First reported 6 Mar 2014•Latest report 8 Feb 2026
Definition
What this concern includes
Includes material deficiencies in the use, deployment, competence assurance, induction, supervision or continuity of agency clinical staff where the report directly connects them to reliance on agency staffing as the shared unsafe condition.
Not included
Excludes permanent-staff shortages or general workforce problems not materially involving agency staffing.
Excludes isolated individual performance failures unless the report links them to agency staffing or the resulting reliance on agency workers.
Excludes unrelated reliance on external providers, untrained people, patients, families, questionnaires or other non-staffing controls.
Reports
22
Distinct published reports
Individual concerns
32
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
62
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.
Department of Health and Social Care5
NHS England2
Barchester Healthcare Limited1
Care Quality Commission1
Cygnet Behavioural Health Limited1
Darnall Grange Nursing Home1
Essex Partnership University NHS Foundation Trust1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Hc-One Limited1
Home Office1
Leeds Teaching Hospitals NHS Trust1
Malhotra Family Holdings Limited1
Medway Maritime Hospital1
National Police Chiefs’ Council1
NHS trust9
Ministerial department6
Private limited company6
Healthcare site4
Executive non-departmental public body2
Multi-service care provider2
Care-home operator1
English metropolitan district council1
Health and social care service regulator1
Independent healthcare provider1
Integrated care board1
National policing body1
Residential care home1
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.
East London
Concerns raised1
Use of nursing staff without training or experience in NG tube management
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Revise the Trust induction policy to require assurance that temporary staff are competent for their allocated patient care.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
Action
Configure the temporary-staff booking system to record specialist skills and prevent bookings that do not meet requested skills.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
Action
Develop and provide a comprehensive local induction pack for new temporary clinical workers.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
Action
Improve the knowledge and skills of the nursing workforce and verify that temporary surgical staff meet service and safe-practice requirements.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
Surrey
Concerns raised1
Failure to ensure agency staff are familiar with the Head Injury Policy
Responses linked to these concerns
Each 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.7
Action
Provide an agency folder containing key policies and require agency nurses to review and sign acknowledgment during induction.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
Action
Disseminate the revised agency nurse induction procedure through staff notices and individual briefings.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019.
Action
Complete spot checks of agency nurses’ knowledge to test understanding of the relevant policies.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
Action
Develop a pocket guide summarising key points from ten policies, including head injury and falls policies, with FAQs and advice contacts for agency staff.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019.
Action
Introduce a wall-mounted poster providing key policy information for staff in each home.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
Action
Print and introduce a modified agency worker induction checklist across all Barchester homes, incorporating the pocket guide once available.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
Action
Monitor compliance with the revised agency induction checklist through Regional Director checks and the Barchester audit programme.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
Brighton and Hove
Concerns raised1
Insufficient substantive staffing and reliance on bank and agency staff
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester West
Concerns raised5
Absence of another qualified nurse when an agency nurse is on duty
Medication administration by agency nurses unfamiliar with the unit
Reliance on nursing qualifications and agencies to establish agency nurses' ability, suitability and training
Use of agency nurses as senior staff in charge of shifts
Lack of formal induction and orientation for agency nurses
Responses linked to these concerns
Each 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
Action
Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.
Action
Complete and distribute a strengthened agency-staff orientation booklet across the company.
Stated by Hc-One LimitedStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.
Action
Orient agency nurses to risk assessments, care plans, diabetes resources, hypoglycaemia materials, medicines, and relevant policies through senior home staff.
Stated by Hc-One LimitedStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.
Action
Require agency nurses to submit insulin-training records, audit qualifications annually, and suspend non-compliant agencies.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.
Action
Revise the implemented agency procedure to strengthen checks on agency suppliers.
Stated by Hc-One LimitedStated in progressThe respondent said that this action was in progress when they made their response on 13 September 2019.
Action
Store agency profiles with completed orientation booklets in Cornerstone and allow agency workers to retain booklet copies.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
HC-One does not rely solely on nursing qualifications; it verifies agency nurses’ training, skills and qualifications for safe insulin administration.
Stated by Hc-One LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Significant reliance on agency nurses for ward staffing
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.11
Action
Run quarterly recruitment open days for registered nursing posts.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Advertise nursing vacancies through NHSJobs, recruitment websites, Trust systems and social media.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Attend regional college job fairs and university open days to promote Trust employment opportunities.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019.
Action
Recruit and retain newly qualified nurses through coordinated recruitment and preceptorship support.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Implement a Recruitment and Retention Action Plan with executive and workforce oversight.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Strengthen exit interviews, career-development conversations and internal transfers to improve nursing retention.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Improve vacancy filling and roster forecasting using recruitment and electronic rostering systems.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Use onboarding and staff-recognition schemes to support nursing staff retention.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Design and deliver a preceptorship programme for newly qualified nurses.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Trial alternative staffing roles, including Registered Nurse Associates.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019.
Action
Continue monitoring retention performance and take proactive steps to support future improvement.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Bank and agency nurses remain necessary for safe operations, with consistent deployment, local induction and communicated performance expectations considered sufficient safeguards.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Significant reliance on locum doctors to cover clinical shifts
Responses linked to these concerns
Each 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
Action
Target the medical workforce expansion at areas with the greatest need.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
Action
Consider return-of-service work within the Enhancing Junior Doctors’ Working Lives programme and workforce implementation plan.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
Action
Consult on return-of-service arrangements for doctors as part of expanding undergraduate medical education.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
Action
Undertake detailed follow-up work on return-of-service arrangements after the consultation.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
Action
Develop a workforce implementation plan covering required staff and skills, workforce growth, supportive culture and NHS leadership.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
Action
Set out through the workforce implementation plan how to achieve the NHS Long Term Plan’s workforce framework over the next ten years.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
Manchester North
Concerns raised1
Lack of continuity of care caused by reliance on locum GPs
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Failure to ensure agency nurses are familiar with the ward before starting duties
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Review induction processes to cover record keeping, observation and emergency response, including orientation tours for unfamiliar staff.
Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
Action
Implement an agency-nurse induction protocol requiring short-notice staff to attend early and receive policy and environmental orientation.
Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The former operator no longer controls future hospital safety steps, which fall to the successor operator.
Stated by Cambian Group plcRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester West
Concerns raised1
Reliance on Agency staff as the sole trained nurse and senior member of staff during night incidents
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Deployment of an inexperienced agency nurse in the Clinical Decisions Unit
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes material deficiencies in the use, deployment, competence assurance, induction, supervision or continuity of agency clinical staff where the report directly connects them to reliance on agency staffing as the shared unsafe condition.
