Failure to prevent unsafe unaccompanied exit by vulnerable care-home residents
First to latest report 1 Oct 2021 — 26 Oct 2022
Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
7
What this concern includes
Includes failures of care-home arrangements specifically intended to prevent, detect or promptly respond to unsafe unaccompanied exit by residents who lack capacity, cannot assess risk, wander or otherwise have a recognised risk of leaving alone, including exit security, reception coverage, staff monitoring, alerts and comparable safeguards.
What is not included
Excludes ordinary resident supervision, observation or welfare-check failures where unsafe exit prevention or detection is not the identified condition.
Excludes general staffing, training, care-planning or safeguarding deficiencies unless they directly impair a dedicated care-home exit-prevention or alerting control.
Excludes hospital ward, prison, hotel and public-site exit controls unless the assertion explicitly concerns the same care-home resident exit process.
Excludes the underlying fall, wandering episode or other harm where no continuing deficiency in care-home exit controls is identified.
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.
Care Quality Commission1
St Johns Nursing Home Limited1
Westlands Retirement Home1
Health and social care service regulator1
Nursing home1
Residential care home1
Reports and published responses 2 reports
See individual reports that have raised this concern, and the actions taken in response
Hampshire, Portsmouth and Southampton
Concerns raised1
Absence of an effective exit control or alert system for residents at risk of entering the garden alone
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
WESTLANDS CARE HOME LTD
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
WESTLANDS CARE HOME LTD
Install an additional beam to detect garden entry when doors are open.
South London
Concerns raised2
Unavailability of weekend reception monitoring to prevent residents following visitors through the exit door
Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
St Johns Nursing Home Limited
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
St Johns Nursing Home Limited
Restrict visitor access codes and require staff accompaniment for entry and exit.
St Johns Nursing Home Limited
Advise staff about unauthorised exits and require secure door closure and vigilance around reception.
St Johns Nursing Home Limited
Advertise for a weekend receptionist to monitor the door at weekends.
Care Quality Commission
Check at the next inspection that St John’s Nursing Home has embedded its premises-security changes and is effectively minimising identified risks.
St Johns Nursing Home Limited
Station the administrator in reception during normal working hours to monitor the entrance and secure door closure.
St Johns Nursing Home Limited
Position a staff member by the side gate during fire drills and disable the gate's exit code.
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.