Care home safety and capacity
Care homes failing to protect service users from risks due to inadequate premises maintenance and inappropriate admission practices.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
90match
Westwood Residential Care Home
Systems and processes had not been fully established to assess, monitor and manage safety of the environment. Risks to people were not accurately recorded; and there was a failure to ensure sufficient levels of staff training to meet people's individual needs and keep them safe.
Matched on
terms: care, home, safety
CQC action
90match
Lauren Court Residential Care Home
We recommend the service review the environment and make adaptions to the premises, in line with people's needs and best practice guidance.
Matched on
terms: care, home
CQC action
90match
Rushymead Residential Care Home
The provider must ensure that people who use services and others are protected against the risks associated with unsafe or unsuitable premises through adequate maintenance, risk assessment and management, and that risks posed to people's health are routinely managed effectively.
Matched on
terms: care, home
LGO / SPSO decision
86match
23-020-716 - Bupa Care Homes (AKW) Limited
Summary: We will not investigate this complaint about adult social care in a residential care home. The Care Provider has accepted failings in communication and record keeping, has apologised, and has spoken with staff to improve service. It is unlikely an Ombudsman investigation would add to this or lead to a different outcome.
Matched on
terms: care, home
Committee recommendation
86match
#9 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
On 17 March the NHS told trusts to discharge urgently all medically fit hospital patients with COVID-19 to maximise inpatient and critical care capacity. On 2 April, the Department told care homes that they needed to make their full capacity available and could admit patients with COVID-19 by isolating suspected or confirmed cases. Some Local Authorities were pressurising...
Matched on
terms: capacity, care, home
Committee recommendation
86match
#11 - Lack of oversight leaves children in illegal unregistered homes at significant risk.
Ofsted cannot routinely inspect unregistered homes and local authorities are not obliged to inform Ofsted when they place children in unregistered care, even though it is illegal for providers to operate such homes.22 In such cases there are no formal checks to ensure that children receive high quality care and that they and the wider community are safe....
Matched on
terms: care, home, safety
Committee recommendation
86match
#2 - Reaffirm commitment to reducing children in unregistered homes to zero by 2027 and detail specific actions.
It is unacceptable that children are placed in illegal settings that are not inspected, increasing safety risks and offering no assurance over the quality of care. Over the last five years, local authorities have reported placing more and more children into unregistered homes. It is illegal to run a children’s home or supported accommodation that is not registered...
Matched on
terms: care, home, safety
Inquiry recommendation
83match
P2-60 - Care homes in scope for new regulatory regime
The regulatory measures recommended in Chapter 11 should apply to care homes in England. Regulation should cover both systems and professionals where staff are providing care to deceased people in care homes.
Matched on
terms: care, home
Committee recommendation
83match
#44 - Unacceptable placement of vulnerable children in unsuitable homes, requiring full care provision for all.
It is unacceptable that vulnerable children are being placed in unsuitable homes such as barges and caravans with little or no support. The new regulatory and inspection regime is an important step in the right direction, but the Department for Education needs to go further and ensure that all children under 18 receive care where they live, rather...
Matched on
terms: care, home
CQC action
82match
Heatherdene Residential Care Home
Environmental risks were not always considered which placed people at the risk of harm. People were not protected from the risks associated with the management and administration of medicines.
Matched on
terms: care, home
CQC action
82match
Laurel Lodge Care Home
The provider must ensure that premises and equipment used by the service provider are safe, suitable for the purpose for which they are being used, and properly maintained.
Matched on
terms: care, home
LGO / SPSO decision
82match
21-000-200a - Amberley Lodge Care Home (21 000 200a)
Summary: We found fault by a care home acting on behalf of the Council regarding the care it provided to Mr X, an elderly man with complex care needs. We found the care home failed to support Mr X and his wife, Mrs X, to make an informed choice about his GP registration. We also found the care...
Matched on
terms: care, home
PFD report
81match
Marjorie Evelyne Keogh
The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments and non-compliant staircase furniture also posed safety issues.
Matched on
terms: care, home, safety
LGO / SPSO decision
78match
22-000-089 - Blanchworth Care Homes Limited
Summary: We will not investigate this complaint about missing items belonging to the complainant’s deceased mother. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. An investigation would be unlikely to add anything to the Care Provider’s response.
Matched on
terms: care, home
LGO / SPSO decision
78match
PSOW-202104529 - A Care Home
Mr X complained about aspects of care provided to his late father Mr Z, by the Care Home between April 2020 and May 2021. The Ombudsman found that there was no failure to consider the interaction between trazadone (an antidepressant) and lamotrigine (epilepsy medication) and that it was, ultimately the role of the prescribing clinicians, as opposed to...
Matched on
terms: care, home
LGO / SPSO decision
78match
PSOW-202202308 - A Care Home
Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately manage her mother’s skin integrity, leading to the...
Matched on
terms: care, home
LGO / SPSO decision
78match
20-005-997 - Conifers Care Homes Ltd
Summary: Mrs X complains the Care Provider failed to reduce her late mother’s care fees when it successfully applied for Funded Nursing Care contributions. The Care Provider said it did not charge for services covered by the Funded Nursing Care contribution and so it has not overcharged for its services. We found the Care Provider acted in line...
Matched on
terms: care, home
Committee recommendation
77match
#11 - Sixteenth Report - Progress in remediating dangerous cladding
One category of buildings below 18 metres that might present increased risks are care homes. In January 2020 the Department published advice from its independent expert advisory panel that buildings of any height with residents who need significant assistance to evacuate exacerbate the risks presented by dangerous cladding.38 While acknowledging that the presence of elderly or vulnerable residents...
Matched on
terms: care, home, safety
Committee recommendation
77match
#3 - Sixteenth Report - Progress in remediating dangerous cladding
The Department has no knowledge of how many care homes below 18 metres in height have dangerous cladding. The Department has published advice that the risks of unsafe cladding are increased for buildings, such as care homes, where there are residents who need significant assistance to evacuate. The Department is confident there are no high-rise care homes (above...
Matched on
terms: care, home, safety
IMB annual report
76match
Hull (2022)
This report for HMP Hull, ending February 2022, highlights a challenging period marked by the ongoing impact of Covid-19 restrictions, which limited IMB monitoring capacity and led to significant staff absences. While safety metrics showed reductions in violence, self-harm, and use of force, serious concerns remain regarding healthcare provision, which was deemed failing by HMIP and led to...
Matched on
terms: capacity, care, safety
Committee recommendation
74match
#10 - Significant rise in children placed in unregistered homes with lengthy placement durations.
In recent years, the number of children reported to Ofsted as being placed in unregistered homes at some point each year rose significantly, from 147 during 2020–21 to 982 during 2023–24.20 More recently, the Children’s Commissioner found that as at September 2024, 775 children were in unregistered accommodation—around 10% of all children in residential care at that point...
Matched on
terms: care, home
CQC action
74match
Highcliffe House Nursing Home
The gate must be locked to ensure people's safety.
Matched on
terms: home, safety
CQC action
74match
Clova House Residential Care Home
We recommend that the provider makes suitable arrangements to ensure people who use these bedrooms are safe.
Matched on
terms: care, home
CQC action
74match
Ashdale Care Home
The radiators in the care home did not heat the home enough. During the inspection, the provider was unable to resolve this heating issue.
Matched on
terms: care, home
CQC action
74match
Ridgeway Manor Residential Care Home
Some parts of the home were not adequately maintained or sufficiently clean.
Matched on
terms: care, home
LGO / SPSO decision
74match
25-012-341 - Bupa Care Homes (GL) Limited
Matched on
terms: care, home
LGO / SPSO decision
74match
24-018-019 - Barchester Healthcare Homes Limited
Matched on
terms: care, home
LGO / SPSO decision
74match
21-011-179 - Caring Homes Healthcare Group Limited
Summary: We will not investigate this complaint about the quality of residential care and the Care Provider’s response when Miss X raised concerns.
Matched on
terms: care, home
LGO / SPSO decision
74match
21-000-792 - Porthaven Care Homes No 3 Limited
Summary: Mr X complained Porthaven Care Homes No 3 Limited (the Care Provider) failed to provide adequate care to his wife, Mrs X during her respite stay for ten nights in the autumn of 2020. We found the Care Provider failed to identify an illness Mrs X was suffering from and to administer medicine in good time. We...
Matched on
terms: care, home
LGO / SPSO decision
74match
21-005-089 - Country Court Care Homes 3 OpCo Limited
Summary: Mrs X complained on behalf of Mrs Y, about the care she received at Tallington Care Home (the Care Provider). She says Mrs Y was put at risk and when family raised concerns, staff were aggressive. We found the Care Provider did cause injustice to Mrs Y and Mrs X because staff did not always follow care...
Matched on
terms: care, home
LGO / SPSO decision
74match
21-007-565 - Aegis Residential Care Homes Limited
Summary: The care provider did not provide sufficiently clear information about the fees or placement before Mr and Mrs X moved into the home. It should repay the deposit amount to Ms A.
Matched on
terms: care, home
LGO / SPSO decision
74match
21-013-311 - Ideal Carehomes (Number One) Limited
Summary: Mrs X complained the care home failed to provide adequate care for an illness her mother Mrs Y was suffering from, during her respite stay. Mrs X said Mrs Y suffered unnecessarily during her stay and subsequently died. We do not find fault with the care providers actions.
Matched on
terms: care, home
LGO / SPSO decision
74match
21-004-973 - Barchester Healthcare Homes Limited
Summary: Mrs D complains about the standard of care and support her father (Mr H) received while in residential care. Among other things, Mrs D says the Care Provider failed to meet Mr H’s health and care needs and provided him medication he was not prescribed. We found some fault by the Care Provider in relation to its...
Matched on
terms: care, home
PFD report
73match
Peter Pattinson
Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.
Matched on
terms: care, home
PFD report
73match
Joan Mary Jones
Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.
Matched on
terms: care, home
PFD report
73match
Alois Piska
The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.
Matched on
terms: care, home
PFD report
73match
Allan Beasley
Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.
Matched on
terms: care, home
PFD report
73match
Arthur Adley
Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Matched on
terms: care, home
PFD report
73match
Lesley Hanson
Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control measures.
Matched on
terms: care, safety
PFD report
73match
John Edwards
The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.
Matched on
terms: care, home
PFD report
73match
Joan Osborne
Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.
Matched on
terms: care, home
CQC action
73match
Normanton Retirement Home
The provider must ensure that the premises where care and treatment is delivered are clean and that all pieces of equipment are suitable for their use.
Matched on
terms: care, home
CQC action
73match
Precious Nursing & Residential Home
The provider must ensure the premises is secure with sufficient regard to people's personal safety and the security of their possessions.
Matched on
terms: home, safety
LGO / SPSO decision
73match
23-010-449 - Avery Homes (Cannock) Limited
Summary: Ms X complained about issues with the service and care provided by Avery Homes Limited. We find Avery Homes Limited at fault for providing insufficient care which caused distress to Ms X and her family. Avery Homes Limited has apologised to Ms X, refunded care homes fees and made a payment to recognise injustice.
Matched on
terms: care, home
CQC action
73match
Tregertha Court Care Home
Regulation 15 HSCA RA Regulations 2014 Premises and equipment
Matched on
terms: care, home
IMB annual report
72match
Birmingham (2021)
HMP Birmingham has shown significant improvement in safety and stability under new leadership, making it the safest it has been in years, despite challenges posed by the Covid-19 pandemic. Healthcare provision is good, and peer support systems are strong. However, key concerns persist regarding the inhumane nature of prolonged in-cell lock-up, the high levels of use of force,...
Matched on
terms: care, home, safety
Committee recommendation
70match
#12 - Local authorities resort to unregistered homes as last resort due to placement scarcity.
We asked the Association of Directors of Children’s Services how it could possibly be right for any local authority to place children in homes that are not inspected. It described this as a consequence of local authorities having an absolute duty to place young people who needed a home but in some cases no regulated placement being willing...
Matched on
terms: home
PFD report
69match
Walter Gordon Powley
Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Matched on
terms: care, home
PFD report
69match
John William Tugwell
The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Matched on
terms: care, home
PFD report
69match
Peter Norman Nott
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Matched on
terms: care, home