Recurring concern
Failure to ensure care staff can communicate effectively with residents and patients
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Request correctionFirst reported 27 Oct 2014•Latest report 18 Jun 2025
What this concern includes
Includes failures in direct care-staff communication with residents or patients that impair understanding of instructions, expression of needs, recognition of risks or safe delivery of care, including agency staff and communication with highly vulnerable patients.
Not included
- Excludes generic organisational communication, inter-agency information sharing and professional-to-professional handover failures where direct communication between care staff and residents or patients is not the unsafe condition.
- Excludes interpreter-access, translation-service and multilingual communication failures where the principal deficiency is provision of language support rather than the care staff's direct communication capability.
- Excludes failures limited to communicating policies or protocols to staff, or to patient-facing letters and appointment notices, when direct care interaction is not deficient.
- Excludes generic staffing, training or English-language deficiencies unless they directly impair safe communication between care staff and residents or patients.
- Reports
- 13
- Individual concerns
- 13
- Date range
- 2014–2025
- Stated actions
- 24
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure of one-to-one carers to communicate effectively with individuals who have speech difficulties
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Require staff engaged by the service to complete the IELTS exam before working on site.
Stated by Minster Care Management Limited -
Action
Assess overseas agency workers’ spoken and written English at each shift and exclude those with inadequate proficiency from working on site.
Stated by Minster Care Management Limited -
Action
Provide written care descriptions and relevant care-plan information during handovers to irregular staff, alongside verbal handover and electronic access.
Stated by Minster Care Management Limited
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Concerns raised1
Failure to clearly communicate the risk of not returning to hospital
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Update and formalise the Left Without Treatment policy covering patient risk advice, under-18 safeguards and urgent clinical information sharing.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure of agency staff to communicate effectively in English with residents and colleagues
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Seek evidence that providers using agency staff have verified their training, skills and command of English.
Stated by Care Quality Commission -
Action
Publish guidance for social care providers on international recruitment and assessing care workers’ English-language competence.
Stated by Department of Health and Social Care -
Action
Implement more robust contract monitoring processes and quality visits across care homes.
Stated by Tameside Borough Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The care provider is responsible for assessing agency staff’s English proficiency and ensuring their suitability for the role.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to communicate treatment plans effectively to patients
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate treatment plans and condition-related risks to patients and confirm their understanding
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Re-emphasise communication with families and documentation of discussions through clinical-team meetings and regular communications, including providing relevant letters.
Stated by Mersey and West Lancashire Teaching Hospitals NHS Trust -
Action
Audit communication documentation and the quality of recorded clinical information through a routine audit cycle.
Stated by Mersey and West Lancashire Teaching Hospitals NHS Trust -
Action
Develop standardised communication and referral processes with Alder Hey and the wider paediatric network, particularly for shared-care arrangements.
Stated by Mersey and West Lancashire Teaching Hospitals NHS Trust
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Action
Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
Stated by Mersey and West Lancashire Teaching Hospitals NHS Trust
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Concerns raised1
Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The healthcare provider is responsible for responding separately to concerns about clinical issues.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to communicate effectively with the patient and understand her needs
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
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Action
Consult on introducing mandatory learning disability and autism training for health and care staff.
Stated by Department of Health and Social Care -
Action
Publish proposals for training health and social care staff consistently with the two Core Capability Frameworks.
Stated by Department of Health and Social Care -
Action
Work with professional bodies and devolved Administrations to align pre-registration training with the Core Capability Frameworks and develop a common curriculum.
Stated by Department of Health and Social Care
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Action
Develop, test and evaluate a Tier 2 learning disability and autism training package to inform final design and wider rollout.
Stated by Department of Health and Social Care -
Action
Amend regulations to require regulated health and social care providers to ensure staff receive relevant learning disability and autism training.
Stated by Department of Health and Social Care -
Action
Use additional mechanisms to mandate learning disability and autism training for staff working in non-regulated activities.
Stated by Department of Health and Social Care
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Concerns raised1
Lack of communication training and communication resources for language difficulties
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate the availability of alternative support before Monday morning
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Develop and implement a CMHT protocol governing mobile-phone communication and requiring staff to provide urgent-support contacts when service users do not answer calls.
Stated by East London NHS Foundation Trust -
Action
Provide service users with an explanatory letter, including alternative contact arrangements, whenever staff give them a mobile-phone number.
Stated by East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust considers that its action adequately addresses the concern and that no further safety work is necessary.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure of staff to communicate effectively with challenging behavioural unit patients
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Language testing is not required for non-regulated care workers, although employers must ensure they can communicate effectively.
Stated by Department of Health and Social Care
Data last updated 7 September 2026