Staff training and development
Lack of effective systems to ensure staff receive appropriate training, ongoing support, professional development, supervision, and appraisal.
4,371 items
19 sources
33 inquiries
Source spread
Where this theme appears
Staff training and development has been flagged across 19 independent accountability sources:
499 inquiry recs
1030 PFD reports
793 committee recs
316 CQC actions
108 HMICFRS recs
47 ICIBI recs
232 PPO recs
288 IOPC recs
53 NAO recs
2 PHSO recs
1 VC rec
115 IMB reports
671 IMB recs
5 Scottish FAIs
32 Article 2 learning points
70 detention investigation recs
6 PHSO decisions
99 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 (499) — showing 50 strongest matches
WATE-(29) — Make specialist post-qualifying child care training widely available for senior staff
Recommendation: Suitable specialist training in child care at post-qualifying level should be made widely available and, in particular, to the senior residential care staff of children's homes and to field social workers.
Unknown
WATE-(28) — Promote and validate training in safe restraint methods for child care staff
Recommendation: Central government should take the initiative to promote and validate training in safe methods of restraint with a view to making such training readily available for residential child care staff and foster parents.
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
WATE-(26) — Implement Utting's recommendations for children's home staff training expeditiously
Recommendation: The Tribunal endorses all five of the most recent recommendations of Sir William Utting in "People Like Us"918 in relation to the content and provision of training for staff in children's homes and the care units of residential special schools …
Unknown
WATE-(25) — Provide appropriate and timely induction training for new residential child care staff
Recommendation: Social Services Departments should ensure that appropriate and timely induction training is provided for all newly recruited residential child care staff.
Unknown
FENN-99 — British Transport Police to review London Underground officer training appropriateness
Recommendation: The British Transport Police shall review the training given by London Underground to its officers to ensure that it is appropriate to their responsibilities.
Unknown
FENN-98 — Train area and group managers on health and safety responsibilities
Recommendation: Area and group managers must be trained to discharge their responsibility under health and safety legislation.
Unknown
FENN-97 — Train potential station supervisors in station evacuation and closure procedures
Recommendation: Potential station supervisors must be trained in the evacuation and closure of stations.
Unknown
FENN-95 — Train LFB personnel on station technical features and electrical isolation
Recommendation: London Underground shall train London Fire Brigade Personnel on technical features of stations, such as escalator and lift equipment, electrical controls and the means of isolating the electrical supply.
Unknown
FENN-93 — Engage consultants to rewrite rule book and create staff information materials
Recommendation: London Underground shall engage consultants: (i) to rewrite the rule book and its appendices in plain English; (ii) to produce check lists for station supervisory staff and duty cards for members of staff; (iii) to produce relevant extracts from the …
Unknown
FENN-92 — Appoint only qualified relief supervisory staff to stations
Recommendation: Relief supervisory staff shall only be appointed to a station for which they are qualified.
Unknown
FENN-91 — Appoint and train station 'landlords' with total management responsibility
Recommendation: A station 'landlord' shall be appointed and trained to have total management responsibility at each major station or group of smaller stations.
Unknown
FENN-90 — Train and practice London Underground incident officers in their duties
Recommendation: Potential London Underground incident officers must be trained and practised in their duties.
Unknown
FENN-89 — Train all staff in emergency use of public address systems
Recommendation: All staff shall be trained in the emergency use of public address and other communications systems.
Unknown
FENN-87 — Make detailed staff training records locally available to station supervisors
Recommendation: Detailed records of all training given to individual staff shall be available locally to station supervisors.
Unknown
FENN-86 — Review station staff fire and safety training based on consultant advice
Recommendation: Fire and safety training for station staff shall be reviewed in the light of the advice from consultants.
Unknown
FENN-85 — Provide fire safety training for cleaning and engineering staff on stations
Recommendation: Fire safety training for cleaning and engineering staff working on stations shall be provided. London Underground must obtain expert advice.
Unknown
FENN-83 — Provide biannual fire and safety training for non-supervisory and shop staff
Recommendation: Every six months fire and safety training must be provided for non-supervisory staff and booking clerks. Staff must be given site familiarisation training before they are permitted to take part in the running of the station. Specific provision shall be …
Unknown
FENN-82 — Provide biennial refresher training for management and supervisors on station emergency control
Recommendation: Every two years all management and supervisory staff shall receive refresher training in controlling station emergencies, and the use of fire and communications equipment.
Unknown
FENN-81 — Establish continuing fire and safety instruction for station staff by supervisors
Recommendation: London Underground shall establish a programme of continuing instruction at work by supervisors for station staff in fire and safety with the assistance of the London Fire Brigade and British Transport Police. At stations equipped with water fog equipment supervisors …
Unknown
POPP-A.12 — Amend Green Guide for comprehensive steward training and instruction on emergencies.
Recommendation: The Green Guide should be amended to contain a specific provision, in relation to stewards, (i) that they should be trained and instructed to deal with any emergency relating to fire or evacuation (see also Recommendations 7 and 10); (ii) …
Unknown
LADB-84 — Train all on-board train staff in evacuation and protection procedures.
Recommendation: All members of the on-board train staff (including persons working under contract) should be persons who have been trained in train evacuation and protection (para 14.62).
Unknown
LADB-45 — Ensure signallers regularly practise controlling train movements
Recommendation: Signallers should take the opportunity from time to time to practise the controlling of train movements (para 12.18).
Unknown
LADB-42 — Promote mutual understanding of work demands between signallers and drivers
Recommendation: Railtrack and the TOCs should take steps to ensure that signallers and drivers obtain a full appreciation of the nature and demands of each other’s work (para 12.16).
Unknown
LADB-41 — Utilise simulators for effective signaller training in emergency situations
Recommendation: The use of simulators in providing fully effective training of signallers in dealing with emergencies is endorsed (para 12.15).
Unknown
LADB-39 — Establish system for signaller briefing and information sharing after SPAD incidents
Recommendation: Railtrack should institute a system whereby all signallers in the signal box (or centre) are briefed by their line manager following a SPAD in their area, and there is appropriate dissemination of information which may be of assistance to signallers …
Unknown
LADB-38 — Provide signallers with emergency stop options and regular situational briefings on use
Recommendation: The instructions for signallers should provide a set of options, including the use of the CSR (where it is available) either to send an emergency stop message to a particular train or a general stop message. This range of options …
Unknown
LADB-35 — Train SPAD investigators in human factors and root cause analysis
Recommendation: Persons who investigate, and make recommendations as a consequence of, SPADs should be trained in the identification of human factors and in root cause analysis. Their competence in these areas should be formally recorded, and renewed by refresher courses. The …
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
LADB-14 — Review driver competence system effectiveness and retest drivers every three years
Recommendation: TOCs should review the effectiveness of the systems in place to deliver the required level of driver competence at least once every three years, and should retest the driver against the revised systems at the same frequency (para 9.49).
Unknown
LADB-12 — Increase driver briefing frequency with safety as primary agenda item
Recommendation: Thames Trains should increase the frequency of the briefing of drivers with a view to ensuring that each driver has a face to face meeting with his or her driver standards manager at least monthly, if not more often, and …
Unknown
LADB-11 — Implement joint training for signallers and drivers to improve understanding
Recommendation: Signallers and drivers should jointly attend away days and other training processes to develop their mutual understanding (para 9.28).
Unknown
BRIS-99 — Mandate direct supervision for clinicians performing new clinical procedures until expert
Recommendation: Any clinician carrying out any clinical procedure for the first time must be directly supervised by colleagues who have the necessary skill, competence and experience until such time as the relevant degree of expertise has been acquired.
Unknown
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-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-67 — Focus NHS leadership investment on joint, multi-professional training for all staff
Recommendation: The NHS’s investment in developing and funding programmes in leadership skills should be focused on supporting joint education and multi-professional training, open to nurses, doctors, managers and other 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-64 — Create shadowing opportunities for managers and clinicians to understand roles
Recommendation: Greater opportunities should be created for managers and clinicians to ‘shadow’ one another for short periods to learn about their respective roles and work pressures.
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-62 — Increase opportunities for multi-professional teams to learn and train together
Recommendation: There should be more opportunities than at present for multi-professional teams to learn, train and develop together.
Unknown
BRIS-61 — Implement joint inter-professional courses in healthcare professional education and training
Recommendation: The education, training and Continuing Professional Development (CPD) of all healthcare professionals should include joint courses between the professions.
Unknown
BRIS-60 — Include inter-professional engagement and respect in communication skills training
Recommendation: Communication skills must also include the ability to engage with and respect the views of fellow healthcare professionals.
Unknown
BRIS-59 — Make communication skills education essential for all healthcare professionals
Recommendation: Education in communication skills must be an essential part of the education of all healthcare professionals. Communication skills include the ability to engage with patients on an emotional level, to listen, to assess how much information a patient wants to …
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
BRIS-57 — Prioritise non-clinical skills in healthcare professional education and development
Recommendation: Greater priority than at present should be given to non-clinical aspects of care in six key areas in the education, training and continuing professional development of healthcare professionals: (cid:2) skills in communicating with patients and with colleagues; (cid:2) education about …
Unknown
HIDD-83 — BR to ensure proper training and clear instructions for new communication systems
Recommendation: BR shall ensure that those likely to use such systems in recommendations 81 and 82 above shall be properly trained in their use. Instructions in the use of these systems must be clearly drafted, prominently displayed and regularly checked for …
Unknown
HIDD-9 — Introduce national testing instruction with workforce explanation, monitoring, and auditing
Recommendation: BR shall introduce a national testing instruction with all speed. Such introduction shall be accompanied by a full explanation to the workforce, including workshops or seminars as necessary. Implementation must be monitored and audited.
Unknown
R23 — TVN training and qualification
Recommendation: Health Boards should ensure that a nurse appointed as Tissue Viability Nurse (TVN) is appropriately trained and possesses, or is working towards, a recognised specialist post-registration qualification.
Gov response: Section 4.3 of the Scottish Government's response indicates that accredited education programmes for specialist and advanced practice roles, including for Tissue Viability Nurses, are available through universities and funded by NHS boards. The government provided …
Accepted
PFD Reports (1030) — showing 50 strongest matches
Alan Smith
Concerns: A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by employees.
Overdue
Dorothy Townley
Concerns: Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.
Response (Royal College of General Practitioners): The Royal College of General Practitioners provides context on its role, training, and advice to members, highlighting relevant sections of the GP Curriculum related to communication between professionals and patient …
Responded
May Gibson
Concerns: The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, and implementing risk reduction plans at the care home.
Overdue
Labhuden Amarshi Vaghadia
Concerns: A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate training.
Response (Leicestershire Partnership NHS): The Partnership NHS Trust reviewed the case, assessed the nurse's competence, and arranged medicines management and emotional resilience training along with additional clinical supervision. They are also implementing a mobile …
Responded
Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet
Concerns: Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing best practices or lessons learned across units to minimise this risk.
Overdue
Michael Sweeney
Concerns: Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.
Response (Metropolitan Police Service): The Metropolitan Police Service has addressed potential information gaps for civil staff with practice notes and in-house training, and developed a detailed joint agency call-handling protocol with the London Ambulance …
Response (London Ambulance Service): The London Ambulance Service does not agree with the recommendation to use the term 'extreme agitation', preferring 'acute behavioural disturbance' (ABD). They have engaged with police and reviewed guidance, and …
Responded
Jared William McDowall
Concerns: Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.
Response (University Hospital Bristol): University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
Responded
Douglas Grey
Concerns: Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a written policy, compromising resident safety.
Overdue
Isabella Hope Hill
Concerns: Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved guidelines and staff training.
Response (Liverpool Womens NHS): The Trust has enhanced local education for staff on the Neonatal Unit regarding revised guidelines, reviewed and clarified the Service Level Agreement for Radiology to ensure X-rays are performed within …
Responded
Annie Jones
Concerns: An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, posing a significant risk of injury to vulnerable patients.
Response (Abbey Dale House): Abbey Dale House created an updated document providing a snapshot of each resident's needs, including a summary person handling plan, readily available to all staff. The care home adopted the …
Responded
Anthony Hughes
Concerns: Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future incidents, despite appropriate actions in the specific case.
Overdue
Elsie May Treece
Concerns: Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.
Response (Burton Hospitals NHS): Burton Hospitals NHS has always provided training for staff in relation to incident reporting, and they have arranged to provide additional training and support for Ward 6. They have linked …
Responded
William Andrews
Concerns: Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national safety recommendation for such caps was ignored, and no cap counting procedure exists.
Response (Department of Health): The manufacturer of syringes has agreed to supply syringes without caps, has issued a safety notice to all UK customers, and will make syringes without caps available for stock exchange. …
Overdue
Damion Anthony Andre Martin
Concerns: Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
Overdue
Kenneth Smalley
Concerns: A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training or hospital-wide review for similar equipment.
Response (Wrightington Wigan and Leigh NHS): The Trust has reviewed operating tables and handsets, changed pre-operative checks and inspections, implemented a more robust system and matrix for training theatre staff, and expanded the data base within …
Overdue
Anthony Brian Flynn
Concerns: Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and clinicians' powers over restraints.
Response (Sodexo): Sodexo is planning Safer Custody, Cell Sharing Risk Assessment (CSRA) and Escort & Bedwatch awareness days and a training programme for prison officers who conduct escorts, particularly during hospital visits. …
Overdue
Keith Samuel Peters
Concerns: Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
Response (Bolton Council): Bolton Council has cascaded lessons learned and has an action plan in place to improve systems, processes, and officer training, which they will oversee the full implementation of.
Responded
Derek Brierley
Concerns: The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines for competence and training.
Response (The Pennine Acute Hospitals NHS Trust): The hospital has re-drafted the pathway for managing urinary retention, shared it with A&E staff, initiated a training program for inserting catheters outside of the urology division, and will continue …
Overdue
Linda Hudson
Concerns: Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
Overdue
Martin McGlasson
Concerns: Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff were key concerns.
Response (DWF): Lightwater Quarries Ltd has implemented a newly adopted Risk Assessment & Method Statement as the basis for training, Turning Circle awareness and management, changes in lifting from the crane, safety …
Responded
Daniel Williams
Concerns: Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Response: The Trust has implemented a patient record development programme which provides alerts to staff, states a patient centred approach, and has rolled out training for staff and improved patient handovers. …
Responded
Mary Waldron
Concerns: Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
Overdue
Craig White
Concerns: Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt treatment for suspected tuberculous meningitis.
Overdue
Lucy Goulding
Concerns: There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children was also identified.
Response (Womens Childrens Division): The Trust strengthened consultant involvement in shift handovers, including direct supervision of the afternoon handover and telephone contact with the night team. They will audit handover practices in June 2014, …
Overdue
Frederick Davidson
Concerns: Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor and consultant, lack of pneumothorax recognition, premature authorisation of feeding, and delays in X-ray reporting were highlighted.
Overdue
Joan Mary Jones
Concerns: Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.
Response (The Manor): Following an inquest, the care home sent a memo to unit leads emphasizing communication protocols with families and healthcare professionals after GP visits. They also contacted the family and engaged …
Responded
Tallulah Wilson
Concerns: Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.
Response (Department of Health): The Department of Health highlights a Policy Research Programme investing in projects exploring the internet's role in suicidal behaviour and identifies priorities for prevention. It also mentions that the Royal …
Responded
William Kent
Concerns: Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.
Overdue
Samuel Boon
Concerns: The expedition lacked adequate risk assessments, failed to provide sufficient pre-trip information, neglected to formally assess participant fitness, and did not train leaders in managing critical medical conditions, alongside unverified evacuation procedures.
Overdue
Adrian Cowan
Concerns: The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life support training during a patient collapse.
Response: Barnet, Enfield and Haringey Mental Health Trust has reviewed and updated the Trust’s resuscitation policy to include additional action to be taken in response to the “deteriorating patient”. They have …
Overdue
Jack William Partington
Concerns: Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide detector use. There were also no national policies for managing paralysing agents or neonatal ventilation.
Response (Department of Health): The Department of Health believes the issues are local and should be addressed by the Trust, noting existing guidance and the role of NHS England, but will notify the British …
Overdue
Edna Elsie Mary Eden
Concerns: Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.
Response (Heatherwood Wexham Park Hospital NHS Trust): The hospital introduced a policy (TPP 231) for managing deteriorating adult patients, requiring verification of EDOD scores. A 24-hour Central Hub system will be introduced to improve patient tracking, manage …
Responded
Agostino Costa
Concerns: Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.
Overdue
Abdullahi Sharif Abokar
Concerns: Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff abandoning the patient.
Response (Camden & Islington NHS Trust): The Trust implemented a "Rapid Improvement Plan" for Coral ward, including mandatory training in suicide risk assessment and in-hospital life support, simulation exercises every 6 months, revised resuscitation scene management, …
Responded
Rachel Burke
Concerns: An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and failed to appreciate illness severity due to inadequate training.
Response (The Family Adventure Company): The Adventure Company has reviewed its Nepal high altitude treks against Wilderness Medical Society guidelines and implemented changes to reduce some altitude increases, to be fully implemented by the start …
Overdue
Arthur Brockett-Deakins
Concerns: Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal heart rate as fetal heart rate.
Response (N.I.C.E): NICE is currently updating its clinical guideline on Intrapartum Care (CG55) and the progress of the update can be monitored via their website. They will consult on the draft recommendations …
Response (Medicines Healthcare Products Regulatory Agency): The MHRA states that the incident was not reported to them and that the CTG model was placed on the market by Philips Healthcare and sold in the UK between …
Response (NMC): The Nursing and Midwifery Council (NMC) will treat the information about one of the midwives as a new referral and investigate. A local supervisory authority (LSA) would be alerted to …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns and notes that NICE has responded on CTG interpretation. They explain the role of statutory supervision of midwives and state the NMC …
Responded
Lee Curran
Concerns: PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Overdue
Andre Matei
Concerns: The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in theatre.
Response: The Department of Health acknowledges the coroner's concerns and states that NICE guidance addresses the use of interpreters. The Department will ensure the coroner's concerns are brought to NICE's attention …
Responded
Bertram Hamilton
Concerns: The coroner was concerned that a nurse appeared not to know that insulin should not be given to a person whose blood sugars were so low.
Overdue
Peter Norman Nott
Concerns: Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Response (Elizabeth Finn Homes): Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale …
Responded
Anne-Marie Katherine Ellement
Concerns: The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability risk assessments receive insufficient training and follow-up.
Overdue
Natasha Raghoo
Concerns: The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Response (Partnership in Care): Partnership in Care reports improvements in information flow between PiC and SLaM, including a Liaison Nurse attending The Dene from SLaM several days a week utilizing a VPN link. PiC …
Overdue
Andrew Hall
Concerns: Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Response (HM Prison and Probation Service): Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is …
Overdue
Jean James
Concerns: Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Response (City Hospitals Sunderland): The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the …
Responded
Jackson Chadd
Concerns: Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.
Response (Frimley Park Hospital): The Hospital updated sepsis guidelines to include tachycardia, changed practices to fast track children with PEWS scores of less than 4 to the Paediatric Assessment Unit, and now requires blood …
Response (Royal College of Paediatrics Child Health): The RCPCH refers to existing guidance, standards and reports regarding supervision and training and notes their current review of standards to encourage higher levels of consultant supervision.
Overdue
Oliver Hiscutt
Concerns: Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage sick children effectively.
Overdue
Frederick Hall
Concerns: Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, and significant communication breakdowns. Additionally, poor record-keeping and inadequate staffing compounded risks.
Overdue
Sari Keen
Concerns: Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.
Response (Luton Dunstable University Hospital): Luton & Dunstable University Hospital has increased night nursing staff on ward 22 following a staffing review. The hospital is evaluating current training for nurses and doctors, and will present …
Responded
Jennifer Tompkins
Concerns: The coroner expressed concern about potential training issues related to the administration of IV medications, and that the stopping of IV vancomycin infusions early may not be routinely documented, raising risks in other cases.
Overdue
Robert Perkins
Concerns: The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and that medical staff did not raise concerns about this. The prescribed cervical collar was also not readily available despite the hospital being a regional neuroscience centre.
Response (North Bristol NHS Trust): The ED matron discussed communication failures with the nursing team. The hard collar safety alert and other materials related to cervical immobilisation will be redistributed to medical directors, CDs and …
Responded
Committee Recommendations (793) — showing 50 strongest matches
#13 —
Recommendation: As part of its long-term proposals for the future of social care, we recommend that the Government work with Skills for Care and the social care sector to bring forward a plan to streamline the training of social care workers …
Gov response: 7.20 The social care workforce has demonstrated compassion and dedication in responding to the COVID-19 pandemic. They have worked at the front line, supporting people at the heart of their communities. We want to increase …
Under Consideration
#7 —
Recommendation: We recommend that a proportion of maternity budgets should be ringfenced for training in every maternity unit and that NHS Trusts should report this in public through annual Financial and Quality Accounts. It should be for the Maternity The safety …
Gov response: 36. We accept this recommendation in part. 37. In collaboration with national maternity partner organisations, the MTP has led on the development of a Core Competency Framework to address known variation in training and competency …
Not Addressed
#6 —
Recommendation: Training is essential for staff to deliver safe care. Evidence submitted to our inquiry highlighted that insufficient staffing is not only impacting the number of healthcare professionals available to deliver care for mothers and their babies but also the ability …
Gov response: 36. We accept this recommendation in part. 37. In collaboration with national maternity partner organisations, the MTP has led on the development of a Core Competency Framework to address known variation in training and competency …
Not Addressed
#16 —
Recommendation: The FCDO must mandate short, introductory atrocity prevention training for all Ambassadors/Heads of UK Missions, with a refresher every three years and more in- depth training for at-risk countries. Training should also be mandatory for other key Embassy staff, such …
Gov response: 35. The OCSM is working to foster learning, build knowledge and share best practice between teams and Embassies. We will work closely with colleagues across Government (and beyond) to ensure that lessons are captured and …
Under Consideration
#11 —
Recommendation: The Bank told us that, as a result of having insufficient skills and expertise, it has only entered into relatively low risk, more straightforward investment deals, as those are the only deal types it is comfortable delivering with the available …
Gov response: 2.2 The final phase of the Bank’s roll-out will take place during 2023-24 – following the anticipated date of Royal Assent for the UKIB Bill and while the Bank completes its recruitment of its permanent …
Not Addressed
#85 —
Recommendation: Another challenge identified by contributors related to retraining and lifelong learning for the existing workforce. City of Glasgow College told us “a skilled workforce which is regularly upskilled and reskilled across a lifetime is vital to sustaining a world-class shipbuilding …
Gov response: 29 & 30: The UK Shipbuilding Skills Taskforce (UKSST) seeks to address this challenge by collaborating across Government, the Devolved Administrations, industry and training providers to develop and implement a future-focussed skills strategy. The UKSST …
Accepted
#30 —
Recommendation: Building on the work of the UK Shipbuilding Skills Taskforce, the Ministry of Defence should commission regular research to develop and keep up to date its understanding of the current and future skills profile of the shipbuilding workforce, and the …
Gov response: 29 & 30: The UK Shipbuilding Skills Taskforce (UKSST) seeks to address this challenge by collaborating across Government, the Devolved Administrations, industry and training providers to develop and implement a future-focussed skills strategy. The UKSST …
Accepted
#37 — Extensive training programme prioritised for implementation of the new Procurement Act.
Recommendation: The GCF told us that the priority for implementing the new Act is training and said that it had a training programme ready to roll out from December. The GCF commented that it expects that the Act will be implemented …
Gov response: The government agrees with the Committee’s recommendation Recommendation implemented It is currently anticipated that the new regime in the Procurement Act 2023 will go-live in October 2024 following an implementation period of 6 months post …
Accepted
#2 — Set clear targets for Oliver McGowan Part Two training rollout, including tailored elements.
Recommendation: The Government should set out clear targets for the rollout of part two of the Oliver McGowan Mandatory Training on Learning Disability and Autism to help increase take up. The training should include elements tailored to specific health settings.
Response Pending
#46 — Develop funding and training strategy to address insufficient LARC provision in general practice.
Recommendation: The Government should develop a funding and training strategy to address the lack of LARC provision in general practice, particularly in those areas not covered by a women’s health hub. This should include an assessment of whether the current fee …
Gov response: Long-acting reversible contraception (LARC), as one of the most effective and cost-effective forms of contraception, plays a crucial role in supporting women’s reproductive health by: • enabling women to make decisions on if and when …
Not Addressed
#39 — Train primary care practitioners to identify hidden reproductive health concerns during routine interactions.
Recommendation: Primary care practitioners should be trained to use women’s common interactions with the healthcare system, such as cervical screening appointments, ante- and post-natal care checks and visits to STI clinics, as an opportunity to pick up hidden health concerns relating …
Gov response: We recognise the opportunities for making every contact count across the health system, in line with best practice. The suggested contact points are delivered in a range of settings by a range of healthcare professionals. …
Accepted
#38 — Improve undergraduate women's health teaching and incentivise specialisation in reproductive healthcare.
Recommendation: The Government should work with the RCOG, RCGP and the GMC to improve the teaching of women’s health at undergraduate level and ensure it is an integral part of medical education for all those seeking a career in healthcare. As …
Gov response: It is important that healthcare professionals receive the necessary training to provide the best care possible for women with reproductive health conditions. GMC is the regulator of all medical doctors practising in the UK. GMC …
Not Addressed
#37 — Medical schools provide insufficient training on women’s reproductive health, impacting practitioner knowledge.
Recommendation: Training on women’s reproductive health in medical schools needs to be improved. Healthcare practitioners are graduating without sufficient knowledge of the conditions that may affect women over their lifetime . 78 Without that education, healthcare professionals are less likely to …
Gov response: It is important that healthcare professionals receive the necessary training to provide the best care possible for women with reproductive health conditions. GMC is the regulator of all medical doctors practising in the UK. GMC …
Accepted
#34 — GPs struggle to diagnose complex reproductive health conditions due to systemic pressures.
Recommendation: GPs face difficulties diagnosing complicated reproductive healthcare conditions which may present with a variety of symptoms. They face workplace pressures, have short consultation times, and can struggle to access training and guidance. While it is positive to see that medical …
Gov response: The government recognises that early intervention is crucial to prevent women’s reproductive health conditions from worsening and support women to remain in education and work. As set out in previous responses to ‘Recommendation 5’ and …
Under Consideration
#32 — Set out plans to improve primary care practitioners' training in women’s reproductive health conditions.
Recommendation: The Department of Health and Social Care should set out plans to improve the accessibility and take up of professional development in women’s reproductive health conditions among practitioners in primary care. Those plans should include allocating increased funding for training …
Gov response: The government funds research through the National Institute for Health and Care Research ( NIHR ), which is the research delivery arm of DHSC , and UK Research and Innovation ( UKRI ). The government …
Under Consideration
#15 — Mandate NHS practitioners to stay updated and address regional disparities in reproductive health treatments.
Recommendation: The NHS must take steps to ensure healthcare practitioners keep up to date with the full range of diagnostic and treatment options available for reproductive health conditions. Those options, as well as waiting times and potential outcomes of surgical procedures …
Gov response: The government recognises the harm that can come from the use of the word ‘benign’ to describe some gynaecological conditions. In clinical terminology, the term ‘benign’ is commonly used across medical specialties to distinguish between …
Under Consideration
#14 — Healthcare practitioners insufficiently understand reproductive health treatment options and their impact on patients.
Recommendation: Healthcare practitioners lack sufficient understanding of the range and suitability of treatment options available to treat reproductive health conditions. Too often conditions are viewed through the prism of fertility which, while a necessary consideration, should not be the only factor …
Gov response: We sympathise with anyone suffering with infertility. We acknowledge the report’s finding that hospital waiting areas and wards that bring together patients with reproductive health conditions and women who are pregnant, or have recently given …
Under Consideration
#13 — Implement RCOG inclusive care guidelines throughout healthcare, ensuring practitioner training and monitoring by RCOG.
Recommendation: We support the Royal College for Obstetricians and Gynaecologists’ initiative for a guideline on inclusive care. When finalised it should be implemented throughout the healthcare system and medical practitioners must receive adequate training, with implementation monitored by the RCOG.
Gov response: We are committed to moving towards a neighbourhood health service, with more care delivered in local communities to spot problems earlier. Women’s health hubs are an example of this approach and can play an important …
Under Consideration
#11 — Implement urgent NHS training challenging racial biases to improve reproductive healthcare in primary care.
Recommendation: The NHS needs to urgently implement a training programme to improve the experience of treatment and diagnosis in primary care for women, girls, trans and non-binary people with reproductive ill health. Improving early diagnosis, including through the provision of follow …
Gov response: The government recognises that raising awareness of reproductive ill health is crucial to improving people’s experiences of care and ensuring that no one feels that their pain is dismissed, regardless of ethnicity or socio-cultural situation …
Accepted
#3 — Ensure RSHE teachers receive training and deliver comprehensive reproductive health education early
Recommendation: The Government should ensure teachers tasked with delivering the menstrual and gynaecological health element of RSHE receive the training necessary to deliver it effectively. Information on women’s reproductive health conditions should be taught early on in secondary education, preferably around …
Gov response: We must ensure high-quality health information and signposting is available for everyone across the country. We know that many women access health information through online sources, including the NHS website and social media, as well …
Under Consideration
#2 — Revise draft RSHE guidance on menstrual health due to insufficient and late teaching
Recommendation: However, we are concerned that the teaching of the menstrual health element of relationships, sex and health education is insufficient and inconsistent. It is often delivered too late in a child’s development to be of use and by teachers who …
Gov response: We agree that all students, including both girls and boys, should receive comprehensive education on menstrual health, and that all girls and women should be informed on what a ‘normal’ period is. Relationships, sex and …
Not Addressed
#28 — Ensure Department and HS2 Ltd secure necessary skills for successful programme delivery.
Recommendation: The Public Accounts Committee has repeatedly raised concerns over whether the Department and HS2 Ltd have had the necessary skills and capability to deliver HS2 successfully. In 2020 the previous Committee cautioned that it was not yet convinced that the …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Target implementation date: December 2026 5.2 The new CEO of HS2 Ltd started in post in December 2024. He has commenced, as part of the reset, a …
Accepted
#16 — Establish an expert unit to review, benchmark, and standardise transport accessibility training packages.
Recommendation: It is not sufficient for training to be delivered on disability awareness, accessibility and preventing discrimination: the training must be of a guaranteed minimum standard and proven to be effective in improving outcomes. The Department for Transport should, with the …
Gov response: To understand what works best and is most likely to impart a lasting awareness and understanding of accessibility amongst operator management and staff, the Department agrees that there is merit in reviewing the training packages …
Partially Accepted
#22 — Insufficient capacity and capability within the Building Safety Regulator is delaying remediation efforts
Recommendation: We heard concerns about insufficient capacity and capability at the Building Safety Regulator (BSR), which oversees the safety and standards of buildings over 18 metres. The HBF told us that the BSR was continuing to hold up development, including self-remediation …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: July 2025 The government agrees to update the Committee on the work it is doing to increase capacity and skills across the building sector to …
Accepted
#21 — Regulators' capacity, funding, and skills shortages hinder effective building safety remediation enforcement
Recommendation: When buildings are stuck in the remediation process, regulators (local authorities, fire and rescue authorities, and the Building Safety Regulator– for higher-risk buildings33 ) take enforcement action to get the process moving. MHCLG’s Plan recognised that constraints around the capacity …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: July 2025 The government agrees to update the Committee on the work it is doing to increase capacity and skills across the building sector to …
Accepted
#19 — Disagreement persists regarding the sufficiency and calibre of Chartered Fire Engineers for remediation assessments.
Recommendation: The Home Builders Federation told us that it was concerned that a shortage of “Chartered Fire Engineers” was a barrier to speeding up developer self– remediation. MHCLG assured us that it did not currently see a shortfall of fire engineers, …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: July 2025 The government agrees to update the Committee on the work it is doing to increase capacity and skills across the building sector to …
Accepted
#18 — Limited qualified professionals compromise quality and consistency of PAS 9980 fire risk assessments.
Recommendation: The National Fire Chiefs Council (NFCC) told us that the PAS 9980 standard for assessing the fire safety risk of external walls relied on specialist knowledge of building construction, fire engineering principles and material performance. The NFCC warned that there …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: July 2025 The government agrees to update the Committee on the work it is doing to increase capacity and skills across the building sector to …
Accepted
#17 — Construction industry continues to report a lack of skills for essential building remediation activities.
Recommendation: The Home Builders Federation (HBF) told us that there remained a lack of skills within the industry, making it difficult to find qualified people to undertake remediation work. It explained that addressing this issue was challenging, but could, and was, …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: July 2025 The government agrees to update the Committee on the work it is doing to increase capacity and skills across the building sector to …
Accepted
#16 — Specialist skill shortages for remediation, particularly fire engineering expertise, remain a concern.
Recommendation: In 2020, the previous Committee warned that shortages of specialist skills to support remediation would increase owing to an expected increase in the number of buildings included in the government’s remediation programmes. Following the creation of the Building Safety Fund …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: July 2025 The government agrees to update the Committee on the work it is doing to increase capacity and skills across the building sector to …
Accepted
#2 — Write to committee setting out actions to ensure sufficient remediation system capacity.
Recommendation: Insufficient capacity and skills across regulators, local authorities and the construction sector risks undermining MHCLG’s acceleration plans. In 2020, the previous Committee warned that skills needed for remediation work would come under pressure as the scope of government’s programmes increased. …
Gov response: The government agrees with the Committee’s recommendation. capacity and skills across the building sector to accelerate remediation, by the end of July 2025. Progressing remediation and ensuring that residents are safe in their own homes …
Accepted
#8 — Loan agents initially lacked expertise, prompting appointment of specialist provider.
Recommendation: During 2020, the Department had appointed two of its arm’s–length bodies, Arts Council England and Sport England, as its loan agents for the day–to–day monitoring and management of the loans, including relationships with borrowers. However, both Arts Council England and …
Gov response: 1.1 The government agrees with the Committee’s recommendation. Target implementation date: March 2026 1.2 DCMS’s Loan Book management refers to loans issued to selected organisations as part of the broader Culture Recovery Fund (CRF) and …
Not Addressed
#68 — Create a National Screen Heritage Strategy with BFI covering funding, skills and infrastructure.
Recommendation: Within the next 12 months, the Government should work with the BFI and wider screen heritage sector to create a National Screen Heritage Strategy, including in the areas of funding, skills and infrastructure. The strategy should be reviewed and renewed …
Gov response: The BFI would be best placed to work with the screen heritage sector on the creation of any new National Screen Heritage Strategy. The government will consider this recommendation with the BFI, but is not …
Not Addressed
#67 — Develop a degree-level apprenticeship standard for film preservation and provide dedicated funding.
Recommendation: The Government, in collaboration with the screen heritage sector and education providers, should develop a degree-level apprenticeship standard for film preservation and presentation within the next 24 months. To enable education institutions to deliver apprenticeships with small student cohorts, the …
Gov response: Apprenticeship standards are proposed and developed by employer- led trailblazer groups. We are not aware of any proposals for a film preservation apprenticeship but Skills England, the new body overseeing apprenticeships development, would consider any …
Not Addressed
#37 — Launch a national campaign highlighting film and HETV employment opportunities and required skills.
Recommendation: The Government and BFI should launch a national awareness campaign highlighting the employment opportunities offered by film and HETV, and the range of skills the industry requires. (Recommendation, Paragraph 127)
Gov response: We want a career in the creative industries to be open to everyone, whatever their background. We agree with the Committee that the breadth of roles required across the film and TV sector means that …
Accepted
#36 — Clear need to convince educators and young people about film and HETV career viability.
Recommendation: The range of roles required to make film and HETV means entire cohorts of sixth-form students could find jobs in the industry that fit their skills and interests, and building awareness of career opportunities is essential to attracting new talent …
Gov response: We want a career in the creative industries to be open to everyone, whatever their background. We agree with the Committee that the breadth of roles required across the film and TV sector means that …
Accepted
#35 — DCMS lacks sufficient influence in driving creative industries skills agenda across Government.
Recommendation: Skills will be vital to the ability of the film and HETV sectors to contribute to the Government’s industrial strategy, but the Department for Culture, Media and Sport does not have enough of a stake in driving the skills agenda …
Gov response: Working with industry and Skills England, the government will refine and develop the Growth and Skills offer to deliver apprenticeships and skills training that recognises the particular needs of the creative industries. This will build …
Accepted
#34 — Ensure Growth and Skills Levy compatibility with film and HETV by addressing specific barriers.
Recommendation: The Growth and Skills Levy must be fully compatible with work in the film and HETV sectors by: (Recommendation, Paragraph 120) • Ensuring portability of apprenticeships between employers; • Supporting smaller companies with the overhead costs of delivering apprenticeships; • …
Gov response: Working with industry and Skills England, the government will refine and develop the Growth and Skills offer to deliver apprenticeships and skills training that recognises the particular needs of the creative industries. This will build …
Partially Accepted
#33 — Government must ensure the Growth and Skills Levy fully benefits film and HETV sectors.
Recommendation: We welcome the Government’s plans for a Growth and Skills Levy that meets the needs of the film and HETV sectors, and wider creative industries. The rollout of shorter apprenticeships is welcome, but the Government must now go further to …
Gov response: We agree. The UK Global Screen Fund is a valuable and well-regarded programme,15 and as part of our new £75 million Screen Growth Package (2026–2029) the government has committed to scaling up the Fund from …
Under Consideration
#32 — Introduce statutory requirement for film and HETV industry to report annual training spending.
Recommendation: We recommend that the Government introduces a statutory requirement for the entire film and HETV production industry to report their spending on skills and training as a percentage of their production budgets every financial year. (Recommendation, Paragraph 114) 104
Gov response: The government agrees with the Committee that having data on industry investment in skills and training is vital in order to understand the landscape, and to develop a coherent skills strategy that reduces the risk …
Not Accepted
#31 — Film and HETV industry lacks transparency on training spending and relies on unreliable contributions.
Recommendation: Given how important skills are to the film and HETV industry, we are surprised that major streamers and studios could not give us a straight answer on how much they spend on training. The companies either don’t know how much …
Gov response: The government agrees with the Committee that having data on industry investment in skills and training is vital in order to understand the landscape, and to develop a coherent skills strategy that reduces the risk …
Not Addressed
#29 — ScreenSkills remains inadequate in addressing urgent film and HETV skills challenges.
Recommendation: We are not convinced ScreenSkills is up to the challenge of delivering meaningful action on skills and training. It has been slow to grasp the urgency of the situation, to identify its priorities and performance indicators and ultimately to tackle …
Gov response: The government agrees that public funding for ScreenSkills must be linked to their effective delivery. ScreenSkills is primarily funded through voluntary industry contributions through their Skills Investment Funds. In 2025/26, ScreenSkills is receiving grant funding …
Accepted
#28 — Film and HETV industry too slow responding to critical skills shortages.
Recommendation: The film and HETV industry has been too slow to respond to skills shortages. That has had serious consequences for those working in it, and for the ability of domestic productions to afford to pay crews and creatives. Countless reviews, …
Gov response: The government agrees with the Committee that having data on industry investment in skills and training is vital in order to understand the landscape, and to develop a coherent skills strategy that reduces the risk …
Not Addressed
#22 — HMRC attributes decreased compliance productivity to onboarding new, less experienced staff.
Recommendation: As its compliance productivity had fallen, we asked HMRC whether it could reassure us that it was delivering value for money. It said when it brings in new compliance resource it expects to see a dip in productivity before recovering. …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 HMRC has written to the Committee alongside this Treasury Minute response. 3.3 In 2023-24, HMRC secured record compliance yield of £41.8 billion compared to …
Accepted
#27 — Increase Heat Training Grant to fully compensate workers for lost earnings during retrofit upskilling.
Recommendation: The Government should increase the value of the Heat Training Grant to provide workers with full compensation for lost earnings when taking time off work to upskill on low carbon retrofit. This should take effect until market demand provides sufficient …
Gov response: The government continues to work with training providers and industry to ensure the Heat Training Grant offers the best value for money. The Heat Training Grant helps to overcome the barriers that existing professionals face …
Partially Accepted
#26 — Publish Net Zero and Nature Workforce Action Plan by 2025 for home retrofit skills.
Recommendation: We recommend that the Government resumes work undertaken by the previous Government to prepare a Net Zero and Nature Workforce Action Plan. This should be published by the end of 2025 and include a specific roadmap for meeting the skills …
Gov response: The government recognises that a skilled, competent and robust supply chain is needed to deliver the necessary upgrades to buildings. Growing this workforce requires certainty, via government funding or regulation, so that companies can make …
Partially Accepted
#25 — Heat Training Grant inadequately compensates workers for lost earnings during low carbon retrofit upskilling.
Recommendation: The Heat Training Grant does not adequately incentivise workers to take time off work to upskill on low carbon retrofit or compensate them for lost earnings. Many workers in the retrofit sector are self-employed and cannot afford to take time …
Gov response: The government continues to work with training providers and industry to ensure the Heat Training Grant offers the best value for money. The Heat Training Grant helps to overcome the barriers that existing professionals face …
Not Accepted
#24 — Low demand for low carbon retrofit training due to inadequate grants and uncertain sector future.
Recommendation: Training providers are reluctant to invest in courses on low carbon retrofit due to low demand for training. This is underpinned by the uncertain future technical direction of the sector, inadequate training grants, weak promotion of careers in retrofit and …
Gov response: The government recognises that a skilled, competent and robust supply chain is needed to deliver the necessary upgrades to buildings. Growing this workforce requires certainty, via government funding or regulation, so that companies can make …
Accepted
#12 — Publish a plan for a just transition for marine sectors impacted by changes
Recommendation: The Government should publish a plan to secure a just transition for those affected by changes through targeted support, skills development, identification of long-term opportunities and associated funding. The support should reflect both traditional and emerging marine sectors, to ensure …
Gov response: In January 2025, as part of a Written Statement on the Marine Environment, the Government recognised that accelerating development of marine activities is increasing marine spatial tensions. Government has committed to work with the industry …
Partially Accepted
#24 — Commission and publish analysis of skills gaps across eight growth-driving sectors.
Recommendation: We recommend that: • Skills England commission and publish an analysis of the skills gaps across the eight growth-driving sectors and report to Parliament within six months. This should include an estimate of the current and future skills gaps across …
Gov response: 14.1. Skills England will be data-driven. It will be the single authoritative voice on current and future skills needs allowing Government to make informed decisions. 14.2. It will use this data to find the right …
Partially Accepted
#23 — Skills shortages and fragmented system deter growth and investment across UK economy.
Recommendation: Skills shortages are holding back growth and deterring investment across large parts of the economy, including within the UK’s growth-driving sectors. The skills system is too fragmented and inflexible. The needs of employers must be at the centre of the …
Gov response: 14.1. Skills England will be data-driven. It will be the single authoritative voice on current and future skills needs allowing Government to make informed decisions. 14.2. It will use this data to find the right …
Accepted
CQC Inspection Actions (316) — showing 50 strongest matches
Chy Byghan Residential Home
The provider must ensure people who use services are protected against the risks associated with staff not receiving appropriate support, supervision and appraisal to enable them to carry out the duties they are employed to perform.
Must Do
Baby Bump Limited
Persons employed by the service must have appropriate training that is necessary to fulfil their role.
Must Do
Assured Care Formby
Staff had not received appropriate training or induction to ensure they were competent in their roles.
Must Do
Ash Court Care Centre - Camden
The registered person had not ensured that staff received such appropriate training and professional development as is necessary to enable them to carry out the duties they were employed to perform. Regulation 18 (2) (a)
Must Do
Woodlands
Regulation 18 HSCA RA Regulations 2014 Staffing
Must Do
Winterton House
Staff did not always have sufficient skills and knowledge to enable them to support people living with dementia. Persons employed by the service provider in the provision of a regulated activity did not receive appropriate support, training, professional development, supervision …
Must Do
We Can Recover CIC
Staff were not provided with the skills needed to safely deliver care to clients in the service. Training records were updated to reflect staff had completed mandatory training, but there were still gaps in the nursing and support staff completion. …
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
Valewood House Nursing Home
We recommend that the manager review the induction and training processes to ensure that staff are equipped with the skills to deliver care to an appropriate standard, and prepared for the launch of the Care Certificate in 2015.
Should Do
Reside at Southwood
The provider must ensure that staff are supported with regular training and supervision.
Must Do
Nicholas House
The provider failed to ensure staff were adequately trained.
Must Do
Laurel Lodge Care Home
The provider must ensure that persons employed in the provision of a regulated activity receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
Must Do
Haisthorpe House
The provider must ensure people who used services are cared for and supported by staff that are appropriately supported by the provider to enable them to deliver care and treatment safely to people because staff have received appropriate training, professional …
Must Do
Benedict House Nursing Home
The provider must ensure staff receive appropriate supervision in their role to make sure competence is maintained.
Must Do
Worcestershire Imaging Centre
The provider should ensure that staff attend information governance training and other mandatory training required to enable them effectively carry out their role.
Should Do
Wii Care Limited
We recommend that the provider and registered manager seek training from a reputable source to ensure staff are trained to meet people's needs.
Should Do
Westwood Care Home
The provider had failed to ensure staff training needs were reviewed and that regular supervision was in place.
Must Do
Vision Care Wakefield
We recommend the management team ensures staff training is kept up to date in line with the provider's policy.
Should Do
Victory SocialCare Enterprise
The provider had failed to ensure that staff were skilled, trained and competent to perform their roles. The provider had failed to ensure that staff received supervision in line with their policies and procedures. The provider had failed to ensure …
Must Do
Unit 4 Cornishway Industrial Estate
The provider must ensure that staff are competent, receives such appropriate training, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
Must Do
The Peter Gidney Neurodisability Centre
Staff were not receiving adequate training, support and supervision.
Must Do
The Old Post Office
The provider must ensure staff receive the training needed to provide safe effective care to people.
Must Do
The Goddards
The provider must ensure staff are enabled where appropriate to obtain further qualifications appropriate to the work they perform, and to support staff to obtain appropriate further qualifications that would enable them to continue to perform their role.
Must Do
The Goddards
The provider must ensure staff receive such appropriate support and training, as is necessary to enable them to carry out the duties they are employed to perform.
Must Do
The Elms
The provider had failed to ensure staff received appropriate training to enable them to carry out their duties.
Must Do
TerraBlu Homecare
Newer staff had not received the COVID specific training.
Should Do
Suite 4, Jason House
The provider must ensure there is effective oversight of staff training.
Must Do
Suffolk House
The provider had failed to ensure that all staff working with people were adequately trained.
Must Do
Stirling Park Residential Home
Persons employed by the service provider in the provision of a regulated activity must receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
Must Do
Spindrift Care Home Limited
Not all staff had received appropriate training to ensure they had the knowledge and skills to meet people's needs. Staff had not received a regular appraisal. The provider had not ensured a sufficient number of suitably qualified, skilled and experienced …
Must Do
South Network
Lack of up to date training and consistent staff supervision. Regulation 18 (2) (a).
Must Do
Slate House Residential Home
The provider must have suitable arrangements in place to ensure that staff are appropriately trained and that staff receive an appraisal of their work.
Must Do
Ranyard at Mulberry House
Persons employed by the service provider did not receive appropriate training to enable them to carry out the activities they were employed to perform.
Must Do
Ransdale House
The provider ensures staff training in all relevant areas is completed and staff complete ongoing refresher training when appropriate.
Should Do
Prospects for People with Learning Disabilities - 3 Norwich Road
A number of staff were not up to date with their training. Four staff did not have up to date training in the Deprivation of Liberty Safeguards and two staff had not received training in the Mental Capacity Act (2005). …
Should Do
Pheonix Healthcare
The registered person must ensure persons employed by the service provider receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
Must Do
Orchid House
The provider had failed to ensure that staff had the skills, knowledge and experience to deliver effective care and support.
Must Do
Moorview Care (Derby)
The provider did not ensure all staff had completed training in line with requirements. Not all staff had received regular supervision.
Must Do
Meet The Baby
The provider must ensure that there are arrangements in place for all staff to undertake annual mandatory training.
Must Do
M N Pulse Solutions
Improvement was needed to ensure staff consistently had the skills and knowledge they needed.
Should Do
Lambeth and Southwark Mencap
The provider must ensure compliance with Regulation 18 HSCA RA Regulations 2014 (Staffing) by addressing that staff were not fully supported to receive regular training, supervision or appraisal.
Must Do
Kingsdowne Residential Home
We recommend that specific training is provided so staff can be better equipped to meet the needs of people.
Should Do
Heritage Healthcare-Middlesbrough
The provider must ensure sufficient and appropriately supported staff, including proper induction, supervision, appraisals, and training.
Must Do
Heatherdene Residential Care Home
The provider had failed to ensure that staff received the required training to meet the needs of the people they supported.
Must Do
Gloucestershire Old Peoples Housing Society
The provider must ensure staff develop the skills and knowledge they require to undertake their roles through appropriate training and supervision.
Must Do
Forge House Services Limited
The registered manager should ensure staff understanding and training regarding sensory diets, as one person's behaviour support plan stated this person needed support with a sensory diet but staff did not know what this was and had not received training.
Should Do
Essex Shared Lives
The provider must ensure all shared live hosts complete and hold up to date training relevant to their role.
Must Do
Cherished Moments
The service must ensure all staff are appropriately trained for their role.
Must Do
Beech Close
The provider had failed to ensure staff attended or accessed training, learning and development relevant to their role to enable them to meet people's needs and promote safety, which included first aid training.
Must Do
BMI Southend Private Hospital
The provider must improve training rates for safeguarding adults, safeguarding children and patient moving and handling.
Must Do
HMICFRS Recommendations (108) — showing 50 strongest matches
FRS 2018-19 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: Northamptonshire FRS needs to ensure that it has systems in place to effectively provide, record and monitor risk-critical training. Recommendation: By September 2019 the service must ensure that it provides, assesses and accurately records suitable operational training …
Recommendation
FRS 2018-19 CoC Recommendations: London Fire Brigade
Cause of concern: The Brigade has a significant backlog of training for staff in risk-critical skills such as incident command and emergency fire engine driving. Some staff haven’t had continuing training in these skills for many years. There is no …
Recommendation
FRS 2018-19 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: Lincolnshire Fire and Rescue Service needs to assure itself that it has systems in place for the effective recording and monitoring of training. Recommendation: By 31 July 2019 the service must ensure that suitable operational training is …
Recommendation
FRS 2021-22 CoC Recommendations: Cumbria Fire and Rescue Service
Cause of concern: At the time of our inspection, the service couldn’t assure us that staff were maintaining risk-critical skills Recommendation: By 31 October 2022, the service must ensure it provides, assesses and accurately records suitable operational training, and that …
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 work with its workforce to understand the risks and threats to staff wellbeing, …
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
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, chief constables should review and update their learning and training provision relating to stalking to meet national policing curriculum outcomes, incorporate College of Policing e-learning, use external expertise, include local policies, and provide training to relevant …
Recommendation
FRS 2023-25 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since our last inspection to improve equality, diversity and inclusion. Recommendation: The service should improve equality, diversity and inclusion (EDI) by: • developing effective ways to show how it monitors and …
Recommendation
FRS 2021-22 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since the last inspection to improve EDI. Recommendation: By 31 August 2022, the service should develop an action plan to: • engage with its staff to develop clear EDI objectives and …
Recommendation
FRS 2021-22 CoC Recommendations: North Yorkshire Fire and Rescue Service
Cause of concern: The service doesn't have in place adequate workforce planning processes. This means that areas such as safety-critical training, succession planning, absence and work-time management don't support its current and future integrated risk management plan. Recommendation: By September …
Recommendation
FRS 2021-22 CoC Recommendations: North Yorkshire Fire and Rescue Service
Cause of concern: The service doesn't have in place adequate workforce planning processes. This means that areas such as safety-critical training, succession planning, absence and work-time management don't support its current and future integrated risk management plan. Recommendation: By September …
Recommendation
FRS 2021-22 CoC Recommendations: North Yorkshire Fire and Rescue Service
Cause of concern: The service doesn't have in place adequate workforce planning processes. This means that areas such as safety-critical training, succession planning, absence and work-time management don't support its current and future integrated risk management plan. Recommendation: By September …
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 ensure that staff act in line with its values and are …
Recommendation
FRS 2021-22 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve how staff understand and display its expected values and behaviours. Recommendation: By 31 August 2022, the service should develop an action plan to ensure that staff …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service isn’t taking a proportionate approach to promoting equality, diversity and inclusion (EDI) in the workplace. Recommendation: By 31 August 2021, the service should make sure that senior leaders respond appropriately and quickly to EDI feedback …
Recommendation
FRS 2023-25 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since our last inspection to improve equality, diversity and inclusion. Recommendation: The service should improve equality, diversity and inclusion (EDI) by: • making improvements to the way it collects equality data …
Recommendation
FRS 2021-22 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since the last inspection to improve EDI. Recommendation: By 31 August 2022, the service should develop an action plan to: • make improvements to the way it collects equality data to …
Recommendation
FRS 2018-19 CoC Recommendations: London Fire Brigade
Cause of concern: The Brigade has a significant backlog of training for staff in risk-critical skills such as incident command and emergency fire engine driving. Some staff haven’t had continuing training in these skills for many years. There is no …
Recommendation
FRS 2023-25 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: Since our last inspection, the service has made enough improvement to address two of our previous recommendations. But it still needs to improve equality, diversity and inclusion. The following recommendations remain in place. Recommendation: Within 28 days, …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t taken sufficient action since the last inspection to appropriately resource its protection function. Recommendation: By 30 September 2021, the service should review its administration of the protection function to make sure it can record …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t taken sufficient action since the last inspection to appropriately resource its protection function. Recommendation: By 30 September 2021, the service should make sure it has an effective quality assurance process in place so the …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve its EDI. Recommendation: By 30 September 2021, the service should improve how it works with its staff and provides feedback in relation to EDI issues.
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 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 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: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS doesn’t have enough controls in place to monitor the competence of its staff. This is because it has suspended its centralised assessment of incident command and breathing apparatus training. Recommendation: The service should ensure …
Recommendation
FRS 2018-19 CoC Recommendations: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS has no strategy, visible leadership and limited training on equality, diversity and inclusion. This is affecting watch culture and undermining positives steps to attract new entrants from diverse backgrounds. Recommendation: By 31 December 2019, …
Recommendation
FRS 2018-19 CoC Recommendations: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS has no strategy, visible leadership and limited training on equality, diversity and inclusion. This is affecting watch culture and undermining positives steps to attract new entrants from diverse backgrounds. Recommendation: By 31 December 2019, …
Recommendation
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • …
Recommendation
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • …
Recommendation
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • …
Recommendation
FRS 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 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 make sure …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to improve how …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to establish effective …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve understanding and awareness of the importance of equality, diversity and inclusion (EDI) and remove barriers to embedding EDI in the service. Recommendation: By 28 February 2022 …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve understanding and awareness of the importance of equality, diversity and inclusion (EDI) and remove barriers to embedding EDI in the service. Recommendation: By 28 February 2022 …
Recommendation
FRS 2018-19 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: The service has insufficient resources to meet its risk-based inspection programme. It is currently not meeting its targets. As a result, partially-skilled operational staff are carrying out high-risk visits, although the service acknowledges these are not audits. …
Recommendation
FRS 2021-22 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: The service has insufficient resources to meet its risk-based inspection programme. It is currently not meeting its targets. As a result, partially skilled operational staff are carrying out high-risk visits, although the service acknowledges that these are …
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
PEEL 2021-22 CoC Recommendations: Wiltshire Police
Cause of concern: The force is failing to understand and promptly identify vulnerability at the first point of contact. Recommendation: Wiltshire Police should, within three months:- make sure that call handlers are skilled enough to identify vulnerability and warning signs …
Recommendation
PEEL 2018-19 CoC Recommendations: Nottinghamshire Police
Cause of concern: We are concerned that Nottinghamshire Police does not consistently support the wellbeing of its workforce. The force has a wellbeing strategy in place, but has not made enough progress to promote it and create a culture where …
Recommendation
PEEL 2018-19 CoC Recommendations: Nottinghamshire Police
Cause of concern: We are concerned that Nottinghamshire Police does not consistently support the wellbeing of its workforce. The force has a wellbeing strategy in place, but has not made enough progress to promote it and create a culture where …
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 fairly and consistently identify those with the potential to become senior leaders and …
Recommendation
A joint thematic inspection of the police and Crown Prosecution Service's response …
By September 2022 ensure regular clinical supervision available to all prosecutors dealing with rape/RASSO cases
Recommendation
How the police respond to victims of sexual abuse when the victim …
Update existing sexual abuse APP to include risk of honour-based abuse
Recommendation
How the police respond to victims of sexual abuse when the victim …
Update forces' sexual abuse policies to include the risk of honour-based abuse
Recommendation
ICIBI Immigration Recommendations (47)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 1 Review the Stansted “staffing formula” and ensure overall numbers, including the “Seasonal Workforce (SWF)”, are sufficient to enable permanent staff to be released for skills training, and allow …
An inspection of Border Force operations at Stansted Airport
Recommendation 1 Review the Stansted “staffing formula” and ensure overall numbers, including the “Seasonal Workforce (SWF)”, are sufficient to enable permanent staff to be released for skills training, and allow …
An inspection of the use of deprivation of citizenship by the Status …
Training and Guidance - Review the resourcing and role specific training required by the training team to ensure they are equipped with the skills, knowledge, and resource to meet the …
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 3 Provide appropriate training and support for newly-promoted Border Force Higher Officers (BFHO) to enable them to become fully-effective managers in the minimum time.
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 2 Support and encourage permanent staff to become “multi-functional officers”, ensuring that those who wish to do so are able to access places on all 3 “Core Skills” training …
An inspection of Border Force operations at Stansted Airport
Recommendation 3 Provide appropriate training and support for newly-promoted Border Force Higher Officers (BFHO) to enable them to become fully-effective managers in the minimum time.
An inspection of Border Force operations at Stansted Airport
Recommendation 2 Support and encourage permanent staff to become “multi-functional officers”, ensuring that those who wish to do so are able to access places on all 3 “Core Skills” training …
An inspection of Border Force insider threat (January – March 2023)
Make insider threat awareness training part of formal induction training for new recruits and mandatory training for existing staff.
An inspection of asylum casework (August 2020 – May 2021)
To address workplace culture, create a mandatory regular ‘face behind the case’ style training course focused on asylum
An inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Review the role of team leaders and introduce professional supervision and support to ensure they are able to meet the challenges of managing operations to safeguard the safety and welfare …
An inspection of the Border Force intelligence functions at the Humber ports …
Review the training and accreditation provision for Border Force intelligence staff to:ensure training and accreditation pathways are agreed and in place for all intelligence rolesensure staff receive role-specific training on …
An inspection of asylum casework (June - October 2023)
To address workplace culture, create a mandatory regular ‘face behind the case’ style training course focused on asylum
An inspection of Border Force practice and procedures in relation to firearms …
Develop and implement a continuous professional development plan for all Make Safe Officers, ensuring that there is a mechanism in place to access technical support.
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to training: a) Ensure that wherever peers rather than specialist trainers are used to deliver initial training (as with IECA decision makers) they have received at least basic …
An inspection of General Maritime (October 2024 – February 2025)
Create and maintain a centralised record of what training every Border Force officer has completed and their training needs (including for refresher training), readily accessible to regions and commands, so …
Inspection report of Birmingham Airport, February 2013
Accepted - The Home Office recognises the benefits hosts can bring to assist the efficiency of queue management. The provision of hosts is the responsibility of port operators, and we …
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 7 Ensure that all Border Force staff at Stansted, including the “Seasonal Workforce (SWF)”, understand the need for, and are allocated sufficient time to produce, an accurate and detailed …
A short inspection of Border Force queue management at Birmingham Airport based …
Accepted - The Home Office recognises the benefits hosts can bring to assist the efficiency of queue management. The provision of hosts is the responsibility of port operators, and we …
An inspection of illegal working enforcement (August – October 2023)
Implement a system to allow operational staff access at all times to up-to-date and succinct guidance.
A re-inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Review the role of team leaders and introduce professional supervision and support to ensure they are able to meet the challenges of managing operations to safeguard the safety and welfare …
An inspection of Border Force practice and procedures in relation to firearms …
Conduct a firearms training needs analysis and review of existing national training provision to define the mandatory attendance requirements and to ensure that the quality and availability of training delivery …
An inspection of Border Force practice and procedures in relation to firearms …
Address the firearms risk of Border Force staff conducting searches under immigration or customs powers without completing the Firearms & Explosives Awareness and Recognition (FXAR) training course.
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to safeguarding, establish a dedicated, full-time safeguarding team within the IECA with the capacity and expertise to: a) Respond to all cases where a safeguarding risk (Levels One, …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to quality assurance: a) Ensure that the ratio of tech specs to DMs in the IECA is sufficient to prevent ‘second pair of eyes’ (SPOE) backlogs and slow …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to NRM referrals: a) By November 2024, evaluate the new (as of April 2024) training package for Immigration Prison Teams (IPTs) and Detention Engagement Teams (DETs) with reference …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to recruitment and workforce planning: a) Review recent instances where the department has recruited at speed and in large numbers to resource new or expanding functions (including the …
An inspection of the Border Force operation to deter and detect clandestine …
Overhaul training provision for front-line Border Force officers at the juxtaposed ports to ensure that they are as far as possible multi-functional and can be deployed flexibly, in particular: a) …
An inspection of the Home Office’s use of age assessments (July 2024 …
In relation to initial age assessments and decisions: With input from KIU’s ‘in-house’ social workers and the NAAB, set minimum quality standards for the KIU triage process at Western Jet …
An inspection of the Home Office’s use of age assessments (July 2024 …
In relation to initial age assessments and decisions: Before the end of 2025, conduct a formal evaluation of initial age decision training, meanwhile involving Kent Intake Unit’s ‘in-house’ social workers …
An inspection of General Maritime (October 2024 – February 2025)
Produce a short-term (1-2 years) succession plan for Border Force Maritime Command (BFMC), identifying the risks, mitigations and contingencies involved with filling key posts, and setting out the work required …
An inspection of asylum casework (August 2020 – May 2021)
To help improve retention, ensure there is clarity among DMs on opportunities for progression and, in consultation with DMs, conduct a review of InSight weekly targets
An inspection of asylum casework (June - October 2023)
To help improve retention, ensure there is clarity among DMs on opportunities for progression and, in consultation with DMs, conduct a review of InSight weekly targets
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to IECA decisions: a) Clarify the process(es) that DMs should follow where they consider that they have insufficient evidence to make a positive decision, including where this is …
An inspection of the Home Office’s management of fee waiver applications (August …
Overhaul how the quality and consistency of the work of fee waiver caseworkers (not solely decision outcomes) is managed, defining the roles and responsibilities of line managers, ‘technical specialists’, and …
An inspection of the Home Office’s management of fee waiver applications (August …
Create a more exacting ‘quality score marking’ system for use with fee waiver caseworkers that reinforces the importance of eliminating all errors, giving more weight than hitherto to correct spelling, …
An inspection of the Home Office’s management of fee waiver applications (August …
Formalise regular (at least quarterly) meetings of senior managers and caseworkers from the three fee waiver teams to share information and promote ‘best practice’ and consistency, and to flag and …
An inspection of Border Force operations at Stansted Airport
Recommendation 7 Ensure that all Border Force staff at Stansted, including the “Seasonal Workforce (SWF)”, understand the need for, and are allocated sufficient time to produce, an accurate and detailed …
An inspection of Border Force operations at Stansted Airport
Recommendation 6 Review the guidance to “Monitoring Officers” regarding their safeguarding responsibilities and produce workable advice on how they are to satisfy themselves that a child or young person, or …
An inspection of Border Force operations at south coast seaports
Accelerate the publication of guidance from the consultation on the use of Personal Protective Equipment (PPE). 4.10. Accepted. 4.11. Body armour is only one element of the control measures that …
An inspection of Border Force insider threat (January – March 2023)
Conduct role-based risk assessments in key areas and specialist roles.
An inspection of Border Force’s fast parcels operations (May–July 2023)
Set and assure performance expectations for all staff working in fast parcels.
An inspection of Border Force’s fast parcels operations (May–July 2023)
Review current methodologies for the search and transportation of suspected prohibited and restricted goods to:
An inspection of Border Force’s fast parcels operations (May–July 2023)
Designate a single national team to manage detection equipment who should:
An inspection of General Maritime (October 2024 – February 2025)
To support the Maritime Director in promoting a consistent Home Office-wide approach to general maritime, identify GM leads at regional/command and ports levels and establish a national network that links …
Inspection report of Border Force operations at Stansted Airport, January 2014
The Home Office response to the recommendations In relation to resourcing and training:
Inspection report on an interim re-inspection of family reunion, July 2017
In consultation with decision team managers (DTM), conduct a review of the DTM role and responsibilities.
An inspection of Border Force operations at Stansted Airport
The Home Office response to the recommendations In relation to resourcing and training:
PPO Death in Custody Recommendations (232) — showing 50 strongest matches
SSCL
SSCL should provide refresher training to its switchboard staff to ensure that they know what to do when they receive calls raising concerns about a prisoner’s wellbeing.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, in particular that staff efficiently communicate the nature of a medical emergency using the appropriate code.
The Governor and Head of Healthcare
identify what training is needed so there is clear understanding of the lawful authority of prison staff, and when the Mental Capacity Act should be used instead, or in parallel.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff receive training on the Mental Capacity Act and that staff know when and how to assess mental capacity.
The Head of Healthcare
The Head of Healthcare to assure herself that the healthcare staff who undertake the role of Nurse in Charge on H3 have the sufficient skills and competencies to recognise a clinically deteriorating patient.
The Head of Healthcare
The Head of Healthcare should review the systems and processes for training and supporting staff to complete escort risk assessments for patients requiring emergency hospital admission.
The Head of Healthcare (HMP Styal)
The Head of Healthcare should ensure that staff understand how and when to administer adrenaline in medical emergencies and that they have received the appropriate training to do so.
The Governor and Head of Healthcare (HMP Styal)
The Governor and Head of Healthcare should review how staff are trained on the use of medical emergency codes and satisfy themselves that all staff are aware of their responsibilities during medical emergencies.
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: all staff involved in the escort risk assessment process receive training on the Graham judgment and have a clear understanding of how it …
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should ensure that agency staff receive an appropriate induction when they start at Wandsworth so that they are clear about the expectations of healthcare staff at the prison.
The Director of HMP Peterborough
The Director should review the local training programme for control room staff to ensure that it is sufficiently rigorous, includes the full range of frequently occurring events and an understanding of the actions required by national instructions, and involves an …
The Governor of The Mount
The Governor of The Mount should ensure that all staff understand their responsibilities about calling emergency codes so that emergency responses are timely.
The Governor
The Governor should ensure that when staff draw a radio or receive one from another staff member, they check that the radio is functioning correctly and is set to the appropriate channel.
The Governor
The Governor should ensure that staff are aware of the signs of rigor mortis, and fully understand the circumstances in which they should not start, or continue, resuscitation, in line with Resuscitation Council Guidelines.
The Governor
The Governor should share a copy of this report with CM A and arrange for a senior manager to discuss the Ombudsman’s findings with him.
The Head of Healthcare
The Head of Healthcare should ensure that: • the welfare check sheet used for monitoring prisoners suspected to be under the influence of a substance includes timescales for review, escalation and transfer to hospital; and that • training is provided …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff know how to use TOXBASE and escalate cases of concern promptly.
The Head of Healthcare
The Head of Healthcare should ensure that prison staff in the FNC have written guidance on what symptoms they should watch for in detoxing prisoners and when they should seek medical help.
The Governor
The Governor should consider detoxification awareness training for all officers who work in the First Night Centre, to ensure safe and supportive management of prisoners withdrawing from drugs.
The Governor
The Governor should remind all staff of the appropriate emergency codes and how these should be used.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff contributing to the ACCT process have the necessary training.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with all staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Governor and Head of Healthcare
reception staff are appropriately trained.
The Governor
The Governor should ensure that staff are aware of their responsibilities during medical emergencies, including that they should call the appropriate medical emergency code immediately.
The Head of Healthcare
The Head of Healthcare should ensure that all staff receive training in two stage mental capacity assessments.
The Governor
The Governor should ensure that all staff are fully aware of and understand their responsibilities in a medical emergency, including the use of an emergency response code if a prisoner has breathing difficulties, or is unresponsive.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are aware of the circumstances in which resuscitation is inappropriate.
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should commission an outreach service from the community diabetes team to ensure that nursing staff are adequately trained and know when to seek advice from secondary services.
Governors of prisons with MCBS units
Governors should ensure that: contingency plans are in place for a range of possible incidents in MCBS units; staff who may be called upon to act as Silver Commanders have received the appropriate training, including refresher training and have a …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff follow the protocols for clinical escalation as per NEWS2 and sepsis pathways.
The Head of Healthcare
The Head of Healthcare should ensure the local operating policy for managing omitted doses of medication is reviewed and includes more specific and clearer guidance to the Pharmacy Team on the management (including when to alert the GP) of in-possession …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff are compliant in the correct level of safeguarding training in accordance with their roles as set out in the Royal College of Nursing (RCN) Intercollegiate Document for ‘Adult Safeguarding: Roles and …
The Head of Healthcare
staff use appropriate clinical assessment and monitoring tools.
The Governor and Head of Healthcare
ensure that staff use appropriate interpretation services when discussing complex matters with prisoners with limited English language skills.
The Governor
The Governor should ensure that staff are offered appropriate support, including access to TRiM practitioners, following a death in custody or other traumatic event.
The Head of Healthcare
The Head of Healthcare should share a copy of this report with Senior Nurse A and Nurse B and discuss the Ombudsman’s findings with them.
The Governor of HMP Leyhill
The Governor should ensure that a senior manager debriefs all relevant staff immediately following a death in custody and that they receive appropriate support afterwards.
The Governor of HMP Leyhill
The Governor should ensure that all staff are aware of the location of defibrillators and that they understand how to access and use them during a medical emergency.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies.
The Head of Healthcare
The Head of Healthcare should ensure that staff understand when they should make referrals under the suspected cancer pathway.
The Head of Healthcare
The Head of Healthcare should ensure that clinical staff receive training on when to make referrals under the two-week wait cancer pathway, in line with national guidance.
The Governor of HMP Holme House
The Governor should ensure that local systems and arrangements are in place for effective post-incident care for staff who are exposed to distressing or traumatic events during their duties.
The Head of Policy and Capability in the Security Directorate …
The Head of Policy and Capability in the Security Directorate of HMPPS should amend the Use of Force Policy Framework to include the particular references to sickle cell disease that were contained in PSO 1600 and ensure that national use …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should examine Reception practices and devise a plan to ensure that all relevant staff read and appropriately respond to information contained in Person Escort Records when processing prisoners.
The Head of Healthcare
The Head of Healthcare should check and ensure that all staff, including agency staff, have been trained to access the digital Person Escort Record.
The Barnet, Enfield and Haringey Mental Health Trust Service Manager
The Barnet, Enfield and Haringey Mental Health Trust Service Manager should ensure that the RMN and all H3 staff are invited and have the opportunity to engage in a reflective session utilising the Practice Plus Group reflective presentation already completed. …
Practice Plus Group and NHS England and Improvement
Practice Plus Group and NHS England and Improvement should undertake further enquiries to ensure that healthcare agencies which provide staff to prisons are appropriately trained, competent and are practising safely
The Head of Healthcare
The Head of Healthcare should ensure that all staff are aware of the normal range for clinical observations, the relevance of finding an abnormal physical observation and action to take when this is noted.
The Head of Healthcare
The Head of Healthcare must ensure that all healthcare staff are trained and competent in the use of the NEWS2 assessment.
The Director of HMP Fosse Way
The Director should review the prison’s local instructions on roll checks, unlocking and welfare checks to ensure that there are sufficient quality assurance processes in place to establish that: • staff are clear about the type of check required, when …
IOPC Learning Recommendations (288) — showing 50 strongest matches
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends the MPS should create a role profile for Directorate of Professional Standards (DPS) investigators and DPS IOPC Single Point of Contacts (SPoC), outlining the requirements of the role and the role holder’s key responsibilities. The MPS should …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends that the MPS Should consider providing role specific training to all of its professional standards investigators. It is recommended that this training addresses the following requirements: Another issue raised in this investigation was the lack of role …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police take steps to ensure custody staff, in particular custody officers and healthcare professionals, understand when detained persons require an Appropriate Adult. This should include: Providing updated training on the legislation and national guidance regarding …
An investigation into complaints made about the treatment of a man with …
The IOPC recommends SWP consider using this incident as an anonymised case study to promote learningamong officers. This should include consideration of: 1. how officers responded to this incident; and 2. explore (drawing upon best practice) what alternative actions could …
An investigation into complaints made about the treatment of a man with …
The IOPC recommends SWP take steps to ensure that when a detainee is brought into custody: 1. the custody officer makes sure appropriate enquiries are undertaken to confirm whether the detainee has any medical conditions and, if so, whetherthe detainee …
An investigation into complaints made about the treatment of a man with …
The IOPC recommends SWP take steps to ensure custody staff, in particular custody officers and healthcare professionals, understand when detained persons require anAppropriate Adult. This should include consideration of: 1. Issuing communications to custody officers reminding them when a detainee …
An investigation into complaints made about the treatment of a man with …
The IOPC recommends SWP take steps to ensure police officers and custody staff are supported to identify and interact with people who have neurodiverse needs, including those with autism spectrum conditions. This should include consideration of the training and guidance …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police takes steps to ensure all relevant officers and staff, included but not limited to: Gold, Silver, and Bronze Commanders and Force Incident Managers, receive training on the following policies and how they interact …
Recommendations - North Wales Police, January 2025
The IOPC recommends that North Wales Police review, and where necessary amend, their training, guidance and policies provided to police officers and staff about how to write a statement. This learning recommendation has arisen following an IOPC investigation review following …
Recommendations - Gloucestershire Constabulary, March 2025
The IOPC recommends that Gloucestershire Constabulary should review their training in relation to stalking to ensure that: This recommendation has arisen following an independent investigation into a longstanding neighbour dispute that sadly resulted in murder. Following the investigation, Gloucestershire Constabulary …
Recommendations - Gloucestershire Constabulary, March 2025
The IOPC recommends that Gloucestershire Constabulary should provide training to all neighbourhood policing team officers to ensure improved awareness of antisocial behaviour and the use of community protection warning letters, community protection notices and antisocial behaviour injunctions, as well as …
Police contact with a man and a woman before he murdered her …
The College of Policing (CoP) and National Police Chiefs' Council (NPCC) should work together to address how best to ensure forces use a skills and needs assessment approach to ensure each officer/staff member is fully equipped to perform the role …
Police contact with a man and a woman before he murdered her …
Sussex Police should ensure that all practitioners are adequately prepared and trained to complete risk assessments fully. Do you accept the recommendation? Yes
Police contact with a man and a woman before he murdered her …
When officers or staff move to a different role they should be given training and support to carry out the new role. Transition training and support should also be made available. Do you accept the recommendation? Yes
Recommendations - Surrey Police, April 2020
The IOPC recommends that Surrey Police training and/or policy on the use of mobile data terminals is reviewed to ensure officers are aware of the practical uses this piece of equipment can provide. Surrey Police provide a three hour training …
Police response to a domestic incident - Essex Police, September 2020
The IOPC recommends that Essex Police should review the quality and effectiveness of its initial and refresher domestic abuse training for frontline officers with specific reference to: In this case, the attending officers requested no Police National Computer or other …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police consider updating force policy to robustly cover checking cells specifically for the purpose of detainee safety. Force policy should be clearly communicated to custody staff with training and oversight to ensure that cell checking …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This could be reinforced by additional …
National recommendation - National Police Chiefs' Council, February 2021
The IOPC recommends that the National Police Chiefs’ Council (NPCC) takes steps to ensure that all police forces provide training to officers and staff who regularly come into contact with members of the public, whether face-to-face or by some other …
Recommendations - Kent Police, November 2020
The IOPC recommends that Kent Police provides their operational employees with clarity on the different definitions of the term ‘vulnerable.’ There are two strands to this recommendation: This recommendation was made after some of the evidence appeared to suggest Kent …
Recommendation - Norfolk Constabulary, March 2021
The IOPC recommends that Norfolk Constabulary devise a training programme or incorporate into existing training the content of the revised Home Office Guidance (Conduct, Efficiency and Effectiveness: Statutory Guidance on Professional Standards, Performance and Integrity in Policing)2020 regarding off duty …
Recommendation - South Wales Police, October 2020
The IOPC recommends that South Wales Police (SWP) amends the first aid training provided to front line officers to ensure all officers and staff receive training regarding managing a casualty with a head injury. In the interim, SWP should take …
National recommendation - The College of Policing, April 2021
The IOPC recommends that the College of Policing should take steps to ensure that all officers and staff (in particular front line officers) are best supported (for example through training and guidance) to recognise the signs and symptoms of head …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police provide the same training to Local Policing Unit (LPU) and control room staff in relation to ControlWorks system and in relation to vulnerability, risks, safeguarding and THRIVE. Staff within the LPU explained they had …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends South Yorkshire Police ensures knowledge and skills of those involved in child sexual exploitation work are kept up to date as part of their continuous improvement cycle. This should include:• regular training to take into account staff …
Recommendations - Cleveland Police, February 2021
The IOPC recommends Cleveland Police reviews its management systems for performance and training to ensure there are robust mechanisms in place to ensure staff comply with all mandatory training packages, while ensuring performance reviews are carried out and maintained. Do …
Recommendations - Wiltshire Police, September 2021
The IOPC recommends that Wiltshire Police should introduce mandatory specialist training for staff delivering specialist functions within the Public Protection Department. Once completed, training records should be updated to record completion and the need and frequency of refresher should be …
Recommendations - Humberside Police, January 2022
The IOPC recommends that Humberside Police consider implementing the use of metal detecting wands in their Custody Suites. This follows a Death or Serious Injury (DSI) incident whereby a detainee was able to hide a razor blade within a copy …
Recommendations - Humberside Police, January 2022
The IOPC recommends that Humberside Police use this case, within; officer training, force communications and policy/guidance, to highlight the need to maintain effective supervision of a detainee, especially prior to the completion of a search. This follows a Death or …
Police contact with a mother and unborn child subject to child protection …
The IOPC recommends that the Metropolitan Police Service (MPS) deliver mandatory bespoke training to Police Conference Liaison Officers (PCLOs) and their respective Detective Sergeants on the Child Abuse Investigation Team (CAIT) to highlight the policies and procedures within which they …
Police contact with a mother and unborn child subject to child protection …
The IOPC recommends that the Metropolitan Police Service (MPS) deliver mandatory safeguarding training to all Child Abuse Investigation Team (CAIT) officers and staff. This should be tailored to the work carried out by the team and include areas such as: …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police take steps to ensure that all custody staff pro-actively offer showers to detainees during their detention in police custody. As a minimum, detainees should be offered a shower if they have been incontinent. Appropriate …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police should review its policy and procedures to clarify and improve existing guidance in relation to: The length of time officers should conduct close proximity observations before they are replaced by another officer. What is …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police ensure that officers conducting close proximity observations in custody are of the appropriate sex. A complainant was in police custody for 35 hours. She had mental health conditions and was placed on level four …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police remind all police officers and custody staff of their responsibility to sign the constant observations front sheet following a briefing from a Custody Sergeant, and the Custody Sergeant's responsibility to countersign the entry. A …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police takes steps to ensure all relevant referrals are made for detained persons. This should include consideration of providing guidance on how to make referrals, including who is responsible for doing so and ensuring that …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police should amend their policy to ensure that where a Health Care Professional (HCP) decides not to administer a medication that they have been informed a detainee has been prescribed, the HCP should record this …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police remind all Custody Staff of their policy in relation to assigning female carers to female detainees. A female complainant was detained in police custody for around 35 hours. Essex Police have a policy that …
Man tasered during arrest in the presence of a child – Greater …
The IOPC recommends that the College of Policing include a learning point in national training for officers equipped with Taser, in relation to considerations when a child is present during an incident where Taser is used. This is to enable …
Man tasered during arrest in the presence of a child – Greater …
The IOPC recommends that Greater Manchester Police include a learning point in local training for officers equipped with Taser, in relation to considerations when a child is present during an incident where Taser is used. This is to enable officers …
Recommendation - Bedfordshire Police, May 2022
The IOPC recommends that Bedfordshire Police review its arrangements for managing officers who have returned from extended periods of absence. The review should consider: This recommendation was made following an IOPC casework review which found an officer returning from extended …
Investigation into the West Yorkshire Police response to reports of injuries to …
The IOPC recommends that West Yorkshire Police (WYP) remind all WYP control room staff of the importance of protecting vulnerable victims of domestic abuse by consistent and effective use of the THRIVE process, to include a review of their THRIVE …
Investigation into a serious injury afflicted by a man on police bail …
The IOPC recommends that Essex Police takes steps to ensure that officers and staff have accurate and up-to-date knowledge in relation to domestic abuse and breaches of bail and breaches of civil orders. This should include consideration of issuing communications …
Recommendations - Norfolk Constabulary, August 2023
The IOPC recommends that Norfolk Constabulary takes steps to ensure that response officers, who come into contact with a person who is believed to have consumed drugs, consider the possibility of whether the person has consumed different drugs. Drugs taken …
Recommendations - Norfolk Constabulary, August 2023
The IOPC recommends that Norfolk Constabulary takes steps to ensure that response officers, who come into contact with a person who is believed to have consumed drugs, can recognise the signs and symptoms of toxicity for commonly encountered drugs (as …
Recommendation - North Yorkshire Police, August 2023
The IOPC recommends that North Yorkshire Police should take steps to satisfy itself that, in line with Authorised Professional Practice, officers and members of police staff understand how to identify the signs that a person is drunk and incapable. Such …
Use of force against man during unlawful arrest – South Wales Police, …
The IOPC recommends that the National Police Chiefs' Council asks force custody leads to review their systems and processes to ensure that risk assessments completed during the booking-in process support custody officers to identify if a detainee has a potential …
Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, …
The IOPC recommends that Hampshire Constabulary ensure that Police Constables who provide cover in custody receive custody-specific training so that they have the appropriate level of knowledge and skills to competently perform their role. This follows an IOPC investigation into …
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police provides guidance to front line officers and the Street Triage Team (STT) in respect of their responsibilities and actions to be taken when encountering a member of the public who has self-harmed in their …
Recommendations - North Yorkshire Police, August 2024
The IOPC recommends that North Yorkshire Police assures itself that their training for custody officers and staff covers the management of detainees with chronic conditions in line with Authorised Professional Practice (APP) and adhering to Code C of thePolice and …
NAO Audit Recommendations (53) — showing 50 strongest matches
Government's general grant schemes
To improve grant practitioners' capability, the Grants Management Function should work with departments to: (e) promote take-up of the learning and training opportunities available, including mandating the managers of large, complex or novel grant schemes to have achieved the grants …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should continue work to clarify opportunities for career progression within the department and support staff to navigate them. Staff still lack clarity around career progression and capability requirements in the merged organisation. FCDO has developed a new capability framework …
Accepted
Increasing the capacity of the prison estate to meet demand
MoJ should combine thinking on policy objectives for the prison estate and improved evidence of different approaches to develop a long-term strategy to improve the resilience of the estate. It should: set out how it will ensure it has the …
Accepted
Civil service workforce: Recruitment, pay and performance management
Each department?s HR director should report regularly to the department?s executive committee on the number and grade breakdown of staff identified as underperforming. This should include reporting on what happens after staff have been identified as underperforming, to help departments …
Accepted
Managing central government property
g) The OGP should: ? support departments to improve maturity of property skills; and ? monitor departments? level of skills against the functional standard to ensure they are being met across government; collect data on the impact and benefits of …
Accepted
Investigation into the management of the Holocaust Memorial and Learning Centre
To help manage the emerging risks, we recommend that the Department: c ensure that senior programme and project leaders have the necessary skills or have completed appropriate training, to help comply with IPA guidance which states that SROs are expected …
Accepted
Evaluating government spending
k) work with the Policy Profession to deliver plans to assess and improve evaluation literacy for policy professionals and analysts across government.
Accepted
Department for Work and Pensions Annual Report and Accounts 2020-21
Ensure that tackling fraud and error is part of claimant-facing staff job design. This should be built into job descriptions, with the right supporting tools andincentives, so that front-line staff recognise that tackling fraud and error is an integral part …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should accelerate its work on culture change. Now that the core elements of integration have been mostly delivered, FCDO should focus on working with teams in the UK and overseas to build cultures that align with FCDO?s strategy and …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 12: Future versions of the modelling would be improved by greater consultation and by taking better account of the factors that could limit the expansion of education and training, and of any reductions in service that might result from …
Accepted
Civil service workforce: Recruitment, pay and performance management
The Cabinet Office should work with departments to help them assess the effectiveness of their own performance management systems, including line manager/employee ratios and approaches to performance-related pay. These assessments should consider the requirements of the civil service performance management …
Accepted
Resilience to flooding
d take realistic account of staff resource constraints when setting out the objectives, scope and ambition of the next capital programme and the impacts on whole-life asset management
Accepted
Digital transformation in government: addressing the barriers to efficiency
CDDO should e) review what departments can realistically achieve in terms of closing their skills gap and keep the scope of Roadmap activities under continuous review to ensure it matches available resources, accepting that prioritisation may be necessary
Accepted
Digital transformation in government: addressing the barriers to efficiency
CDDO should c) continue to push for central reforms in the way digital change is justified, funded and procured and work with policymakers, who often do not have the digital skills to understand how digital services work, to improve policy-making …
Accepted
Digital transformation in government: addressing the barriers to efficiency
CDDO should b) increase its capability-building through formal training and mentoring support to help senior non-specialist leaders develop their understanding of government's operating environment and the constraints posed by legacy data and systems
Accepted
Developing workforce skills for a strong economy
Support the Unit for Future Skills to focus on the most important areas of forecasting and assess whether the Unit is effectively influencing stakeholders to use the intelligence and insights it generates
Accepted
Developing workforce skills for a strong economy
Consider specific issues relating to older workers who form a growing proportion of the workforce, including current and future skills gaps, barriers to participation in skills training and how these barriers could be addressed. DfE should work with DWP in …
Accepted
Developing workforce skills for a strong economy
Strengthen oversight of government?s portfolio of skills initiatives by regular reporting against performance metrics from across departments to the Labour Market Steering Group; and clarifying how different cross-government forums fit together. DfE should work with the Cabinet Office in particular …
Accepted
Developing workforce skills for a strong economy
Work with mayoral combined authorities and other local bodies to establish how it can achieve the 2030 Levelling Up skills mission most effectively, and report regularly on whether it is on track. DfE should work with DLUHC in particular on …
Accepted
Developing workforce skills for a strong economy
Develop a strategy and supporting implementation plan for achieving its objectives on workforce skills, building on the approach set out in the Skills for Jobs white paper. This should set out: ? how different parts of the system, and different …
Accepted
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
To maximise the value of AO assessments in supporting good-quality decision-making, accounting officers should: ? regularly identify those areas of the AO assessment that prove the most challenging to complete, and identify what additional support may be required for staff
Rejected
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
To maximise the value of AO assessments in supporting good-quality decision-making, accounting officers should consider sharing AO assessments with those parts of their organisation that need to understand departmental risk and spending (such as the investment committee) and the governance …
Rejected
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
HM Treasury should remind accounting officers of the need to fulfil their responsibility to publish summary AO assessments and ensure that these are easily accessible through its GOV.UK website to improve transparency.
Accepted
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
HM Treasury should as part of any wider governance review provide greater clarity on how AO assessments fit within the wider governance and accountability framework, including the IPA?s reviews of major programmes. This should also set out when AO assessments …
Accepted
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
HM Treasury should enhance its support to accounting officers and departments by, for example, completing an annual review of the quality of AO assessments to help identify good practice, providing training and facilitating conversations across government on what ?good? looks …
Partially accepted
Evaluating government spending
To deliver a step-change in the evaluation capacity and capability of analysts and policy staff, the Analysis Function should: j) work with the CGEG, departments and the Cabinet Office to assess government’s specialist evaluation capacity and capability and agree a …
Accepted
Evaluating government spending
To raise standards and support departments in consistently meeting evaluation requirements, the Analysis Function and the Evaluation Task Force should work with others in the evaluation community of practice (including CGEG and government professions) to make available in a single …
Accepted
Environment Agency Annual Report and Accounts 2023-24
maintaining the environment ? through appropriate resourcing and training, and broader leadership which promotes good data quality and continuous improvement ? for improvements in financial management to be sustained over the long-term
Accepted
The UK border: Implementing an effective trade border
By September 2024 the Cabinet Office and Defra, working with the Northern Ireland Civil Service (NICS), should consider how they can provide ongoing support and advice to the NICS in the context of NI?s unique access to the UK and …
Accepted
The UK border: Implementing an effective trade border
By September 2024, the Cabinet Office should agree with Border Force and with the Northern Ireland authorities a plan for ensuring compliance with new rules being introduced through the Windsor Framework and the Command Paper.
Accepted
The UK border: Implementing an effective trade border
The Cabinet Office should ensure it has published in good time clear guidance for traders on the arrangements necessary to implement the next phases of the Windsor Framework and the Command Paper.
Accepted
The UK border: Implementing an effective trade border
The Cabinet Office, working with Defra, HMRC and the Home Office, should, by July 2025, have a plan in place to monitor compliance with the new controls. This should include any necessary reprioritisation of border resources and management of risks …
Partially accepted
The UK border: Implementing an effective trade border
Defra, HMRC and the Home Office, working with the devolved administrations, should take action as soon as they can to ensure full controls are operating at all ports, and the Cabinet Office should provide central oversight and coordination of this …
Partially accepted
Implementing statutory biodiversity net gain
be proactive in co-ordinating opportunities for best practice to be shared and adopted quickly, particularly among local authorities.
Accepted
Customer service
[On protecting tax revenue:] j. HMRC should look at cases of taxpayers failing to take reasonable care, to understand the main reasons and identify whether there are changes it can make to its services and systems to reduce occurrences
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should implement a revised internal communications and engagement strategy setting out its plan to deliver future organisational improvement, incorporating where appropriate the remaining elements of integration. This will help to address the uncertainty and remaining concerns which are affecting …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should complete its work to align allowances as a matter of urgency, and should also prioritise work to resolve remaining issues with the basics of HR, IT and corporate services provision.
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 15: Ahead of the next version of the LTWP, NHSE modellers should consult further with a wide range of stakeholders, including Royal Colleges, healthcare providers and other health bodies about the appropriate substitution rates to use when meeting demand …
Accepted
The asylum and protection transformation programme
The Home Office should: put in place a performance measurement system for the Programme that gives a comprehensive overview of performance across all of its objectives. In particular, in its programme reporting, it should include measures of the flexibility and …
Accepted
Progress with trade negotiations
DIT should work with other departments, including Defra, FCDO and BEIS, to further embed across government the trade negotiating capacity and capability that it has built over the past few years. For example, to improve staff retention, DIT should continue …
Accepted
Investigation into underpayment of State Pension
h) improves training on and management of complex State Pension cases. For example, for the duration of the LEAP exercise it should regularly consider what additional training, guidance and case studies of complex cases its State Pension case workers need, …
Accepted
The challenges in implementing digital change
The new Central Digital and Data Office, along with the Government Digital Service and the Cabinet Office, should work to provide clear leadership for this agenda, in particular: a) revise existing training programmes to better equip and train all decision?makers …
Accepted
Improving the performance of major equipment contracts
e) The Department should do more to keep key personnel in place on contracted programmes for as long as is needed to meet specific milestones. SROs and senior members of their team are crucial to the delivery of contracted programmes …
Accepted
Central oversight of arm’s-length bodies
The Cabinet Office and departments should develop and strengthen centres of ALB expertise and support them with organising events, training and sharing of good practice.
Accepted
Central oversight of arm’s-length bodies
The Cabinet Office should set out common standards for what good departmental sponsorship arrangements look like, and work with departments to ensure sponsorship teams have the right capability and sufficient capacity. It should monitor how this is adopted by departments …
Accepted
The adult social care market in England
b) develop a workforce strategy, in line with its previous commitments, to recruit, retain and develop staff, aligned with the NHS People plan where appropriate;
Accepted
Immigration enforcement
c) Develop a common understanding of ‘harm’, so that all staff are confident they see harm in a consistent way for their area. Immigration Enforcement’s ongoing work to assess current and emerging threats helps teams focus on harm, but there …
Accepted
Digital transformation in the NHS
d) Alongside the implementation plan, develop specific resources and plans for high-risk issues: • Establish a resource to provide bespoke support to trusts in managing the adaptive change required for digital transformation. • Prepare a communication plan to ensure trusts, …
Partially accepted
BBC Studios
• BBC Studios’ management of its staff, development of organisational capacity and delivery of cultural change.
Accepted
Department for Work and Pensions annual report and accounts 2018-19
• raise awareness among Housing Benefit claimants of the change in the ‘abroad’ eligibility rule to reduce this cause of fraud and error, learning from the reduction achieved in Pension Credit.
Accepted
PHSO Ombudsman Recommendations (2)
Ignoring the alarms: How NHS eating disorder services are failing patients
Health Education England should review how its current education and training can address the gaps in provision of eating disorder specialists we have identified.
Ignoring the alarms: How NHS eating disorder services are failing patients
The General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders.
Victims' Commissioner Recommendations (1)
IMB Annual Reports (115) — showing 50 strongest matches
Stoke Heath (2021)
HMP/YOI Stoke Heath faced significant challenges during the Covid-19 pandemic, leading to a restricted regime with prisoners locked in cells for extended periods, impacting their wellbeing and rehabilitation. Despite this, the IMB found the prison to be safe, with well-led healthcare services and positive staff-prisoner relationships. Key concerns include severe funding cuts to education and vocational training, an inadequate heating system, and the detrimental impact of the restrictive regime and blended learning on purposeful activity and rehabilitation.
PRISON
Key concerns
Wetherby (2022)
HMYOI Wetherby faced significant challenges during the reporting year, including persistent staffing shortages which severely impacted the regime, leading to limited time out of cell, particularly in evenings. The Board noted concerning levels of violence, self-harm, and the continued problem of weapon creation. Additionally, there were unacceptable delays in transferring young people with complex mental health needs and significant evidence of racism. Despite these challenges, the Board commended positive staff-young person relationships, good physical healthcare provision, and welcome investments in the estate and engaging educational programs.
PRISON
Key concerns
Aylesbury (2020)
Aylesbury YOI, operating with a reduced population of 209 due to special measures, successfully improved its safety and operational performance, leading to the withdrawal of its special measures status. Despite positive developments like improved staff-prisoner relationships and infrastructure upgrades, significant concerns persist regarding the amount of time prisoners spend locked in cells, the quality of purposeful activity, and ongoing staffing and estate issues. The report also highlights challenges in addressing equality and diversity, and the impact of long segregation stays on young prisoners' wellbeing.
PRISON
Key concerns
Oakwood (2021)
HMP Oakwood navigated the COVID-19 pandemic under a strict 22-23 hour lockdown regime, with staff showing exemplary commitment in maintaining a safe environment and humane treatment. Despite these efforts, the regime severely limited education, purposeful activity, and access to services, leading to concerns about sentence progression and mental health impacts. Key issues included the poor performance of the education provider Novus, persistent problems with prisoner property transfers, and challenges in managing transfers of vulnerable prisoners without appropriate medical information or COVID-19 testing.
PRISON
Key concerns
Bristol (2021)
HMP Bristol successfully managed Covid-19, implementing strong infection control and a good vaccination programme. The prison saw significant improvements in accommodation and the general environment, alongside a reduction in self-harm and violence. However, the Board remains concerned about inconsistent key work delivery, staffing shortfalls, persistent issues with disability access, and the appropriate placement of vulnerable prisoners.
PRISON
Key concerns
Brinsford (2021)
Despite a severely restricted Covid-19 regime, HMP/YOI Brinsford is deemed a safe prison where prisoners are treated fairly. While incidents of violence, self-harm, and substance misuse have reduced due to lockdown, persistent issues include delays in transferring prisoners with mental health needs and an education contract that largely failed to meet prisoner requirements for much of the reporting period.
PRISON
Key concerns
Werrington (2021)
HMYOI Werrington operated with significant challenges during the reporting year, marked by the ongoing pandemic, major refurbishment, and a sharp increase in violence and disruption in the latter months. The Board raised serious safety concerns, noting restricted time out of room and staff shortages led to inhumane treatment. While healthcare was proactive and efficient, education struggled amidst disruptions, and the Board highlighted issues with the use of Rule 49 and long remand waiting times.
PRISON
Key concerns
Thorn Cross (2022)
HMP/YOI Thorn Cross experienced a challenging year due to the pandemic and staffing issues but maintained a safe and humane environment. The Board found the prison's rehabilitative culture and healthcare provision to be strong, with positive staff-prisoner relationships. Key concerns include budget pressures, delays in high-risk transfers, persistent property issues, and the need to improve data collection on protected characteristics and reduce absconds.
PRISON
Key concerns
Young Offender Institutions (YOIs) in England (2021)
This national IMB report covers Young Offender Institutions (YOIs) in England from June 2020 to August 2021, a period heavily shaped by the Covid-19 pandemic. While some positive developments were noted, such as improved reception processes and generally lower self-harm, significant concerns persisted. These included limited time out of cell, insufficient education, and critical delays in mental health transfers and post-release support from local authorities, all exacerbated by pandemic restrictions.
PRISON
Key concerns
Woodhill (2022)
HMP Woodhill faced significant challenges during the reporting year, primarily driven by severe staffing shortages which restricted the regime and impacted prisoner safety, wellbeing, and access to services. While there were positive efforts in areas like Covid-19 response and family contact initiatives, high levels of violence, prolonged segregation, and inadequate progression opportunities remained key concerns. The IMB judges that the prison requires improvement, particularly in addressing staffing, regime delivery, and resettlement support.
PRISON
Key concerns
Dungavel House IRC (2021)
Dungavel IRC was well-managed by both GEO and Mitie throughout 2021 despite COVID-19 challenges, treating residents fairly and safely. Healthcare provision was good, and a relaxed regime with ample activities was maintained due to low resident numbers. Key concerns included IMB member recruitment, high CSU temperatures, the need for a disability officer, and unresolved issues like staff negotiation training and parking.
IRC
Key concerns
Swinfen Hall (2022)
HMP/YOI Swinfen Hall, a YOI and Category C training prison, held 583 prisoners during the reporting year. The Board noted positive progress in safety initiatives and equality, diversity, and inclusion. However, significant concerns remain regarding slow responses to prisoner property and complaints, insufficient purposeful activity places, and delays in offender management. Healthcare provision, particularly night cover and mental health staffing, also raises concerns.
PRISON
Key concerns
Stoke Heath (2022)
HMP/YOI Stoke Heath maintained a safe and positive environment during the reporting year ending March 2022, despite ongoing Covid challenges. Key positives included improved in-cell telephony, good routine GP access, and declining use of force. However, significant concerns persist regarding the slow restoration of the key worker scheme, inadequate vocational training and resettlement support, and persistent delays in dental care and access to mental health beds.
PRISON
Key concerns
Wormwood Scrubs (2022)
HMP Wormwood Scrubs experienced a slow return to normal regime during the reporting year ending May 2022, impacted by Covid-19 restrictions and persistent staff shortages. The Board noted some improvements in reception and healthcare provision but raised significant concerns regarding the poor quality of food, high number of cancelled hospital appointments, and long delays for mental health transfers. Key challenges included disproportionate use of force against Black prisoners, a largely closed library and depleted education, and a patchy key worker scheme.
PRISON
Key concerns
Berwyn (2022)
HMP Berwyn continues to be a safe establishment, though it faces significant challenges from staffing shortages, which impact regime delivery, purposeful activity, and key work. The Board notes improvements in resettlement outcomes and a reduction in serious assaults, alongside robust use of force data collection. Key concerns remain the long waiting times for dental care and mental health transfers, as well as the poor timeliness in responding to prisoner complaints.
PRISON
Key concerns
Lindholme (2023)
HMP Lindholme successfully transitioned to a full regime post-Covid, with many prisoners feeling safe, though issues like overcrowding and double-occupancy cells persist. Healthcare needs are generally met, but access challenges remain. The Board highlights concerns regarding property issues, the complaints system, and the need for improved resettlement and IPP prisoner progression.
PRISON
Key concerns
London STHF (2023)
This report covers the London Short-Term Holding Facilities at Heathrow and City Airports, and reporting facilities Becket and Eaton House for the reporting year ending January 2023. The Board found that while holding rooms generally provide a safe environment and most inductions were done well, significant concerns persist around excessive lengths of stay, inadequate facilities, and lack of access to internet and medication. Recommendations target the Minister, Home Office, Border Force, Mitie Care & Custody, and Clearsprings to address these issues, many of which are repeated from previous years.
PRISON
Key concerns
Five Wells (2023)
HMP Five Wells, a Category C prison, opened in February 2022 and housed 1200 prisoners by March 2023, below its operational capacity of 1680. The IMB noted successes such as positive visitor feedback and streamlined safeguarding, but raised significant concerns including widespread illicit items, severe staffing shortages, and numerous design flaws in the new build. Key areas needing development involve consistent regime application, improved food and canteen services, and the re-establishment of resettlement-focused programmes like ROTL.
PRISON
Key concerns
Littlehey (2023)
HMP Littlehey is a Category C training prison for men convicted of sexual offenses, holding 1,171 prisoners. The Board commended the prison for its generally safe environment, compassionate end-of-life care, and excellent PE regime. Key concerns include persistent overcrowding due to shared cells, long waiting times for specialist healthcare, and significant issues with managing prisoner property transfers between prisons. The report also highlights the over-representation of Black and Muslim prisoners in adjudications and use of force incidents, and ongoing problems with heating infrastructure and the use of temporary freezers.
PRISON
Key concerns
Guys Marsh (2023)
The Independent Monitoring Board at HMP Guys Marsh noted positive developments including sufficient organisational support for safety, the appointment of a neurodiversity support manager, and a seamless transition to a new healthcare provider. However, significant concerns remain regarding persistent drug and alcohol use driving violence, ineffective risk management plans, and unacceptably high prisoner-on-prisoner assaults. The Board also highlighted issues with accommodation standards, a long dental waiting list, and underutilised education and work provisions.
PRISON
Key concerns
Isis (2023)
HMP/YOI Isis, a YOI and Category C training prison, experienced a marked increase in violence and self-harm during 2023, attributed partly to a younger demographic and increased prisoner mixing. Staffing shortages and a high number of 'ineffective' staff consistently impacted regime delivery, education, and healthcare access. The Board highlighted persistent concerns with property management, cell cleanliness, and the limited range of rehabilitation programmes.
PRISON
Key concerns
High Down (2023)
HMP High Down, a Category C training and resettlement prison, experienced significant increases in assaults and illicit item finds during 2023, raising serious safety concerns. Staffing shortages in key work and the Offender Management Unit severely impacted regime delivery and prisoner progression. While improvements were noted in mental health transfer times and family contact, persistent issues with property loss, poor shower conditions, and limited purposeful activity for prisoners, particularly vulnerable ones, remained key challenges.
PRISON
Key concerns
Kent Coast Short Term Holding Facilities (STHF) (2023)
The IMB's report for Kent Coast STHF (WJF, KIU, Manston) for 2023 highlights commendable staff empathy and improved medical provisions. However, it raises significant concerns regarding the lack of clear information for detainees about their processing and length of stay, inadequate privacy for interviews, and substandard conditions in isolation units and sleeping arrangements. The Board also noted issues with facility maintenance and the inconsistent receipt of vital monitoring reports.
PRISON
Key concerns
Gatwick IRC (2023)
The Gatwick IRC experienced a deterioration in safety during 2023, marked by increased violence, assaults on staff, and a rise in use of force incidents, partly attributed to a changing detainee population. Key safeguards for vulnerable individuals, such as Rule 34 and Rule 35 assessments, were found to be insufficient or subject to unacceptable delays. The report highlighted significant concerns regarding inadequate mental health provision, unfair regime practices including prolonged lock-in times, and a lack of effective pathways for release for detainees granted bail.
IRC
Key concerns
Gatwick pre-departure accommodation (2023)
The IMB report for Gatwick Pre-Departure Accommodation for 2023 highlights concerns regarding the detention of four families, all of whose removal attempts failed. The Board questions the fairness and humanity of the process, particularly noting the trauma to children and callous treatment of a pregnant mother. Key recommendations include the closure of the PDA and prohibiting the detention of pregnant women.
PRISON
Key concerns
Heathrow immigration removal centre (2023)
The IMB report for Heathrow IRC (2023) highlights increasing safety concerns, including a rise in self-harm (180 incidents), assaults (131 detainee-on-detainee, 54 on staff), and drug finds (104). The Board expresses significant concerns over the detention of mentally unfit individuals, the dilapidated infrastructure, and the misuse of segregation units. While health needs are generally met, staffing shortages and delayed Rule 35 responses remain problematic. The report also notes repeated concerns about prolonged detention times and the need for improved resettlement pathways for those on bail.
IRC
Key concerns
Bullingdon (2020)
HMP Bullingdon, a local and resettlement prison, experienced high overcrowding and staffing challenges, with a significant proportion of inexperienced officers. While physical health services were generally good and some educational outcomes improved, violence and drug finds remained high, and mental health provision, particularly counselling, was inadequate. The COVID-19 pandemic severely restricted the regime, leading to prolonged cell confinement, but the prison successfully prevented widespread infection. Persistent issues include inadequate reception facilities for vulnerable prisoners, property loss, and maintenance backlogs, while resettlement outcomes remain patchy.
PRISON
Key concerns
Dartmoor (2020)
HMP Dartmoor, a Category C training prison, faces significant challenges due to uncertainty about its 2023 closure, leading to under-investment in infrastructure and impacting staff morale. The COVID-19 pandemic severely restricted the regime, reducing time out of cell and exacerbating mental health issues, despite staff efforts to maintain safety and welfare. Key concerns include inadequate mental health provision, substance misuse, and deficiencies in resettlement support, as Dartmoor is not funded as a dedicated resettlement prison.
PRISON
Key concerns
Rye Hill (2021)
The IMB report for HMP Rye Hill (April 2020 – March 2021) details the prison's operation under COVID-19 restrictions, maintaining a safe and humane environment with commendations for case management and a prompt vaccination program. Key challenges included the significant impact of restrictions on IPP prisoner progression, insufficient mental health transfer places, and the need for broader education courses. The report also raised concerns about equality monitoring, the high threshold for upholding discrimination complaints, and ongoing difficulties with resettlement accommodation and Probation Service arrangements for released prisoners.
PRISON
Key concerns
Peterborough (Women) (2021)
The reporting year was dominated by the Covid-19 pandemic, during which HMP Peterborough (Women) managed the emergency well, leading to significant improvements in safety outcomes. However, the restrictive regime severely impacted women's wellbeing and rehabilitation. Key concerns remain regarding national support for complex needs women, the effectiveness of the key worker system, and the need to adapt the regime better to women's specific needs.
PRISON
Key concerns
Winchester (2021)
HMP Winchester successfully navigated the Covid-19 pandemic, preventing internal outbreaks and earning commendation for its management. Despite this, the prison continues to face significant challenges including high levels of violence, severe regime restrictions, and ongoing issues with overcrowding and the dilapidated prison estate. While healthcare provision has improved and ACCT cases have reduced, the IMB raises multiple concerns regarding the inhumane out-of-cell time, inadequate facilities for vulnerable prisoners, and a lack of funding for critical improvements.
PRISON
Key concerns
Birmingham (2021)
HMP Birmingham has shown significant improvement in safety and stability under new leadership, making it the safest it has been in years, despite challenges posed by the Covid-19 pandemic. Healthcare provision is good, and peer support systems are strong. However, key concerns persist regarding the inhumane nature of prolonged in-cell lock-up, the high levels of use of force, and persistent issues with long stays in segregation. Other areas needing development include support for homelessness on release, addressing learning difficulties, and ensuring equity in the IEP scheme.
PRISON
Key concerns
Ashfield (2021)
HMP Ashfield is judged to be a well-managed Category C prison for sex offenders, maintaining high standards and humane treatment despite significant COVID-19 challenges. The prison effectively managed the pandemic, achieving low infection rates and progressively easing restrictions to maximize purposeful activity. Key concerns include persistent difficulties in securing suitable accommodation for released prisoners, a severe reduction in offending behaviour programme places, and issues with mental health support and equality and diversity monitoring.
PRISON
Key concerns
Buckley Hall (2021)
The reporting year at HMP Buckley Hall (Aug 2020 - July 2021) was largely defined by Covid-19, leading to significant operational challenges and a restrictive regime. Despite these difficulties, the IMB judged the prison to be safe, with dedicated leadership and staff, and good healthcare provision. Key concerns persist regarding prisoner progression, funding for new initiatives, and some basic decency issues such as secure in-cell medication storage and shower quality.
PRISON
Key concerns
Wayland (2021)
HMP Wayland's reporting year was dominated by the Covid-19 pandemic, leading to a severely restricted regime with prisoners often locked in cells for up to 22 hours daily, and a virtual halt to education and purposeful activity. The Board raised significant concerns about critically low staffing levels and inexperience, alongside a substantial minority of prisoners feeling unsafe and declining trust in staff. While improvements were noted in use of force management and new drug detection methods, the Board struggled to monitor healthcare due to exclusion from meetings.
PRISON
Key concerns
Aylesbury (2021)
This report covers a year dominated by the Covid-19 pandemic at Aylesbury YOI, which saw a reduced prisoner population of around 209. Despite a severely curtailed regime and poor education provision, the prison maintained stability, low infection rates among prisoners, and provided daily showers and exercise. Key concerns include the lack of mental health beds, the weakening of the key worker scheme, and the risk that post-pandemic priorities will shift from prisoner outcomes to risk management as population numbers increase.
PRISON
Key concerns
Guys Marsh (2021)
HMP Guys Marsh, a Category C training prison, navigated a challenging year (Dec 2020 – Nov 2021) under a restrictive "red regime" due to COVID-19. While recording no deaths in custody and a 20% drop in self-harm, concerns persisted regarding a significant increase in staff assaults, high mental health transfer waiting times, and problems with key working and purposeful activity due to staffing pressures and regime restrictions. The Board highlighted the need for improved staff retention, better IT systems, enhanced resettlement provisions, and a more consistent application of incentive schemes.
PRISON
Key concerns
Usk and Prescoed (2021)
HMP Usk (Category C) and HMP Prescoed (Category D) operated under significant Covid-19 restrictions during the reporting period, leading to an atypical regime. Despite these challenges, the Board considers them to be safe, well-run prisons with low levels of violence and self-harm, effectively managed by staff. Key achievements include the early rollout of vaccinations and successful maintenance of off-site work placements for Prescoed prisoners, though concerns remain regarding education funding, OASys document quality, staffing retention, and telephone access.
PRISON
Key concerns
Swaleside (2022)
HMP Swaleside experienced a challenging year (May 2021 - April 2022), marked by severe staff shortages, a restricted regime due to Covid-19, and a high number of deaths in custody and self-harm incidents. The Board highlighted significant concerns regarding staffing, the impact of new prisoner allocations, and the lack of essential equipment like body-worn cameras. Positive developments included excellent education provision, effective outreach services, and improvements in discrimination incident reporting, though overall challenges to prisoner welfare and safety persist.
PRISON
Key concerns
Erlestoke (2022)
The report covers HMP Erlestoke from April 2021 to March 2022, a period significantly impacted by Covid-19 restrictions that limited out-of-cell time. Despite challenges like staff shortages and high turnover, the Board found prisoners to be relatively safe, though violence increased and self-harm remained high. Key concerns include delays in transfers, inadequate mental health provision, and the slow pace of infrastructure improvements.
PRISON
Key concerns
Winchester (2022)
HMP Winchester, a complex local B/C category prison, continues to face significant challenges, including high levels of violence and self-harm, a restricted regime with prolonged cell confinement, and critical issues with its outdated building infrastructure. While staff efforts to provide humane treatment are commendable, severe staffing shortages and high turnover undermine consistency and effective key working. The IMB highlights persistent problems such as cell overcrowding, inadequate CCTV, and vermin infestation, which compromise safety and wellbeing despite some recent positive trends in violence reduction and effective pandemic management.
PRISON
Key concerns
Isle of Wight (2021)
HMP Isle of Wight operated under a continued restricted regime in 2021 due to Covid-19, impacting daily life and increasing tensions. While the Board praised staff efforts and noted positive developments in healthcare, equality, and complaint handling, significant concerns persisted regarding the dilapidated laundry, unhygienic meal services, and underfunded estate repairs. Staffing shortfalls in mental health and probation services critically hampered prisoner support and progression, alongside challenges posed by the delayed transfer of Category C prisoners.
PRISON
Key concerns
Werrington (2022)
The IMB has grave concerns about HMYOI Werrington, deeming it unsafe for both young people and staff due to a significant increase in violence, including assaults and weapon making. Low staffing levels and sickness led to a severely restricted regime, particularly at weekends, with young people spending excessive time locked in their rooms. Education provision was inadequate, and staff-young person relationships deteriorated.
PRISON
Key concerns
Wayland (2022)
The IMB for HMP Wayland concludes that the prison continues to be failed by the Prison Service and the government across multiple areas, from infrastructure maintenance to adequate staffing and training. The report notes a decline in the quality and effectiveness of prisoner treatment, with key concerns including prisoner safety, deteriorating accommodation, and inadequate resettlement support. While some positive initiatives have begun, the Board finds that fundamental issues persist and require urgent, comprehensive intervention.
PRISON
Key concerns
Lincoln (2023)
HMP Lincoln, a Category B prison, experienced a decrease in self-harm incidents and drug finds during the reporting period, alongside generally positive staff-prisoner relationships. However, significant concerns persist regarding the length and quality of maintenance work by Amey, and the inadequate access to specialist mental health facilities. Other key challenges include the impact of increasing operational capacity, difficulties for transient prisoners accessing education, issues with property transfers, and unsuitable infrastructure for vulnerable prisoners.
PRISON
Key concerns
Dungavel House IRC (2022)
Dungavel House IRC maintained a safe and humane environment in 2022, with sufficient staffing and a positive staff-detainee relationship fostering a relaxed regime. While healthcare provision was good and significant efforts were made for purposeful activity, concerns persist regarding the uncertainty of detainees' futures and the need for improved roof access prevention. Repeated recommendations, such as staff negotiation training and CSU temperature control, remain ongoing issues.
IRC
Key concerns
Hindley (2023)
HMP/YOI Hindley, a Category C training and resettlement prison for adult males and young adults, operated near its 600 operational capacity during the reporting period. The Board noted positive developments in leadership presence, communication, and some healthcare provision, which was rated good by HMIP. However, significant concerns persist, particularly regarding escalating violence, high self-harm rates (up 87%), and widespread drug availability. Persistent staff shortages lead to redeployment, impacting purposeful activity, key worker sessions, and overall regime delivery. The Board also highlights issues with outdated accommodation, delays in adjudications, and the need for improved support for complex mental health needs and disabled prisoners.
PRISON
Key concerns
Holme House (2023)
HMP Holme House, a Category C prison, experienced a challenging year ending December 2023, marked by increased violence, use of force, and significant issues with building disrepair and illicit items. While healthcare services notably improved and purposeful activity places expanded, staffing shortages impacted resettlement and Ofsted rated all five inspection areas as 'requires improvement'. The Board highlights the need for urgent attention to infrastructure, safety, and addressing the impact of a growing young adult population.
PRISON
Key concerns
Chelmsford (2024)
HMP Chelmsford, a category B local prison, faced significant challenges during the reporting year ending August 2024, particularly with overcrowding affecting 69% of its population and leading to poor conditions in older wings. While the prison saw a reduction in self-harm incidents towards the end of the year and staff were commended for managing gym facilities, use of force incidents increased, and access to healthcare remained a major concern with substantial waiting times. Processes for safeguarding prisoner property and approving telephone PINs were consistently problematic, hindering rehabilitation and family contact, although the introduction of the Launchpad system was a notable success.
PRISON
Key concerns
Kirkham (2023)
HMP Kirkham faced unprecedented challenges in 2023, primarily due to the Temporary Presumptive Recategorisation Scheme (TPRS) which led to a significant influx of prisoners and placed immense pressure on staff, resources, and the prison's resettlement-focused regime. While the Board noted staff's resilience and improvements in some areas like healthcare waiting times and new facilities, key concerns included increased assaults, persistent illicit substance issues, and significant disruption to purposeful activities and resettlement services. Staffing shortages exacerbated these problems, leading to curtailment of activities and impacting crucial offender management processes.
PRISON
Key concerns
IMB Recommendations (671) — showing 50 strongest matches
Exeter (2020)
Will the Governor arrange for refresher training for all prisoner-facing staff and implement arrangements for more effective monitoring of compliance and case management procedures? (See paragraph 4.2).
Governor / Director
Bullingdon (2021)
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-19. How will the Governor ensure that these staff receive appropriate training so that they can carry out their duties effectively?
Governor / Director
Grendon (2022)
Delivery of staff training e.g. suicide and self-harm (SASH) (4.2.6).
Governor / Director
Exeter (2022)
Address the backlog in staff training and particularly control and restraint (C&R), basic, refresher and advanced training.
HMPPS
Coldingley (2022)
In all these cases the solution must be to continue and intensify the programmes of in-house staff training and mentoring.
Governor / Director
Hewell (2023)
Is the Prison Service satisfied that training for new officers prepares them for the roles and tasks that will be expected of them? We are concerned about the length and content of training for new officers, outside aspects relating to security and control.
HMPPS
Ranby (2024)
There continues to be a high proportion of new staff with limited experience. What further steps will the Governor take to ensure these officers receive further appropriate training to enable them to carry out their duties effectively?
Governor / Director
Ranby (2024)
The proportion of inexperienced staff has continued to increase. How does the Prison Service plan to improve the training of inexperienced staff?
HMPPS
Preston (2024)
The Board recommends reviewing the refresher training and mentoring with regard to pro-social modelling, de-escalation and neurodiversity awareness.
HMPPS
Exeter (2024)
Given the high proportion of prisoners with mental ill health, will the Prison Service ensure the delivery of standalone mental health training for all officers?
HMPPS
Bullingdon (2020)
How will the governor ensure that new officers and other staff receive the training and mentoring that they need to develop in their roles, especially when the proportion of experienced operational staff is so low? And what steps can she take to retain good recruits, recognising that many factors are outside her control?
Governor / Director
Bullingdon (2020)
The recruitment of new officers over the last two years has been welcome, but the prison has lost many experienced officers, and many current members of uniformed staff have relatively little experience of working in a prison environment (see above, description of the prison, 3.1.1). How will the prison service take steps to address the issue of retaining staff, both …
HMPPS
Bullingdon (2020)
The increased number of uniformed officers during the last two years is very welcome, but it will take a long time to build up the amount of experience and knowledge that has been lost as a result of past staff cuts and subsequent attrition. How will the minister ensure that staff levels are maintained at an adequate level for the …
Ministry of Justice
Lewes (2021)
Will the Prison Service facilitate and fund staff training that has been missed or reduced due to the Covid-19 pandemic?
HMPPS
Lancaster Farms (2021)
To arrange for the training for new Listeners to be arranged and completed as soon as possible (paragraph 4.2.5).
Governor / Director
Exeter (2021)
As a matter of some urgency support Governors to reduce the backlog in staff training and particularly C&R basic, refresher and advanced training.
HMPPS
Aylesbury (2021)
To make prison sentences more purposeful, and to diminish reoffending rates, set higher requirements for basic training within the whole Prison Service.
Ministry of Justice
Whitemoor (2022)
Will HMPPS give priority to improving the training and support given to prison officers in their early years in post in order to halt the haemorrhaging of staff in the first five years after their appointment?
HMPPS
Wayland (2022)
The Board recommends that prison officer training is reviewed to include deeper and more extensive training on key work and staff/prisoner relationships.
HMPPS
Wayland (2022)
The IMB at Wayland can see no effective alternative to a request to the Minister to order a complete review of the initial and development training of prison officers.
Ministry of Justice
Swaleside (2022)
The Board has seen examples of inadequacy of apprentice officer training and believes that training must at least result in those staff knowing what to expect when they arrive at their establishment. Shortage of trained staff exacerbates failings in this respect.
HMPPS
Send (2022)
The Board would like to see provision of training to address the specific needs of female prisoners such as trauma-informed care, de-escalation and distraction techniques (5.3).
HMPPS
Oakwood (2022)
The Board is concerned about the number and experience of new staff on the house blocks. From observing some of the case notes of key worker sessions, the quality of the reporting varies. The Board suggests that senior managers look at putting further training in place.
Governor / Director
Erlestoke (2022)
What actions will be taken to develop managers and frontline staff to increase supervision and confidence so that staff/prisoner relationships improve?
Governor / Director
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
Swaleside (2023)
The Board has raised before the inadequacy of basic apprentice officer training and believes that training must at least result in them knowing what to expect when they arrive at their establishment. Support for new officers has improved considerably at Swaleside, especially with the introduction of the mentoring system. However, this is no substitute for proper basic training.
HMPPS
Onley (2023)
What additional support can be made available to increase the number of qualified instructors, given that a lack of instructors has had an impact on available workshop spaces?
HMPPS
Kent Coast Short Term Holding Facilities (STHF) (2023)
Recommend that Board Members are given some form of personal safety training.
Home Office
Hewell (2023)
Protect staff time to deliver key work and push for national resources, including training, to make this central to the regime and culture at Hewell.
Governor / Director
Dovegate (2023)
Continue to train and develop the inexperienced staff to maintain a safe and respectful working environment for all.
Governor / Director
Bullingdon (2023)
There continues to be a high proportion of officers with limited experience. What further steps can the Governor take to ensure that these officers receive further appropriate training so that they can carry out their duties effectively?
Governor / Director
Thorn Cross (2024)
To reduce the number of staff who are overdue control and restraint training.
Governor / Director
Moorland (2024)
Can the training available to prison officers be reviewed to develop more specialised skills for the wide variety of different needs represented in the prison population?
HMPPS
Gatwick IRC (2024)
Ensure that suitable training and support is provided so that professional interpretation services are used effectively in communications with the detained men, particularly during critical safeguards such as initial screening, and Rule 34 and 35 appointments.
NHS / Healthcare Provider
Full Sutton (2024)
Can the Minister address concerns about the training provided for new staff, in particular their preparedness for communicating effectively and confidently with prisoners? The Board has seen examples of staff being hesitant in their dealings with prisoners. We have also heard comments from prisoners about this aspect of staff and prisoner relations, who feel that situations may be de-escalated or …
Other
Aylesbury (2024)
Put in place centrally funded, continuing support for the newly trained officers who begin work after just ten weeks’ foundation training. The Board welcomes the new recruits, but the short length of training they undergo is insufficient to meet the many challenges on the wing. In turn, new recruits lean too heavily on the more experienced staff and this diminishes …
HMPPS
Wymott (2025)
What steps are being taken to mentor and support the professional development of new and recently recruited officers?
HMPPS
Wayland (2025)
We therefore make a similar recommendation this year as we have done in previous years; that more focused staff training is needed for all staff. We would now add to that general call that this should especially be for those in the new induction unit. Staff of this unit should not believe that they can solve all the problems that …
Governor / Director
Wandsworth (2025)
The quality of new staff recruited centrally was often poor and training was inadequate. What steps are being taken to improve training and reject unsuitable candidates?
Ministry of Justice
Swaleside (2025)
The inexperience of staff is compounded by the limited training they receive. This is not sufficient to commence employment. What steps will the Minister take to involve Governors in the recruitment process, and what is the rationale for the exclusion of Governors from the process?
Ministry of Justice
Gatwick IRC (2021)
Training should be strengthened for frontline staff, especially in Tinsley House, to help ensure that potentially under-age individuals are identified and feel able to challenge the age imputed to them (section 4.4.3).
Governor / Director
Derwentside (2022)
To ensure all staff are trained and fully confident and competent in the governance, techniques and reporting requirements around use of force and rules 40 and 42.
Governor / Director
Wandsworth (2020)
Many of the induction meetings observed by Board members were of a low quality. The presentations were often unsympathetic and inconsistent, with inadequate slides and handouts. The Board was very disappointed that this counterproductive and poorly managed situation had continued, despite similar criticism in four previous annual reports.
Governor / Director
Onley (2020)
Greater training/support is needed for POELTs to ensure that they carry out their jobs to the best of their abilities.
Ministry of Justice
Littlehey (2020)
When will the Prison Service ensure that prison officers are given adequate training to deal with the different needs of these groups of prisoners?
HMPPS
Lancaster Farms (2020)
The Board notes the continued issues regarding cover arrangements for education staff who are absent due to sickness (see paragraph 9.2), and continues to observe allocation delays, prisoners sent back to their cells, and class cancellations (see paragraph 9.3).
Governor / Director
Huntercombe (2020)
To introduce or renew practical and vocational contracts so that meaningful training and work that carries a recognised international qualification can be achieved – see section 7.2.
HMPPS
Highpoint (2020)
The Board asks the governor to look proactively to appointing a suitably qualified person to the kitchen staff, who can support prisoners in obtaining an NVQ qualification, as a positive outcome of the experience gained by working there.
Governor / Director
Heathrow Short Term Holding Facility (2020)
[All holding rooms] The Detention Contractor should ensure that DCOs are trained so that they know which of the meals from different manufacturers are halal (para. 8.5).
Other
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport] The Detention Contractor should ensure that DCOs use the Big Word interpretation service for inducting non-English speaking passengers and not just assume that passengers with a smattering of English really understand what they are being told (para. 4.9).
Other
Health Investigations (4)
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
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 5b
Health Boards should embed trauma-informed training for all perinatal staff and those involved in incident processes and work collaboratively with staff to understand wellbeing needs and coproduce effective, monitored support arrangements.
wales
Accepted
Themes and lessons learnt from NHS investigations into matters relating … — Rec R4
All NHS trusts should ensure that their staff and volunteers undergo formal refresher training in safeguarding at the appropriate level at least every three years.
national
Accepted
Themes and lessons learnt from NHS investigations into matters relating … — Rec R3
The Department of Health and NHS England should facilitate the establishment of a properly resourced forum for voluntary services managers in the NHS through which they can receive peer support and learning opportunities and disseminate best practice.
national
Accepted
Scottish Fatal Accident Inquiries (5)
Antonio Joao Da Silva Linares
Joint health and safety drills on windfarms focusing on rescue from height; basket stretchers and spinal boards in every turbine; industry to consider fall arrest disconnect detection technology
Dec 2024
Workplace
3 recs
Scotland
Robert Wagstaff
Transition report information to be shared with all relevant SPS and NHS staff; SPS Prevention of Suicide in Prison Strategy guidance to be amended for healthcare assessments; regular training including refresher training on suicide prevention
Jan 2019
Custody
3 recs
Scotland
Andrew McCallum Pirie
The Arboricultural Association considers whether there are further steps it can take to maximise awareness within the arboriculture industry throughout the UK of the contents of the Industry Code of Practice for Arboriculture, and in particular section 3.4.6. If there are further steps it can take to that end, I recommend that those steps be taken. I have also recommended …
Jan 2026
Workplace
2 recs
Scotland
Allan Stewart Marshall
(i) It is recommended that SPS bring the C&R manuals used for the training of prison staff up to date and that the content and delivery of training provided is kept under regular review. In that regard, it is recommended that SPS give urgent consideration to revising all versions of the C&R Manual to include the information and advice contained …
Aug 2019
Custody
13 recs
Scotland
Gary Ross
It is recommended that the SPS improve their system of working by making further provision for ongoing refresher training courses for residential officers at regular intervals, to continually ensure that all such officers remain fully cognisant of and appreciative of the necessity of strictly adhering to the said Lock-up Procedures, doing so across the entire prison estate and not just …
Jan 2023
Custody
1 rec
Scotland
Article 2 Learning Points (32)
— LP 2
We recommend that at HMP Pentonville all temporary staff receive a prison induction before working in the prison for the first time. As well as covering safety and security issues, this induction should provide coverage of the ACCT Foundation training module (which has since been superseded by ‘Introduction to Safer …
HMPPS
Accepted
— LP 5
(a) We recommend that a single system be introduced at HMP Pentonville that records who has received ACCT training and when the training took place. This system should cover both staff in the main prison and those working on the Healthcare unit. It should also cover both temporary and permanent …
HMPPS
— LP 4
Assuming that it’s impractical for non‐permanent clinical staff to attend an ACCT training course as permanent staff members do and long‐term bank and agency nurses could, we recommend that a protocol be developed at HMP Pentonville to ensure that these staff are at least provided with a systematic ACCT briefing. …
HMPPS
Accepted
— LP 3
We recommend that HMP Pentonville’s Healthcare unit keeps a log of temporary staff who have received a prison induction, whether they be booked through NHS Professionals or otherwise. We think it’s important that this log is easily accessible and made visible to help promote ownership for the provision of these …
PPG
Accepted
— LP 5
Methods of translating Formal Policy Documents into accessible and simplified instructions for Prison Officers using skills-based training methods should be developed.
HMPPS
— LP 20
We recommend that, as a matter of course, escort officers at HMP Pentonville are provided with a briefing as to the nature of the circumstances of the prisoner in their charge and what has been learned about that prisoner. This should provide further clarity for the escort officer as to …
The Governor
Accepted
— LP 7
Staff at HMP Birmingham should receive refresher training on the completion of Cell Sharing Risk Assessment reviews following the receipt of new information.
The Governor
Accepted
— LP 4
Managers at HMP Birmingham should remind staff of the factors that can lead to an increased likelihood that a prisoner will harm his cellmate.
The Governor
Accepted
— LP 3
Managers at HMP Birmingham should ensure that all staff involved in the initial assessment of prisoners on reception receive appropriate training.
The Governor
Accepted
— LP 12
We recommend that GEOAmey review the staff training modules on mental health awareness and interpersonal skills in the light of Dr Craissati’s advice in paragraphs 5.42 to 5.46, noting in particular her focus on behaviours likely to be encountered in a prisoner population, and in developing skills in listening, exploring, …
GEOAmey
Accepted
— LP 11
We recommend that training in suicide prevention is undertaken by all staff who come into contact with prisoners and that the training is refreshed on a regular basis with managers having responsibility for ensuring continued understanding and compliance with the areas covered.
HMPPS
Accepted
— LP 23
We recommend that efforts are made to ensure that representatives from Healthcare units across the Prison Estate meet on a regular basis. We feel that the key to making this a reality is ensuring that the agenda for such meetings is clear and agreed as a group. Meetings should then …
HMPPS
Accepted
— LP 22
We recommend that steps are taken at HMP Pentonville to share findings of future internal investigations, whether these investigations are formal or otherwise, with the relevant audience(s). We would encourage the use of face‐to‐face fora for this, rather than simply circulating investigation reports. This approach should help enhance the feeling …
The Governor
Accepted
— LP 21
We recommend that following serious incidents, measures are taken at HMP Pentonville to ensure that support is provided, and information is actively disseminated, beyond the day of the incident itself. Responsibility for how this support is provided and how information is disseminated should be agreed at the post‐incident hot debrief …
The Governor
Accepted
— LP 18
We recommend that at HMP Pentonville recently‐made entries in the ACCT document, including triggers, are checked by a member of staff attending morning briefings so that any pertinent issues are identified and discussed in this forum.
The Governor
Accepted
— LP 15
We recommend the ongoing use of the record‐keeping audit tool being used on HMP Pentonville’s Healthcare unit, whilst ensuring that it continues to make a tangible difference and informs decision‐making, rather than being seen as a paper‐filling exercise. Showing staff exactly how it is making a difference should further encourage …
PPG
Accepted
— LP 13
(a) We recommend that more is done at HMP Pentonville to make it easier for staff conducting ACCT Case Reviews by clarifying for them what they are trying to achieve and how to fill in the form. We suggest this could be achieved by providing accompanying guidelines. Although it’s in …
HMPPS
— LP 10
We recommend that existing mechanisms for ensuring that quality ACCT entries are made at HMP Pentonville be enhanced. This process may involve: making the process easier for staff by OSRR providing guidance notes to accompany the ACCT document. These guidance notes should make explicit what is being looked for and …
HMPPS
Accepted
— LP 8
We recommend that HMP Pentonville’s Healthcare unit takes steps to understand why ACCT triggers are not always given due consideration in prompting Case Conferences and documented discussions among staff. With this understanding, steps should be taken to improve the current situation. We recommend that any steps identified go beyond simply …
PPG
Accepted
— LP 7
We recommend that the views of clinical staff with respect to ACCT are sought when they attend ACCT training at HMP Pentonville. By understanding in what regard ACCT is held, ACCT trainers will be better placed to explore with those attending how shared ownership of ACCT might be best promoted. …
HMPPS
Accepted
— LP 6
We recommend that part of the ACCT training (Foundation and Case Manager) should be modified by the Prison Service to convey an understanding of prisoner non‐communication and how this should be interpreted, particularly when formulating risk assessments.
HMPPS
Accepted
— LP Healthcare 7
An auditable system should be implemented to monitor completion of annual resuscitation training updates for staff within the healthcare team.
Healthcare Provider
— LP 8
HMPPS should ensure that liaison between Article 2 investigators and prisons is improved by ensuring that the member of staff in an establishment appointed to liaise: a) understands the nature of the Article 2 process, and b) is of sufficient seniority to direct staff and resources to facilitate the investigation.
HMPPS
Accepted
— LP 6
As the impact on staff well-being of traumatic incidents may not be immediately apparent, all staff should be actively encouraged by their managers to access staff care services following such incidents.
HMPPS
Accepted
— LP 19
The prison should perform a formal debrief for all staff involved in a serious incident, with the offer of counselling support.
HMP Altcourse
Accepted
— LP 14
We recommend that some impetus be created at HMP Pentonville to ensure that the option of using discipline staff for one‐to‐one supervision is explored (see Chapter 13). Providing clear accountabilities and a timeframe for getting this piece of work done will go some way towards creating this impetus.
The Governor
Accepted
— LP 9
To improve current audit trails, we recommend making it a requirement at HMP Pentonville that all staff print their name on the ACCT On‐going Record rather than relying on initials or signatures to identify who has made each respective entry. We suggest that amendments are made to the prison’s ‘Guide …
The Governor
Accepted
— LP 11
We recommend that GEOAmey puts in place express policy for aftercare for staff involved in a serious incident through immediate informal support from managers, and further recognition over a longer period, as well as access to independent counselling for staff who wish to use it.
GEOAmey
Accepted
— LP 5
We recommend that policy on the sharing of medical information in the prison setting is clarified and a training programme established to ensure staff understand its implications.
HMPPS
Accepted
— LP 6
I recommend that NOMS checks whether provision and deployment of first aid staff and equipment at Ranby are now at an acceptable level.
NOMS
— LP 5
I recommend that the Governor of HMP Ranby is asked: to note the absence of case notes or other evidence of constructive engagement with WA; to consider what practical arrangements are now in place at Ranby to cultivate positive interaction between staff and prisoners and whether more can be done; …
The Governor (HMP Ranby)
— LP P
Training should be given to ACCT Case Managers to develop skills for use whenever prisoners are unwilling to discuss the trigger points or circumstances surrounding their self-harming.
HMPPS
Partially Accepted
Detention Investigations (70)
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R31
Serco managers should undertake a thorough review of the initial training course and the refresher training programme to ensure that they enable staff to fulfil their roles and responsibilities. The review and any consequent redesign of staff training should ensure that staff are adequately trained in mental health matters affecting …
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
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R14
Managers at Gatwick IRCs should undertake a full review of the training needs of existing staff, including needs identified in individual EDRs, and should ensure that the annual refresher training programme and specialist further training meet those needs. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R13
G4S and the SMT should ensure that all staff receive annual refresher training in a timely way. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R9
The SMT and G4S managers should undertake regular and systematic evaluation and quality assurance of the training provided at Gatwick IRCs to ensure that staff receive training of a consistently high standard; that it meets the operational needs of the IRCs, trains and develops staff appropriately and promotes appropriate values. …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R8
The SMT must ensure that all trainers are appropriately trained in the subject on which they deliver training and in how to deliver training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R2
The SMT must ensure that DCMs are given adequate training to fulfil the tasks and responsibilities of their role. (To be completed as a matter of urgency)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 29
I recommend that all caseworkers involved in detention decisions should visit an IRC either on secondment or as part of their mandatory training.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 56
Finally, a comprehensive training package be drawn up for new contract monitors. This should include a period shadowing another contract monitor.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 33
I recommend that further training be provided to escort staff on effective and appropriate engagement with detainees.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R32
Serco managers should consider with the Home Office the possibility of providing training to give DCOs a better understanding of the rudiments of immigration processes.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R7
Managers should review the appraisal process and ensure that those who undertake appraisals have the time, training and support they need to appraise staff in a robust and meaningful way.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R42
G4S Health Services should develop a career pathway for nurses working in Care and Justice. This should be accompanied by the development of customised training materials. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R49
The SMT with the violence reduction manager should undertake a development programme with staff to: • develop their confidence and skills in dealing with disruptive detainees; and • improve their awareness and understanding of the anti-disruption policy and how it should be implemented. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R43
Healthcare and G4S management should ensure that nurses involved in control and restraint understand their role and responsibilities. This should be as part of their induction and refreshed yearly. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R40
The SMT in consultation with the local safeguarding boards must ensure that all staff receive appropriate annual safeguarding refresher training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R38
The SMT must ensure that staff are trained in the management of age dispute cases. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R36
Residential DCMs responsible for ACDT case management should receive regular refresher training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R15
The SMT should ensure that staff dealing regularly with detainees with mental health problems or with drugs or other substance misuse issues receive specialist training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R10
The SMT should undertake unannounced observation of training sessions as part of the evaluation and quality assurance of training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R3
G4S managers should work with DCMs undertaking training to ensure a common understanding of requirements of that training and how much time DCMs will be given away from operational duties as study leave. (To be completed within 3 months)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 36
I recommend that IRC staff who have regular contact with detainees should receive mandatory safer detention training on an annual basis.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 26
All relevant Home Offce staff should be trained in making assessments of vulnerability within the parameters of the Adults at Risk policy.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 18
NHS England should continue to roll out staff training on SystmOne/HJIS, and should make sure that patient consent is consistently recorded by conducting a national case fle audit and ensuring that this is a mandatory feld in HJIS.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 57
In my earlier report on Yarl’s Wood, I made a range of recommendations regarding the IMB. These were that the Board: • regularly attends training for DCOs; • undertakes training in race relations and cultural awareness; • draws up a Mission Statement; • introduces instructions for duties which must be …
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 52
I recommend that a module on complaints handling and investigation is incorporated in the training package for contract monitors.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 39
I recommend that Oakington’s IMB members be offered refresher training in relation to their powers and how to ensure maximum effectiveness.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 32
I recommend that staff be trained to ask the detainee by what name he/she would like to be called and to check with him/her their pronunciation of the name.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 15
I recommend that GSL develops a training package for newly promoted managers which should cover amongst other things leadership, giving positive and negative feedback, and effective supervision of staff.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 7
I recommend that GSL reorganises its ITC to ensure that race relations training informs the whole of the course.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R6
Managers should review the centre’s policies, its recruitment, training and appraisal arrangements and the regime at the centre to ensure they are consistent with its mission, role and purpose.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R12
The SMT should consider giving trainees the opportunity to view body camera images of incidents recorded at Brook House. (To be completed within 6 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R11
G4S managers should agree with the Home Office ways that recruits in training can be given early and regular opportunities to experience the environment at times when the detainees are at large in Brook House. (To be completed within 3 months)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 31
Case progression panel chairs should be of suffcient competence for the role. Attendance from all relevant parts of the Home Offce should be ensured.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 16
A best practice forum should be established across IRC healthcare providers.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 6
Given my observations at each of the Heathrow terminals and at Cayley House, Tascor should arrange for refresher training for its staff on their duty of care, and the need for proper and meaningful engagement with detainees.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 43
GSL seeks the views of its existing staff to determine what more is required by way of training.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 38
GSL reviews its staff training in respect of handling and defusing confrontation.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 26
in future, all contractors be required to affiliate to the Custodial Care National Training Organisation.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 37
I recommend that IND negotiates with GSL to produce a version of the DVD that could be used for training purposes.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R14
Managers should review staff handover arrangements as a matter of urgency.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R13
Managers should review policy and procedure in relation to entering residents’ rooms and interviews with and checks on residents, particularly at night, to ensure that interviews and checks are as thorough as necessary and carried out in a consistently by all staff.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R5
Managers at Yarl’s Wood should put in place a programme of organisational development work involving all staff, to develop a clearer and better shared understanding of the centre’s mission, role and purpose, and the cultures and arrangements, including staffing arrangements, that will ensure the appropriate care of Yarl’s Wood’s residents. …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R35
The residential DCMs should ensure that ACDT case reviews are conducted by DCMs accompanied by a DCO acquainted with the detainee whose case they are assessing. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R50
The SMT must ensure regular and timely review of all use-of-force incidents by appropriately trained staff and that regular meetings take place, involving the SMT, dedicated to considering matters arising from use-of-force incidents and to ensuring that any concerns are addressed. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R5
The SMT should ensure staff have time for debriefing and reflecting about serious incidents in which they have been involved and an opportunity to learn from them. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R18
The SMT should ensure that teachers at Brook House, including the arts and crafts teachers, have ready access to the equipment and resources to provide worthwhile programmes for detainees. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R33
G4S and the SMT should consider with the Home Office the possibility of providing the welfare team with training in immigration processes. (To be completed within 6 months)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 41
The Home Offce should increase the number of its staff who have direct operational experience in closed institutions.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 50
contract monitors be given training in complaints handling.
Immigration Detention
PHSO Casework Decisions (6)
P-001871 — Manchester University NHS Foundation Trust
Ms G complains about the nursing care the Trust gave to her son in 2020.
NHS in England
Mar 2023
P-002931 — Norfolk and Suffolk NHS Foundation Trust
Ms L complains about the content of an autism awareness course that she attended at the Trust. She also complains about how her concerns were handled and being banned from the rest of the course and any future courses.
NHS in England
Sep 2024
P-004158 — Gloucestershire Hospitals NHS Foundation Trust
Miss G complains of a lack of escalation from nurses to medics, a lack of surgical review and a delay in treatment from the time her father, Mr G, showed signs of deterioration over a 24 hour period in November 2021, with consistent pain, low blood pressure and a distended …
NHS in England
Partly Upheld
Oct 2025
P-001722 — Leeds Teaching Hospitals NHS Trust
Miss I complains Trust staff used excessive force and pinned her partner, Mr E, down after he asked to go for a cigarette. She also says Mr E experienced abuse and neglect leaving bruising on his body.
NHS in England
Jan 2023
P-002570 — Great Ormond Street Hospital for Children NHS Foundation …
Mr S complains the Trust gave his son an inappropriate dose of an immunoglobulin infusion, it did not understand his son's medical condition or give the right treatment and it did not give him oxygen properly.
NHS in England
Apr 2024
P-002542 — James Paget University Hospitals NHS Foundation Trust
Mr A complains the level of restraint used against him by security and porter staff in February 2023 was excessive.
NHS in England
Apr 2024
LGO / SPSO Decisions (99)
21-015-968 — Birmingham City Council
Summary: Mr X complained the Council failed to properly consider reports he made about an extension his neighbour built. We found the Council did not properly consider the relevance of permitted development rights in this case. However, we found that the outcome was unlikely to have been different. We recommended …
LGO (Local Government & …
Planning
Upheld
Sep 2022
22-005-932 — North Yorkshire County Council
Summary: We will not investigate this complaint about the Council’s Supported Employment Service. The Council has accepted fault, apologised to Mr C and changed his support worker. The Council is monitoring the service and has provided Autism communication training to its staff. It is unlikely that further investigation would lead …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
24-003-010 — Medway Council
Summary: There was fault by the Council in failing to seek confirmation of whether a pupil had previously hit staff on school transport before reaching a decision about the nature of transport required. The Council will apologise, provide a payment to remedy injustice and make service improvements. The complaint is …
LGO (Local Government & …
Education
Upheld
Nov 2024
24-016-542 — London Borough of Bromley
LGO (Local Government & …
Adult Care Services
25-012-608 — Hertfordshire County Council
LGO (Local Government & …
Adult Care Services
25-011-835 — Nottinghamshire County Council
LGO (Local Government & …
Adult Care Services
23-006-082 — Calderdale Metropolitan Borough Council
Summary: Mr and Mrs X complain about the lack of support they experienced from the Council as registered foster carers since 2017. They said it caused them avoidable distress. We found the Council was not at fault in how it supported Mr and Mrs X. However, the Council was at …
LGO (Local Government & …
Children S Care Services
Upheld
May 2024
24-020-695 — Stratford-on-Avon District Council
Summary: We will not investigate this complaint about the conduct of an officer. The Council has acknowledged the Officer’s behaviour fell short of that expected. It has apologised and arranged for further training. We cannot achieve the outcome the complainant is seeking. And we do not consider an investigation will …
LGO (Local Government & …
Planning
May 2025
24-007-592 — Leeds City Council
Summary: Miss X complained that the Council had failed to secure suitable education for her son (Y) and had failed when reviewing his Education Health and Care Plan. She also complained about the lack of adequate training for the Council’s staff. We found fault with the Council’s delay to address …
LGO (Local Government & …
Education
Upheld
May 2025
24-001-796 — London Borough of Bromley
Summary: Ms X complained about the Council’s decision to suspend her child, Y, from school transport. The Council accepts it should not have suspended Y and failed to consult Ms X. The Council has agreed to make a payment to Ms X and train its staff to prevent a recurrence …
LGO (Local Government & …
Education
Upheld
Nov 2024
201102648 — University of the West of Scotland
Mrs C complained on behalf of her son (Mr A) that the university failed to offer guidance and support on his projects during his final honours year. She also complained that the university failed to deal appropriately with her complaint. We upheld Mrs C's complaints, as our investigation found that …
SPSO (Scottish Public Se…
Education
Upheld
Mar 2013
201605940 — Glasgow Caledonian University
Miss C complained that her university failed to provide adequate guidance for her first attempt at her dissertation. She also complained that the university did not allow her to resit two assessments that she had previously passed, even though she had mitigating circumstances. We found that when dealing with her …
SPSO (Scottish Public Se…
Education
Partly Upheld
Jun 2017
201602354 — Lothian NHS Board - Acute Division
Mr C attended A&E at the Royal Infirmary of Edinburgh on two occasions. The first occasion was for constipation and increasing back pain. Mr C's second attendance was due to concern that he may have deep veinous thrombosis (a blood clot in a vein). Mr C complained that when he …
SPSO (Scottish Public Se…
Health
Partly Upheld
Sep 2017
24-015-212 — Avery Homes Kirkstall Limited
Summary: There was an error in the contract presented to Mr X which caused him to believe he would receive a refund of Funded Nursing Care (FNC) payments once paid by the NHS. The care provider has reviewed its staff training and agrees to reimburse the payments to Mr X.
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
201809208 — Lothian NHS Board - Acute Division
C complained on behalf of their late parent (A) regarding nursing and medical care and treatment provided to A during an admission to the Western General Hospital. We took independent advice from a nurse and from a consultant in general medicine and care of the elderly. With regard to the …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2020
201902642 — Lanarkshire NHS Board
C complained about the care and treatment provided to their late parent (A) at University Hospital Monklands. During their admission, there was an incident involving A in the early hours of the morning. The board said that A was mobilised to a commode and, at A's request, given privacy to …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2021
201900708 — Edinburgh College
C, a support and advocacy worker, complained on behalf of their client (A) who was a student at Edinburgh College. A has Autism Spectrum Disorder (ASD, a developmental disability that affects how a person communicates with, and relates to, other people) and dyslexia (a common learning difficulty that can cause …
SPSO (Scottish Public Se…
Education
Upheld
May 2021
23-015-382 — West Northamptonshire Council
Summary: Mrs B complained the Council delayed in completing an Education, Health and Care assessment and failed to meet the statutory timeframe for issuing an Education, Health and Care Plan for her child, X. Mrs B says this caused distress for X and the family. We have found the Council …
LGO (Local Government & …
Education
Upheld
Jul 2024
23-005-990 — London Borough of Croydon
Summary: Mr D says the Council failed to properly investigate his concerns about noise and anti-social behaviour. We have found evidence of fault by the Council and upheld the complaint. We have completed the investigation because the Council agrees to the provide staff training and pay redress to Mr D.
LGO (Local Government & …
Environment And Regulation
Upheld
Jul 2024
24-002-781b — NHS Lincolnshire ICB (24 002 781b)
Summary: Mr X complains about the way the Nursing Home cared for his mother, Mrs Y, and her belongings. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mrs Y’s care. It has apologised, made service improvements, and trained its staff to …
LGO (Local Government & …
Health
Aug 2024
24-002-887 — Royal Borough of Windsor and Maidenhead Council
Summary: X complained the Council failed to take planning enforcement action against their neighbour. We found fault because the Council could not take enforcement action it had intended. This was because it failed to serve papers to a court within time. The Council has agreed to our recommendations and will …
LGO (Local Government & …
Planning
Upheld
Oct 2024
24-004-165 — Royal Borough of Windsor and Maidenhead Council
Summary: X complained the Council failed to take planning enforcement action against their neighbour. We found fault because the Council could not take enforcement action it had intended. This was because it failed to serve papers to a court within time. The Council has agreed to our recommendations and will …
LGO (Local Government & …
Planning
Upheld
Oct 2024
201003865 — Lothian NHS Board
Mrs C entered into an agreement with the board for IVF treatment in accordance with the criteria in place at that time. She waited from December 2008 until 2010 to reach within the top places on the waiting list, however by that time the board’s IVF treatment policy had changed. …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2011
201003746 — Education Scotland
Mr C taught at a school which was the subject of an HMIE inspection. Mr C had a number of issues with the outcome of the inspection and this resulted in him raising his concerns in writing with HMIE. His complaint to the Ombudsman stemmed from the way in which …
SPSO (Scottish Public Se…
Education
Partly Upheld
Oct 2011
201104145 — Tayside NHS Board
Mrs C suffered from lung cancer and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). She was receiving chemotherapy but after the second cycle her condition deteriorated and she was admitted to hospital, where she died a few days later. Her daughter, Miss …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201202303 — Edinburgh's Telford College
Mr C complained that the college failed to respond to his complaints about the teaching staff on his course. We found that there were a number of shortcomings in the college's handling of Mr C's complaints. It took them too long to respond, not all issues he had raised were …
SPSO (Scottish Public Se…
Education
Partly Upheld
Apr 2013
201104623 — Queen Margaret University
Ms C complained that the university did not follow their regulations in the way they handled her PhD programme. She also complained that when she appealed against being de-registered from the programme, the university failed to respond reasonably to her appeals. The particular issues which Ms C complained about related …
SPSO (Scottish Public Se…
Education
Partly Upheld
Apr 2013
201202324 — Scottish Prison Service
Mr C, who is a prisoner, complained that his personal officer had failed to engage with him appropriately. He was also unhappy with the prison governor's response to his complaint. We were unable to comment on whether the personal officer had encouraged or motivated Mr C in line with the …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Aug 2013
201300592 — Scottish Prison Service
Mr C, who is a prisoner, complained after the prison took the decision to place him under restraint, using a body belt. He said that the decision was unnecessary and that he was held under restraint for more than 12 hours without approval from Scottish Ministers. He also complained that …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Feb 2014
201406688 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C complained that when she was admitted to the Western Infirmary with increasing shortness of breath and a productive cough (a cough that produces mucus and phlegm), she was assessed by a clinical nurse specialist (CNS) who said that she could be discharged home that day under the Early …
SPSO (Scottish Public Se…
Health
Not Upheld
Dec 2015
201406068 — Lanarkshire NHS Board
Mrs C complained that her mother (Mrs A) did not receive adequate care during two admissions to hospital. Mrs A underwent surgery in Monklands Hospital to repair a fractured hip, before being transferred to Wester Moffat Hospital for rehabilitation. Mrs C complained that her mother had not been provided with …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2015
201601079 — Lanarkshire NHS Board
Mrs C complained that her mother (Mrs A) was left sitting in a chair for nine hours without access to a bed, whilst waiting to be moved to a new ward. Mrs C said that Mrs A had asked to go to bed during this time. The board told us …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2016
201508619 — Lothian NHS Board
Mrs C complained to us about the medical care and treatment provided to her late father (Mr A) at the Western General Hospital before his death. Mr A had previously been diagnosed with rheumatoid arthritis associated interstitial lung disease (a group of disorders characterized by inflammation and scarring of the …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2016
201604519 — City Of Glasgow College
Mr C complained that the college unreasonably failed to deliver his course in line with the course criteria and that they failed to respond to his subsequent complaint in accordance with their responsibilities. We were satisfied that the college acted in line with the Scottish Qualifications Authority criteria for Mr …
SPSO (Scottish Public Se…
Education
Partly Upheld
Jul 2017
201606182 — Heriot-Watt University
Mr C was removed from his PhD studies following his annual review on the basis of his academic knowledge and performance not being of the required standard to complete his studies. Mr C appealed the decision through the academic appeals process and in supporting his appeal, he complained that the …
SPSO (Scottish Public Se…
Education
Upheld
Jan 2018
201806418 — University of Glasgow
Ms C complained that the university failed to provide her with adequate support after the death of her parent. We found that the university had acted in line with their guidance in relation to this matter. We did not consider that the actions of the university in responding to Ms …
SPSO (Scottish Public Se…
Education
Partly Upheld
Jun 2020
201809975 — Borders NHS Board
C agreed to specialist reconstructive surgery, underwent their treatment, but experienced urinary incontinence thereafter. C said that they had believed the surgery would be of a routine nature and felt that they had not been not provided with adequate information about it; in particular, that a possible side effect was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2020
201809966 — Fife NHS Board
Mr C complained on behalf of his daughter (Ms A) in relation to charges for treatment provided to Ms A in Victoria Hospital. Ms A was visiting the UK from overseas and attended A&E with palpitations (noticeably rapid, strong or irregular heartbeat). Following assessment in A&E, Ms A was admitted …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2020
201900612 — University of Glasgow
C complained on behalf of their family member (A) who was a disabled student at the University of Glasgow. A had encountered a number of issues which they complained about. As a result of one of those complaints, A understood an action plan for the support for their learning was …
SPSO (Scottish Public Se…
Education
Partly Upheld
Nov 2020
201900610 — University of Glasgow
C’s family member (A) was a disabled student at the University of Glasgow. A month before A sat an exam, adjustments were agreed for the conduct of the exam. The exam was for a subject taught by a different school of the university than their core degree subject. When A …
SPSO (Scottish Public Se…
Education
Upheld
Nov 2020
201803596 — The Robert Gordon University
Ms C began her studies and was given a laptop by the university to assist her. The laptop went on to develop a fault and Ms C requested a repair. The university established that she had been given the laptop without having completed the normal procedures for assessing students requirements …
SPSO (Scottish Public Se…
Education
Partly Upheld
Nov 2020
201900021 — University of Glasgow
Ms C, a postgraduate student, complained that she had paid for classes and seminars which had been cancelled due to industrial action. We found that the University had taken appropriate steps to minimise the academic impact of the industrial action by giving students advance notice of the industrial action and …
SPSO (Scottish Public Se…
Education
Partly Upheld
Feb 2021
201808095 — University of Glasgow
Mr C was required to complete three school placements as part of his secondary teaching course. Mr C complained that the university failed to provide him with appropriate support during his course and that, after he was deemed to have failed, they did not follow their normal procedure. He was …
SPSO (Scottish Public Se…
Education
Partly Upheld
Feb 2021
201902491 — Tayside NHS Board
C, a support and advocacy worker, complained on behalf of their client (A). A is profoundly deaf and British Sign Language (BSL) is their first language, and so A relies upon BSL interpreters when attending medical appointments. A requested a gender specific interpreter for a GP appointment but when they …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2021
201900199 — Tayside NHS Board
C, a support and advocacy worker, complained on behalf of their client (A). A, whose first language is British Sign Language (BSL), was admitted to Perth Royal Infirmary with concerns about their heart and lungs. During their admission, A's spouse (B) had to translate for them, which they found extremely …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2021
201804582 — Grampian NHS Board
C, a patient adviser, complained on behalf of their client (A) in relation to the care and treatment provided to A's child (B) by the board. B was diagnosed with a type of slow growing brain tumour and subsequently underwent a surgical procedure to treat build-up of fluid in the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2021
201905097 — Glasgow School of Art
C applied for a Collaborative Doctoral Award (CDA) programme. One of the key features of a CDA is the opportunity to work with an industry partner (IP) as well as academic staff. C complained that their supervision had been flawed and that there had been a lack of engagement with …
SPSO (Scottish Public Se…
Education
Partly Upheld
Sep 2021
202008878 — Lothian NHS Board - Acute Division
C raised complaints about the nursing and medical care their parent (A) received whilst in hospital. English was not A's first language and C also raised complaints about the board's communication with A and their family and whether appropriate follow-up care was provided by the board following C's discharge. The …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2023
202110475 — Lanarkshire NHS Board
C complained on behalf of their deceased grandparent (A) about care and treatment provided by the board during an admission to hospital following a fall and broken hip. C complained that A received poor nursing care, poor rehabilitation support, had not received enough nutrition and fluids, and had developed necrotic …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2023
202403923 — Ayrshire and Arran NHS Board
C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died. We took independent advice from a nursing …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2025