Unreliable safety assessment of new care-home residents on admission
First to latest report 3 Apr 2020 — 11 Apr 2025
Reports that mention this concern
6
Times this concern has been raised
7
Stated actions linked to this concern
16
What this concern includes
Includes failures in the care-home admission and immediate post-admission process to obtain relevant information about new residents and assess their safety risks, including infection, behavioural, clinical and care needs where those risks affect safe placement and care.
What is not included
Excludes general care-plan, risk-assessment or documentation omissions unrelated to the admission or immediate post-admission assessment of a new care-home resident.
Excludes failures in ongoing resident-risk management after admission when the admission assessment and information process operated reliably.
Excludes generic care-home staffing, training, communication or placement-capacity deficiencies unless they directly impair safety assessment or information gathering for a new resident on admission.
Excludes hospital, prison, community-care and other non-care-home admission assessments unless the assertion explicitly concerns the same care-home admission process.
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.
Avery Healthcare Group1
Betsi Cadwaladr University LHB1
Care Quality Commission1
Deerlands Residential Home1
Elvy Court Care Home1
Greater Manchester Health and Social Care Partnership1
Highfield Care Home, Wrexham1
NHS England1
Oak Court House1
Pelham House Residential Care Home with Dementia1
Public Health England1
The Vicarage1
Wolverhampton City Council1
Residential care home4
Care-home operator1
English metropolitan district council1
Executive agency1
Executive non-departmental public body1
Health and social care service regulator1
Health-system partnership1
Local health board1
Nursing home1
Type not available1
Reports and published responses 6 reports
See individual reports that have raised this concern, and the actions taken in response
North Wales (East and Central)
Concerns raised1
Failure to ensure receipt of all relevant patient-care information before transfer
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Betsi Cadwaladr University LHB
Highfield Care Home, Wrexham
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Highfield Care Home, Wrexham
Update the pre-admission assessment document with prompts to obtain all required information, including diabetes information.
Betsi Cadwaladr University LHB
Establish a Task and Finish Group of Community Hospital Matrons and Discharge Nurses to review the care-home discharge plan form.
Betsi Cadwaladr University LHB
Review the care-home discharge plan form to define observation and medication frequencies clearly.
Betsi Cadwaladr University LHB
Share the finalized and approved form changes with the North Wales Care Home Forum.
Betsi Cadwaladr University LHB
Share the new form and supporting examples with teams through Team Meeting Safety Briefs.
Betsi Cadwaladr University LHB
Develop audit questions, complete peer-review monitoring, and report findings through monthly Matron Reports to local quality groups.
South Yorkshire (Western)
Concerns raised1
Failure to conduct falls risk assessments on admission
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sheffcare
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
Sheffcare
Update admissions, falls prevention and risk-assessment policies to require timely assessment, injury monitoring and medical escalation.
Sheffcare
Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.
Sheffcare
Discuss falls, documentation and escalation requirements with staff through huddles, supervision and management briefings.
Sheffcare
Analyse Person-Centred Care falls-assessment data and present findings to the Quality Committee.
Mid Kent and Medway
Concerns raised1
Failure to complete risk assessments within 24 hours of admission
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of risk assessment for admission of new residents
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Clarkson House Care Home Ltd / The Vicarage Care Home
Public Health England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Public Health England
Support development of adult social care guidance on admissions, hospital discharges, infection prevention and control, PPE and visiting.
Care Quality Commission
Undertake an unannounced focused inspection of the care home covering infection control, risk management, falls, records and access to health support.
Clarkson House Care Home Ltd / The Vicarage Care Home
Review and update the admissions policy using current infection-control and public-health guidance, including testing requirements.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Public Health England
Other named organisations, including the care home, regulators, NHS England, and the local partnership, were responsible for commenting on remaining concerns.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
Existing admission controls, including government guidance, isolation and regular testing, are considered sufficient to manage infection risks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex
Concerns raised1
Failure to obtain sufficient and accurate information before admission
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Pelham house
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Pelham house
Restructure the pre-admission assessment process, expand forms to capture activities of daily living, and obtain family sign-off.
Pelham house
Record admission-related telephone calls to preserve relevant information about residents’ history and needs.
Pelham house
Obtain patient summaries from GPs for current and newly admitted residents.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Pelham house
The available admission information supported a sufficient falls risk assessment, disputing that inadequate information caused an insufficient assessment.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Black Country
Concerns raised2
Failure to undertake violence risk assessments after admission or incidents
Lack of information on admission of new residents
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.