Recurring concern
Unreliable safety assessment of new care-home residents on admission
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Request correctionFirst reported 3 Apr 2020•Latest report 11 Apr 2025
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.
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.
- Reports
- 6
- Individual concerns
- 7
- Date range
- 2020–2025
- Stated actions
- 16
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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
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Action
Update the pre-admission assessment document with prompts to obtain all required information, including diabetes information.
Stated by Highfield Care Home, Wrexham -
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 LHB -
Action
Review the care-home discharge plan form to define observation and medication frequencies clearly.
Stated by Betsi Cadwaladr University LHB
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Action
Share the finalized and approved form changes with the North Wales Care Home Forum.
Stated by Betsi Cadwaladr University LHB -
Action
Share the new form and supporting examples with teams through Team Meeting Safety Briefs.
Stated by Betsi Cadwaladr University LHB -
Action
Develop audit questions, complete peer-review monitoring, and report findings through monthly Matron Reports to local quality groups.
Stated by Betsi Cadwaladr University LHB
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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.
Responses linked to these concernsEach 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
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Action
Update admissions, falls prevention and risk-assessment policies to require timely assessment, injury monitoring and medical escalation.
Stated by Sheffcare -
Action
Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.
Stated by Sheffcare -
Action
Discuss falls, documentation and escalation requirements with staff through huddles, supervision and management briefings.
Stated by Sheffcare
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Action
Analyse Person-Centred Care falls-assessment data and present findings to the Quality Committee.
Stated by Sheffcare
-
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
Responses linked to these concernsEach 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
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Action
Support development of adult social care guidance on admissions, hospital discharges, infection prevention and control, PPE and visiting.
Stated by Public Health England -
Action
Undertake an unannounced focused inspection of the care home covering infection control, risk management, falls, records and access to health support.
Stated by Care Quality Commission -
Action
Review and update the admissions policy using current infection-control and public-health guidance, including testing requirements.
Stated by Clarkson House Care Home Ltd / The Vicarage Care Home
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Other named organisations, including the care home, regulators, NHS England, and the local partnership, were responsible for commenting on remaining concerns.
Stated by Public Health England
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Position
Existing admission controls, including government guidance, isolation and regular testing, are considered sufficient to manage infection risks.
Stated by Care Quality Commission
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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.
Responses linked to these concernsEach 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
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Action
Restructure the pre-admission assessment process, expand forms to capture activities of daily living, and obtain family sign-off.
Stated by Pelham house -
Action
Record admission-related telephone calls to preserve relevant information about residents’ history and needs.
Stated by Pelham house -
Action
Obtain patient summaries from GPs for current and newly admitted residents.
Stated by Pelham house
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The available admission information supported a sufficient falls risk assessment, disputing that inadequate information caused an insufficient assessment.
Stated by Pelham house
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026