Recurring concern
Failure to prevent unsafe unaccompanied exit by vulnerable care-home residents
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Request correctionFirst reported 1 Oct 2021•Latest report 26 Oct 2022
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.
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.
- Reports
- 2
- Individual concerns
- 3
- Date range
- 2021–2022
- Stated actions
- 7
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
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.
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.1
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Action
Install an additional beam to detect garden entry when doors are open.
Stated by WESTLANDS CARE HOME LTD
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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.
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
Restrict visitor access codes and require staff accompaniment for entry and exit.
Stated by St Johns Nursing Home Limited -
Action
Advise staff about unauthorised exits and require secure door closure and vigilance around reception.
Stated by St Johns Nursing Home Limited -
Action
Advertise for a weekend receptionist to monitor the door at weekends.
Stated by St Johns Nursing Home Limited
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Action
Check at the next inspection that St John’s Nursing Home has embedded its premises-security changes and is effectively minimising identified risks.
Stated by Care Quality Commission -
Action
Station the administrator in reception during normal working hours to monitor the entrance and secure door closure.
Stated by St Johns Nursing Home Limited -
Action
Position a staff member by the side gate during fire drills and disable the gate's exit code.
Stated by St Johns Nursing Home Limited
Data last updated 7 September 2026