Recurring concern
Failure to control risks posed by care-home residents to themselves and others
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Request correctionFirst reported 3 Aug 2016•Latest report 1 Aug 2025
What this concern includes
Includes care-home safeguarding and risk-control failures concerning risks posed by a resident to themselves or other residents, including failure to assess or reassess those risks, create or use risk-informed care plans, arrange protective supervision or separation, and implement or review safeguards intended to prevent harm.
Not included
- Excludes generic care-plan or risk-assessment omissions where no risk posed by a care-home resident to themselves or others is identified.
- Excludes routine resident care, staffing, training or documentation deficiencies that are not directly part of controlling resident-related safeguarding risks.
- Excludes isolated resident behaviour or harm outcomes where no continuing failure in the care-home risk-control or safeguarding arrangements is asserted.
- Excludes safeguarding concerns involving children, prisoners or non-residential settings unless the assertion explicitly concerns the same care-home resident-risk process.
- Reports
- 6
- Individual concerns
- 6
- Date range
- 2016–2025
- Stated actions
- 11
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 to complete proper risk assessments and care plans for risks to residents and others
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 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
Implement PCS as an integrated electronic system for care plans, risk assessments, task alerts and management oversight.
Stated by Capital Care Group Limited -
Action
Require monthly sample audits and random spot checks of care documentation and delivered care, with action plans addressing audit findings.
Stated by Capital Care Group Limited -
Action
Complete organisation-wide audits of care documentation to establish baselines and identify lessons for training, tools, governance and further audit scheduling.
Stated by Capital Care Group Limited
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
Existing electronic systems, training, audits and governance are considered sufficient to support robust risk assessments and care documentation.
Stated by Capital Care Group Limited
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Concerns raised1
Absence of an effective exit control or alert system for residents at risk of entering the garden alone
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 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
Install an additional beam to detect garden entry when doors are open.
Stated by WESTLANDS CARE HOME LTD
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Concerns raised1
Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk
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.6
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Action
Restrict visitor access codes and require staff accompaniment for entry and exit.
Stated by St Johns Nursing Home Limited -
Action
Advise staff about unauthorised exits and require secure door closure and vigilance around reception.
Stated by St Johns Nursing Home Limited -
Action
Station the administrator in reception during normal working hours to monitor the entrance and secure door closure.
Stated by St Johns Nursing Home Limited
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Action
Advertise for a weekend receptionist to monitor the door at weekends.
Stated by St Johns Nursing Home Limited -
Action
Position a staff member by the side gate during fire drills and disable the gate's exit code.
Stated by St Johns Nursing Home Limited -
Action
Check at the next inspection that St John’s Nursing Home has embedded its premises-security changes and is effectively minimising identified risks.
Stated by Care Quality Commission
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Concerns raised1
Lack of supervision of residents in communal areas of care homes
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
Increase staffing levels across homes, including adding a deputy manager and increasing night cover.
Stated by Borough Care Ltd
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
Existing staffing, risk assessments and nurse-call access are considered sufficient to keep communal areas safe despite occasional short unattended periods.
Stated by Borough Care Ltd
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Concerns raised1
Failure of safeguarding systems to prevent risks posed by residents to other residents in care homes
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
Oversight of the reported safety concerns was assigned to the Care Quality Commission as the independent regulator of providers.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to include absconding risk and previous absconding behaviour in the care plan
This report raised 4 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.
Data last updated 7 September 2026