First reported 31 Oct 2013•Latest report 21 May 2026
Definition
What this concern includes
Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
Not included
Generic mobility, staffing or environmental failures not explicitly tied to falls
The occurrence of a fall without an identified control deficiency
Falls from windows where the asserted control is the design or restriction of the window
Reports
165
Distinct published reports
Individual concerns
285
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
349
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
Barts Health NHS Trust6
Office of the Chief Coroner5
Aneurin Bevan University LHB4
Manchester University NHS Foundation Trust4
Royal London Hospital4
University Hospitals Sussex NHS Foundation Trust4
East Kent Hospitals University NHS Foundation Trust3
Hc-One Limited3
Swansea Bay University Local Health Board3
University Hospitals Birmingham NHS Foundation Trust3
Barchester Healthcare Limited2
Borough Care Ltd2
Cardiff & Vale University LHB2
NHS trust65
Healthcare site22
Residential care home21
Nursing home19
Private limited company16
Ministerial department14
Type not available11
Health and social care service regulator9
Local health board9
English metropolitan district council7
Multi-service care provider7
Care-home operator5
Coronial office5
English county council5
Executive non-departmental public body4
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.
Sefton, St Helens and Knowsley
Concerns raised3
Failure to provide appropriate falls prevention for a resident with evolving dementia
Failure to provide training and development on falls prevention
Failure to accurately and promptly report falls and complete falls-prevention referral forms
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised3
Lack of falls risk training for care home staff
Inadequate and inconsistent documentation of falls risk management
Failure to review risk management plans when risks change or after falls
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
Include the falls-specific training package in mandatory induction and annual refresher training for staff.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Action
Review risk management plans and clarify documentation, review, updating and clinical-rationale expectations for staff.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Action
Make falls-documentation compliance and quality a continuing review point in annual appraisals.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Review accident and incident reports to identify required responses and further falls-mitigation measures.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Discuss accidents and incidents in weekly clinical reviews and assign actions to update assessments and management plans.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Have the Deputy Manager review assessments and plans to triangulate care and verify completion of assigned clinical-review actions.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Audit high-risk patients’ assessments and management-plan documentation to verify appropriate assessment and recording.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Action
Maintain improved falls-documentation standards through an ongoing audit programme.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 14 February 2024.
Action
Remind staff of reassessment triggers, including after hospital discharge and return to the home.
Stated by Care UKStated 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
The specific falls-prevention package was developmental rather than mandatory; all staff had completed mandatory training containing falls-risk elements.
Stated by Care UKDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Wiltshire and Swindon
Concerns raised1
Failure to complete initial falls risk assessments using all available information
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.5
Action
Operate staffing governance and deployment processes using acuity data, enhanced-care assessments and three-times-daily staffing meetings.
Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Review the enhanced-care policy, documentation and teaching to clarify assessment requirements and supervision levels.
Stated by Great Western Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
Action
Trial the enhanced-care and ‘Stay in the bay’ approach on three wards, with daily review of assessments, care gaps and education.
Stated by Great Western Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
Action
Develop a handover tool that records patients’ falls risks in greater detail.
Stated by Great Western Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
Action
Provide Acute Medical Unit training on multifactorial falls assessment, including risks, information sources and supervision levels.
Stated by Great Western Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
Avon
Concerns raised2
Failure of ambulance staff to recognise falls risk and initiate further action
Failure to complete falls risk assessments in accordance with JRCALC guidelines
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The JRCALC holistic falls assessment cannot be reliably implemented in ACA because it is time-consuming and incompatible with dynamic, high-turnover work.
Stated by Bristol Ambulance EMSUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East London
Concerns raised2
Failure to complete falls care plans
Failure to complete falls risk assessments
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Lincolnshire
Concerns raised1
Inadequacy of the generic falls prevention policy
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.2
Action
Personalise generic care-home policies, including the falls prevention and management policy.
Stated by Phoenix Care CentreStated plannedThe respondent said that this action was planned when they made their response on 14 September 2023.
Action
Personalise generic care-home policies, including the falls prevention and management policy.
Stated by Phoenix Care CentreStated plannedThe respondent said that this action was planned when they made their response on 14 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The comprehensive falls prevention policy is legally and operationally adequate, although generic policies will be personalised for the home.
Stated by Phoenix Care CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The comprehensive falls prevention policy, supplied by a professional provider and accessible to staff, was considered sufficient despite its generic format.
Stated by Phoenix Care CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Norfolk
Concerns raised1
Failure to address falls risks and faulty sensor mats
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.3
Action
Install and operate a monitoring system linking room-entry records, sensor mats, audible alarms and response-time reporting.
Stated by Broadland View Care HomeStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.
Action
Increase maintenance alarm checks from monthly to weekly and replace faulty sensor mats immediately, with additional resident observations until repairs are completed.
Stated by Broadland View Care HomeStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.
Action
Check sensor mats three times daily and record testing, faults, replacements and handover information.
Stated by Broadland View Care HomeStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Sensor-mat risks are addressed through checks three times daily, immediate replacement, increased observations and maintenance arrangements.
Stated by Broadland View Care HomeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Riding and Hull
Concerns raised1
Lack of training for pharmacy delivery staff on responding to service-user falls at home
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
Set training requirements for unregistered pharmacy staff, including delivery drivers.
Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
Action
Assess the pharmacy’s safeguarding risks and factor the concern into inspection timing and focus decisions.
Stated by General Pharmaceutical CouncilStated plannedThe respondent said that this action was planned when they made their response on 18 July 2023.
Action
Enrol all delivery agents on the Delivering Medicines Safely and Effectively training programme.
Stated by Excel Chemists T/A Orchard 2000 PharmacyStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
Action
Supervise delivery agents’ completion of the safety training and provide support through pharmacy managers.
Stated by Excel Chemists T/A Orchard 2000 PharmacyStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
Delivery drivers are not directly regulated by the regulator.
Stated by General Pharmaceutical CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Pharmacy owners are responsible for ensuring unregistered staff receive appropriate training.
Stated by General Pharmaceutical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The regulator does not mandate training details for particular scenarios because pharmacy support staff have diverse roles.
Stated by General Pharmaceutical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The regulator’s role covers registered pharmacists and pharmacy technicians, not unregistered delivery drivers.
Stated by General Pharmaceutical CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Delivery drivers are not generally expected to receive training specifically for managing a service-user’s fall at home or to enter patients’ homes.
Stated by General Pharmaceutical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The pharmacy defines support staff roles, while its Superintendent pharmacist is responsible for ensuring their training and competencies meet requirements.
Stated by General Pharmaceutical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Berkshire
Concerns raised2
Insufficient sensor mat provision for a high-falls-risk resident
Failure to position a high-falls-risk resident’s bed appropriately
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised2
Inadequate falls risk assessment training during staff induction
Failure to audit falls risk assessments for correctness
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.7
Action
Create an action plan covering falls assessment, enhanced supervision training and falls-risk-assessment auditing.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2023.
Action
Deliver an Essential to Role training week for new starters within two months of commencing, including falls and enhanced supervision training.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Update temporary-staff ward induction checklists to include essential falls-risk-assessment and falls-prevention content.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2023.
Action
Audit temporary-staff induction checklists through Matrons and discuss findings at inpatient quality review meetings.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Use the launched Essential Care Framework to support clinical-team self-assessment and incorporate falls-training improvements into it.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Conduct spot-check reviews of falls-risk assessments during care rounding.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Develop a quarterly falls-prevention effectiveness audit covering assessment correctness and care-plan impact.
Stated by Birmingham Community Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
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Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
