Failure to control risks posed by care-home residents to themselves and others
First to latest report 3 Aug 2016 — 1 Aug 2025
Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
11
What this concern includes
Includes care-home safeguarding and risk-control failures concerning risks posed by a resident to themselves or other residents, including failure to assess or reassess those risks, create or use risk-informed care plans, arrange protective supervision or separation, and implement or review safeguards intended to prevent harm.
What is not included
Excludes generic care-plan or risk-assessment omissions where no risk posed by a care-home resident to themselves or others is identified.
Excludes routine resident care, staffing, training or documentation deficiencies that are not directly part of controlling resident-related safeguarding risks.
Excludes isolated resident behaviour or harm outcomes where no continuing failure in the care-home risk-control or safeguarding arrangements is asserted.
Excludes safeguarding concerns involving children, prisoners or non-residential settings unless the assertion explicitly concerns the same care-home resident-risk process.
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.
Birmingham City Council1
Capital Care Group Limited1
Care Quality Commission1
Department of Health and Social Care1
Kerria Court1
Reinbek1
Sandwell and West Birmingham Hospitals NHS Trust1
St Johns Nursing Home Limited1
Westlands Retirement Home1
Residential care home3
English metropolitan district council1
Health and social care service regulator1
Ministerial department1
NHS trust1
Nursing home1
Private limited company1
Reports and published responses 6 reports
See individual reports that have raised this concern, and the actions taken in response
Worcestershire
Concerns raised1
Failure to complete proper risk assessments and care plans for risks to residents and others
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Capital Care Group 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.3
Capital Care Group Limited
Implement PCS as an integrated electronic system for care plans, risk assessments, task alerts and management oversight.
Capital Care Group Limited
Require monthly sample audits and random spot checks of care documentation and delivered care, with action plans addressing audit findings.
Capital Care Group Limited
Complete organisation-wide audits of care documentation to establish baselines and identify lessons for training, tools, governance and further audit scheduling.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Capital Care Group Limited
Existing electronic systems, training, audits and governance are considered sufficient to support robust risk assessments and care documentation.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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 raised1
Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk
This report raised 2 other concerns. 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
Station the administrator in reception during normal working hours to monitor the entrance and secure door closure.
St Johns Nursing Home Limited
Advertise for a weekend receptionist to monitor the door at weekends.
St Johns Nursing Home Limited
Position a staff member by the side gate during fire drills and disable the gate's exit code.
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.
Manchester South
Concerns raised1
Lack of supervision of residents in communal areas of care homes
Linked response
Borough Care 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
Borough Care Ltd
Increase staffing levels across homes, including adding a deputy manager and increasing night cover.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Borough Care Ltd
Existing staffing, risk assessments and nurse-call access are considered sufficient to keep communal areas safe despite occasional short unattended periods.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North London
Concerns raised1
Failure of safeguarding systems to prevent risks posed by residents to other residents in care homes
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
Oversight of the reported safety concerns was assigned to the Care Quality Commission as the independent regulator of providers.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Failure to include absconding risk and previous absconding behaviour in the care plan
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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.