First reported 10 Sep 2014•Latest report 8 Jan 2026
Definition
What this concern includes
Includes failures of training, practical preparation, shadowing, competence assessment, currency monitoring or role-specific competence assurance for carers providing care, including the anchor's lack of monitored training and comparable failures concerning practical care, repositioning, hoist operation or scope-of-care limits.
Not included
Excludes failures limited to staffing numbers, availability or scheduling where carer competence is not the unsafe condition.
Excludes generic training or supervision deficiencies unrelated to carers providing care.
Excludes competence concerns for clinicians, emergency responders or other professional groups unless the assertion specifically concerns carers providing care.
Excludes failures of a separately named safety system or hazard where that system or hazard supplies the more specific parent boundary.
Excludes isolated poor performance where no deficiency in the carer training or competence-assurance process is identified.
Reports
16
Distinct published reports
Individual concerns
17
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
42
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 Commission3
Department of Health and Social Care3
Aran Court Care Centre1
Berkeley Home Health Limited1
Bupa1
Homedotcare Limited1
Ignite Health and Home Care Services Ltd1
Inspire You Care Ltd1
Islington Social Services1
Jubilee Gardens1
Lean on Me (Northolt)1
Leeds Teaching Hospitals NHS Trust1
MiHomecare Limited1
Mill View1
NHS England1
Domiciliary care provider5
NHS trust4
Health and social care service regulator3
Ministerial department3
Private limited company3
Nursing home2
English metropolitan district council1
Executive non-departmental public body1
Health and care professional regulator1
Multi-service care provider1
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.
Worcestershire
Concerns raised1
Lack of adequate training on the limits of care carers are able to provide
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.3
Action
Reinforce guidance that wound care and pressure sore management are outside carers’ scope and must be undertaken only by qualified persons.
Stated by Ignite Health and HomecareStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Issue formal reminders requiring staff to escalate clinical concerns to district nursing or medical professionals and not act beyond authorised duties.
Stated by Ignite Health and HomecareStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Review supervision and audit processes to strengthen oversight of adherence to scope-of-practice boundaries.
Stated by Ignite Health and HomecareStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The incidents reflected individual judgment contrary to policy, training and instructions, not a deficiency in carers’ understanding or the agency’s systems and governance.
Stated by Ignite Health and HomecareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Lack of carer training on pressure sores, skin assessment or repositioning
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
Provide further training in wound prevention.
Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.
Action
Conduct competency spot checks of staff after the training period.
Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Staff state that they understood the importance of repositioning bed-bound service users and had appropriate skills or training to support Celia.
Stated by Inspire You Care LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Northamptonshire
Concerns raised1
Failure of care homes to ensure agency carers' suitability, experience and training
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.3
Action
Revise and expand the Care Workforce Pathway to provide a national structure for adult social care knowledge, skills, values, behaviours and progression.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 December 2025.
Action
Launch the Adult Social Care Learning and Development Support Scheme to fund eligible care staff courses and qualifications, including the Level 2 Adult Social Care Certificate.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 December 2025.
Action
Launch the Quality Assured Care Learning Service to help individuals and employers identify trusted sector learning and development opportunities.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Regulated care providers, rather than employment agencies, are responsible for ensuring agency staff are suitably experienced, competent and recruited safely.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing CQC registration requirements, staffing duties, training, supervision and regulatory action provide safeguards for agency staff suitability and competence.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Lack of clarity about carers’ aspiration pneumonia training
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.4
Action
Launch redesigned annual Care Professional Development training covering choking, aspiration and related care-safety topics.
Stated by MiHomecare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Update induction training with additional clarity on aspiration and choking.
Stated by MiHomecare LimitedStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Launch the further updated refresher training with additional clarity on aspiration and choking.
Stated by MiHomecare LimitedStated plannedThe respondent said that this action was planned when they made their response on 29 April 2024.
Action
Update themed choking supervision to include aspiration and aspiration pneumonia, and release the revised version.
Stated by MiHomecare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
Inner North London
Concerns raised1
Failure to provide suitably trained, experienced and competent carers
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.3
Action
Strengthen recruitment and induction through Care Certificate completion, orientation, induction, shadowing, supervision, competency sign-off and refresher training.
Stated by HomeDot CareStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Provide specialist training for staff in complex care needs, including stoma care, tracheostomy, epilepsy, PEG feeding, mental health, autism, suctioning and dysphagia.
Stated by HomeDot CareStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Establish structured supervision and monitoring of carers through early supervision, electronic attendance checks, care-note audits, training sign-off and response-to-concern meetings.
Stated by HomeDot CareStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The organisation considers that the carer received training in accordance with its policies and had prior care experience.
Stated by HomeDot CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No evidence was found that the concerns identified in the prevention of future death report remain.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West London
Concerns raised1
Lack of adequate training and shadowing for new carers
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.12
Action
Consider and implement new staff training and assessment systems.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Add safe Zimmer-frame transfers and emergency responses to moving-and-handling knowledge tests.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Develop and implement policies and procedures covering shadowing records and competency observations.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Implement ongoing quality monitoring of staff training.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Redevelop senior-staff training, including the new-carer manual-handling competency test.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Source staff training from a vetted preferred provider aligned with Skills for Care and CQC standards.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Require vetted new staff and management to complete Level 1 and Level 2 induction training and follow the service’s policies and procedures.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Provide strength-based and train-the-trainer courses so supervisory and management staff can support field care workers.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Recruit seven experienced management personnel, including field care supervisors.
Stated by Lean on Me Community Care Services LtdStated completedThe respondent said that this action was complete when they made their response on 13 March 2023.
Action
Continue recruiting care workers and field supervisors to provide competent field shadowing and performance appraisal.
Stated by Lean on Me Community Care Services LtdStated in progressThe respondent said that this action was in progress when they made their response on 13 March 2023.
Action
Support care workers without RQF qualifications to enrol on RQF courses.
Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
Action
Use the new field-shadowing form to document shadowing activity.
Stated by Lean on Me Community Care Services LtdStated completedThe respondent said that this action was complete when they made their response on 13 March 2023.
Hampshire, Portsmouth and Southampton
Concerns raised2
Lack of training and skills to respond to a medical emergency
Lack of training and skills to identify a medical emergency
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
Send carers guidance on when to call emergency and non-emergency health services.
Stated by Trinity Homecare Group LtdStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Incorporate emergency-call examples into induction and refresher training.
Stated by Trinity Homecare Group LtdStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
Action
Enhance spot checks and conduct field monitoring to test carers’ knowledge of emergency procedures.
Stated by Trinity Homecare Group LtdStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
Action
Introduce an emergency and unexpected death of a client policy for the care delivery team.
Stated by Trinity Homecare Group LtdStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The incident is considered isolated, limiting the basis for further responsive safety work.
Stated by Trinity Homecare Group LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
London Inner (West)
Concerns raised1
Failure to implement, administer and communicate 1:1 care training
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.
West London
Concerns raised1
Untrained and unqualified care staff
This report raised 19 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.
Birmingham and Solihull
Concerns raised1
Lack of objectively assessed basic training and competence standards for HCAs
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.5
Action
Incorporate Care Certificate standards into guidance for providers and assess induction compliance during inspections.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Maintain the Care Certificate as an induction and development standard covering safe, effective care for health and social care workers.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Provide £12 million through the Workforce Development Fund to support adult social care employers with workforce training and qualifications.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
Action
Continue working with Skills for Care to improve adult social care workforce skills.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Recruitment, induction and care-certificate arrangements are considered sufficient to ensure HCAs have appropriate qualities, aptitude and role preparation.
Stated by Avery Healthcare GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Care Certificate induction standards and workplace competence assessment were considered sufficient to ensure HCAs had necessary knowledge and skills.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures of training, practical preparation, shadowing, competence assessment, currency monitoring or role-specific competence assurance for carers providing care, including the anchor's lack of monitored training and comparable failures concerning practical care, repositioning, hoist operation or scope-of-care limits.
