Staff suitability and fitness
Failure to ensure that employed staff possess good character, necessary qualifications, skills, experience, and physical and mental fitness for their roles.
436 items
14 sources
14 inquiries
Source spread
Where this theme appears
Staff suitability and fitness has been flagged across 14 independent accountability sources:
66 inquiry recs
39 PFD reports
38 committee recs
103 CQC actions
50 HMICFRS recs
1 ICIBI rec
4 PPO recs
1 IOPC rec
70 IMB recs
1 Article 2 learning point
9 detention investigation recs
3 PHSO decisions
46 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 (66) — showing 50 strongest matches
F191 — Recruitment for values and commitment
Recommendation: Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should be required to do so by commissioning and regulatory requirements.
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
COVID-M2.1 — NI CMO Independence
Recommendation: The Department of Health (Northern Ireland) should reconstitute the role of the Chief Medical Officer for Northern Ireland as an independent advisory role. The Chief Medical Officer for Northern Ireland should not have managerial responsibilities within the Department of Health …
Gov response: No formal response published by this government.
Unknown
WATE-(24) — Mandate stringent, independent vetting for all foster parent applications, especially staff
Recommendation: Similar vigilance should be mandatory in relation to all applications for approval as foster parents. In particular, any application to foster by a member of a local authority's child care staff should be stringently vetted by a social worker who …
Unknown
WATE-(23) — Periodically audit Social Services staff recruitment and management vigilance
Recommendation: Social Services Departments should be reminded periodically that they must exercise vigilance in the recruitment and management of their staff in strict accordance with the detailed recommendations of the Warner committee917; and compliance with them by individual local authorities should …
Unknown
FENN-96 — Allocate physically suitable staff to roles, ensuring station safety balance
Recommendation: London Underground shall only allocate staff to a role for which they are physically suitable. In the cause of safety, a proper balance must be ensured at each station.
Unknown
BRIS-89 — Involve public, employers, and professional groups in revalidation processes
Recommendation: The public, as well as the employer and the relevant professional group, must be involved in the processes of revalidation.
Unknown
BRIS-88 — Mandate periodic revalidation for all healthcare professionals in employment contracts
Recommendation: Periodic revalidation, whereby healthcare professionals demonstrate that they remain fit to practise in their chosen profession, should be compulsory for all healthcare professionals. The requirement to participate in periodic revalidation should be included in the contract of employment.
Unknown
BRIS-87 — Incorporate periodic appraisal requirement into General Practitioners' terms of service
Recommendation: The requirement to undergo periodic appraisal should also be incorporated into GPs’ terms of service.
Unknown
BRIS-86 — Expedite implementation of regular appraisal for all hospital consultants
Recommendation: The commitment in ‘The NHS Plan’ to introduce regular appraisal for hospital consultants must be implemented as soon as possible.
Unknown
BRIS-85 — Mandate periodic appraisal for all healthcare professionals in employment contracts
Recommendation: Periodic appraisal should be compulsory for all healthcare professionals. The requirement to participate in appraisal should be included in the contract of employment.
Unknown
BRIS-80 — Involve NHS and public in establishing selection criteria for healthcare professionals
Recommendation: The NHS and the public should be involved in (a) establishing the criteria for selection and (b) the selection of those to be educated as doctors, nurses and as other healthcare professionals.
Unknown
BRIS-79 — GMC's 'Good Medical Practice' to inform medical school selection and curricula
Recommendation: The attributes of a good doctor, as set down in the GMC’s ‘Good Medical Practice’, must inform every aspect of the selection criteria and curricula of medical schools.
Unknown
BRIS-78 — Widen medical school access for diverse academic and socio-economic backgrounds
Recommendation: Access to medical schools should be widened to include people from diverse academic and socio-economic backgrounds. Those with qualifications in other areas of healthcare and those with an educational background in subjects other than science, who have the ability and …
Unknown
P2-13 — Mortuary Manager professional background prerequisite
Recommendation: A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.
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
P1-3 — Criminal record checks compliance
Recommendation: Maidstone and Tunbridge Wells NHS Trust must assure itself that it is compliant with its own current policy on criminal record checks and re-checks for staff. The Trust should ensure that staff who are employed by its facilities management provider …
Gov response: Implemented. The Trust mandates contractors to renew security clearances every 3 years. Policy on criminal record checks is being followed for both direct staff and contractors. (Source: Trust assurance statement, February 2024; confirmed in Written …
Accepted
IHRD-14 — Clinician Competence Assessment
Recommendation: The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.
Gov response: Competence assessment processes incorporated into recruitment procedures for paediatric roles.
Accepted
F188 — Aptitude test for compassion and caring
Recommendation: The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in particular, candidates' attitudes towards caring, compassion and other necessary 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 in Part
F172 — Proficiency in the English language
Recommendation: The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required for a registered medical practitioner to assume professional responsibility for …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F23 — Responsibility for regulating and monitoring compliance
Recommendation: The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
BRIS-84 — Trusts must ensure CPD resources meet patient needs and professional aspirations
Recommendation: Trusts and primary care trusts must take overall responsibility through an agreed plan for their employees’ use of the time allocated to CPD. They must seek to ensure that the resources deployed for CPD contribute towards meeting the needs of …
Unknown
BRIS-83 — Provide incentives, funding, and time for healthcare professional continuous professional development
Recommendation: Trusts and primary care trusts should provide incentives to encourage healthcare professionals to maintain and develop their skills. The contract (or, in the case of GPs, other relevant mechanism) between the trust and the healthcare professional should provide for the …
Unknown
BRIS-82 — Make Continuing Professional Development (CPD) compulsory for all healthcare professionals
Recommendation: CPD, being fundamental to the quality of care provided to patients, should be compulsory for all healthcare professionals.
Unknown
BRIS-71 — Establish a single body to coordinate all healthcare professional regulatory bodies
Recommendation: In addition, a single body should be charged with the overall co-ordination of the various professional bodies and with integrating the various systems of regulation. It should be called the Council for the Regulation of Healthcare Professionals. (In effect, this …
Unknown
BRIS-70 — Establish single regulatory bodies for each distinct healthcare professional group
Recommendation: For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine, and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and …
Unknown
BRIS-68 — Involve NHS Leadership Centre in all healthcare professional education and development stages
Recommendation: The NHS Leadership Centre should be involved in all stages of the education, training and continuing development of all healthcare professionals.
Unknown
BRIS-66 — Identify and train potential NHS leaders, investing in leadership skills development
Recommendation: Steps should be taken to identify and train those within the NHS who have the potential to exercise leadership. There needs be a sustained investment in developing leadership skills at all levels in the NHS.
Unknown
BRIS-63 — Provide healthcare management education for all aspiring clinical professionals
Recommendation: All those preparing for a career in clinical care should receive some education in the management of healthcare, the health service and the skills required for management.
Unknown
BRIS-58 — Formally assess non-clinical patient care competence for initial professional qualification
Recommendation: Competence in non-clinical aspects of caring for patients should be formally assessed as part of the process of obtaining an initial professional qualification, whether as a doctor, a nurse or some other healthcare professional.
Unknown
P2-74 — HTA require suitable qualified staff with enforcement
Recommendation: The Human Tissue Authority, and/or the new inspectorate, should require the organisations it licenses to ensure that any individual who provides care to deceased people is suitably qualified, experienced and supervised. The regulatory regime should set minimum standards on the …
Gov response: This recommendation is under consideration.
Response Unclear
P1-6 — Review policies on mortuary access
Recommendation: Maidstone and Tunbridge Wells NHS Trust must review its policies to ensure that only those with appropriate and legitimate access can enter the mortuary.
Gov response: Implemented. Policies have been reviewed and updated. Access is now controlled via individual swipe cards with appropriate restrictions. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
P1-1 — Non-mortuary staff accompanied in mortuary
Recommendation: Maidstone and Tunbridge Wells NHS Trust must ensure that non-mortuary staff and contractors, including maintenance staff employed by the Trust's external facilities management provider, are always accompanied by another staff member when they visit the mortuary. For example, maintenance staff …
Gov response: Implemented. The Trust has implemented this requirement. All non-mortuary staff and contractors must be accompanied when visiting the mortuary. This was confirmed in NHS England's oversight meetings with the Trust. (Source: Trust assurance statement, February …
Accepted
12a — Suspension during investigation
Recommendation: We recommend that if, when a hospital investigates a healthcare professional's behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional.
Gov response: Not accepted. Government does not support blanket automatic suspension. Suspension should be decided case-by-case based on risk assessment. Automatic suspension could deter reporting and be disproportionate. Existing guidance from NHS Employers and professional regulators provides …
Not Accepted
IHRD-13 — Foundation Doctors in Children's Wards
Recommendation: Foundation doctors should not be employed in children's wards.
Gov response: Reviewed in context of workforce planning. Some concerns raised by Royal Colleges about potential de-skilling impacts. Implementation being balanced against training needs.
Accepted in Part
No update 2+ yrs
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
F185 — Focus on culture of caring
Recommendation: There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures the delivery of proper standards of nursing requires: Selection of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
WATE-(56) — Ensure sufficient intermediate management staff for children's services supervision and support
Recommendation: Staffing resources at intermediate management level for a local authority's children's services should be sufficient in number and quality to enable positive and close supervision and support to be given to residential establishments and the fostering service.
Unknown
WATE-(55) — Assign children's services policy and oversight to Assistant Director level manager
Recommendation: The responsibility for policy and service development and for oversight of the delivery of a local authority's children's services should be assigned to one member of the social services department management team of at least Assistant Director status.
Unknown
WATE-(54) — Mandate child care expert on local authority social services management team
Recommendation: There should be at least one full member of a local authority's social services department management team with child care expertise and experience.
Unknown
WATE-(48) — Ensure inspectors of children's services have substantial child care experience
Recommendation: When inspections are made by the agency of homes, schools or services mentioned in recommendation (47) at least one of the inspectors should have substantial experience of child care.
Unknown
WATE-(27) — Require senior children's home staff to be qualified social workers or train
Recommendation: It should be a requirement that senior staff of children's homes (including private and voluntary homes) must be qualified social workers or, if that is not practicable before appointment, that it should be a condition of their appointment that they …
Unknown
FENN-102 — Review London Underground staff promotion policy to promote on merit
Recommendation: London Underground shall review its policy on the promotion of staff and promote more on merit.
Unknown
LADB-18 — Establish specific, validated criteria and pass standards for driver training
Recommendation: Thames Trains and other TOCs should ensure that their driver training and testing programmes adequately reflect the need for specific, relevant and validated criteria. Drivers should be tested against these criteria, and a definite pass standard should be established. Consideration …
Unknown
BRIS-94 — Appoint clinicians to managerial roles based solely on demonstrated competence
Recommendation: Clinicians should not be required or expected to hold managerial roles on bases other than competence for the job. For example, seniority or being next in turn are not appropriate criteria for the appointment of clinicians to managerial roles.
Unknown
BRIS-92 — Provide protected time for clinicians undertaking managerial roles beyond clinical practice
Recommendation: Where clinicians hold managerial roles which extend beyond their immediate clinical practice, sufficient protected time in the form of allocated sessions must be made available for them to carry out that managerial role.
Unknown
BRIS-69 — Broaden healthcare professional regulation to include education, training, CPD, and revalidation
Recommendation: Regulation of healthcare professionals is not just about disciplinary matters. It should be understood as encapsulating all of the systems which combine to assure the competence of healthcare professionals: education, registration, training, CPD and revalidation as well as disciplinary matters.
Unknown
BRIS-65 — NHS Leadership Centre to issue guidelines on acceptable leadership styles and practices
Recommendation: An early priority for the new NHS Leadership Centre should be to offer guidelines as to leadership styles and practices which are acceptable and to be encouraged within the NHS, and those which are not.
Unknown
P2-9 — Monitor and review staff access numbers
Recommendation: All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine review.
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
P1-4 — Mortuary Managers qualified and supported
Recommendation: Maidstone and Tunbridge Wells NHS Trust must assure itself that its Mortuary Managers are suitably qualified and have relevant anatomical pathology technologist experience. The Mortuary Manager should have a clear line of accountability within the Trust's management structure and must …
Gov response: Implemented. The Trust has reviewed Mortuary Manager arrangements and ensured appropriate qualifications and support are in place with clear lines of accountability. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 …
Accepted
IHRD-75 — Independent Disciplinary Action
Recommendation: Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.
Gov response: Trust disciplinary procedures updated to address professional code breaches independently.
Accepted
IHRD-19 — Senior Lead Nurse in Children's Wards
Recommendation: To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating to each patient, be visible to both patients and staff …
Gov response: Senior lead nurse roles established in children's wards across Trusts.
Accepted
PFD Reports (39)
Jack William Payton
Concerns: Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.
Response (Avon and Somerset Police): The police are commissioning an independent assessment of current shift patterns and their effects on staff, anticipated to commence in January 2014, with recommendations to be considered at Force level.
Responded
Karl Doran
Concerns: The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial supervision over their activities.
Overdue
Neil Carter
Concerns: There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Response (CQC): The CQC will include information held on deaths in psychiatric detention in all future annual reports. They will also work with partners in developing the Mental Health Crisis Care Concordat …
Response (Priory Group): The organisation disciplined and dismissed a nurse for falsifying records and referred them to the NMC. They have also implemented changes to the staff induction programme and introduced daily monitoring …
Responded
Lalitaben Patel
Concerns: A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.
Response (Department of Health and Social Care): DHSC highlights recommendations from a 2013 working group to strengthen quality assurance of locum doctors, including strengthened GMC appraisal guidance, pre-employment standards, audit guides, and guidance for Trusts. DHSC continues …
Responded
Lloyd Butler
Concerns: A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.
Response (West Midlands Police): West Midlands Police instigated misconduct procedures against officers and staff involved, resulting in disciplinary sanctions. They have provided clear guidance on dealing with individuals arrested for being drunk and incapable, …
Responded
Thomas Warren
Concerns: The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations from other healthcare bodies, and relying solely on basic GMC restriction checks.
Response (Department of Health): NHS England's Medication Safety Team is planning to highlight the risks of prescribing Fentanyl patches to opiate-naive patients and the recommended safer practices at a future meeting of the National …
Response (Lewisham Greenwich NHS Trust): The Trust ensures compliance with NHS Employment Check Standards and uses agencies approved under the National Agency Framework Agreement. An internal audit team will review temporary staff processes in January …
Overdue
Pauline Edwards
Concerns: UK hospitals allowed EU-trained doctors to practice unsupervised without ensuring equivalent training or experience, driven by EU law, thereby increasing patient risk.
Response (Department of Health): The Department of Health acknowledges the coroner's concerns about EU-trained doctors and refers to the GMC's verification process and hospital observer programs. It notes Health Education England's view that St …
Responded
Simon Tree
Concerns: The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.
Response (Surrey Borders Partnership): The Trust has recruited a Security Manager, employs an out-of-hours receptionist, transferred administration support to the wards and improved camera coverage in the airlock. The Trust has also introduced cards …
Responded
Thor Dalhaug
Concerns: Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing distress.
Response (United Lincolnshire Hospitals NHS Trust): United Lincolnshire Hospitals NHS Trust has implemented changes to staff induction, supervision, and investigation procedures following the death. A fresh SUI report was undertaken and process changes were underway to …
Responded
Laurence Boyens
Concerns: Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone or buprenorphine, and some nurses did not know when to withhold medication or escalate concerns.
Response: Following the PFD report, the GMC commenced a review of their earlier decision not to proceed with a complaint about the doctor's care. They have obtained the doctor's comments and …
Response: The Nursing and Midwifery Council acknowledges receipt of the referral and states that it will go through an initial assessment process to determine how to proceed and will then write …
Overdue
Mary Hyden
Concerns: A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and risks to patient safety.
Response (University Hospitals of North Midlands NHS Trust): The University Hospitals of North Midlands NHS Trust has reviewed the consultant's job plan, which will be updated from October 2015 to allow for a better work-life balance. The consultant …
Responded
Bradley Hooper
Concerns: An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club rules for marshall allocation were not followed, and the MCF Code of Practice lacks smartphone use guidance.
Response (Portsmouth Motocross Club): Updated Rules of Marshalling have been implemented, with briefings at every race meeting. Experienced marshals are placed on "high-risk" points, and less experienced marshals on "low-risk" points; marshals will be …
Overdue
Michael Hanlon
Concerns: An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.
Response (Pluteus Limited): A keyless entry system has been installed to address concerns around access, and a 24-hour watch system is in place when owners/guests are onboard. A Captain's Standing Order is to …
Responded
Steven Rogers
Concerns: A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.
Response (Steven Rogers): The Trust is moving towards a Trust-wide electronic patient record (EPR) which should resolve issues around paper charts. In the meantime, a specialist "Task & Finish Group" is in place …
Responded
John Rogers
Concerns: The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.
Response: The University Health Board has undertaken and completed a detailed action plan relating to Ysbyty Glan Clwyd with specific training requirements. They are strengthening systems to ensure training and qualifications …
Responded
Jakub Moczyk
Concerns: Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, relying instead on a non-medically qualified referee/trainer.
Response (Lifeshield Medical Services Ltd): The organisation claims they informed the referee and promoter about incomplete medicals and states that new policies are in place for boxing events including drug testing and head scanning, leading …
Responded
Peter O’Donnell
Concerns: Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic safety risks.
Response (Department of Health): The Department of Health acknowledges concerns regarding independent hospitals and refers to existing standards, CQC ratings, and quality monitoring data submissions, also noting the ongoing Paterson Inquiry looking into accountability …
Responded
Cyril Anderton
Concerns: Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.
Overdue
Kevin Miles
Concerns: The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues and risking divers' and potential rescuers' lives.
Response (UKDMC): The UK Diving Medical Committee (UKDMC) discussed the coroner's points but sees no reason to change the current system of self-certification for divers, where the onus is on the diver …
Overdue
Polly Drew
Concerns: The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading to her working alone and posing risks to patients.
Overdue
Alex Blake
Concerns: Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
Response (NMC): The NMC has referred the two registered nurses mentioned in the report to their Fitness to Practise team for further investigation, and the Employer Link Service has contacted the trust …
Response (NHS Professionals): NHS Professionals has implemented measures including competency assessments for bank members, reviews with the Interim Director of Nursing, and a dedicated Clinical Governance Nurse Lead and Education Liaison Team to …
Responded
Russell Bowry
Concerns: Employers in the rigging industry delegate critical work-at-height safety to individual riggers without ensuring proper planning, supervision, or adequate safety features. This leads to routine unsafe practices, with riggers having minimal influence over their own fall protection.
Overdue
Ifeoma Onwuka
Concerns: An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.
Overdue
Arthur Hughes
Concerns: A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond their capabilities.
Response (Betsi Cadwaladr University Health Board): The Health Board is revising and implementing a SOP for locum appointments, including additional pre-employment checks and reviews of practice. Implementation was delayed due to COVID-19 but is intended from …
Overdue
Macloud Nyeruke
Concerns: Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE training, increasing infection risk to staff and patients. Nursing agencies failed to share health vulnerabilities.
Response (Leeds Teaching Hospitals NHS Trust): The Trust is providing additional 'fit testing' for PPE outside of usual provision and plans to standardise 'bank notes' on shifts in high risk areas specifying the need for fit …
Response (Reed Specialist Recruitment Ltd): Reed Specialist Recruitment states they have complied with their contractual obligations and notified relevant authorities (EAS, CCS, CQC). They suggest the report be re-addressed to ID Medical, the direct supplier …
Response (Employment Agency Standards): The Employment Agency Standards (EAS) Inspectorate explains its role in enforcing regulations for employment agencies, outlining the checks and authorisations required to ensure the suitability of work-seekers, including healthcare workers.
Responded
Rachel Johnston
Concerns: The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Response (Holmleigh Care Homes Ltd): Following a death, the care home introduced training for all nurses and reviewed its policies. They have since implemented the Staff Retention policy to ensure agency workers under investigation do …
Overdue
Ian Taylor
Concerns: Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and required physical assistance.
Response (Royal College of Emergency Medicine): The Royal College of Emergency Medicine states that provision of medical cover to police custodial units does not fall within its remit.
Response (Independent Office for Police Conduct): The IOPC will not be undertaking an investigation but is satisfied that the reflective practice review process can be used effectively to prompt reflection and insight into this incident.
Response (Metropolitan Police Service): The Metropolitan Police Service will implement the Reflective Practice Review Process (RPRP) for the officer in question, which will include an opportunity to reflect on the missed opportunity to offer …
Response (Department of Health and Social Care): The Department of Health and Social Care outlines the process and considerations involved in allowing police officers to carry salbutamol inhalers, noting it would require a change in legislation, and …
Responded
Kate Hyatt
Concerns: A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper consideration for their impact, especially on psychosis sufferers.
Response (Hands of Light Academy): Hands of Light Academy states they have no record of the deceased as a student but will implement several actions. These include continuing thorough screening of prospective students, educating staff …
Responded
Ruwaida Adan
Concerns: The report raises concerns about the reliance on reception checks for go-kart clothing and hair, noting track marshals frequently miss loose items, and there is a lack of changes to training and monitoring of track marshals.
Response (Capital Karts): Capital Karts implemented enhanced safety measures following the incident, including providing safety information at booking, reiterating warnings at reception, and ensuring staff check for loose clothing before customers enter the …
Responded
Sean Duignan
Concerns: Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, and incorrect single access permissions, allowing unauthorized access to weapons.
Response (HMICFRS): HMICFRS will ensure the College of Policing and NPCC issue a national circular by March 31, 2023, addressing lessons learned and requesting a review of armoury access procedures, and will …
Response (Bedfordshire Police): Bedfordshire Police has already commissioned a review of armoury access, rectified incorrect access levels, restricted single access, introduced mandatory training, installed additional security measures, completed an ICT system upgrade, and …
Response (HMICFRS): HMICFRS reviewed Bedfordshire Police's armoury processes, finding progress in regulating and controlling access, including new systems and technology, and improved security measures at the new Luton firearms base; the number …
Responded
Tarik Drakes
Concerns: Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating an environment where drug use and safeguarding risks are prevalent.
Response (BCHA): BCHA has reviewed safeguarding and support at Dorset Lodge, provided safeguarding training to managers, and will review risk management via link meetings with partner agencies. All actions have been incorporated …
Responded
Barbara Rymell
Concerns: Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency services, potentially delaying urgent medical attention.
Response (Home Office): The Home Office expresses condolences and explains the English language requirements for various immigration routes. They will tighten requirements for care workers coming to the UK on the Health and …
Overdue
Michael Dalkin
Concerns: The premises was using an unlicensed door supervisor, the SIA registered designated premises supervisor as a part time door supervisor, and an SIA registered manager who was not carrying out the role of a door supervisor; SIA registers were completed with information that did not reflect the real number of operational door supervisors.
Response (Goldies Bar): Following a review of the premises license, the hours for the supply of alcohol have been reduced, an incident book is maintained, an external customer management policy is in place, …
Pending
Alice Clark
Concerns: Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of driver competence.
Response (South East Coast Ambulance Service): The ambulance service has taken action to address concerns about driving standards complaints, responses, and supervision, including publishing a new driving policy with appendices on speaking up, launching a Speak …
Responded
Lee Stammers
Concerns: Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without accountability, risking patient harm.
Response (Doncaster and Bassetlaw Teaching Hospitals): The Trust has completed part of recommendation 1 regarding monitoring observations and escalation of care in the ED (June 2025) and is targeting completion of the second part by October …
Responded
Jack Brown
Concerns: Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic checks.
Response (Department for Health and Social Care): The Department for Health and Social Care is supporting the professionalisation of the workforce through the revised Care Workforce Pathway, and the Adult Social Care Learning and Development Support Scheme …
Responded
[REDACTED]
Concerns: There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking system's reliability and staff guidance for its failure.
Response (East London NHS Foundation Trust): East London NHS Foundation Trust has already made progress improving patient observations, observation practices, record keeping, risk assessments, understanding of risk, and clinical oversight, with interventions like new observation policy, …
Responded
Syeda Fatima
Concerns: Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.
Response (University Hospitals Birmingham NHS Foundation Trust): The Trust acknowledges cultural and systemic concerns in maternity services, stating significant improvements have already been made. They have also outlined an action plan with key initiatives to be undertaken, …
Responded
Valerie Gibson
Concerns: Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Response (Cumbria Northumberland Tyne and Wear NHS Foundation Trust): Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has established an executive-led Incident Management Review Group and taken several actions to address concerns about medication dispensing and administration. Actions include …
Responded
Committee Recommendations (38)
#40 — Systemic working condition issues persist in film and HETV, causing worker loss.
Recommendation: The film and HETV industry will continue to lose workers if it does not address systemic issues with working conditions, and the Government should hold it accountable for doing so. The prioritisation of the predominantly freelance creative industries in the …
Gov response: The government is committed to strengthening rights and protections to deliver good quality self-employment. DCMS will appoint a creative freelance champion to advocate for the sector’s freelancers within government. This is different to a commissioner …
Accepted
#15 — Require the next permanent or interim CCRC Chair to be solely dedicated to the organisation.
Recommendation: The next permanent chair or interim chair of the CCRC should be dedicated to the organisation above all other duties. (Recommendation, Paragraph 50)
Gov response: The Ministry of Justice agrees that the Chair of the CCRC should be fully dedicated to the mission of the CCRC. Dame Vera has already made public her commitment to making reforms to the organisation. …
Accepted
#14 — Former CCRC Chair's multiple roles contributed to perceived lack of focus and CCRC failings.
Recommendation: The former Chair held multiple executive roles which gave the perception of a lack of focus and may have contributed to the CCRC’s failings. (Conclusion, Paragraph 49)
Gov response: The Ministry of Justice agrees that the Chair of the CCRC should be fully dedicated to the mission of the CCRC. Dame Vera has already made public her commitment to making reforms to the organisation. …
Accepted
#13 — Mandate the CCRC Chair demonstrate criminal justice expertise and commitment to upholding CCRC independence.
Recommendation: The Chair should have a background in criminal justice, have recognised experience in that field and, above all, be absolutely dedicated to the CCRC’s purpose of identifying miscarriages of justice and upholding its independence. (Recommendation, Paragraph 48)
Gov response: We agree that the Chair of the CCRC should be absolutely dedicated to the CCRC’s purpose of identifying miscarriages of justice and upholding its independence. These are attributes that we expect to be tested during …
Partially Accepted
#186 — Align HMPPS personnel vetting requirements with tier-one security agencies and mandate lifelong vetting
Recommendation: HMPPS must immediately commit to aligning its personnel vetting requirements with those of other tier-one security and law enforcement agencies, such as the police. While the nature of the work differs, the threat profile is comparable. This alignment must establish …
Gov response: The Committee’s report makes clear that levels of drugs in prisons are too high and tackling this is a priority for HMPPS as set out in the response to chapter 4. This context makes it …
Partially Accepted
#7 — Amend prison staff recruitment to grant Governors ultimate decision and mandate face-to-face interviews.
Recommendation: Governors must have the ultimate decision on the recruitment of staff who work in their prison. HMPPS must amend its recruitment process to ensure that all frontline staff, including prison officers, undergo a mandatory face-to-face interview process led by Governors …
Gov response: 24. Historic underinvestment and paused projects driven by a rising prison population has worsened the maintenance backlog and left the estate vulnerable to sudden capacity losses. A stable prison estate is essential to wider system …
Partially Accepted
#16 — Numerical recruitment targets for neighbourhood policing risk cheap hires and lack of experienced officers.
Recommendation: We commend the efforts of police forces to maintain business-as- usual policing, particularly the importance attached to maintaining neighbourhood policing. Nonetheless, the disorder and subsequent investigations have had a knock-on impact on other areas of policing, including neighbourhood policing. The …
Gov response: For the purposes of funding and conditions for the neighbourhood policing programme, the local base for each force is set as at March 2025. We have been working closely with policing to develop the neighbourhood …
Under Consideration
#187 — Amend HMPPS recruitment to mandate face-to-face interviews by local governors for frontline staff
Recommendation: HMPPS must amend its recruitment process to ensure that all frontline staff, including prison officers, undergo a mandatory face-to-face interview process led by local governors. This critical step addresses the identified deficiency in governors not having direct involvement in the …
Gov response: NHSE and MoJ will work in partnership to explore research to identify the best, evidence based psychosocial and pharmacological interventions and treatments to address behaviours that drive use of psychoactive substances and synthetic opioids. DHSC …
Accepted
#42 — Ensure all children's homes are led by registered managers; launch recruitment campaign.
Recommendation: The Department for Education must ensure that all children’s homes are led by a registered manager and set out the steps it intends to take to achieve this. Additionally, it should launch a recruitment campaign to raise the profile of …
Gov response: It is a legal requirement for all children’s homes to be led by a manager registered with Ofsted. We are committed to improving the registration process to help providers deploy managers more quickly, as set …
Not Addressed
#17 —
Recommendation: The pandemic and increasing demand on the justice system will continue to put pressure on staff who are at the heart of ensuring prisons are well run, court backlogs are addressed, and probation services are effective. HMPPS told us of …
Gov response: 6.2 The department agrees with the Committee that its staff are at the heart of delivering a world-class justice system and that they have performed extraordinarily during the course of this pandemic to ensure the …
Not Addressed
#16 —
Recommendation: We received evidence from the Bar Council raising concerns around the safety of court staff during the pandemic. A recent survey they conducted showed 84% of barristers who attended court in December 2020 had concerns about their safety and wellbeing.23 …
Gov response: 6.2 The department agrees with the Committee that its staff are at the heart of delivering a world-class justice system and that they have performed extraordinarily during the course of this pandemic to ensure the …
Not Addressed
#2 —
Recommendation: We recognise that all prisons and other custodial institutions face additional pressures during the current covid-19 pandemic, but we do not consider those to be justification or excuse for the continued poor conditions at Rainsbrook and the repeated absence of …
No Published Response
#24 —
Recommendation: Guidance to all Research Council staff should include a specific requirement to ensure representative Committees—for example, greater diversity could be achieved by appointing on potential, rather than on past achievements.
Gov response: 124. The Government agrees that more can be done to make committees in UKRI more representative. The UKRI EDI strategy sets out a commitment to include and value a diversity of people, experiences and perspectives …
Not Addressed
#20 —
Recommendation: Some STEM researchers face a discriminatory working environment. Whilst this reflects inequities that exist elsewhere in society it is nevertheless a source of deep concern. The process of reducing and ultimately ending such prejudice will not be swift but is …
Gov response: 21. As mentioned in paragraph 6, we recognise that there is still some way to go to improve the numbers of young people from these different backgrounds taking STEM subjects at GCSE and A Level. …
Under Consideration
#12 —
Recommendation: There were fundamental failures in the implementation and oversight of the care worker visa route when it was expanded in 2022, which led to unexpectedly high numbers of arrivals in a short space of time. The Home Office significantly underestimated …
Response Pending
#19 —
Recommendation: The Government should bring forward consistent, enforceable standards for the non-surgical cosmetic sector that prioritise patient safety and competency, while ensuring training routes remain accessible and affordable for a predominantly female-led workforce. Training routes should include Ofqual-approved qualifications and apprenticeship …
Response Pending
#18 —
Recommendation: The absence of a legislative framework for training and qualifications in the non-surgical cosmetic sector has resulted in significant variability in standards, with justified concerns about short courses, online training, and the ease of entry into practice. (Conclusion, Paragraph 77)
Response Pending
#17 —
Recommendation: The Government should accelerate regulatory action. Procedures that are deemed high risk such as liquid BBLs and liquid breast augmentations, which have already been shown to pose a serious threat to patient safety, should be restricted to appropriately qualified medical …
Response Pending
#14 —
Recommendation: The Government should require all practitioners performing invasive surgical cosmetic procedures to have specialist training and hold appropriate board certification in the procedures they undertake. (Recommendation, Paragraph 52) Non-surgical cosmetic procedures
Response Pending
#13 —
Recommendation: Currently, any doctor on the medical register can legally perform highly invasive cosmetic surgery in the private sector, regardless of specialist training or competence. This is a risk to patient safety. Despite the introduction of the Intercollegiate Cosmetic Surgery Certification …
Response Pending
#9 —
Recommendation: We are satisfied that Mr Gurr has the professional competence and independence required to be appointable by the Secretary of State to the position of Chair of the CMA, as the role has been defined. However, we believe that a …
Response Pending
#16 — Bullying, harassment, and discrimination levels in Cabinet Office remain a significant concern.
Recommendation: Levels of bullying, harassment and discrimination at the Cabinet Office remain a point of concern. We welcome the desire expressed by senior leaders to reduce those levels and are encouraged to learn that a formal programme is in place to …
Gov response: The Cabinet Office should report to the Committee on its progress in delivering the ‘A Better Cabinet Office’ programme, in its response to this report. As part of that work, the Cabinet Office should include …
Accepted
#3 — Inconsistent police vetting practices and evaded transfer vetting undermine public trust
Recommendation: Some will be attracted to a career in policing precisely because it provides a position of power that can be exploited or abused. Vetting upon recruitment and in-service needs to reflect this. It cannot be right that vetting practices vary …
Gov response: 7. Forces are required to vet in line with the statutory code of practice on vetting and the vetting authorised professional practice (APP) which are issued by the College of Policing. These both set out …
Accepted
#14 —
Recommendation: We are concerned that Ministry of Justice awarded MTC the maximum possible contract extension. Based on the evidence heard on 9 March, coupled with the inspectorates’ findings, it is clear that MTC have failed to fulfil a number of contractual …
No Published Response
#13 —
Recommendation: Embedding YCS staff within the institutions whose performance they are monitoring is clearly good practice in principle but is not sufficient on its own. The Minister should consider having additional monitors travelling around sites, or a further form of independent …
No Published Response
#1 —
Recommendation: The litany of inaction and what one inspector called “utter incompetence” at Rainsbrook year after year provides a cautionary tale of how badly an arms-length relationship between the Ministry of Justice as a client and MTC as the company hired …
No Published Response
#25 —
Recommendation: STEM-related roles are an important part of the UK labour market, and just as is the case in other workplaces, the benefits of improved diversity and inclusion are clear, for employers and employees alike. The path to achieving this is …
Gov response: 125. The establishment of the Department for Science, Innovation and Technology (DSIT) is a clear signal of the Government’s commitment to ensuring the UK is the most innovative economy in the world and a science …
Not Addressed
#17 — Require Cabinet Office to report progress and evaluate 'A Better Cabinet Office' programme.
Recommendation: The Cabinet Office should report to the Committee on its progress in delivering the ‘A Better Cabinet Office’ programme, in its response to this report. As part of that work, the Cabinet Office should include a thorough evaluation of its …
Gov response: Progress with A Better Cabinet Office A Better Cabinet Office (ABCO) is the Department’s people transformation programme, with an overarching focus on improving employee experience and engagement. There are six workstreams, focussed on the areas …
Accepted
#10 — Require all police forces to explicitly prohibit officers from paying for sex
Recommendation: We heard that here has been a lack of clarity on what constitutes misogynistic or predatory behaviour, as well as multiple reports of police officers engaging in commercial sexual exploitation. For that reason, we recommend that forces which have not …
Gov response: 26. The decision on how to deploy resources and drive delivery in force is a matter for Chief Constables.
Under Consideration
#4 — Empower College of Policing to mandate consistent, values-based recruitment processes for all forces
Recommendation: We recommend the Home Office empower the College of Policing to require forces to use consistent recruitment processes which include values-based interviewing. We expect to see all forces aligning recruitment processes and utilising values-based interviewing within 12 months.
Gov response: 11. Wellbeing and onboarding surveys consistently demonstrate that quality of supervision and line management is the biggest factor in retention and wellbeing. CoP have rolled out new national leadership standards and accompanying development programmes for …
Under Consideration
#1 —
Recommendation: For too many disabled people, the workplace remains a hostile environment. This manifests itself in two main ways: a reluctance among employers to make reasonable adjustments, and inaccessible workplaces and practices that leave disabled people unnecessarily reliant on reasonable adjustments …
Response Pending
#3 —
Recommendation: We are conscious, however, that—given wider economic uncertainty—her spouse’s situation may change. In that event, we would urge TPR, the Pensions Minister and Mrs Smart herself to consider whether she can remain in her role.
No Published Response
#2 —
Recommendation: During the pre-appointment hearing, we discussed with Mrs Smart the potential conflicts of interest arising from her spouse’s role as Chief Executive of British Airways Pensions. She told us that he was making plans to leave that role and would …
No Published Response
#19 —
Recommendation: The Department does record some data on the more serious issues it has become aware of, including cases where health and safety concerns had been raised by participants or account managers, and instances where young people were working in Kickstart …
Not Addressed
#8 —
Recommendation: The regulators set out a number of ways in which they are addressing these skills shortages. On recruitment and retention of veterinarians, FSA has worked with the Royal College of Veterinary Surgeons to agree a temporary arrangement that allows veterinarians …
Gov response: 2b. PAC recommendation: The FSA should work with the Department for Education and relevant professional bodies to address the shortage in qualified veterinarians. 2.15 The FSA agrees with the Committee’s recommendation. Recommendation implemented 2.16 There …
Accepted
#8 — Biased interpreters negatively impact asylum claims, especially in SOGI and religious belief cases.
Recommendation: Biased or prejudiced interpreters can adversely affect a person’s asylum claim, particularly in cases where claims are based on sexual orientation or gender identity and religion or renunciation of religious belief. No interpreter contracted by the Home Office should be …
Gov response: In relation to the recommendations at paragraphs 74 and 75, as our interpreters are not Home Office employees we are unable to mandate training, however they must adhere to our code of conduct which sets …
Accepted
#21 — Skilled Worker visa sponsorship model leaves migrant workers vulnerable to widespread exploitation.
Recommendation: The Skilled Worker visa system is based on a sponsorship model where a migrant’s right to remain in the United Kingdom is dependent on their employer.49 This reliance makes migrant workers vulnerable to exploitation, and there is widespread evidence of …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2027 4.2 The Home Office collaborates with bodies such as the Director of Labour Market Enforcement, Gangmasters and Labour Abuse Authority, Employment Agency …
Accepted
#18 — Home Office fails to adequately tackle exploitation and unethical practices against migrant care workers.
Recommendation: We remain concerned, however, that the Home Office has not done enough to tackle unethical practices and the exploitation of migrant workers in the social care sector.42 Evidence provided by UNISON highlighted that some employers were exploiting workers’ vulnerability, making …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2027 4.2 The Home Office collaborates with bodies such as the Director of Labour Market Enforcement, Gangmasters and Labour Abuse Authority, Employment Agency …
Accepted
CQC Inspection Actions (103) — showing 50 strongest matches
Cotton Exchange
The provider must have processes in place to ensure that staff are suitably qualified, competent, skilled and experienced to provide a safe service.
Must Do
Baby Bump Limited
The service must ensure that all persons providing care to service users have the appropriate competence, skills, and experience to do so.
Must Do
We Can Recover CIC
The registered manager was not aware of or understood that the named GP under practicing privileges required a license as defined by the GMC. The named GP had not been vetted under Regulation 18 (schedule 3) fit and proper person …
Must Do
Tregertha Court Care Home
Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed
Must Do
St.Theresa's Nursing Home
Recruitment procedures were not established and operated effectively. Regulation 19(1)(2)(3) Schedule 3 (3) & (4)
Must Do
Laurel Lodge Care Home
The provider must ensure that persons employed are fit and proper for the purposes of the regulated activity.
Must Do
Wishingwell Residential Care Home
The provider had not ensured staff were safely recruited. Regulation 19(3).
Must Do
The Hailey Residential Care Home
People were not supported by staff who had been safely recruited. Two of the 3 staff files reviewed did not evidence a full employment history. Gaps in employment had not been explored and recorded.
Should Do
Rosglen Residential Home
The provider must ensure recruitment procedures operate effectively in a way to ensure persons employed are of good character and have the qualifications, competence, skills and experience necessary for the work to be performed.
Must Do
Lovat House Residential Care
The provider must ensure staff are suitably qualified, competent, skilled and experienced to carry out their roles effectively.
Must Do
We Can Recover CIC
The service did not ensure that pre-employment checks were carried out prior to staff starting work. Staff did not have disclosure and barring service checks completed.
Must Do
Cheshire Hair Transplant Clinic Limited
The service must ensure that robust recruitment processes are in place to ensure staff are ‘fit and proper’ to fulfil their role.
Must Do
Continuity Healthcare Services Private Limited
The provider did not adequately assess and protect people against risks by doing all that was practicable to identify and mitigate such risks. The provider did not ensure staff had adequate qualifications, competence and skills to provide safe care. The …
Must Do
Chandos Lodge Nursing Home
The provider did not always implement procedures to ensure staff were of a good character prior to them working with adults at risk.
Must Do
Assured Care Formby
Staff were not recruited safely.
Must Do
Aspen Lodge
Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed
Must Do
Verve Health
The service must ensure staff including those who work at the service but are not directly employed have the right skills and training to meet the needs of the service users in their care and that they receive a full …
Must Do
Bellevue Healthcare Limited
We took urgent action to require the registered provider reviewed the competency of the staff employed at the home and managed the risks posed to people who used the service.
Must Do
Attwood's Manor Care Home
We recommend that the service makes improvements in this area and can demonstrate that references and other documents are in place before staff start. We also recommend the home demonstrates how they have assessed the candidate's suitability for employment in …
Should Do
Woodview House Nursing Home
There was a lack of oversight in place to ensure staff were competent and skilled in their role/.
Must Do
Walfinch West Suffolk
The provider must ensure recruitment checks are completed on all new staff to check their suitability or competence to work with vulnerable people prior to commencing employment.
Must Do
The Withins
There was a failure to ensure staff were suitably qualified, competent and experienced to enable them to meet the needs of the people using the service at all times.
Must Do
The Old Post Office
The provider must complete recruitment checks effectively.
Must Do
Sundial Cottage Rest Home Ltd
Systems to ensure only fit and proper persons were employed were not sufficiently robust. This was a breach of regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Must Do
St Albans House
The provider must recruit staff safely.
Must Do
Spindrift Care Home Limited
The provider had not ensured appropriate checks were undertaken before staff commenced their employment, to confirm they were safe to work with vulnerable people.
Must Do
Royalcare- Thanet
The provider and registered manager failed to operate effective recruitment processes and ensure information specified in Schedule 3 of the Health and Social Care Act was available for each member of staff.
Must Do
Paxigate Healthcare Limited
The required pre-employment checks had not been fully completed to help ensure staff employed were suitable. This included completing a new Disclosure and Barring Service (DBS) check and obtaining additional references.
Must Do
Paxigate Healthcare Limited
Improvements were needed in the recruitment of staff to ensure the provider followed their own policy and procedure.
Must Do
M N Pulse Solutions
Improvements were needed to ensure staff were consistently recruited in a safe way.
Must Do
Lindcare Ltd
The provider must ensure safe staffing and recruitment procedures are established and operated effectively to ensure that persons employed are of good character, including robust recruitment checks, complete employment application forms, and comprehensive references from previous employers.
Must Do
Kingfishers Nursing Home
Recruitment procedures were not established and operated effectively to ensure that fit and proper persons were employed. All information specified in Schedule 3 was not available for each such person employed.
Must Do
Kare Support Services Ltd
The registered person had not followed their established recruitment procedures to ensure the suitability of all staff employed. The registered provider had not ensured the information specified in Schedule 3 was available for each person employed. Regulation 19 (1)(2)(3)(a) and …
Must Do
Hey Baby 4D Halifax
The service must implement systems and processes, including but not limited to appraisals and supervision to ensure staff are suitably qualified, competent, skilled and experienced.
Must Do
Heatherdene Residential Care Home
The provider had failed to ensure that robust staff recruitment procedures were followed to ensure only fit and proper persons were employed.
Must Do
Gordon Road
The failure to operate recruitment procedures to ensure fit and proper persons were employed.
Must Do
Edwina Place
The provider should seek advice from a reputable source to ensure they gather and record all necessary information for recruitment purposes.
Should Do
Community Outreach
The provider had failed to ensure that staff were suitably competent, skilled, and experienced to support people effectively.
Must Do
Christie Care
The provider had failed to carry out complete appropriate employment checks.
Must Do
Chirnside House
Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed: The service was not always safe. There was limited assurance that staff were recruited safely.
Must Do
Chandos Lodge Nursing Home
Systems were either not in place or robust enough to demonstrate staff recruitment checks were effectively managed.
Must Do
Bradley Street
The providermusthaveprocessesinplacetoensurethatstaffaresuitablyqualified,competent,skilledandexperiencedtoprovideasafeservice.
Must Do
Benhall Care
The provider must ensure safe recruitment practices are used to ensure fit and proper staff are employed to provide the regulated activity of personal care.
Must Do
Badger House
Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed
Must Do
Ashton Lollipop
The provider must have processes in place to ensure that staff are suitably qualified, competent, skilled and experienced to provide a safe service.
Must Do
Winterton House
The provider did not demonstrate they had the skills or competence required to carry on the regulated activity.
Must Do
Winterton House
The provider did not operate effective recruitment procedures to ensure persons employed were of good character.
Must Do
We (Always) Care Under One Roof Limited
The provider must ensure that recruitment procedures are established and operated effectively.
Must Do
V&C Family Care Ltd
The provider must ensure that persons employed are of good character, have the necessary qualifications, skills and experience, and are physically and mentally fit for the purposes of the work they are to perform.
Must Do
Tregertha Court Care Home
The provider must ensure that persons employed are fit and proper for the purposes of the regulated activity, by completing all necessary employment checks, including Disclosure and Barring Service (DBS) checks, before staff commence unsupervised work.
Must Do
HMICFRS Recommendations (50)
FRS 2018-19 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: Devon and Somerset FRS cannot assure itself that operational members of staff meet the minimum fitness requirements to perform their role. Recommendation: By 28 February 2020, the service should provide an action plan that details how they …
Recommendation
FRS 2023-25 CoC Recommendations: Bedfordshire Fire and Rescue Service
Cause of concern: Bedfordshire Fire and Rescue Service can’t assure itself that its operational members of staff meet the minimum fitness requirements to perform their roles. Recommendation: Within 28 days, the service should provide an action plan that details 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 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 that arrangements for staff working on dual contracts meet statutory …
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 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: 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
PEEL 2018-19 CoC Recommendations: Metropolitan Police Service
Cause of concern: The size of the vetting backlog within the Metropolitan Police Service is a cause of concern. Recommendation: The force should undertake work to ensure it fully understands the vetting status of staff where their current vetting status …
Recommendation
PEEL 2021-22 CoC Recommendations: Greater Manchester Police
Cause of concern: Greater Manchester Police doesn’t currently have the arrangements in place to support and build its workforce. Recommendation: Within six months Greater Manchester Police should understand the performance of its workforce, support staff development and deal with poor …
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 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 2023-25 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: The service lacks adequate organisational level plans that set out and bring together current and future workforce and skills requirements. The service doesn’t have in place adequate service-level processes to direct its recruitment and succession planning work. …
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
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 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 doesn’t have enough trained and experienced protection staff to implement its risk-based inspection programme and take proportionate action to reduce risk and enforce fire safety regulations. Recommendation: Within 28 days, the service should provide an …
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 support managers …
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 engage with …
Recommendation
FRS 2021-22 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: The service has shown a clear intent from the executive board to improve the culture of the service. However, more needs to be done throughout the organisation. We have found evidence of poor behaviours that are not …
Recommendation
FRS 2023-25 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to make sure staff have access to gender-appropriate facilities. Access to welfare and hygiene facilities at incidents has been limited, and staff don’t have access to gender-appropriate uniform …
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 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
PEEL 2018-19 CoC Recommendations: West Yorkshire Police
Cause of concern: West Yorkshire Police is failing to place enough resources into tackling potential corruption within its workforce. This is a cause of concern. Recommendation: The force should ensure that it has enough capability and capacity to counter corruption …
Recommendation
PEEL 2018-19 CoC Recommendations: West Midlands Police
Cause of concern: The size of the vetting backlog within West Midlands Police is a cause of concern. Recommendation: The force should ensure all staff have received at least the lowest level of vetting clearance for their roles as quickly …
Recommendation
PEEL 2018-19 CoC Recommendations: Metropolitan Police Service
Cause of concern: The size of the vetting backlog within the Metropolitan Police Service is a cause of concern. Recommendation: Within 12 months the force should ensure all staff have received at least the lowest level of vetting clearance for …
Recommendation
PEEL 2023-25 CoC Recommendations: Metropolitan Police Service
Cause of concern: The force isn’t safely managing risks posed by registered sex offenders in the community Recommendation: The Metropolitan Police Service should immediately review its use of reactive management.
Recommendation
PEEL 2023-25 CoC Recommendations: Lincolnshire Police
Cause of concern: The force needs to make sure that it has the capacity and capability to manage the risks posed to the public by registered sex offenders. Recommendation: Within six months from the date of publication of this letter, …
Recommendation
PEEL 2018-19 CoC Recommendations: Cleveland Police
Cause of concern: Many senior leaders (superintending and chief officer ranks, and senior police staff managers) aren’t consistently demonstrating ethical behaviour. The inappropriate behaviour of these leaders within Cleveland Police is so profound that it is affecting the efficiency and …
Recommendation
PEEL 2018-19 CoC Recommendations: Cleveland Police
Cause of concern: Many senior leaders (superintending and chief officer ranks, and senior police staff managers) aren’t consistently demonstrating ethical behaviour. The inappropriate behaviour of these leaders within Cleveland Police is so profound that it is affecting the efficiency and …
Recommendation
PEEL 2018-19 CoC Recommendations: Cleveland Police
Cause of concern: Many senior leaders (superintending and chief officer ranks, and senior police staff managers) aren’t consistently demonstrating ethical behaviour. The inappropriate behaviour of these leaders within Cleveland Police is so profound that it is affecting the efficiency and …
Recommendation
PEEL 2018-19 CoC Recommendations: Cleveland Police
Cause of concern: Many senior leaders (superintending and chief officer ranks, and senior police staff managers) aren’t consistently demonstrating ethical behaviour. The inappropriate behaviour of these leaders within Cleveland Police is so profound that it is affecting the efficiency and …
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
PPO Death in Custody Recommendations (4)
The Governor and the Head of Healthcare
nurses always undertake their own assessment of a prisoners’ condition and do not accept an officer’s evaluation that the prisoner is apparently well.
The Governor and Head of Healthcare
review the two incidences in November 2021 where the HCA thought that prison staff gave her authority to move Mr Roalfe out of bed;
The Director of HMP Northumberland
The Director should review the process for allocating prisoners to positions of trust, to ensure there is an auditable record that relevant security information and potential risks have been fully considered.
The Governor
The Governor should commission a disciplinary investigation into Officer C’s and Officer A’s actions on the evening of 22 March 2023.
IMB Recommendations (70) — showing 50 strongest matches
Birmingham (2023)
High rates of attrition are partly attributable to the appointments process which has resulted in too many unsuitable appointments. The process excludes the local Governor from involvement in the interview. Will HMPPS review the appointments process with a view to including local Governors in the selection process and a more rigorous assessment of a candidate’s suitability for the role of …
HMPPS
Guys Marsh (2024)
The rise in assaults on prison staff and the worrying increase in the poor treatment of prisoners by some prison officers suggests a failure in the process of assessment, selection and training of officers. When will the Prison Service take action to address these shortcomings?
HMPPS
Garth (2021)
The recruitment of uniformed staff needs urgent attention: • Each prison and each category of prison has its own needs in terms of staff recruitment and balance. • Each prison should have a say in the recruitment of individual officers in order to address the above requirements. This would be facilitated by face-to-face interviews in the prison. • Each prison …
HMPPS
The Mount (2022)
On staffing levels and new recruits, the Prison Service needs to better appraise applicants as to their suitability for the role. A lot of effort and money is wasted when trainees leave because they cannot cope with the environment. Numbers recruited should not be the only measure. The number that finish their training who are still employed 12 months later …
HMPPS
Garth (2022)
it is strongly suggested that only experienced officers should be seconded to prisons.
HMPPS
Onley (2023)
What local actions are underway to improve officer staffing levels, given that prison officer shortages impacted on the daily life of prisoners and on the implementation of key work as intended in the offender management in custody (OMiC) model?
Governor / Director
Onley (2023)
What further support can be provided to ensure key work is delivered consistently and to a high standard for all prisoners despite the shortage of prison officers?
HMPPS
Garth (2023)
As above, to the Minister: staff recruitment and interview procedures need to be substantially changed to improve the process.
HMPPS
Swinfen Hall (2024)
Why can staff who are completing their residential course prior to appointment to their prison not have their offer of employment withdrawn if, during the course or on completion, it is clear they do not have the capacity or suitability to take on the role of prison officer?
HMPPS
Swinfen Hall (2024)
The HMPPS prison officer appointment process has resulted in some unsuitable appointments. Why are the Governing Governors not permitted to review the suitability of newly appointed band 3 staff prior to their starting the job at the prison?
HMPPS
Garth (2024)
it is strongly recommended that applicants who are interest in joining the staff at Garth should visit the prison before interview and should be interviewed face-to-face by a panel that includes senior staff of the prison. It is essential that applicants fully understand what they are coming into and that management are as sure as possible that they have the …
Ministry of Justice
Garth (2024)
The whole process of recruitment and retention needs to be addressed with the Governor and senior management being included in the process and able to determine suitability of individual applicants for this prison.
HMPPS
Garth (2024)
The whole policy and process of staff recruitment needs to be reviewed and revised as a matter of urgency, because many of the operational problems within the prison derive from the inadequacies of the current process.
Ministry of Justice
Featherstone (2024)
The culture amongst staff remains problematic in some cases. We believe this issue is understood by the Governor, but continued vigilance is necessary to ensure these issues continue to be addressed.
Governor / Director
Wandsworth (2025)
Officer recruitment has been poor, leading to a high turnover of often unsuitable staff. Recruitment is handled centrally. Will the Prison Service consider allowing the prison to become involved in the process so that applicants receive a realistic impression of the role?
HMPPS
Littlehey (2025)
The Board is, again, disappointed that, despite repeated requests for change, the IMB recruitment process continues to be inadequate and inappropriate to support the timely recruitment of candidates with the necessary qualities and skills. Again, the Board is eager to know what improvements the Minister plans to address this issue.
Ministry of Justice
Featherstone (2021)
Shortly after appointment, the Governor recognised that there were some problems with the culture of some staff and took steps to improve it. More than a year on, our applications indicate that some of these problems may remain and vigilance will need to be maintained to ensure issues are addressed.
Governor / Director
Wandsworth (2023)
Staff recruitment is managed centrally. Would the Service consider involving HMP Wandsworth in the process to ensure that suitable staff are selected and given a realistic understanding of the role, thus reducing staff turnover?
HMPPS
Portland (2023)
Key work is crucial to the early identification of deteriorating mental health. If an individual has mental health issues it can adversely affect their ability to engage with learning and training. It therefore makes sense to prioritise key work over training and learning opportunities rather than being seen as an “add-on” with the option to drop it if staffing is …
Governor / Director
Peterborough (women) (2023)
Can the Director continue to focus on embedding quality key work?
Governor / Director
Peterborough (men) (2023)
Can the Director continue to focus on embedding quality key work?
Governor / Director
Pentonville (2023)
Will you commit to renewing the focus on key work to ensure that all prisoners can benefit from the valuable personal contact that this brings?
Governor / Director
Altcourse (2023)
Recruitment and retention of staff have been major concerns this year, particularly in the context of the transfer to Sodexo. These issues could undermine the stability and safety of the prison. Can the Board be reassured therefore that the recruitment and retention of staff remain the highest priority?
Governor / Director
Wandsworth (2024)
Staff recruitment is managed centrally. Would the Service consider involving HMP Wandsworth in the process to ensure that suitable staff are selected and given a realistic understanding of the role, thus reducing staff turnover?
HMPPS
Wandsworth (2024)
Officer recruitment has been poor, leading to a high turnover of often unsuitable staff. Recruitment is handled centrally. Will the Service consider allowing the prison to become involved in the process so that applicants receive a realistic impression of the role?
HMPPS
Swinfen Hall (2025)
The HMPPS prison officer appointment process continues to result in some unsuitable appointments. As governing governors are not permitted to review the suitability of newly appointed band 3 staff prior to their starting the job at the prison, is the Prison Service accepting that staff appointed lack confidence and competence?
HMPPS
Bedford (2025)
What actions is the prison taking to address this [assaults on staff remain far too high]?
Governor / Director
Manchester (2020)
What processes are being put into place to reduce staff sickness further, to provide a healthy workforce, with high levels of staff attendance?
Governor / Director
Long Lartin (2020)
The Board notes the unacceptably high number of assaults on officers in the segregation unit and the shortage of dedicated staff in this unit.
Governor / Director
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport T3] The Home Office should arrange for the layout of the Terminal 3 office/reception area to be modified to enable both DCOs to exercise continuous surveillance of the detainees in their care (para. 7.2).
Home Office
Swaleside (2021)
The Board asks the Governor to note the high level of applications we have received complaining about staff. These should have translated into complaints sent to him and the DDC, and are at a much higher level than last year. (see section 8)
Governor / Director
Garth (2021)
Staff retention problems throughout HMPPS have increased throughout this period in large part because of the erosion of staff salaries and conditions of service. This matter needs to be urgently addressed and rectified.
HMPPS
Foston Hall (2021)
The IMB is concerned about: increase in violent incidents due to an increase in assaults on staff
Governor / Director
Eastwood Park (2021)
What action is being taken to improve officer recruitment and retention at Eastwood Park?
Governor / Director
Eastwood Park (2021)
Given the fluctuations in staffing levels caused by this pandemic, which are likely to continue for some time, will HMPPS ensure that prisons are staffed sufficiently to cope with this ongoing situation?
HMPPS
Cookham Wood (2021)
Is the YCS confident that an appointment of a substantive postholder to the role of Governor at Cookham Wood can be made? And will there be adequate plans in place to support a smooth leadership transition when this eventually takes place?
HMPPS
Wayland (2022)
The Board recommends to the Prison Service that the review of staff profiling for which we have called in previous reports, and for which we are now calling again, must take into account the context we have just described, at least until the balance of experience is restored.
HMPPS
Styal (2022)
There is an urgent need to review pay and conditions at all levels in the prison service to ensure the recruitment and retention of high quality staff.
HMPPS
Stocken (2022)
The Board has concerns about the performance of PeoplePlus, which is clearly not functioning well with low staff morale and some targets not being met.
Governor / Director
Send (2022)
Recruitment issues continue to impact on all areas of prison life including operational staff, healthcare and catering (3.1, 5.1, 6.1, 6.2).
HMPPS
Pentonville (2022)
Will you introduce more initiatives (like Graduates Unlocked) to help raise the calibre of people applying to be prison officers?
HMPPS
Long Lartin (2022)
Will the Prison Service continue to provide a sufficient number of detached uniformed staff to ensure safety and fair and humane treatment for prisoners?
HMPPS
Bullingdon (2022)
There continues to be a high proportion of staff with limited experience. In some instances, these staff have no experience of the prison regime before Covid. How will the Governor ensure that these staff receive further appropriate training so that they can carry out their duties effectively?
Governor / Director
Garth (2023)
How and when does the Minister propose to tackle the urgent issue of uniformed staff recruitment and retention? Specifically, it is strongly recommended that applicants who are interested in joining the staff at Garth should visit the prison before interview and should be interviewed by a panel that includes senior staff at the prison. This should help ensure that new …
HMPPS
Five Wells (2025)
How are all parties ensuring the safety of pharmacists and men at the dispensary hatches?
Governor / Director
Five Wells (2025)
How are all parties ensuring the safety of pharmacists and men at the dispensary hatches?
Governor / Director
Dovegate (2025)
The Board recommends that the Director remains vigilant of staff complacency and take measures to minimise it.
Governor / Director
Maidstone (2020)
Support local managers to reduce staff absence (see paragraph 3.7).
HMPPS
Durham (2021)
The Board is concerned that prisoners are working as cleaners before checks are completed and they are not receiving back-pay (5.3.10).
Governor / Director
Brixton (2021)
The introduction of the offender flow process has resulted in men who do not meet the profile being sent to Brixton which is not equipped to support men very recently convicted, or those who have not been in a training prison, or men with substantial sentences still to serve. The process is setting up both these prisoners and the prison …
HMPPS
Health Investigations (5)
Themes and lessons learnt from NHS investigations into matters relating … — Rec R11
NHS hospital trusts should review their recruitment, checking, training and general employment processes to ensure they operate in a consistent and robust manner across all departments and functions and that overall responsibility for these matters rests with a single executive director.
national
Accepted
Themes and lessons learnt from NHS investigations into matters relating … — Rec R10
All NHS hospital trusts should ensure that arrangements and processes for the recruitment, checking, general employment and training of contract and agency staff are consistent with their own internal HR processes and standards and are subject to monitoring and oversight by their own HR managers.
national
Accepted
Themes and lessons learnt from NHS investigations into matters relating … — Rec R7
All NHS hospital trusts should undertake DBS checks (including, where applicable, enhanced DBS and barring list checks) on their staff and volunteers every three years. The implementation of this recommendation should be supported by NHS Employers.
national
Accepted
Themes and lessons learnt from NHS investigations into matters relating … — Rec R6
The Home Office should amend relevant legislation and regulations so as to ensure that all hospital staff and volunteers undertaking work or volunteering that brings them into contact with patients or their visitors are subject to enhanced DBS and barring list checks.
national
Not Accepted
Themes and lessons learnt from NHS investigations into matters relating … — Rec R2
All NHS trusts should review their voluntary services arrangements and ensure that: - they are fit for purpose; - volunteers are properly recruited, selected and trained and are subject to appropriate management and supervision; and - all voluntary services managers have development opportunities and are properly supported.
national
Accepted
Detention Investigations (9)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 55
relevant experience in either custodial management or contract management be a requirement for the post.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 26
I recommend that Officers B and C’s status is checked and that their accreditation be withdrawn if this has not already happened.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 4
I recommend that Securicor draws my views to the attention of those officers still employed who were responsible for taping the detainee's skirt together between her legs, and considers what further action may be required.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R16
The SMT and DCMs at Brook House must ensure that all staff are subject to an effective annual appraisal process that results in identifying and addressing training and other developmental needs. (To be completed within 3 months)
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 25
arrangements are introduced to prohibit the staff of removal centres and escort contractors from membership of racist organisations.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 25
I recommend that a protocol is drawn up between GSL and IND specifying the qualities necessary for DCOs allocated to the DDU. Any officers so allocated should have enhanced interpersonal skills and training, and their integrity must be beyond doubt.
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
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
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R3
Serco should consider with the Home Office the development of suitability criteria for the detention of time-served foreign national offenders at Yarl’s Wood.
Immigration Detention
PHSO Casework Decisions (3)
P-001694 — HCRG Care Group
Mrs O complains carers were unprofessional and mistreated her father, Mr A, by refusing to change his incontinence pad and pulling his arm. She says staff listened to the family's conversations and reported them. She also complains the service would not give Mr A a male carer and dismissed the …
NHS in England
Nov 2022
P-003829 — Sheffield Children's NHS Foundation Trust
Ms P complains about how the Trust cared for her son. She questions if the consultant was qualified to give care, and complains about the treatment decisions the Trust made, its communication with her and how it treated her. She also complains about its complaint handling.
NHS in England
Partly Upheld
Oct 2023
P-002564 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss R complains about the behaviour of a nurse who she says acted aggressively, misgendered her and failed to take into account that she is autistic.
NHS in England
Apr 2024
LGO / SPSO Decisions (46)
PSOW-202502399 — Betsi Cadwaladr University Health Board
Mr C complained that Betsi Cadwaladr University Health Board withdrew an offer of a place on a training programme because it could not fund the Sponsorship Certificate that Mr C required. The Ombudsman found that the advert and recruitment pack had not made it clear that sponsorship was not available …
PSOW (Public Services Om…
Health
Oct 2025
24-022-201 — Stockton-on-Tees Borough Council
Summary: We will not investigate Mrs X’s complaint about the actions and behaviour of a support worker. This is because the complaint is not in our jurisdiction.
LGO (Local Government & …
Adult Care Services
Jun 2025
22-007-143 — Stockton-on-Tees Borough Council
Summary: We will not investigate this complaint about the Council’s conclusion that the complainant poses a risk to staff. This is because there is insufficient evidence of fault in how the Council dealt with the matter.
LGO (Local Government & …
Other Categories
Oct 2022
24-013-139 — Staffordshire County Council
Summary: Mr X and Mr Y complained about the Council’s biased and inaccurate information which led to its decision to remove their foster child from their care. They also complained about a lack of support and the Council withholding information. We do not find the Council was at fault.
LGO (Local Government & …
Children S Care Services
Not Upheld
Jul 2025
201804797 — Edinburgh College
Mr C complained that the college's handling of his concerns about the behaviour of a learning support worker was unreasonable. We found that the college was aware of Mr C's support needs, how this affected him and had put in place reasonable support for him. We noted that two meetings …
SPSO (Scottish Public Se…
Education
Not Upheld
Mar 2020
21-011-656 — Aman Care Limited
Summary: We will not investigate this complaint about a carer. This is because the alleged harassment and stalking by a carer is best dealt with by the Police. And we have no remit to consider the carer’s employment with the care company.
LGO (Local Government & …
Adult Care Services
Jan 2022
21-007-679 — Barnsley Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s decision to end Mr and Mrs X’s approval as Shared Lives carers. That is because the complaint is late.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-011-174 — Hales Group Ltd
Summary: Mr C complained that Hales Group Ltd was at fault for errors made in administering medication, for poor social care and for a failure to provide documents requested. Hales was at fault for failures in administering medicine and for a failure to provide Mr C with requested documents. Its …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
24-002-973 — London Borough of Sutton
Summary: We will not investigate Mrs X’s complaint about the Council not sourcing suitable carers for her when she needed help with showering. She says the carers did not hold enhanced disclosure and barring service clearance. This is because the complaint is late and there are no good reasons to …
LGO (Local Government & …
Adult Care Services
Oct 2024
24-008-885 — Norfolk County Council
Summary: Mr and Mrs X complain about a LADO investigation and the removal of a child they were fostering. There was no fault in the Council’s response to allegations by a child Mr and Mrs X fostered.
LGO (Local Government & …
Children S Care Services
Not Upheld
Apr 2025
25-000-505 — Hertfordshire County Council
Summary: We will not investigate this complaint about the alleged attitude of a social worker in taking three and a half days to make a phone call. The situation is unlikely to have been an emergency and there is not enough evidence of fault or injustice to warrant our further …
LGO (Local Government & …
Children S Care Services
Jun 2025
25-011-715 — Hereford & Worcester Fire & Rescue Service
Summary: We will not investigate this complaint that members of the Fire Service stalked him. Further investigation would not lead to a different outcome.
LGO (Local Government & …
Other Categories
Sep 2025
25-004-926 — London Borough of Lambeth
Summary: The Council was not at fault for refusing to pay Ms X its full fostering rate (including additional fees) from the date she became a kinship foster carer. This decision was in line with its policy – which says only fully approved foster carers get the full rate – …
LGO (Local Government & …
Children S Care Services
Upheld
Nov 2025
201502802 — Scottish Prison Service
Mr C complained that a member of prison staff had acted unreasonably by making a comment which he felt was discriminatory and constituted harassment. We carefully considered the information Mr C had provided and sought further information from the Scottish Prison Service (SPS), which included a copy of their investigation …
SPSO (Scottish Public Se…
Prisons
Upheld
Dec 2015
PSOW-202107843 — Gwynedd Council
The Ombudsman’s office received a complaint that a member (“the Member”) of Gwynedd Council (“the Council”) had breached the Code of Conduct. It was alleged that the Member had behaved inappropriately when she responded in German to correspondence she received in Welsh. The investigation considered whether the Member failed to …
PSOW (Public Services Om…
Local Government
Oct 2022
PSOW-202500170 — Carmarthenshire County Council
Miss X complained that Carmarthenshire County Council failed to respond to the complaint she submitted in February 2025 regarding the housing allocation and damp at the property. The Ombudsman found that the Council had not considered the complaint under its formal complaints procedure. The Ombudsman said this caused uncertainty and …
PSOW (Public Services Om…
Local Government
May 2025
PSOW-202410015 — Caerphilly County Borough Council
Ms A complained that Caerphilly County Borough Council had failed to respond to a verbal complaint she made in August 2024 regarding housing support. The Ombudsman decided that whilst the Council did return Ms As call to discuss her concerns, it was recorded as a service request rather than a …
PSOW (Public Services Om…
Local Government
May 2025
22-000-919 — Knowsley Metropolitan Borough Council
Summary: We will not investigate this complaint about how the Council dealt with an application for a private hire taxi licence. This is because further investigation would not lead to a different outcome.
LGO (Local Government & …
Environment And Regulation
May 2022
22-000-028 — Kent County Council
Summary: We will not investigate Mr X’s complaint about the actions of an Appropriate Adult who was allocated to advocate for him after he was arrested in October 2020. This is because an investigation by this office could not add to the responses previously provided by the provider and the …
LGO (Local Government & …
Adult Care Services
May 2022
22-003-783 — West Northamptonshire Council
Summary: We will not investigate this complaint about individual Council officers not being held to account for failings in an upheld complaint. Investigation would be unlikely to lead to a different outcome or achieve the remedy Mr X wants.
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2022
21-012-864 — London Borough of Lewisham
Summary: Mr and Mrs X complain about the Council’s decision to end their arrangement to foster a child after five years causing distress and financial loss. We have found no evidence of fault in the way the Council considered these matters. So we are completing our investigation.
LGO (Local Government & …
Children S Care Services
Not Upheld
Jul 2022
21-012-055 — Oldham Metropolitan Borough Council
Summary: The complainant (Mr X) complained about the way the Council recorded information about him in his social care files and about the conduct of his previous Social Worker. He also complained about other social care staff, saying they discriminated against him. We discontinue this investigation as for some issues …
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
22-011-130 — Essex County Council
Summary: We will not investigate this complaint about the Council’s response to the complainant’s representations about the content of a report. This is because we can achieve nothing significant by doing so.
LGO (Local Government & …
Children S Care Services
Dec 2022
24-001-176 — Rochdale Metropolitan Borough Council
Summary: We will not investigate this complaint alleging the Council breached the terms of a licence agreement for a commercial property. It is not our role to adjudicate on disputed points of law. It is reasonable to expect the complainant to take the matter to court.
LGO (Local Government & …
Environment And Regulation
Jun 2024
23-010-618 — Peterborough City Council
Summary: We found fault by the Council on Mrs D’s complaint about how she was dealt with following allegations from her foster child. Concerns were not consistently raised with her, a serious allegation was not properly dealt with, there was a failure to follow procedures, and she was not given …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2024
24-007-466 — Redcar & Cleveland Council
Summary: We will not exercise discretion to investigate this complaint about the Council’s support of allegations about Mr X by its tenant in 2022. This complaint which was received outside the normal 12-month period for investigating complaints. There is no evidence to suggest that Mr X could not have complained …
LGO (Local Government & …
Other Categories
Sep 2024
24-009-950 — Suffolk County Council
Summary: We will not investigate this complaint that the complainant was unfairly banned from working as a taxi driver on under the Councils’ home to school transport contract. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Environment And Regulation
Sep 2024
24-015-556 — London Borough of Ealing
Summary: We will not investigate this complaint about the conduct of a social worker. That is because the complaint is late.
LGO (Local Government & …
Adult Care Services
May 2025
24-022-314 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s decision not to provide Mrs X’s son with free transport to school. This is because there is not enough evidence of fault.
LGO (Local Government & …
Education
Jun 2025
24-010-932 — North Northamptonshire Council
Summary: Mrs X complained that the Council failed to properly consider all the relevant information when she appealed its decision to deny school transport assistance for her son Y. She said the decision has had significant negative impacts; causing anxiety, stress and logistical challenges for Y and the family. We …
LGO (Local Government & …
Education
Not Upheld
Jun 2025
24-022-812 — Brighton & Hove City Council
Summary: We will not investigate this complaint that the Council has failed to reassess the complainant’s son’s Education Health and Care plan within the statutory timescale. This is because the complainant has used her right to appeal to the First-tier Tribunal (Special Educational Needs and Disability), and the complaint is …
LGO (Local Government & …
Education
Jun 2025
24-022-665 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s decision to remove provision from the complainant’s son’s Education Health and Care plan. This is because the complainant has the right to appeal to the First-tier Tribunal (Special Educational Needs and Disability) and it would be reasonable for her to …
LGO (Local Government & …
Education
Jun 2025
24-022-547 — Sefton Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s decision to refuse the complainant’s application and appeal for school transport assistance for her son. There is insufficient evidence of fault on the Council’s part to warrant our intervention.
LGO (Local Government & …
Education
Jun 2025
24-016-280 — Buckinghamshire Council
Summary: We will not investigate Miss X’s complaint about the Council not authorising a school place offered to her daughter, or naming that school in her daughter’s Education, Health and Care Plan. This is because she has already used her right of appeal at Tribunal.
LGO (Local Government & …
Education
Upheld
Jun 2025
25-003-801 — Kent County Council
Summary: We will not investigate Mr X’s complaint about an unsuccessful appeal for a school place. This is because an investigation would be unlikely to find fault.
LGO (Local Government & …
Education
Jun 2025
24-020-806 — Suffolk County Council
the Council’s decision to refuse the complainant’s application and appeal for school transport for her son. There is
LGO (Local Government & …
Education
Jun 2025
25-000-800 — Cambridge City Council
Summary: We will not investigate this complaint about taxi licensing. This is because the complaint is late, there is not enough evidence of fault to justify investigating and any injustice is not significant enough to justify our involvement.
LGO (Local Government & …
Environment And Regulation
Jun 2025
25-016-478 — Dudley Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint about the unlicensed sale of alcohol, allegations of abuse against a relative, and the alleged criminal behaviour of a person he knows. This is because parts of his complaints are late and there is not enough evidence of fault in the Council’s …
LGO (Local Government & …
Other Categories
Nov 2025
201101605 — Scottish Prison Service
Mr C complained that the SPS had failed to properly and fairly investigate a confidential complaint, which he had submitted to the governor. Our investigation found that the matter had been fully investigated and appropriate action taken as a result. Related reading View Decision Report 201101605 as a PDF (13.2 …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Dec 2011
201205112 — Scottish Prison Service
Mr C, who is a prisoner, complained that he was subjected to discriminatory abuse by a fellow prisoner. Our investigation considered the steps that the Scottish Prison Service (SPS) took to deal with the abuse, and we were satisfied they were reasonable in the circumstances. There was no evidence that …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2013
201602142 — New College Lanarkshire
Miss C complained that college staff did not take action to prevent her from being subjected to inappropriate behaviour from other students on her course. We found that the college had taken reasonable action in line with their policy and procedures when Miss C had experienced difficulties with other students …
SPSO (Scottish Public Se…
Education
Not Upheld
Jun 2017
22-005-194 — Wirral Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint that the financial remedy offered by the Council is not enough. That is because further investigation will not lead to a different outcome.
LGO (Local Government & …
Children S Care Services
Upheld
Aug 2022
22-005-482 — Lancashire County Council
Summary: We will not investigate this complaint about what happened during a wedding. This is because there is not enough evidence of fault by the Council or injustice to the complainant. It is unlikely we could add anything to the Council’s response.
LGO (Local Government & …
Other Categories
Sep 2022
23-017-538 — Luton Borough Council
Summary: We will not investigate Mr X’s complaint about matters relating to his employment. This is because the Council is not Mr X’s employer and an investigation by this office would not be able to add to the response the Council has already provided on this matter.
LGO (Local Government & …
Children S Care Services
Apr 2024
24-013-196 — Manchester City Council
Summary: We will not investigate this complaint about how the Council dealt with a complaint about the conduct of a councillor. This is because we are unlikely to find fault.
LGO (Local Government & …
Other Categories
Nov 2024
24-011-483 — Transport for London
Summary: We will not investigate this complaint about the Authority’s staff because the courts and insurers are better placed to consider the complaint.
LGO (Local Government & …
Transport And Highways
Nov 2024