Unqualified Staff Deployment
Deployment of insufficient numbers of suitably qualified, competent, skilled, and experienced staff, failing to meet fundamental standards.
129 items
10 sources
5 inquiries
Source spread
Where this theme appears
Unqualified Staff Deployment has been flagged across 10 independent accountability sources:
15 inquiry recs
55 PFD reports
21 committee recs
14 CQC actions
3 PPO recs
2 IOPC recs
3 IMB recs
1 detention investigation rec
3 PHSO decisions
12 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 (15)
COVID-M2.3 — UK-wide Expert Register
Recommendation: The Government Office for Science (GO-Science) should develop and maintain a register of experts across the four nations of the UK who would be willing to participate in scientific advisory groups, covering a broad range of potential civil emergencies.
Gov response: GO-Science already maintains an expert register for SAGE and is committed to refreshing the register; improving selection processes to broaden participation across disciplines, institutions and backgrounds; and increasing our engagement with experts outside of emergencies. …
Accepted
COVID-M1.5 — Pandemic Data Systems and Research
Recommendation: The UK government, working with the devolved administrations, should establish mechanisms for the timely collection, analysis, secure sharing and use of reliable data for informing emergency responses, in advance of future pandemics. Data systems should be tested in pandemic exercises. …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.2 — Cabinet Office Leadership for Emergencies
Recommendation: The UK government should: abolish the lead government department model for whole-system civil emergency preparedness and resilience; and require the Cabinet Office to lead on preparing for and building resilience to whole-system civil emergencies across UK government departments, including monitoring …
Gov response: The government agrees with the need for a greater Cabinet Office role for whole-system civil emergencies. This is in addition to the Lead Government Department model which retains an essential role in preparedness and resilience. …
Accepted in Part
In progress
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
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
IHRD-13 — Foundation Doctors in Children's Wards
Recommendation: Foundation doctors should not be employed in children's wards.
Gov response: Reviewed in context of workforce planning. Some concerns raised by Royal Colleges about potential de-skilling impacts. Implementation being balanced against training needs.
Accepted in Part
No update 2+ yrs
F213 — Training standards for healthcare support workers
Recommendation: Until such time as the Nursing and Midwifery Council is charged with the recommended regulatory responsibilities, the Department of Health should institute a nationwide system to protect patients and care receivers from harm. This system should be supported by fair …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F212 — Training standards for healthcare support workers
Recommendation: The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation with all relevant stakeholders, including the Department of Health, other …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F211 — Training standards for healthcare support workers
Recommendation: There should be a common set of national standards for the education and training of healthcare support workers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F210 — Code of conduct for healthcare support workers
Recommendation: There should be a national code of conduct for healthcare support workers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F209 — Registration of healthcare support workers
Recommendation: A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor (or who are …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Not Accepted
F208 — Strengthening identification of healthcare support workers and nurses
Recommendation: Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F207 — Strengthening identification of healthcare support workers and nurses
Recommendation: There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
BRIS-186 — Require all surgeons operating on children to obtain paediatric qualification and revalidation
Recommendation: All surgeons who operate on children, including those who also operate on adults, must undergo training in the care of children and obtain a recognised professional qualification in the care of children. As matter of priority, the GMC, the body …
Unknown
BRIS-184 — Ensure children are cared for in paediatric environments by qualified professionals
Recommendation: Children should always (save in exceptional circumstances, such as emergencies) be cared for in a paediatric environment, and always by healthcare professionals who hold a recognised qualification in caring for children. This is especially so in relation to paediatric intensive …
Unknown
PFD Reports (55) — showing 50 strongest matches
Lalitaben Patel
Concerns: A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.
Response (Department of Health and Social Care): DHSC highlights recommendations from a 2013 working group to strengthen quality assurance of locum doctors, including strengthened GMC appraisal guidance, pre-employment standards, audit guides, and guidance for Trusts. DHSC continues …
Responded
Albert Flynn
Concerns: Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.
Response (Lester Aldridge LLP): HC-One Limited will re-emphasise the need to call for qualified assistance during individual supervision for staff and induction for new staff, and senior care staff involved in this incident will …
Responded
Elsie Mallalieu
Concerns: Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Response (Tameside Hospital NHS Trust): Tameside Hospital NHS Trust provided training to doctors in the Orthopaedic Department regarding patient transfer protocols and the involvement of senior medical staff. The training also forms part of the …
Responded
James Stewart
Concerns: There was no system for new GP practices to verify medication with previous providers for nursing home patients, leading to prescribing errors and reliance on unqualified staff for medication initiation.
Response (Bedfordshire Clinical Commissioning Group): The CCG developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. An action plan has been written to …
Responded
John Leyin
Concerns: There was a failure to disseminate trust policy and NPSA guidance, along with weak training systems. Staff training currency was not checked, and knowledge of trained staff numbers for critical procedures was lacking.
Response (Basildon Thurrock University Hospitals NHS Trust): Following the death, Basildon and Thurrock University Hospitals NHS Trust undertook an investigation and developed an action plan. Actions include appointing a Risk and Document Control Manager, overhauling NPSA Alert …
Responded
Pauline Edwards
Concerns: UK hospitals allowed EU-trained doctors to practice unsupervised without ensuring equivalent training or experience, driven by EU law, thereby increasing patient risk.
Response (Department of Health): The Department of Health acknowledges the coroner's concerns about EU-trained doctors and refers to the GMC's verification process and hospital observer programs. It notes Health Education England's view that St …
Responded
X Rokeby
Concerns: Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved in the incident confirmed receiving no such training whatsoever.
Overdue
George Marks
Concerns: Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes documentation, and correct handover procedures.
Response (Mayday Healthcare): Mayday Healthcare has implemented measures including monthly SMS reminders to staff, consultant training, client feedback forms, quarterly letters to staff, and updated yearly training program in regards to documentation, escalation, …
Responded
Peter Wright
Concerns: Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching drug rounds. Additionally, the hospital lacks adequate out-of-hours doctor cover, relying on paramedics.
Response (South Staffordshire Shropshire Healthcare NHS Trust1): The Trust undertakes nurse staffing establishment reviews every six months, using quality metrics and workload calculators. They also provide basic life support training to medical and nursing staff and have …
Responded
Alison Evers
Concerns: The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member on every shift. Furthermore, first aid training for health support workers, especially for dependent service users, was insufficient.
Response (Leeds City Council): The council has a "no treats" policy, provides first aid training, and employs staff trained in First Aid. All new staff within the Learning Disability Community Support Service receive training …
Responded
Willow Davies
Concerns: An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the 'Supervisors of Midwives' support system.
Response (Bedford Hospital NHS Trust): Bedford Hospital NHS Trust explains its procedures for newly qualified midwives, neonatal resuscitation training, and supervision of midwives, asserting compliance with relevant standards and effective operation of the supervision system. …
Responded
Dorothy McDermott
Concerns: A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.
Overdue
Wilfred Pearson
Concerns: Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.
Response (W Pearson): Tameside Hospital NHS Foundation Trust revised the Status Epilepticus Policy twice since Mr. Pearson's admission, including references to recent guidance in the Lancet Medical Journal. They have also provided MCA/DOLS …
Responded
Ratidzai Sangare
Concerns: Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. Agency staff had limited access to telephones for emergencies.
Overdue
Patrick Curran
Concerns: Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.
Response (Manchester University NHS Foundation Trust): The hospital strengthened post-operative clinics by ensuring a consultant is present in the same clinic, along with nurses, and radiology reports X-rays with any concerns.
Responded
David Phillips
Concerns: An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical records.
Overdue
Frederick Chisnall
Concerns: Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.
Response (St Helens Clinical Commissioning Group): Following a safeguarding investigation, Reflex Agency provided further training to its staff, and disciplinary action was taken against a nurse by St Mary's Nursing Home, who also assured they would …
Responded
David Evans
Concerns: An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.
Overdue
Sheila Hynes
Concerns: A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.
Overdue
Reginald Lewis
Concerns: Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients created an unsafe care environment.
Overdue
Jakub Moczyk
Concerns: Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, relying instead on a non-medically qualified referee/trainer.
Response (Lifeshield Medical Services Ltd): The organisation claims they informed the referee and promoter about incomplete medicals and states that new policies are in place for boxing events including drug testing and head scanning, leading …
Responded
Paul Daniels
Concerns: An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and hand signals hindered safety during work at height.
Response (Arboricultural Assocation): The Arboricultural Association will publish a summary of the events in a safety bulletin to its members and partner organisations by the end of February 2018 and in their quarterly …
Response (Forestry Commission): The Forestry Commission will circulate the Arboricultural Association safety bulletin, review emergency procedures with in-house arborists, re-brief employees supervising arboricultural contracts, and update the training module for supervisors.
Response (Health and Safety Executive): The Arboriculture and Forestry Advisory Group (AFAG) will promulgate learning points from the incident via its committee members, and will ensure that these points are considered when specific guidance leaflets …
Responded
Simon Graham
Concerns: Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and unqualified staff conducting suicide risk assessments without training.
Response (NHS Birmingham and Solihull ICB): The CCG provided funding to Forward Thinking Birmingham (FTB) for a personality disorder pathway and clinical lead, and invested in BSMHFT to appoint a clinical lead for personality disorder; they …
Response (NHS England): NHS England will ensure services are commissioned and provided to ensure risk assessments are available 24/7, and the CCG will meet with the local authority to address differences in opinion …
Overdue
Terence Bennett
Concerns: The jury found that failures in mental healthcare contributed to the death, including inadequate care plans, insufficient staff knowledge of medical records, and a lack of family involvement.
Response (NHS England): NHS Improvement is working with mental health trusts to improve patient safety through a national mental health safety initiative. They are also reviewing concerns and failings with the Trust and …
Overdue
Andrea Franzosi
Concerns: Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.
Overdue
Daniel Stokes
Concerns: Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to drug abuse incidents.
Overdue
Polly Drew
Concerns: The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading to her working alone and posing risks to patients.
Overdue
Theresa Feehan
Concerns: The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led to dangerous medications being continued and a lack of proper rationale for prescribing.
Response (CQC): The CQC conducted inspections of Lisson Grove Health Centre but ultimately did not find concerns in the areas identified in the prevention of future death report. They rated the health …
Overdue
Mildred Clark
Concerns: A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital for a suspected strangulated hernia, possibly due to pressure to avoid admissions.
Overdue
William Vickers
Concerns: Ambulance crews attending the prison lack access to the main radio system, and the first response to emergencies does not consistently include a fully qualified paramedic, impacting effective communication and care.
Response (HM Prison and Probation Service): HMP Woodhill updated contingency plans to expedite emergency vehicle access, including immediate contact with ambulance services, staff reporting to the prison to await the ambulance, and training for Operational Support …
Response (CNWL NHS Trust): CNWL NHS Trust has implemented new AEDs with data cards, introduced an Offender Care Resuscitation Review Group, and commissioned an external review of emergency response practices. A 'Train the Trainer' …
Responded
Robert Rostron
Concerns: Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and patient care plans, resulting in medication errors.
Response (The Kind Care Company): HC-One has implemented actions including requiring two colleagues to support all insulin administrations, creating a Home Improvement Plan for insulin administration safety, and revising the agency procedure to include robust …
Responded
Trinder Birdi
Concerns: A psychiatric liaison nurse downgraded a patient's high suicide risk without consulting the referring GP or obtaining a second opinion, highlighting a critical lack of safeguards in risk assessment.
Response (North East London NHS Foundation Trust): The Trust will introduce a referral requirement for on-call psychiatrists in specific risk scenarios, amend assessment templates to include consideration of family concerns, implement monthly supervisions for bank staff, introduce …
Responded
Rodney Gates
Concerns: Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential equipment on the ward.
Response (Medway Maritime Hospital): Medway Maritime Hospital has implemented electronic observation recording with a red-flagging system, delivered MHLS training to nurses, trained Band 6 nurses in ALERT and Advanced Life Support, established an acute …
Responded
Emma Dorman
Concerns: Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over three years due to persistent recruitment failures.
Response (South West Yorkshire Partnership NHS Foundation Trust): The Trust is reviewing its Patient Flow Procedure, skill-mix for vacant psychology posts, and will update the Job Description and Person Specification for the vacant part-time Psychologist post in Ward …
Responded
Joan Coley
Concerns: Inadequate training and lack of competency assessment for junior doctors on central line blood draws, compounded by poor handover between wards, create inherent safety risks.
Response: The Department of Health has been in contact with multiple organisations including medical schools who have agreed that medical students will cease undertaking blood sampling from a central line under …
Overdue
Adam Brunskill
Concerns: An unqualified and inexperienced employee worked on a roof without proper training, a CSCS card, or designated supervision, indicating a lack of structured training programs and adequate supervisory arrangements.
Response (Health Safety Executive): HSE reports that Proclad Developments Ltd has appropriate systems in place and are extending them to their subcontractors, including Wayne Clarey Roofing & Cladding Ltd where appropriate; Proclad's revised Contract …
Response (Wayne Clarey Roofing Cladding Ltd): Wayne Clarey Roofing Cladding Ltd states they now have a clear designated structured training programme for new and unqualified employees using the Pro-Clad training structure, and supervisors appraise workers daily …
Responded
Jan Goodliffe
Concerns: Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.
Overdue
Maria Howell
Concerns: The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff with inadequate clinical judgment for critically ill residents.
Overdue
Zachariah Richardson
Concerns: An inexperienced worker was left unsupervised with poorly maintained Fork Lift Trucks lacking critical safety devices. The company demonstrated a profound lack of health and safety understanding and failed to implement changes years after the death.
Response (DAC Beachcroft): DAC Beachcroft, on behalf of Lincs Firewood Company, states that the procedures were either already in place at the time of the incident, or have been enhanced since. Training includes …
Responded
Carl Wright
Concerns: Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not reviewed promptly, risking patient safety.
Response (Nottingham University Hospital Foundation Trust): Nottingham University Hospital has taken immediate actions, including a Consultant from Linden Lodge physically assessing patients transferred there, and developing a specialty referral guidance and a Standard Operating Procedure (SOP) …
Responded
Michael Smith
Concerns: Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.
Response (HM Prison and Probation Service): HMP Durham SACU staffing levels are above national benchmarking, overseen by a dedicated Custodial Manager. A full-time nurse is based within the SACU to provide more flexible healthcare input. HMP …
Overdue
Terri Malone
Concerns: An inexperienced practitioner made treatment decisions without senior oversight. Patients were discharged for a single missed appointment and voicemail, despite long waiting lists, without assessing their current situation or input from other agencies.
Response (Herefordshire and Worcestershire Health and Care NHS Trust): Herefordshire and Worcestershire Health and Care NHS Trust, responding for its Healthy Minds service, asserts that the initial assessment was appropriate, was reviewed by a senior colleague, and was rated …
Responded
Katie Wilkins
Concerns: Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.
Response (Department of Health and Social Care): The Department of Health and Social Care notes that Alder Hey Children's NHS Trust undertook a Root Cause Analysis and implemented improvements, including reviewing handover arrangements. The government is also …
Responded
Ben Shipley
Concerns: A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in A&E for hours, unable to be legally detained and without appropriate specialist care.
Overdue
Catriona Martin
Concerns: There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or intervention by the nursing team.
Response (Aneurin Bevan University Health Board): The Health Board clarifies its position on delegation of nursing responsibilities to family members. They also report implementation of a digital platform for visibility of staffing levels and dissemination of …
Responded
Lamarah Scarlett
Concerns: Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, poor handovers, insufficient personnel change notifications, and a lack of mandatory training or oversight.
Response (Department for Education): The Department for Education has contacted Gloucestershire County Council, who now require all members of transport crews to undertake first aid training. The Department is drafting non-statutory guidance to support …
Overdue
David Martin
Concerns: A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.
Response (Royal Cornwall Hospitals): The Trust has reviewed and amended the wording in the PCI pack to clarify Dual Anti-Platelet Therapy provision, with changes approved by the Safer Surgery Group and Forms Review Group. …
Responded
Christiana Dawson
Concerns: Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident after a fall.
Response (Darnell Grange Nursing Home): Darnell Grange Nursing Home has updated its agency nurse induction to include istumble and post fall protocol, reinforced the policy of not moving a service user post fall until clinical …
Responded
Leslie Swindells
Concerns: Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient risk assessment.
Response (GTD Healthcare): GTD Healthcare has implemented changes to the standard templates used by Assistant Practitioners and provided hard copies to clinicians for use during IT issues. They have also implemented safeguards to …
Response (Department of Health and Social Care): The DHSC acknowledges the concerns, states they fall under the provider's remit, and notes that NHS England and the CQC have been contacted to address them. It provides context on …
Responded
James Keen
Concerns: Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a lack of proper training oversight.
Response (Revon Healthcare): Support workers received additional physical health monitoring training, vital signs equipment was verified as functional, and community teams were engaged regarding residents with physical health concerns. New support workers receive …
Responded
Committee Recommendations (21)
#43 — Review children's home staff qualifications and introduce minimum standards for residential childcare workers.
Recommendation: The Department should use its children’s home workforce census to review the levels of qualifications currently held by residential staff. It should also consult on introducing minimum qualification standards for residential childcare workers and work with local authorities to assess …
Gov response: The Government has committed to review qualifications, standards and access to training for the children’s homes workforce to ensure they can continue to meet the needs of children in their care. The review will be …
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
#60 — Learning Support Assistants and Teaching Assistants lack adequate SEND-specific training
Recommendation: Learning support assistants and teaching assistants are integral to the effective delivery of SEND support and resourcing their deployment properly can help reduce the need for expensive specialist placements. To sustain and strengthen their contribution, improvements are urgently needed in …
Gov response: Teaching Assistants (TAs) play an important role in supporting pupils with SEND. We recognise that training and career progression opportunities for TAs help schools have the skilled staff they need. This Government values and recognises …
Not Addressed
#59 — Introduce requirement for all new headteachers to hold a SEND-specific qualification within four years.
Recommendation: Within four years, the Department should introduce a requirement for all new headteachers to hold a SEND-specific qualification. Ensuring that SEND expertise is embedded at the highest levels of school or multi- 167 academy trust leadership will promote strategic oversight, …
Gov response: The Government is grateful to the Education Select Committee for its inquiry report into Solving the SEND Crisis and we welcome the opportunity to respond to the Committee. Every child should have a childhood rich …
Not Addressed
#57 — Mandate at least one Senior Leadership Team member holds SENCO qualifications in all schools.
Recommendation: To strengthen leadership on SEND, the Department should, in the short term, mandate that at least one member of the Senior Leadership Team in every school and every multi-academy trust holds SENCO qualifications. (Recommendation, Paragraph 218)
Gov response: In autumn 2024, we began delivery of the NPQ for Special Educational Needs Co-ordinators (NPQ for SENCOs). This is now the mandatory qualification for SENCOs in mainstream schools. Participants will develop the essential knowledge and …
Accepted
#49 — Initial Teacher Training and Early Career Framework inadequately prepare teachers for SEND support.
Recommendation: While the Department’s update to the Initial Teacher Training and Early Career Framework is a positive move, it needs to go further to adequately prepare teachers to support pupils with SEND. SEND is still not fully integrated across all training …
Gov response: In schools, we want to make sure teachers can access high quality professional development that supports them to deliver the best teaching for all pupils, including those with SEND. We are considering how we can …
Not Addressed
#41 — High-quality residential care is essential, requiring improved workforce recruitment and training.
Recommendation: We agree that, for most children, a focus on supporting them to live in a family setting is the right one; however, this should not come at the expense of developing and maintaining high-quality residential care for children who need …
Gov response: It is a legal requirement for all children’s homes to be led by a manager registered with Ofsted. We are committed to improving the registration process to help providers deploy managers more quickly, as set …
Accepted
#54 — Mandate SEND continuing professional development for all educators via qualification or module incorporation.
Recommendation: SEND CPD should be made mandatory to ensure that all educators are equipped to meet the diverse needs of children and young people with SEND. This could be achieved through a nationally recognised supplementary qualification in SEND that all existing …
Gov response: In schools, we want to make sure teachers can access high quality professional development that supports them to deliver the best teaching for all pupils, including those with SEND. We are considering how we can …
Not Addressed
#52 — Mandatory SEND-specific continuing professional development for educators remains absent.
Recommendation: It is deeply concerning that SEND-specific continuing professional development (CPD) is not mandatory. The education workforce must be consistently equipped with up-to-date, evidence-based knowledge through ongoing CPD to ensure an inclusive mainstream with high-quality support for children and young people …
Gov response: In schools, we want to make sure teachers can access high quality professional development that supports them to deliver the best teaching for all pupils, including those with SEND. We are considering how we can …
Not Addressed
#50 — Implement continuous review for ITT and ECF, increase placements, and mandate specialist setting experience.
Recommendation: The Department for Education must implement a continuous review and update cycle for the ITT and ECF to keep training relevant and effective. It must urgently increase the number of ITT placements and explore the viability of mandating every teacher …
Gov response: In schools, we want to make sure teachers can access high quality professional development that supports them to deliver the best teaching for all pupils, including those with SEND. We are considering how we can …
Not Addressed
#28 — Work with Security Industry Authority to urgently standardise and improve security guard training across UK.
Recommendation: Independently of the Draft Bill, the Government must work with the Security Industry Authority to look to urgently standardise and improve training for security guards across the UK.
No Published Response
#27 — UK security industry's low training entry thresholds are unacceptable and concerning.
Recommendation: We are gravely concerned to hear that the UK security industry has one of the lowest entry thresholds in Europe for training. This is simply unacceptable. If the Government is serious about protecting the public from terrorist attacks, improving the …
No Published Response
#24 — Make career development for early years practitioners an urgent priority to attract and retain staff.
Recommendation: Early years professionals are vitally important. We recommend career development for early years practitioners be made an urgent priority in order to attract and retain more people in the profession. We are concerned about lack of parity of esteem between …
Gov response: The early years workforce makes a huge contribution to young children’s lives, and supporting the workforce continues to be a priority for DfE. We offer many opportunities for early years practitioners to develop their careers, …
Not Addressed
#21 — Monitor staff:child ratio changes, reverse if quality suffers, and develop comparable staff qualifications.
Recommendation: We recommend that the Government’s controversial changes to staff:child ratios be closely monitored and reversed if quality and education outcomes are seen to suffer. If the Government’s goal is truly to “bring the UK in line with Scotland and comparable …
Gov response: 3. ... • Committing to providing flexibility for group-based providers, which is why we have proceeded with changing staff:child ratios from 1:4 to 1:5 for two-year-olds in England. This will align us with Scotland and …
Not Accepted
#21 — Skilled Worker visa sponsorship model leaves migrant workers vulnerable to widespread exploitation.
Recommendation: The Skilled Worker visa system is based on a sponsorship model where a migrant’s right to remain in the United Kingdom is dependent on their employer.49 This reliance makes migrant workers vulnerable to exploitation, and there is widespread evidence of …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2027 4.2 The Home Office collaborates with bodies such as the Director of Labour Market Enforcement, Gangmasters and Labour Abuse Authority, Employment Agency …
Accepted
#18 — Home Office fails to adequately tackle exploitation and unethical practices against migrant care workers.
Recommendation: We remain concerned, however, that the Home Office has not done enough to tackle unethical practices and the exploitation of migrant workers in the social care sector.42 Evidence provided by UNISON highlighted that some employers were exploiting workers’ vulnerability, making …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2027 4.2 The Home Office collaborates with bodies such as the Director of Labour Market Enforcement, Gangmasters and Labour Abuse Authority, Employment Agency …
Accepted
#29 — Draft Bill misses opportunity to address concerns about security officer education and procurement.
Recommendation: Security at publicly accessible venues is vital in preventing and handling a terrorist attack. Yet there are some serious concerns about the education and procurement of security officers that the Draft Bill does not attempt to address, despite the fact …
No Published Response
#25 — Engage Local Authorities to provide affordable and flexible mandatory training for early years professionals.
Recommendation: We recommend the Government engage with Local Authorities and seek to address the cost of mandatory training required by early years professionals, such as paediatric first aid and safeguarding courses. Local Authorities should work towards providing 76 Support for childcare …
Gov response: We will engage with local authorities on the availability and accessibility of safeguarding and welfare training provision and associated costs. The EYFS guidance is clear that providers are responsible for identifying and selecting a competent …
Partially Accepted
#23 — Reintroduce a Leadership Quality Fund for diverse early years professional qualifications.
Recommendation: The Government has acknowledged the importance of graduate leadership in the ECEC sector. It should now listen to sector-wide calls for an equivalent of the Graduate Leader’s Fund to be reintroduced. We recommend that this is given a broader name, …
Gov response: Supporting the early years workforce continues to be a priority for this Government. The Graduate Leader Fund was designed to support all full day care PVI sector providers in employing a graduate or early years …
Not Accepted
#22 — Review Level 2 English and maths requirements for ECEC staff, prioritising numeracy quality.
Recommendation: In the short term, to prevent the existing qualification levels of falling any further, the Level 2 English and maths requirements for ECEC staff to count in staff:child ratios should be reviewed , and alternatives considered that are more tailored …
Gov response: The Government has carefully considered the Committee’s recommendation regarding the Level 2 English and maths requirement for staff counting in staff:child ratios. In June 2023, the Government launched a consultation on a package of possible …
Accepted
#30 — Incorporate provisions into Draft Bill for education and procurement of security at enhanced tier premises.
Recommendation: The Government should consider incorporating provisions into the Draft Bill in relation to education and procurement of security at enhanced tier premises and venues.
No Published Response
CQC Inspection Actions (14)
Worcestershire Imaging Centre
The provider must ensure that bank staff are competent to operate scanning machines.
Must 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
St Gabriel's House - Apartments
The provider must deploy suitably qualified, competent, skilled and experienced staff.
Must Do
Benthorn Lodge
The registered person has failed to ensure that sufficient numbers of suitably qualified, competent, skilled and experienced persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
Must Do
Bellevue Healthcare Limited
We took urgent action to require the registered provider reviewed the competency of the staff employed at the home and managed the risks posed to people who used the service.
Must Do
St Edmunds Court
We recommend that the provider considers a formal induction and competency spot checks for agency staff working at the service. This would give assurance about their skills and knowledge.
Should Do
Lady Ida Lodge
Agency workers did not understand people or their needs, leading to mixed feedback about the quality of care.
Should Do
Woodland Care Home
Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this Part. Persons employed by the service provider in the provision of a regulated activity must— receive such appropriate support, …
Must Do
Winterton House
The provider did not demonstrate they had the skills or competence required to carry on the regulated activity.
Must Do
We (Always) Care Under One Roof Limited
The provider must ensure staff are suitably qualified, competent and supervised.
Must Do
Precious Nursing & Residential Home
The provider must ensure people receive safe care by deploying sufficient trained staff to meet their needs.
Must Do
Oakleigh House Nursing Home
The registered person did not ensure that persons providing care or treatment to service users had the qualifications, competence, skills and experience to do so safely. Regulation 18 (1) (2).
Must Do
Kingsley Nursing Home
The registered manager and provider failed to: 4. ensure that staff had the competencies and skills to provide people with care that met their needs. 12 (2c)
Must Do
Willow Brook House
Improvements were needed to ensure staff were better equipped when supporting people on enhanced support.
Should Do
PPO Death in Custody Recommendations (3)
The Head of Healthcare
The Head of Healthcare should ensure that agency staff are clinically competent to be assigned to the role of lead emergency nurse.
The HMPPS Executive Director for Wales and the Chief Executive …
The HMPPS Executive Director for Wales and the Chief Executive of NHS Wales should write to the Ombudsman setting out what they have done to satisfy themselves that the nurse-led healthcare service provided at Parc by G4S Medical Services is …
The Governor and Head of Healthcare
review the two incidences in November 2021 where the HCA thought that prison staff gave her authority to move Mr Roalfe out of bed;
IOPC Learning Recommendations (2)
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 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 …
IMB Recommendations (3)
Featherstone (2024)
Mental illness is a serious issue within prisons. The compassionate answer appears to be to locate some of these prisoners in isolation in the CSU, where largely untrained staff attempt to deal with them in a humane way. This is not acceptable and there needs to be a way of speedily transferring these prisoners to more appropriate accommodation that can …
HMPPS
Featherstone (2023)
Mental illness is a serious issue within prisons. At Featherstone, the compassionate answer appears to be to locate some of these prisoners in isolation in the CSU, where largely untrained staff attempt to deal with them in a humane way. This is not acceptable and there needs to be a way of speedily transferring these prisoners to more appropriate accommodation …
HMPPS
Brinsford (2022)
The amount of time taken to transfer the more vulnerable prisoners with mental health problems is another concern raised regularly. Officers within the inpatient health care are very supportive and compassionate to their patients, however they are not specialist-trained in mental health. Some inpatients have been based in the unit for months before being transferred to more specialist accommodation.
Ministry of Justice
PHSO Casework Decisions (3)
P-003862 — A dental practice in the Birmingham area
Miss A complains the Practice took too long to find that she needed a second root canal and then did the procedure despite not being qualified to.
NHS in England
Sep 2023
P-001362 — Hampshire Hospitals NHS Foundation Trust
Ms O complained that when she had suspected meningitis, the Hampshire Hospitals NHS Foundation Trust allowed untrained staff to perform a lumbar puncture incorrectly.
NHS in England
Apr 2022
P-003831 — Moorfields Eye Hospital NHS Foundation Trust
Mrs C complains about a cataract operation at the Trust in April 2021. She says a supervised junior doctor did the operation and made mistakes.
NHS in England
Sep 2023
LGO / SPSO Decisions (12)
NIPSO-202000387 — Western Health and Social Care Trust
The Western Trust approved two special chairs for an autistic child to use in school without properly assessing his needs. The Trust should also have given the school clearer instructions on how the chairs were to be used.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Oct 2024
22-005-432 — Elder Technologies Limited
Summary: We will not investigate this complaint that an introductory care agency withdrew its agreement to provide a care package. We do not have the jurisdiction to investigate.
LGO (Local Government & …
Adult Care Services
Dec 2022
24-007-428 — London Borough of Croydon
Summary: Mr X complains about repeated failures by the Council’s care providers (
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2025
24-023-412 — Community Case Management Ltd
Summary: We will not investigate Miss X’s complaint about the care provider’s handling of concerns she raised about one of her mother’s support workers and of restrictions that were placed on her by the care provider. This is because an investigation would not lead to any worthwhile outcomes.
LGO (Local Government & …
Adult Care Services
Jul 2025
24-001-467 — Suffolk County Council
Summary: We will not investigate this late complaint about Mrs X’s 1997 request to relocate her family member to a care home nearer her home. There is no good reason Mrs X did not complain sooner.
LGO (Local Government & …
Adult Care Services
May 2024
23-010-877 — Stockport Metropolitan Borough Council
Summary: The Council failed to properly respond to Ms X’s concerns about the care her sister received from a care agency acting on behalf of the Council. This led to a prolonged period of short care visits and significant frustration for Ms X. The Council also failed to deal with …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
24-005-757 — K and S Solutions Ltd
Summary: We cannot investigate this complaint about a Care Provider allegedly not paying rent. This is because the actions complained about do not relate to the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Jul 2024
24-023-407 — Salyx Care Limited
Summary: We will not investigate Ms X’s complaint about the Care Provider’s respite home care for her mother Mrs Y. There is insufficient significant injustice to Ms Y or her family caused by the matters complained of to warrant us investigating.
LGO (Local Government & …
Adult Care Services
Jul 2025
23-011-164 — Bedford Borough Council
Summary: Ms X complains the Council’s care provider, Bluebird Care Bedford, failed to meet her needs properly. The evidence shows there has been no fault by the Council.
LGO (Local Government & …
Adult Care Services
Not Upheld
Nov 2024
23-019-969 — City of Wolverhampton Council
Summary: We will not investigate this complaint about adult social care provided at home. The care provider acting on behalf of the Council has accepted fault, apologised for the impact, and acted to improve future service. It is unlikely we would achieve anything further by investigation.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2024
23-020-562 — Kent County Council
Summary: We will not investigate this late complaint about the quality of domiciliary care. There is not a good reason for the delay in the complainant bringing the matter to the Ombudsman.
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
23-015-615 — Aadi Trading Ltd
Summary: Mrs X complained the Care Provider failed to provide her mother (Y) with an adequate standard of care between October and November 2023. The Care Provider was at fault for poor record keeping and not carrying out care visits in line with when Y needed her medication. It was …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024