First reported 10 Jan 2014•Latest report 10 Mar 2026
Definition
What this concern includes
Includes failures in arrangements for determining, preparing and submitting safety-relevant reports to the CQC, including unclear reporting thresholds and omitted mandatory notifications of significant events or care-related information.
Not included
Excludes reporting failures to NHSE, the MHRA or other bodies unless the assertion also directly concerns the CQC reporting process.
Excludes failures in CQC inspection, investigation, record access or regulatory action after information should have been reported.
Excludes generic incident reporting or information-sharing deficiencies without an identified CQC reporting obligation.
Excludes ordinary administrative notifications that have no identified safety relevance.
Reports
9
Distinct published reports
Individual concerns
10
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
14
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 Commission4
Department of Health and Social Care2
NHS England2
Alternative Futures Group Limited1
County Durham and Darlington NHS Foundation Trust1
Durham Constabulary1
Durham County Council1
Four Seasons Health Care Group1
gtd healthcare1
Hurst Hall1
Information Commissioner's Office1
Medicines and Healthcare products Regulatory Agency1
NHS South Yorkshire Integrated Care Board1
Nursing and Midwifery Council1
Pentree Lodge1
Health and social care service regulator4
Executive non-departmental public body2
Ministerial department2
NHS trust2
Residential care home2
Care-home operator1
Company limited by guarantee1
English unitary authority1
Health and care professional regulator1
Independent healthcare provider1
Information rights regulator1
Integrated care board1
Medicines and medical devices regulator1
Nursing home1
Nursing-home operator1
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 notify the CQC of periods of absence without leave
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
Submit general safeguarding concerns to the CQC and clarify staff statutory reporting requirements, including safeguarding duties.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
AFG was not legally required to report unauthorised absences to the CQC because Weaver Lodge did not meet the prescribed security-unit categories.
Stated by Alternative Futures Group LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Nottinghamshire
Concerns raised1
Inaccurate reporting of incidents to regulators and social care
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 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 serious-injury notification reports to receive Operations Manager review before submission.
Stated by Red Oaks Care HomeStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
County Durham and Darlington
Concerns raised1
Lack of clear and timely internal and external fall reporting
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.3
Action
Operate RADAR incident reporting with mandatory fall details, investigation workflows, escalation prompts and regulatory notification requirements.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Provide mandatory falls-awareness training and refresher training for care and clinical staff through blended learning and face-to-face delivery.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Analyse falls incidents monthly, validate home practice through regional reviews and use trend monitoring to identify and address emerging risks.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Inner South London
Concerns raised1
Unclear thresholds for section 10 entity reporting to NHSE and the CQC
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 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
Publish updated national guidance governing assurance and escalation for NHS section 10 aseptic preparation units.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
Action
Operate quarterly section 10 unit status reporting with immediate escalation of high-risk failures and serious patient safety incidents.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 15 November 2024.
Action
Agree and implement an MoU with NHSE for routine updates and dissemination of actionable incident learning.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 15 November 2024.
Action
Remind GPhC, PSNI and CQC of responsibilities concerning Section 10 medicines and information exchange.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 15 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Existing NHS England guidance, SPS oversight, escalation, and patient-safety reporting routes sufficiently address reporting by section 10 NHS aseptic units.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Reporting requirements for trusts are now more clearly defined than they were in 2014.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NHS England, MHRA and CQC are responsible for implementing responses to the identified gaps; DHSC will coordinate their actions.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Other Section 10 providers fall under the relevant pharmacy or healthcare regulators, rather than the MHRA.
Stated by Medicines and Healthcare products Regulatory AgencyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Failure to provide accurate information to the CQC about a death
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.2
Action
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The statutory notification described the padded bumper as being against the child’s chest, rather than his neck.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The statutory notification described Connor’s position, the cot bumper and emergency assessment, although it inaccurately reported the overnight checking frequency.
Stated by The Children's TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Cornwall and Isles of Scilly
Concerns raised2
Inconsistent reporting of absconding incidents
Unclear reporting of seizure-related incidents to relevant bodies
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.2
Action
Establish direct liaison and incident-notification arrangements with GPs, mental health services, care teams, and police for relevant health and absconding events.
Stated by PENTRE LODGE CARE HOME LIMITEDStated completedThe respondent said that this action was complete when they made their response on 10 November 2019.
Action
Introduce assisted or escorted bathroom use, showering preference, specialist epilepsy input, and associated seizure-safety measures for residents with diagnosed seizures.
Stated by PENTRE LODGE CARE HOME LIMITEDStated plannedThe respondent said that this action was planned when they made their response on 10 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
As an open facility, the home cannot prevent residents leaving until legally required deprivation-of-liberty and capacity documentation is completed.
Stated by PENTRE LODGE CARE HOME LIMITEDUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West London
Concerns raised1
Failure to report resident hospital admissions to the CQC
This report raised 19 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 South
Concerns raised1
Lack of understanding of prompt Care Quality Commission reporting requirements
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 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
Implement central checks to ensure deaths trigger immediate notifications to the Care Quality Commission.
Stated by MERIDIAN HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 20 August 2015.
Coventry
Concerns raised1
Inaccurate reporting by nursing home managers to the Care Quality Commission
This report raised 8 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.
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Includes failures in arrangements for determining, preparing and submitting safety-relevant reports to the CQC, including unclear reporting thresholds and omitted mandatory notifications of significant events or care-related information.
