First reported 28 Mar 2013•Latest report 28 Oct 2025
Definition
What this concern includes
Includes failures to carry out, complete or maintain required overnight checks or observations for care recipients, including missed checks caused by staff being occupied with other service users.
Not included
Excludes failures involving daytime or non-overnight checks unless they are part of the same explicitly required overnight checking process.
Excludes deficiencies in training, staffing, documentation or policy where the reports do not directly establish a failure of required overnight checks.
Excludes clinical escalation, treatment, handover or environmental-checking concerns that are not specifically manifestations of missed overnight checks.
Reports
8
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
17
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.
Bradford Teaching Hospitals NHS Foundation Trust1
Care Quality Commission1
Care UK1
Dorset Healthcare University NHS Foundation Trust1
HM Prison and Probation Service1
Home Office1
Independence Homes Limited1
Northside House1
Phoenix Care Centre1
Priory Group1
NHS trust2
Executive agency1
Health and social care service regulator1
Healthcare site1
Independent healthcare provider1
Ministerial department1
Multi-service care provider1
Private limited company1
Residential care home1
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.
West Yorkshire (Western)
Concerns raised1
Failure to complete ward observations in accordance with escalation guidance
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.3
Action
Provide documented staff feedback and mandatory retraining on NEWS escalation requirements.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 October 2025.
Action
Disseminate incident learning through ward safety huddles and the Sisters’ meeting.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 October 2025.
Action
Conduct weekly audits of patient observation charts and report the results to the Clinical Governance Committee.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 October 2025.
East Sussex
Concerns raised1
Failure to carry out required prisoner roll checks
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.5
Action
Review and clarify the roll-check local operating procedure, including required times and recording arrangements.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Publish staff notices reinforcing the importance of completing roll checks and prompting key safety observations.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Continue taking appropriate action, including disciplinary action where necessary, when staff fail to meet roll-check expectations.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Deliver further bite-size roll-check training sessions, prioritising staff who previously lacked the training.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Provide on-the-job roll-check support and training through standards coaching team staff shadowing officers at HMP Lewes.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing roll-check assurance measures and staff accountability are considered sufficient; staff must be trusted to perform required duties.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Lincolnshire
Concerns raised1
Inadequacy of periodic nightly observations
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
Use an electronic care-planning system to record night checks and link them directly to residents’ care plans.
Stated by Phoenix Care CentreStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.
Action
Use an electronic care-planning system to record two-hourly night checks and link them directly to residents’ care plans.
Stated by Phoenix Care CentreStated completedThe respondent said that this action was complete 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
Two-hourly night checks, previously inspected records, and electronic recording are considered sufficient observation arrangements.
Stated by Phoenix Care CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Night checks were conducted every two hours, recorded separately or electronically, and regarded as standard practice accepted during regulatory inspections.
Stated by Phoenix Care CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Exeter and Greater Devon
Concerns raised1
Intermittent night welfare checks and ACCT observations
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.
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
Conduct overnight welfare checks using daily printed checklists and review completed checks the following day.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Have healthcare staff attend ACCT reviews, record their participation, and contribute substance-misuse and detoxification risk information.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
HMPPS owns and operates the ACCT process; healthcare staff contribute risk information but do not oversee or monitor it.
Stated by Care UKRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Milton Keynes
Concerns raised1
Failure to carry out required observations
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.
Surrey
Concerns raised1
Failure to carry out required checks when staff are occupied with other service users
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.1
Action
Review available night staffing resources at services.
Stated by Independence HomesStated completedThe respondent said that this action was complete when they made their response on 26 July 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing waking-night staffing is considered sufficient for assessed needs.
Stated by Independence HomesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Local authorities or CCGs are responsible for arranging and funding higher staffing ratios required by assessed needs.
Stated by Independence HomesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Black Country
Concerns raised2
Failure to carry out required overnight checks
Lack of clear instructions defining required overnight checks
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
Carry out an unannounced responsive inspection of the care provider against safeguarding, risk, welfare and complaints requirements.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 10 September 2014.
Action
Adopt the Health and Social Care Act 2008 fundamental standards, including requirements concerning personalised, safe and competent care.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 10 September 2014.
Action
Develop inspection processes using longer team-based inspections, consistent key lines of enquiry and service ratings.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 10 September 2014.
Action
Ensure the coroner’s report is noted and informs the provider’s next ratings inspection, including examination of processes and training.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 10 September 2014.
Norfolk
Concerns raised1
Failure to check whether patients have moved or remained immobile for an extended period during hourly observations
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.
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 to carry out, complete or maintain required overnight checks or observations for care recipients, including missed checks caused by staff being occupied with other service users.
