First reported 4 Dec 2013•Latest report 9 Apr 2025
Definition
What this concern includes
Includes deficiencies in care-home management capacity or availability, including too few managers, absence of an on-site manager when required, and comparable failures that leave the care home without effective operational oversight.
Not included
Excludes frontline care staffing shortages where the concern is patient or resident care capacity rather than management capacity.
Excludes staff knowledge, training or competence deficiencies that are not specifically part of care-home management oversight.
Excludes failures of registration or qualification alone unless they directly contribute to inadequate management capacity or oversight.
Excludes generic organisational governance deficiencies not specifically concerning operational management of a care home.
Reports
11
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
22
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
Care First Class (UK) Limited1
Care First Homes1
Coed Duon1
Copperfields1
Corbett House Nursing Home1
Downham Grange1
Exemplar Health Care Services Limited1
Hc-One Limited1
HF Trust Limited1
Kingsley Care Homes Limited1
MyMil Limited1
Recipient name withheld1
Scraptoft Court Care Home1
Health and social care service regulator4
Nursing home3
Private limited company3
Care-home operator2
Ministerial department2
English county council1
English metropolitan district council1
Healthcare site1
Independent healthcare provider1
Registered charity1
Residential care home1
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.
Manchester South
Concerns raised1
Lack of sufficient management capacity in the care home
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 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
Promote adult social care careers to jobseekers through recruitment support with the Department for Work and Pensions.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2025.
Action
Expand the Care Workforce Pathway to support progression into adult social care management.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2025.
Action
Implement more robust contract monitoring processes and quality visits across care homes.
Stated by Tameside Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The provider is responsible for determining staffing and management arrangements because legislation does not prescribe the number of managers.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cornwall and Isles of Scilly
Concerns raised1
Understaffing affecting care home management ability to properly monitor care safety and appropriateness
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.6
Action
Maintain safe staffing through permanent staff, dedicated relief workers and block-booked agency colleagues while recruitment continues.
Stated by HF Trust Limited (HFTStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Use daily formal management handovers and management checks and audits to monitor care risks, safety and appropriateness.
Stated by HF Trust Limited (HFTStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Implement a Valley View location-specific pay allowance and targeted recruitment and onboarding measures to attract permanent staff.
Stated by HF Trust Limited (HFTStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Develop local and organisation-wide retention strategies, including pay, reward, recognition, talent management and apprenticeship pathways.
Stated by HF Trust Limited (HFTStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Procure a digital care planning system to support real-time care-plan review, monitoring, auditing and organisational oversight.
Stated by HF Trust Limited (HFTStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Implement and oversee Valley View’s comprehensive improvement plan through enhanced quality assurance support, Steering Group leadership and weekly safety and quality reviews.
Stated by HF Trust Limited (HFTStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Stated by HF Trust Limited (HFTExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Management checks, audits and continuous monitoring are considered sufficient to oversee care safety and appropriateness.
Stated by HF Trust Limited (HFTExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Berkshire
Concerns raised1
Unavailability of an on-site care home manager
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The provider has taken sufficient action to mitigate risks and prevent future deaths.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire
Concerns raised1
Shortcomings in senior management oversight of the Registered Manager
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Lack of ownership and accountability for overall care home operation
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.1
Position
The Company considers it impractical for one Home Manager to undertake all responsibilities or know every service user intimately.
Stated by Kingsley Care Homes LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Yorkshire Eastern
Concerns raised2
Failure of managers to detect inadequate monitoring records
Failure to detect mistakes in ordering replacement catheters
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.6
Action
Deliver catheter-care refresher training and shared learning on fluid-intake recording and alternative catheter access routes.
Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
Action
Digitise EQA governance and establish team-leader accountability, daily management reviews, clinical walkarounds, take-twenty meetings and electronic quality-assurance tracking.
Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
Action
Implement monthly audits of supplementary and care files, with findings discussed with unit managers.
Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
Action
Update the catheter policy to require sufficient stocks for planned, unplanned and emergency catheter changes.
Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
Action
Implement layered catheter-stock controls, including weekly checks, resident-level supplies, minimum backup stocks, daily records and handover sign-off.
Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
Action
Implement EMAR stock visibility, low-stock alerts and daily or weekly dashboard monitoring with remote clinical oversight.
Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.
Stated by Exemplar Health CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The catheter stock failure was an isolated communication error, with no evidence of similar incidents occurring before or since.
Stated by Exemplar Health CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Wales (East and Central)
Concerns raised1
Inadequate management oversight of staff deployment for residents requiring choking-risk or one-to-one food and fluid assistance
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.2
Action
Provide trained mealtime staff in the dining room to oversee dysphagia-trained staff assisting residents at choking risk.
Stated by Coed DuonStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Provide a registered general nurse in the dining room throughout mealtimes.
Stated by Coed DuonStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A registered general nurse is always present in the dining room during mealtimes.
Stated by Coed DuonExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Nottinghamshire
Concerns raised1
Lack of consistent and stable managerial leadership
This report raised 11 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
Sustain senior management cover at the home seven days a week during the nursing-service transition.
Stated by Hc-One LimitedStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2018.
Action
Maintain a registered Senior Turnaround Manager and appoint a Care Manager to progress and embed planned actions across seven days and nights.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
Birmingham and Solihull
Concerns raised1
Unavailability of a registered care home manager
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 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
Monitor the provider’s application to register the new manager.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Action
Maintain a manager in post at Cherry Lodge.
Stated by Care First Class (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Register the Cherry Lodge manager with CQC.
Stated by Care First Class (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Poor management and absences of management staff
This report raised 15 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.
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Includes deficiencies in care-home management capacity or availability, including too few managers, absence of an on-site manager when required, and comparable failures that leave the care home without effective operational oversight.
