Recurring concern
Failure to reliably supervise and monitor residents in care accommodation
- Reports that mention this concern
- 34
- Times this concern has been raised
- 39
- Stated actions linked to this concern
- 35
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.
What is 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
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 34 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Care Quality Commission
The provider and registered manager, not CQC, are responsible for deciding how to address identified care risks and implement improvements.
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Care Quality Commission
Existing individualised care plans and additional welfare checks were considered sufficient to mitigate Mrs Jones’s fall risk while unwell.
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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.
Linked response
- Roseberry Care Centres GB Limited
Stated actions 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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Roseberry Care Centres GB Limited
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.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked responses
- Care Quality Commission
- Meade Close
- Trafford Borough Council
Stated actions 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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Trafford Borough Council
Remind care providers to assess night-time risks and explore technological solutions for supported people who leave their rooms.
-
Care Quality Commission
Check the provider’s regulatory compliance at the next service inspection and require improvements or highlight breaches where warranted.
-
Care Quality Commission
Continue using enforcement powers to require improvements when providers are not meeting regulatory requirements.
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Meade Close
Carry out resident-specific night-time risk assessments covering sleeping patterns and risks from getting out of bed, and communicate outcomes to staff.
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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Trafford Borough Council
Routine sensor use cannot be provided because it may restrict liberty without an individual assessment of need and capacity.
-
Care Quality Commission
The resident did not require a night sensor because assessments identified no harm risk, while an alert mat could create a trip hazard.
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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.
Linked response
- PENTRE LODGE CARE HOME LIMITED
Stated actions 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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PENTRE LODGE CARE HOME LIMITED
Inform the multidisciplinary team or make referrals after absconding incidents and conduct six-weekly or more frequent monitoring visits with placement review where needed.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
PENTRE LODGE CARE HOME LIMITED
As an open facility, the home cannot prevent residents leaving until legally required deprivation-of-liberty and capacity documentation is completed.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of supervision of residents in communal areas of care homes
Linked response
- Borough Care Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Borough Care Ltd
Increase staffing levels across homes, including adding a deputy manager and increasing night cover.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Borough Care Ltd
Existing staffing, risk assessments and nurse-call access are considered sufficient to keep communal areas safe despite occasional short unattended periods.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026