Recurring concern
Failure to reliably supervise and monitor residents in care accommodation
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Request correctionFirst reported 1 Dec 2013•Latest report 21 May 2026
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
- Individual concerns
- 39
- Date range
- 2013–2026
- Stated actions
- 35
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
Lack of continuous observation sufficient to enable prompt medical assistance
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 make an appropriate decision on the level of supervision
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
Insufficient staffing capacity for continuous observation of residents at risk of falls during self-isolation
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The provider and registered manager, not CQC, are responsible for deciding how to address identified care risks and implement improvements.
Stated by Care Quality Commission
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Position
Existing individualised care plans and additional welfare checks were considered sufficient to mitigate Mrs Jones’s fall risk while unwell.
Stated by Care Quality Commission
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Concerns raised1
Failure of resident alert arrangements to alert staff before routine checks
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
Introduce an Observation and Monitoring form, update the Falls Risk Assessment, and require at least hourly sensor-mat checks throughout each shift with daily senior-management monitoring at Alexandra View.
Stated by Roseberry Care Centres GB Limited
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Concerns raised1
Failure to restrict resident departures or observe foyer areas
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of formal policies for observing residents
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.
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Concerns raised1
Failure to provide reliable overnight detection of residents getting up and wandering
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
Remind care providers to assess night-time risks and explore technological solutions for supported people who leave their rooms.
Stated by Trafford Borough Council -
Action
Check the provider’s regulatory compliance at the next service inspection and require improvements or highlight breaches where warranted.
Stated by Care Quality Commission -
Action
Continue using enforcement powers to require improvements when providers are not meeting regulatory requirements.
Stated by Care Quality Commission
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Action
Carry out resident-specific night-time risk assessments covering sleeping patterns and risks from getting out of bed, and communicate outcomes to staff.
Stated by Meade Close
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Routine sensor use cannot be provided because it may restrict liberty without an individual assessment of need and capacity.
Stated by Trafford Borough Council
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Position
The resident did not require a night sensor because assessments identified no harm risk, while an alert mat could create a trip hazard.
Stated by Care Quality Commission
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Concerns raised1
Inadequate monitoring arrangements for residents with previous incidents of absconding
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.1
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Action
Inform the multidisciplinary team or make referrals after absconding incidents and conduct six-weekly or more frequent monitoring visits with placement review where needed.
Stated by PENTRE LODGE CARE HOME 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
As an open facility, the home cannot prevent residents leaving until legally required deprivation-of-liberty and capacity documentation is completed.
Stated by PENTRE LODGE CARE HOME LIMITED
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Concerns raised1
Failure of pressure mats to prevent residents bypassing bed-exit detection
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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
Data last updated 7 September 2026