First reported 28 May 2014•Latest report 10 Jun 2026
Definition
What this concern includes
Includes failures of welfare-check processes for people whose health or welfare is of concern, including unclear purpose, frequency or criteria, inconsistent understanding of what constitutes a check, inadequate recording requirements and related controls needed to ensure checks are meaningful and traceable.
Not included
Excludes routine patient observations, continuous observation, clinical monitoring and named mental-health observation systems unless the assertion specifically concerns a welfare-check process.
Excludes failures limited to conducting welfare checks for people in distress where the broader concern is completion of a distress check rather than the health-concern welfare-check process.
Excludes generic policy, training, documentation or staffing deficiencies unless they directly undermine the definition, delivery or recording of required welfare checks.
Excludes non-person checks, such as premises, equipment or prisoner-security checks, unless the assertion concerns a person's health or welfare.
Reports
28
Distinct published reports
Individual concerns
34
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
54
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.
Ministry of Justice6
HM Prison and Probation Service3
Department of Health and Social Care2
Dorset Healthcare University NHS Foundation Trust2
Metropolitan Police Service2
NHS England2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Cardiff & Vale University LHB1
Care Quality Commission1
Care UK1
College of Policing1
Department for Digital, Culture, Media and Sport1
Depaul UK1
Devon & Cornwall Police1
Exeter Prison1
Ministerial department9
NHS trust9
Prison or young offender institution6
Police force4
Executive agency3
Executive non-departmental public body2
Registered provider of social housing2
Type not available2
Coronial office1
Devolved government1
Health and social care service regulator1
Independent healthcare provider1
Justice inspectorate1
Local health board1
Multi-service care provider1
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.
Inner North London
Concerns raised4
Lack of consistent criteria for welfare checks and their recording
Failure to undertake required welfare checks at least every 24 hours
Inadequacy of the welfare-check recording system
Failure to investigate and implement improvements to welfare-check systems
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.10
Action
Reinforce policy and procedure guidance through team meetings, away days, online training, refresher training and an accessible policy library.
Stated by Sapphire Independent HousingStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Draft and submit a standalone At Risk policy for Board approval and wider publication.
Stated by Sapphire Independent HousingStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
Action
Formulate and use a written contractor induction package covering the conduct and recording of welfare checks.
Stated by Sapphire Independent HousingStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Extend night-shift hours and use a mandatory handover template to communicate failed welfare checks and At Risk issues between shifts.
Stated by Sapphire Independent HousingStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Deliver and continue welfare-check, risk-management, complex-needs and related At Risk training for resident-facing and Conway House staff.
Stated by Sapphire Independent HousingStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Introduce and monthly monitor At Risk procedure performance indicators through operational management meetings, with senior management review and Board reporting of incidents and KPI failures.
Stated by Sapphire Independent HousingStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
Action
Introduce a shift leader on every shift to oversee At Risk compliance and effective handover.
Stated by Sapphire Independent HousingStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Recruit permanent night staff with job descriptions incorporating the At Risk procedure.
Stated by Sapphire Independent HousingStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Implement smaller, more frequent working patterns instead of seven consecutive shifts to reduce fatigue and missed checks.
Stated by Sapphire Independent HousingStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Review the welfare-check spreadsheet every Friday and recruit an administration assistant to provide qualitative oversight and sample testing.
Stated by Sapphire Independent HousingStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The existing At Risk procedure remains fit for purpose and provides adequate welfare checks and escalation mechanisms when correctly followed.
Stated by Sapphire Independent HousingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The existing spreadsheet is considered adequate for recording welfare checks, so its format will be maintained rather than replaced.
Stated by Sapphire Independent HousingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Lack of policy on when to increase welfare checks
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.1
Action
Implement an organisational welfare-check procedure defining routine and increased checks, authorisation, duration and recording requirements.
Stated by Depaul UKStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.
South Yorkshire (Western)
Concerns raised1
Lack of written instructions for conducting welfare checks
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Dorset
Concerns raised1
Failure to require an appropriate verbal response during welfare checks
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
Publish reminders requiring verbal welfare-check responses and cell access when no response is obtained.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Action
Conduct and record daily compliance observations of welfare checks, with monthly assurance review and performance-management challenge for failures.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Action
Train new prison officers to conduct roll-check, unlock and welfare checks, emphasising confirmation of prisoner safety and welfare.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Dorset
Concerns raised1
Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances
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
Gather information from regional prison safety groups about local initiatives for observations and welfare checks.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 22 October 2021.
Action
Discuss nationally rolling out local drug-related safety initiatives with the NHSE/I national team.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 22 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
HMPPS is responsible for deciding whether local welfare, substance intervention and life-support processes should be rolled out nationally.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
West Yorkshire Eastern
Concerns raised1
Absence of specific guidance for conducting welfare checks in the First Night Centre
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 revised welfare-check processes requiring resident responses, specifying timing and requirements, and recording night-state checks in the electronic custody system.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 22 July 2021.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to conduct welfare checks during first morning cell unlocks
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.
Manchester North
Concerns raised2
Failure to update handover information about expected welfare checks
Failure to maintain complete and reliable welfare-check records
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.
West Yorkshire (Western)
Concerns raised1
Client wellbeing checks protocol failing to establish appropriate physical checks and rousing when necessary
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
Update the Observation and Client Wellbeing Checks Policy with expanded explanations and explicit working-practice instructions.
Stated by UK Addiction Treatment GroupStated completedThe respondent said that this action was complete when they made their response on 16 January 2020.
Action
Review related risk assessments, policies and procedures to ensure they operate collectively with the updated checks policy.
Stated by UK Addiction Treatment GroupStated completedThe respondent said that this action was complete when they made their response on 16 January 2020.
Action
Provide all staff with further training on the updated policy and safe, effective working practice.
Stated by UK Addiction Treatment GroupStated plannedThe respondent said that this action was planned when they made their response on 16 January 2020.
Action
Adapt registered-manager monitoring of working practice to reflect the reviewed and updated checks policy.
Stated by UK Addiction Treatment GroupStated plannedThe respondent said that this action was planned when they made their response on 16 January 2020.
Avon
Concerns raised1
Absence of a welfare-check policy for primary care
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.
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
Request close liaison and joint working with Avon and Somerset Police on welfare checks.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The police are responsible for the welfare-check policy, while the Trust will liaise and work jointly with them.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of welfare-check processes for people whose health or welfare is of concern, including unclear purpose, frequency or criteria, inconsistent understanding of what constitutes a check, inadequate recording requirements and related controls needed to ensure checks are meaningful and traceable.
