First reported 1 Dec 2013•Latest report 21 May 2026
Definition
What this concern includes
Includes failures of required resident observation, supervision, bathroom or location monitoring, and arrangements for detecting or responding to unexplained absence in care or supported accommodation.
Not included
Condition-specific clinical monitoring where general resident supervision is reliable
Custody checks or hospital observation outside care accommodation
Generic staffing or documentation failures that do not impair resident supervision or presence awareness
Reports
34
Distinct published reports
Individual concerns
39
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
35
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.
Care Quality Commission4
Department of Health and Social Care2
Hc-One Limited2
Alexandra View Care Centre1
Aria Healthcare Group Ltd1
Bolton Borough Council1
Bournemouth Churches Housing Association Limited1
Bowden Derra Park Limited1
Bupa Care Homes1
Care UK1
Cedar House Nursing and Residential Home1
Chilton Care Centre1
Coombe Dingle Nursing Home1
Essex County Council1
Essex Partnership University NHS Foundation Trust1
Residential care home13
Private limited company7
Nursing home5
Health and social care service regulator4
Independent healthcare provider3
Multi-service care provider3
English county council2
English metropolitan district council2
Healthcare site2
Ministerial department2
NHS trust2
Clinical commissioning group1
Company limited by guarantee1
English unitary authority1
Integrated care board1
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.
County Durham and Darlington
Concerns raised1
Failure to supervise residents at high risk of falls in the lounge area
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.
Surrey
Concerns raised1
Lack of procedures for staff frightened or concerned about entering a resident’s room alone
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.
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
Action
Require staff who feel unsure entering a resident’s room to seek help and enter with a colleague or duty nurse.
Stated by The Red HouseStated completedThe respondent said that this action was complete when they made their response on 17 September 2024.
Action
Deliver challenging-behaviour training covering triggers, de-escalation, safety, positive behavioural support, recording and post-incident procedures.
Stated by The Red HouseStated completedThe respondent said that this action was complete when they made their response on 17 September 2024.
Action
Deliver reflective-practice, lessons-learned and supervision sessions addressing response to resident calls and measures to prevent recurrence.
Stated by The Red HouseStated completedThe respondent said that this action was complete when they made their response on 17 September 2024.
Norfolk
Concerns raised1
Failure to prevent falls through timely intervention when very high-risk residents mobilise
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.
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
Introduce a Falls Champion role and competency checks to provide ongoing falls-prevention coaching and verify staff knowledge.
Stated by Norfolk Care HomesStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.
Stated by Norfolk Care HomesStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
Action
Review and introduce assistive technology in communal and bedroom areas to alert staff when residents attempt to mobilise independently.
Stated by Norfolk Care HomesStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Allocate care staff to communal areas and provide staffed garden access with radios for rapid communication.
Stated by Norfolk Care HomesStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Essex
Concerns raised1
Failure to ensure in-person checks after bathroom alerts
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.
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
Configure Oxevision bathroom alerts to repeat audibly and visually at three-minute intervals until the bathroom is exited.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
Action
Review and update Oxevision and observation procedures to align terminology and clarify alert-reset functionality.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
Action
Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2023.
Action
Monitor Oxevision use through ward spot checks, DATIX review and maintained training records.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
Sefton, St Helens and Knowsley
Concerns raised1
Failure to provide appropriate supervision for a resident with evolving dementia
This report raised 8 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.
Leicester City and South Leicestershire
Concerns raised2
Failure to monitor residents when carers attend competing care needs
Insufficient staffing capacity to meet competing resident care and monitoring needs
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
Update and implement policies covering staffing hours, slips, trips and falls, observations, and general risk assessments.
Stated by PINE VIEW CARE HOMES LTDStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Employ a third daytime staff member to maintain lounge supervision and assist residents across the home.
Stated by PINE VIEW CARE HOMES LTDStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Apply graduated resident-observation procedures, including overnight monitoring and immediate response to sensor alerts.
Stated by PINE VIEW CARE HOMES LTDStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Install and use bedroom sensor mats and CCTV cameras to detect and monitor residents’ movement.
Stated by PINE VIEW CARE HOMES LTDStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Conduct regular staff training on the risks of leaving residents unmonitored or unattended.
Stated by PINE VIEW CARE HOMES LTDStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
Action
Continuously assess residents’ dependency and care needs to determine required staffing hours and mitigate risks.
Stated by PINE VIEW CARE HOMES LTDStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing staffing, monitoring, policies, training and environmental controls are considered sufficient to keep residents safe and mitigate falling risks.
Stated by PINE VIEW CARE HOMES LTDExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Dorset
Concerns raised2
Insufficient staffing and supervision of residents outside staffed hours and at weekends
Failure to monitor and safeguard access to, and presence within, the accommodation
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.2
Action
Maintain additional Night Response Team presence at Dorset Lodge during evening hours.
Stated by Bournemouth Churches Housing Association LimitedStated completedThe respondent said that this action was complete when they made their response on 22 March 2023.
Action
Review the Night Response Team offer to enhance physical evening presence across sites.
Stated by Bournemouth Churches Housing Association LimitedStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Weekend staffing was not commissioned; residents were assessed as suitable for available support, with 24/7 accommodation available for greater needs.
Stated by Bournemouth Churches Housing Association LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
A move to 24/7 accommodation was not pursued because it was considered unsuitable and the resident preferred to remain at Dorset Lodge.
Stated by Bournemouth Churches Housing Association LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
A signing-in book was not required for this HMO, and the accommodation was fully fire compliant under applicable legislation.
Stated by Bournemouth Churches Housing Association LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cornwall and Isles of Scilly
Concerns raised1
Failure to continuously monitor residents
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
Update the nocturnal CCTV monitoring chart to record monitoring periods and explain any gaps.
Stated by Bowden Derra Park LimitedStated completedThe respondent said that this action was complete when they made their response on 22 March 2023.
Norfolk
Concerns raised1
Failure to formalise allocation of resident supervision and meal preparation duties
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.2
Action
Strengthen role allocation, mealtime responsibilities and staff handover processes following staff feedback and debriefing.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Conduct mealtimes in two sittings to enable closer supervision while residents eat and drink.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to effectively observe vulnerable residents entering the garden
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
Install an additional beam to detect garden entry when doors are open.
Stated by WESTLANDS CARE HOME LTDStated completedThe respondent said that this action was complete when they made their response on 28 October 2022.
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Includes failures of required resident observation, supervision, bathroom or location monitoring, and arrangements for detecting or responding to unexplained absence in care or supported accommodation.
