First reported 6 Nov 2013•Latest report 24 Apr 2026
Definition
What this concern includes
Includes deficiencies in the initiation, staffing, training, competence, communication, monitoring, documentation or delivery of one-to-one care when the deficiency is specifically dedicated to ensuring safe one-to-one care.
Not included
Excludes generic staff training, staffing or documentation deficiencies that are not specifically tied to one-to-one care.
Excludes failures concerning other observation, monitoring or support arrangements unless they explicitly concern one-to-one care.
Excludes deficiencies in unrelated care processes or broad organisational governance.
Reports
11
Distinct published reports
Individual concerns
14
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
16
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 Care2
Swansea Bay University Local Health Board2
1st Care 4U Ltd1
Daughter of the deceased1
Essex Partnership University NHS Foundation Trust1
Healthcare Inspectorate Wales1
Holcroft Grange1
London Borough of Hounslow1
Mid Yorkshire Teaching NHS Trust1
Minster Care Management Limited1
Nottinghamshire Healthcare NHS Foundation Trust1
Nursing and Midwifery Council1
Royal Bolton Hospital1
St George'S University Hospitals NHS Foundation Trust1
The Children's Trust1
NHS trust4
Local health board2
Ministerial department2
Care-home operator1
Devolved government1
Health and care inspectorate1
Health and care professional regulator1
Healthcare site1
London borough council1
Registered charity1
Residential care home1
Social-care provider1
Type not available1
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 Riding and Hull
Concerns raised1
Failure to provide required one-to-one nursing care
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.1
Action
Publish a new 10 Year Workforce Plan to support appropriate NHS staffing and workforce distribution.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Individual NHS trusts and employers are responsible for determining staffing levels and workforce composition.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to provide required key-nurse one-to-one sessions
This report raised 30 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing monitoring by charge nurses, record review and reallocation processes is considered sufficient to address gaps in patients’ weekly key-nurse one-to-ones.
Stated by Essex Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cheshire
Concerns raised3
Failure of one-to-one carers to understand individuals’ complex needs
Failure of one-to-one carers to communicate effectively with individuals who have speech difficulties
Failure to ensure provision of required one-to-one care before accepting care responsibilities
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 clinical nurse and director support to managers managing residents with complex needs.
Stated by Minster Care Management LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
Action
Require staff engaged by the service to complete the IELTS exam before working on site.
Stated by Minster Care Management LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
Action
Include agency-worker induction in routine internal monitoring through a documented monthly area-manager audit.
Stated by Minster Care Management LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 July 2025.
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 LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 July 2025.
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 LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 July 2025.
Action
Remind managers to escalate refusals of required one-to-one care to Head Office and the oversight team.
Stated by Minster Care Management LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
Action
Assess and provide interim one-to-one care using the organisation’s workforce while external funding is pursued.
Stated by Minster Care Management LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The suggestion that providers can fund one-to-one care and reclaim costs from local authorities does not reflect the provider’s experience.
Stated by Minster Care Management LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
One-to-one care cannot continue indefinitely without local-authority funding; if funding is refused, the resident may need to leave the home.
Stated by Minster Care Management LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised2
Insufficient staff training on what one-to-one care means in practice
Failure to provide children requiring one-to-one care with sufficiently intensive care and supervision
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 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 mandatory training on monitoring, observation, and one-to-one care requirements.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Require one-to-one carers to confirm care requirements and obtain approval before stepping away or ending shifts.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Provide a 24-hour floating staff role to supply additional care and supervision when needed.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Maintain 24-hour on-site clinical oversight through a Clinical Site Manager.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Conduct and systematically review routine overnight clinical care and observation audits.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Embed an evidence-based staffing model aligned with national standards and individual children’s needs.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Action
Convene a multi-agency Risk Summit to improve specialist NHS access and review monitoring and observation policies.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
London Inner (West)
Concerns raised1
Failure to provide safe break and relief arrangements during 1:1 care
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Failure to clearly allocate responsibility for requesting and securing additional nursing cover for one-to-one support
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 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.1
Action
Establish daily staffing monitoring that identifies patients requiring enhanced observation, includes out-of-hours handover, and checks Nurse Bank availability.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 22 December 2016.
West Sussex
Concerns raised1
Inadequate staffing levels for one-to-one care in inpatient CAMHS units
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 concerns
Each 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.2
Position
Existing staffing reviews, multidisciplinary support, on-call arrangements and staff redeployment are considered sufficient to determine appropriate staffing levels.
Stated by Priory GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing staffing guidance, continual staffing reviews, multidisciplinary support and escalation arrangements are considered sufficient to determine appropriate staffing levels.
Stated by Priory GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls
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 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.
West Yorkshire (East)
Concerns raised1
Failure to provide one-to-one nursing care in accordance with the agreed care plan
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.
Nottinghamshire
Concerns raised1
Inaccurate nursing staff belief that 1:1 nursing care is unavailable for falls risk or physical care needs
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 deficiencies in the initiation, staffing, training, competence, communication, monitoring, documentation or delivery of one-to-one care when the deficiency is specifically dedicated to ensuring safe one-to-one care.
