Recurring concern
Failure to reliably reposition patients at required intervals
- Reports that mention this concern
- 14
- Times this concern has been raised
- 14
- Stated actions linked to this concern
- 22
What this concern includes
Includes failures in arrangements for assessing, scheduling, performing, recording, monitoring and assuring required repositioning or turning of patients at specified intervals, including repositioning for pressure-damage prevention, respiratory care or other clinically identified needs.
What is not included
- Excludes general pressure-ulcer prevention or treatment failures where no patient-repositioning deficiency is identified.
- Excludes generic care staffing, training, documentation or audit failures unless they directly impair required patient repositioning or its assurance.
- Excludes failures concerning mobility, moving and handling or patient positioning where repositioning at clinically required intervals is not the unsafe condition.
- Excludes failures to act on pressure damage or respiratory deterioration after required repositioning has been reliably provided.
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 14 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Lack of turning charts for pressure-sore care
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- The Grange Care Centre Cheltenham
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
The Grange Care Centre Cheltenham
Maintain individual resident folders containing daily care records, including repositioning charts.
-
The Grange Care Centre Cheltenham
Require the responsible nurse to sign off each chart before evening handover and record additional notes.
-
Concerns raised1
Falsification of pressure sore repositioning records
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Stoke-on-Trent City 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.1
-
Stoke-on-Trent City Council
Share investigation learning with New Park House and recommend improvements to recording practices.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Stoke-on-Trent City Council
The investigation found no evidence that the pressure-sore management plan was inadequately followed or that records had been falsified.
-
Concerns raised1
Incomplete and poor repositioning records
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
University Hospitals Sussex NHS Foundation Trust
Monitor documentation more closely and provide nurses with real-time feedback.
-
University Hospitals Sussex NHS Foundation Trust
Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.
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Concerns raised1
Failure to turn patients at the required frequency
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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026