First reported 1 Aug 2013•Latest report 2 Jun 2026
Definition
What this concern includes
Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.
Not included
Excludes standalone procedural instructions, treatment steps, extubation plans and immediate deterioration-management plans unless the source explicitly identifies them as part of the person's formal care plan.
Excludes organisational improvement plans, staffing plans and operational contingency plans.
Excludes discharge planning, risk assessment, family involvement or generic records when that separate control is the concern and formal care-plan reliability is not directly asserted.
Reports
120
Distinct published reports
Individual concerns
141
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
200
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.
Department of Health and Social Care14
Care Quality Commission9
Sussex Partnership NHS Foundation Trust9
Essex Partnership University NHS Foundation Trust7
NHS England7
Ministry of Justice5
Avon and Wiltshire Mental Health Partnership NHS Trust4
Barts Health NHS Trust4
Norfolk and Suffolk NHS Foundation Trust4
North East London NHS Foundation Trust4
Birmingham and Solihull Mental Health NHS Foundation Trust3
Central and North West London NHS Foundation Trust3
Hc-One Limited3
HM Prison and Probation Service3
Office of the Chief Coroner3
NHS trust67
Ministerial department19
Private limited company15
Healthcare site13
Health and social care service regulator9
Residential care home9
Executive non-departmental public body7
Type not available7
Multi-service care provider6
Nursing home6
English county council5
Independent healthcare provider5
Integrated care board4
Prison or young offender institution4
Coronial office3
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.
Avon
Concerns raised1
Failure to complete or review ACCT care plans and support actions at every review
This report raised 4 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.9
Action
Provide ACCT case-review training and refresher training for case coordinators.
Stated by Eastwood Park Prison and Young Offender Institution and HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Develop and operate an ACCT quality-assurance process providing feedback, support and escalation for case-management concerns.
Stated by Eastwood Park Prison and Young Offender Institution and HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Complete consideration of adding a SystmOne tick-box confirming review of care plans and support actions.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Maintain regular audits of ACCT reviews to verify that care plans and support actions are reviewed and updated appropriately.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Collaborate with the prison to ensure clinical staff complete updated ACCT training and have access to regular training sessions.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated in progressThe respondent said that this action was in progress when they made their response on 9 December 2024.
Action
Continue monitoring the ACCT review process.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Revise and approve the local operating procedure for ACCT attendance.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Monitor ACCT training, refresher completion, and record-keeping standards through a scheduled audit programme.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 December 2024.
Action
Develop a Quality Improvement Plan supporting the ACCT procedure and associated monitoring.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Changes to SystmOne are limited because the software provider controls implementation of database changes.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Implementation of a SystmOne care-plan review tick-box would require action by TPP, which owns and operates the software.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A SystmOne tick-box would not ensure that meaningful care-plan reviews and updates were conducted.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Regular audits of ACCT reviews are considered an effective alternative for ensuring care plans and support actions are reviewed and updated.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to follow falls-risk care plans
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
Conduct weekly documentation audits, assurance meetings, metrics reviews and ward action planning across all six divisional wards.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 November 2024.
Action
Provide ward-based falls and enhanced-care risk-assessment training with senior-nurse oversight and refresher documentation sessions for staff.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 November 2024.
Surrey
Concerns raised1
Care plans containing out-of-date and conflicting information
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 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
Complete a full audit of residents’ care plans for accuracy, currency and consistency.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Introduce and operate a care-plan tracker with daily management checks and monthly care-record audits.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Train key staff in care planning, record-keeping and falls management, with refresher training scheduled for record accuracy, falls management and risk recognition.
Stated by Avery Healthcare GroupStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2024.
Action
Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Operate the Resident of the Day programme to review care plans with keyworkers and respond to current risks.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Manchester North
Concerns raised1
Failure to open the four standard care plans during inpatient stay
This report raised 13 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
Remind staff to maintain four core care plans and review completion through daily dashboard checks and audits.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
East London
Concerns raised1
Failure to escalate inability to consistently follow the SALT care plan and obtain a contingency care plan
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.7
Action
Establish escalation guidance identifying relevant professionals, care-review involvement and risk-management planning when safe care is difficult to provide.
Stated by SerencroftStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Monitor adherence to care plans and refer behavioural barriers to external professionals for care-plan adaptation.
Stated by SerencroftStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Action
Review residents with swallowing difficulties and establish robust assessments capturing barriers to prescribed care.
Stated by SerencroftStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Meet with all staff to share inquest findings and reinforce escalation and documentation of care concerns.
Stated by SerencroftStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Action
Use clinical review meetings to identify delivery difficulties and trigger re-referrals to relevant professionals.
Stated by SerencroftStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Action
Hold fortnightly clinical reviews to identify high-risk residents, escalate concerns and notify relevant professional teams and funding authorities.
Stated by SerencroftStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.
Action
Ensure clinical leads, managers or qualified senior staff attend SALT assessments and reviews and promptly flag changes.
Stated by SerencroftStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Manchester North
Concerns raised1
Insufficient care-plan detail for safe administration of thickened fluids
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 enhanced medication, SALT, Care Certificate and related training, including annual refresher training.
Stated by EasyCare Ltd (trading name: EVOLVEStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
Action
Redefine care plans to include greater detail about clients’ needs, choices and preferences.
Stated by EasyCare Ltd (trading name: EVOLVEStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
Norfolk
Concerns raised1
Lack of consistent and clear fall-risk mitigation requirements in care plans and risk assessments
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.
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 care plans and risk assessments to provide person-focused, consistent falls-risk management guidance.
Stated by Norfolk Care HomesStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.
Stated by Norfolk Care HomesStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
Action
Implement monthly care-plan and risk-assessment audits covering at least 10% of the home.
Stated by Norfolk Care HomesStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Inner North London
Concerns raised1
Failure to properly complete Care & Support plans without significant errors
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.1
Action
Improve care assessments through supervisor retraining, specialist risk assessments and requests to the local authority for updated support plans when additional needs are identified.
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.3
Position
Existing monitoring and audit arrangements are sufficient to oversee commissioned providers’ quality and safety.
Stated by London Borough of IslingtonExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The organisation had not been made aware that its care assessment contained significant errors.
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.
Surrey
Concerns raised1
Inadequacy of pathway plans for care leavers
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.4
Action
Roll out the formal local-authority assessment programme, including assessing Surrey County Council and using reported concerns to inform that assessment.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Deliver updated pathway plan training through a rolling programme for personal advisers.
Stated by Surrey County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Provide pathway plan surgeries across relevant teams to support timely completion and practice guidance.
Stated by Surrey County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Action
Audit pathway plans and disseminate resulting learning across the service to improve practice.
Stated by Surrey County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
At the time of Mr Baker’s death, CQC lacked statutory powers to assess Surrey County Council or other local authorities.
Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised3
Lack of bespoke care plans tailored to individual needs
Failure to include key current clinical information in care plans
Failure to include risk management and contingency planning in care plans
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
Implement the International Fundamentals of Care Framework in urgent and inpatient care, including its principles in Newman’s care-planning form.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Use the Admission Checklist to support care planning, timely escalation and referrals, and reduce missed actions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Pin
Get email alerts
Request correction
Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.
