Recurring concern
Unreliable emergency response arrangements in care homes
First reported 15 Feb 2016•Latest report 31 Oct 2025
What this concern includes
Includes care-home arrangements for recognising emergencies, seeking medical or emergency assistance, activating emergency calls, allocating responsibilities, using emergency procedures and coordinating the immediate response, including the anchor's inadequate training of non-clinical staff and failures to provide defined emergency procedures.
Not included
- Excludes generic care-home staffing, training or communication deficiencies unless they directly impair the care home's emergency-response arrangement.
- Excludes failures limited to ambulance dispatch, attendance, hospital handover or treatment after the emergency response has been appropriately initiated.
- Excludes routine clinical care, welfare checks or resident supervision where no care-home emergency-response deficiency is identified.
- Excludes generic first-aid or resuscitation competence concerns unless they are part of the wider care-home emergency-response arrangement.
- Excludes the narrower concern concerning care staff's ability to initiate an appropriate 999 or 111 call when that is the only supported failure.
- Reports
- 17
- Individual concerns
- 19
- Date range
- 2016–2025
- Stated actions
- 26
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.
-
Concerns raised2
Failure to obtain timely alternative clinical input when the registered GP is unavailable
Insufficient training of non-clinical staff in responding to urgent health concerns
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 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.2
-
Action
Supervise senior care assistants on obtaining clinical support, including contacting 111 or 999 when residents are unwell and a GP is unavailable.
Stated by Riversdale (Northwest) Limited -
Action
Arrange local GP registration within 24 hours for new out-of-district residents and obtain 111 advice if they become unwell before registration.
Stated by Riversdale (Northwest) Limited
-
Concerns raised1
Delays in care assistant intervention when a resident shows signs of choking
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 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.2
-
Action
Reissue Basic Life Support and IDDSI/Dysphagia training electronically with defined completion timeframes.
Stated by Hill Care Group -
Action
Deliver face-to-face emergency first aid training to all staff by 14 October 2025.
Stated by Hill Care Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.
Stated by Hill Care Group
-
Concerns raised1
Delays in calling an emergency ambulance for very unwell residents
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 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.3
-
Action
Present learning from the matter to home managers, including escalation expectations and immediate 999 calls for newly unresponsive residents.
Stated by Barchester Healthcare Limited -
Action
Complete themed supervisions covering RESTORE2 clinical judgement and managing resident deterioration.
Stated by Barchester Healthcare Limited -
Action
Provide staff with Clinical Shots guidance for assessing residents and responding to deterioration.
Stated by Barchester Healthcare Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
The reported 09:30 incident time is unsupported; staff identified no concerns about the resident’s health or wellbeing then.
Stated by Barchester Healthcare Limited
-
Position
Staff did not consider a 49-minute escalation period appropriate for an unresponsive resident and recalled no significant delay in this case.
Stated by Barchester Healthcare Limited
-
Concerns raised1
Lack of healthcare assistant and nursing staff training and clinical skills or knowledge for emergency care
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 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.2
-
Action
Continue providing nursing and care staff with up-to-date CPR and emergency-situation training.
Stated by Acorn Lodge Care Centre -
Action
Purchase Lifevac devices and train relevant staff in their use, alongside providing choking-response sessions.
Stated by Acorn Lodge Care Centre
-
Concerns raised1
Failure to maintain emergency-response training through drills and expiry awareness
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 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.4
-
Action
Deliver emergency-response training through eLearning, recorded face-to-face sessions, expiry reminders, a maintained training matrix and weekly compliance review.
Stated by Chiltern Care Services -
Action
Finalise the process document governing emergency CPR drills.
Stated by Chiltern Care Services -
Action
Assess the competency of staff who will deliver emergency CPR training within one month.
Stated by Chiltern Care Services
-
Action
Obtain a PractiMan adult/child CPR training manikin for the home.
Stated by Chiltern Care Services
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Emergency CPR drills have not started because trainer competency assessment is pending; drills are expected to begin within one month.
Stated by Chiltern Care Services
-
Concerns raised1
Failure to provide wearable emergency alert devices to residents not assessed as high risk of falls
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 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
-
Action
Reconfigure the call-bell system to escalate unanswered calls after three minutes to an emergency tone.
Stated by Avery Healthcare Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The reconfigured call bell system makes wrist-worn emergency watches unnecessary for high-risk residents.
Stated by Avery Healthcare Group
-
Concerns raised1
Failure to provide sufficiently frequent and effective emergency response training for care home staff
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 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.4
-
Action
Provide face-to-face basic life-support and Level 1 first-aid training covering choking recognition, immediate response and escalation; training has reached 82% of staff.
Stated by J&K Partnership -
Action
Give the two staff members without face-to-face training choking-response guidance and e-learning training.
Stated by J&K Partnership -
Action
Deliver a face-to-face three-day Level 3 first-aid qualification to all service shift leaders.
Stated by J&K Partnership
-
Action
Introduce tabletop emergency exercises alongside face-to-face training and continuing e-learning.
Stated by J&K Partnership
-
Concerns raised1
Failure of warning alarms to support immediate response throughout the care home
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 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.3
-
Action
Use walkie-talkies to coordinate night staff movements and communication throughout the building.
Stated by Broadland View Care Home -
Action
Install and operate a monitoring system linking room-entry records, sensor mats, audible alarms and response-time reporting.
Stated by Broadland View Care Home -
Action
Add sounders near Rooms 1 and 2 and test alarms to ensure emergency signals can be heard across the home.
Stated by Broadland View Care Home
-
Concerns raised2
Lack of an emergency response procedure
Lack of reliable emergency communication facilities in the residents’ dining room
This report raised 9 other concerns. 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
-
Action
Implement a written emergency procedure, embed it in risk assessments and the improvement plan, and train staff on it.
Stated by Hibiscus Housing Association Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
The CQC is not responsible for regulating the quality of Hibiscus House’s accommodation.
Stated by Care Quality Commission
-
Position
The concern that no emergency alarm was available in the dining room is disputed because a functioning Care Link pull cord was installed there.
Stated by Hibiscus Housing Association Limited
-
Concerns raised1
Failure to provide timely out-of-hours access to the care home for ambulances
This report raised 9 other concerns. 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
-
Action
Install corridor monitoring screens linked to the external doorbell with audible alerts to improve timely building access.
Stated by Castlehill Specialist Care Centre
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Stated by Care Quality Commission
Data last updated 7 September 2026