Service
Mr C complained because he said the prison unreasonably refused to progress him to open (lowest security) conditions. Instead, the risk management team (RMT) - the group responsible for considering whether a prisoner is suitable to progress to less secure conditions - decided that Mr C should transfer to the …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2015
201404931 — University of Edinburgh
Mr C, a postgraduate student, had complained to the university a number of times about a range of matters. When he submitted two new complaints for investigation, as he did not accept the outcome of the front-line resolution, the university responded that they had decided to restrict his access to …
SPSO (Scottish Public Se…
Education
Not Upheld
Jul 2015
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 …
SPSO (Scottish Public Se…
Local Government
Upheld
Jul 2015
201401497 — Scottish Prison Service
Mr C complained to us about the Scottish Prison Service (SPS)'s handling of his post programme report (the report) which was required eight weeks after the completion of his treatment programme. Mr C complained that, due to the delay in completing the report, his tribunal hearing had been adjourned and …
SPSO (Scottish Public Se…
Prisons
Upheld
Jul 2015
201204983 — Dumfries and Galloway NHS Board
Ms C had cognitive and communication problems. Following poor experiences with her GP practice, she asked to be deregistered. However, she subsequently found it difficult to register with a new practice. Before registering with a new GP, Ms C sought reassurance that they would make reasonable adjustments in light of …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2015
201403076 — Tayside NHS Board
Mrs C said her son was admitted to Ninewells Hospital with a suspected infectious disease and was kept in hospital for two nights. Mrs C said she was told that her son's treatment would be free, but during the discharge process she was advised she would have to pay for …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2015
201304125 — Dumfries and Galloway Council
Mr C lives near a holiday chalet park with a history of planning applications and amendments. The council had approved a retrospective planning application, subject to four conditions. He complained to us about the way they handled a number of planning issues, including a failure to follow correct development plan …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Aug 2015
201501567 — Glasgow City Council
Mr C complained to us on behalf of his client (Miss A) who had been refused an application made to the council for a crisis grant. The reasons for the refusal were that she had already received a grant in the preceding 28 days and her circumstances had not changed. …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Sep 2015
201407836 — Scottish Borders Council
Mr C complained that a council officer unreasonably barred his entry into a public event that was being held in a council facility. He also complained that the officer's behaviour at the time was inappropriate. He then complained to the council about this incident but was dissatisfied with their investigation …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2015
201508271 — Scottish Prison Service
Mr C complained that a prison manager unreasonably failed to take action to notify a family member that he had been assaulted in prison and taken to hospital. Scottish Prison Service (SPS) rules state that requests from prisoners for a relative or friend to be informed must be actioned if …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Jan 2017
201603064 — Edinburgh Napier University
Mr C complained on behalf of his daughter (Miss A), a student at the university. Mr C's complaints were about the university's handling of the Fitness to Practise (FtP) process in relation to Miss A, and the university's handling of his complaint. We found that, in general terms, the FtP …
SPSO (Scottish Public Se…
Education
Partly Upheld
May 2017
201805111 — Perth and Kinross Council
Mr C was admitted to hospital following a stroke. In order to prepare for his discharge, the council arranged for a homecare service to be put in place. Due to his level of personal savings, Mr C was advised that he would be required to pay the full amount of …
SPSO (Scottish Public Se…
Local Government
Upheld
Jul 2019
201705215 — Tayside NHS Board
Mr C complained about the actions of a court appointed psychologist who interviewed him after he had been convicted of an offence. In their response to the complaint the board set out the reasons why the court decided to appoint the psychologist. They also explained that specific information was required …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2019
24-018-275 — West Sussex County Council
Summary: Miss Y complained about a support service commissioned by the Council for people in its area recovering from alcohol and drug misuse and provided to Mr X, her late father. We have found fault, causing injustice, by the service provider in failing to: follow its proper procedure in response …
LGO (Local Government & …
Other Categories
Upheld
Dec 2025
201808032 — Highland NHS Board
Mr C complained about the board's actions regarding his access to overnight accommodation at a facility provided by them, whilst Mr C was attending New Craig Psychiatric Hospital for treatment. Mr C said that the board unreasonably failed to provide him with overnight accommodation when he attended the hospital. He …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2020
201800154 — University of Edinburgh
C was enrolled on a programme at the University of Edinburgh. C complained about the university's response to reports of bullying during their placements. We found that the university took reasonable action to address C's concerns regarding the difficulties they experienced on placement, in line with the relevant university procedures. …
SPSO (Scottish Public Se…
Education
Not Upheld
Oct 2020
202003157 — Aberdeen City Health and Social Care Partnership
C complained on behalf of A (an adult who lives as a tenant in supported accommodation provided by the partnership) about the partnership’s communication with A’s welfare guardian (B). A, B and C are siblings. Following incidents between A and other individuals, B emailed A’s carers to make a suggestion …
SPSO (Scottish Public Se…
Health and Social Care
Upheld
Oct 2021
202410198 — Lothian NHS Board - Acute Services Division
C complained that the board failed to communicate appropriately with their partner (A) regarding charges for treatment. A is a non-UK resident and was charged for non-urgent treatment at hospital following an accident. C complained that A was not informed of the financial liabilities they would incur prior to their …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2025
202500059 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board's communication around their spouse (A)'s care and treatment was unreasonable. C complained about a lack of face-to-face appointments, delays and the board not following their diagnostic pathway. C said that they were informed of A's prostate cancer over the phone, with no support provided to …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2026
202304648 — Dumfries and Galloway NHS Board
C complained that the board failed to reasonably communicate with them about the care and treatment of their parent (A). C said that the board failed to inform them that a lump had been found on A’s breast while A was in hospital. A had been due to go into …
SPSO (Scottish Public Se…
Health
Not Upheld
Feb 2026
PSOW-202200329 — Adra
Miss X complained that she had been a subject to hate, abuse, discrimination and harassment by her neighbours. Miss X also complained that despite putting a complaint forward to the Association, the Association had not yet responded to her concerns. The Ombudsman was concerned that Miss X had yet to …
PSOW (Public Services Om…
May 2022
PSOW-202309088 — A GP Practice in the area of Swansea …
Mr B complained because he was unhappy with the actions of a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) following the way he was spoken to during a telephone call with a doctor. He was unhappy that his written complaint was responded to by …
PSOW (Public Services Om…
Health
Apr 2024
21-011-741 — London Borough of Hillingdon
Summary: Ms X complained about the Council’s decision on her son’s school transport, resulting in distress to her son and inconvenience to her. We find the Council at fault for not following its published process, but this did not affect the Council’s decision making. We recommend the Council apologise to …
LGO (Local Government & …
Education
Upheld
Mar 2022
22-000-389 — Leicester City Council
Summary: We will not investigate this complaint about the Council’s failure to supply personal protective equipment during a three-month period from November 2021. The Council’s apology is sufficient for the injustice caused and we could not add to its investigation or achieve a different outcome by investigating.
LGO (Local Government & …
Adult Care Services
Apr 2022
22-009-607 — Devon County Council
Summary: We will not investigate this complaint that the Council will not reimburse Miss X’s taxi fare as there is insufficient injustice to warrant our involvement.
LGO (Local Government & …
Other Categories
Nov 2022
22-010-621 — London Borough of Hackney
Summary: We will not investigate this complaint about the Council issuing the complainant with a Fixed Penalty Notice. This is because we are unlikely to achieve anything more to add to the Council’s investigation.
LGO (Local Government & …
Environment And Regulation
Nov 2022