First reported 3 Feb 2014•Latest report 18 Jun 2025
Definition
What this concern includes
Includes deficiencies in pre-admission or pre-transfer assessment of patient care needs, risks, suitability, or the receiving placement’s ability to provide safe care.
Not included
Excludes assessments occurring after admission or transfer unless they are part of the process for deciding whether to accept the patient.
Excludes generic failures to obtain or communicate information that are not explicitly tied to assessing care needs before acceptance.
Excludes discharge, pre-leave, pre-operative, emergency, and other assessments serving a different operational decision.
Reports
15
Distinct published reports
Individual concerns
17
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
26
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 Commission2
1st Care 4U Ltd1
Amplius Living1
Avenue House Nursing and Care Home1
Betsi Cadwaladr University LHB1
Black Country Healthcare NHS Foundation Trust1
Bolton Borough Council1
Bury Borough Council1
Cardiff Prison1
Cardiff & Vale University LHB1
Department of Health and Social Care1
Devon Partnership NHS Trust1
Durham County Council1
Greater Manchester Mental Health NHS Foundation Trust1
Highfield Care Home, Wrexham1
NHS trust5
Healthcare site4
Residential care home3
English metropolitan district council2
English unitary authority2
Health and social care service regulator2
Local health board2
Ministerial department2
Social-care provider2
Care-home operator1
Domiciliary care provider1
English county council1
Executive non-departmental public body1
Nursing home1
Other public body1
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.
Cheshire
Concerns raised1
Failure to ensure provision of required one-to-one care before accepting care responsibilities
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
Remind managers to escalate refusals of required one-to-one care to Head Office and the oversight team.
Stated by Minster Care Management LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
Action
Assess and provide interim one-to-one care using the organisation’s workforce while external funding is pursued.
Stated by Minster Care Management LimitedStated plannedThe respondent said that this action was planned when they made their response on 3 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The suggestion that providers can fund one-to-one care and reclaim costs from local authorities does not reflect the provider’s experience.
Stated by Minster Care Management LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
One-to-one care cannot continue indefinitely without local-authority funding; if funding is refused, the resident may need to leave the home.
Stated by Minster Care Management LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
North Wales (East and Central)
Concerns raised2
Failure to assess relevant patient-care information before accepting transfer
Failure to ensure receipt of all relevant patient-care information before transfer
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.7
Action
Conduct all pre-admission assessments in person, except for emergency admissions.
Stated by Highfield Care Home, WrexhamStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
Action
Update the pre-admission assessment document with prompts to obtain all required information, including diabetes information.
Stated by Highfield Care Home, WrexhamStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
Action
Establish a Task and Finish Group of Community Hospital Matrons and Discharge Nurses to review the care-home discharge plan form.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
Action
Review the care-home discharge plan form to define observation and medication frequencies clearly.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.
Action
Share the finalized and approved form changes with the North Wales Care Home Forum.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 17 April 2025.
Action
Share the new form and supporting examples with teams through Team Meeting Safety Briefs.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 17 April 2025.
Action
Develop audit questions, complete peer-review monitoring, and report findings through monthly Matron Reports to local quality groups.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 17 April 2025.
South Wales Central
Concerns raised1
Insufficient assessment of whether needs are too complex for HMP Cardiff
This report raised 12 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
Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 25 March 2024.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to assess patients' needs and required measures during the admission process
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.
Plymouth, Torbay and South Devon
Concerns raised1
Failure to physically inspect accommodation suitability before placement
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
Inspect new provider facilities before contracting to assure placement suitability.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
Action
Complete a social care delivery redesign with dedicated community mental health social workers responsible for sourcing and reviewing placements.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
Action
Link community and forensic social work teams to standardise placement sourcing and review and ensure proposed placements reach the contract and review team before contracting.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
Action
Develop an out-of-area placement protocol and provider monitoring form covering suitability assurances and face-to-face reviews.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The local authority has a role in selecting and monitoring care services, including safeguarding, and is expected to address that role.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing CQC ratings, contractual quality provisions and placement experience were considered sufficient assurance that the care home was appropriate.
Stated by Devon Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Placement without a clear understanding of the person's needs
This report raised 9 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.8
Action
Develop a competency framework for identifying and assessing patients with complex health, social and onward care needs.
Stated by Bolton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Develop a Home First competency framework for recommending appropriate intermediate-care placements.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Review transfers to intermediate care daily through an Integrated Discharge Team nurse.
Stated by Bolton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Require ward managers to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before transfer of care.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Develop a skills and competency framework for Integrated Discharge Team members to identify patients with complex onward needs.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Deliver additional training to existing Integrated Discharge Team staff on identifying patients with complex onward needs.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Require wards to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before considering transfer of care.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Local Authority will provide a further response on actions concerning safe placement and transfers of care.
Stated by Bolton NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Reliance on applicant and family information when assessing privately funded applicants
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised2
Inadequate pre-admission assessment of care needs
Inadequate pre-admission risk assessment
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.2
Action
Invite Elmhurst and Spurr House staff to Killelea discharge planning meetings to meet customers and assess suitability.
Stated by Department for Communities & WellbeingStated plannedThe respondent said that this action was planned when they made their response on 25 October 2018.
Action
Establish an additional short-stay admissions post to obtain detailed referral information and support face-to-face assessments or multidisciplinary meetings.
Stated by Persona Care And Support LimitedStated plannedThe respondent said that this action was planned when they made their response on 25 October 2018.
Northamptonshire
Concerns raised1
Failure to identify falls risks during pre-assessment
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised1
Inconsistent application of controls preventing service commencement without a care plan and needs assessment
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
Require all relevant documentation before accepting new placements.
Stated by The Haven Day CentreStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
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Includes deficiencies in pre-admission or pre-transfer assessment of patient care needs, risks, suitability, or the receiving placement’s ability to provide safe care.
