Care risk assessment failures
Ineffective assessment, monitoring, and mitigation of health, safety, and welfare risks for individuals receiving personal care.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
87match
#7 - Inadequate assessment of mental health for children and young people in care.
Young people in care are significantly more likely to have experienced trauma and adverse experiences than their peers, and therefore strong mental health support is crucial. Although local authorities are required to assess the emotional and mental health of children in their care, evidence suggests this does not always happen in practice. Our witnesses were clear that there...
Matched on
terms: assessment, care
CQC action
86match
Roky Care Ltd
The provider must ensure appropriate assessment of risks relating to the health and safety of service users receiving care and do everything reasonably practicable to mitigate any such risks.
Matched on
terms: assessment, care
IOPC learning recommendation
86match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that Thames Valley Police reminds police officers who bring members of the public into custody, custody sergeants and healthcare professionals to be proactive when conducting a risk assessment for a detainee, by reviewing items that belong to the person, whether or not they are still on them or have been seized. When doing so, they...
Matched on
terms: assessment, care
Inquiry recommendation
85match
R101 - Whole-system commissioning with cross-agency risk assessment
Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole system (including primary care, housing, benefits and independent and third sector providers of services). There must be a risk assessment that assesses how the impact of change in one part of the system impacts on another...
Matched on
terms: assessment, care, failure
PFD report
81match
May Gibson
The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, and implementing risk reduction plans at the care home.
Matched on
terms: assessment, care, failure
Inquiry recommendation
78match
WATE-(33) - Base care plans on comprehensive assessment, prepared with child consultation
The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Matched on
terms: assessment, care
Inquiry recommendation
78match
WATE-(31) - Require comprehensive child needs assessment before admission to care
Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Matched on
terms: assessment, care
CQC action
78match
Trent Lodge Residential Care Home
The registered person must ensure that each service user is protected against the risks of receiving care and treatment that is inappropriate or unsafe by means of the effective operation of systems designed to enable the registered person to identify, assess and manage risks relating to the health, welfare and safety of service users and others who may...
Matched on
terms: care
CQC action
78match
TerraBlu Homecare
Registered persons had failed to adequately assess individual risks relating to the health, safety and welfare of people and staff.
Matched on
terms: care
CQC action
78match
Spindrift Care Home Limited
Risk assessments and measures to reduce risks to people who lived at the home were not always up to date and reflective of people's current needs.The provider's business continuity plan was not up to date and required review. Personal Emergency Evacuation Plans were not in place for everyone who lived at the home. We found handwashing facilities were...
Matched on
terms: assessment, care
PFD report
77match
Maya Kantengule
Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments for swimming pool birthday parties, and failures to follow safety procedures, including non-functional CCTV.
Matched on
terms: assessment, failure
Inquiry recommendation
77match
6 - Draw up maternity risk assessment protocol
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who will carry out this assessment against which criteria; and how this will be discussed with pregnant women and...
Matched on
terms: assessment, care
CQC action
74match
Utmostcare Limited
Risks to people were not clearly identified and managed. Risk assessments were either not present or lacked sufficient detail to help staff understand and respond to risks. The service had not ensured the proper and safe management of medicines, including record keeping of the administration of medicines. Systems were not operated effectively to ensure appropriate infection control measures.
Matched on
terms: assessment, care
CQC action
74match
St Marks Residential Care Home
Systems had not been fully established to monitor and mitigate risks to the health, safety and welfare of people using the service. This placed people at potential risk of harm.
Matched on
terms: care
PFD report
73match
Raymond Shepherd
Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without appropriate referrals or a mental capacity assessment.
Matched on
terms: assessment, care
PFD report
73match
Etheline De-Gale
Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Matched on
terms: assessment, care
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: assessment, care
PFD report
73match
Stanley Langdon
A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
Matched on
terms: assessment, care
PPO recommendation
73match
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete the medical risk assessment in full, including signing and dating the form.
Matched on
terms: assessment, care
Committee recommendation
73match
#26 - Fourth Report: Home Office preparedness for COVID-19 (Coronavirus): institutional accommodation
Asylum seekers should not have been moved to new accommodation during the pandemic without justified and urgent reasons for doing so or without a vulnerability assessment demonstrating that the move could be made safely. This must happen Home Office preparedness for COVID-19 (Coronavirus): institutional accommodation 57 in future. If, following such an assessment, a move is found to...
Matched on
terms: assessment, care
CQC action
73match
Nower House
The failure to ensure risks to people's safety were robustly monitored and that safe medicines systems were followed was a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Matched on
terms: care, failure
Inquiry recommendation
73match
SP22 - LCC online harms risk assessment review
Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing Service) assess and manage risk and online harms to children. This review should ensure that all frontline staff have a consistent and up-to-date understanding of online risks, and that they have access to effective tools and...
Matched on
terms: assessment, care
CQC action
70match
The Hailey Residential Care Home
The provider failed to assess the risks to the health and safety of service users and to do all that is reasonably practicable to mitigate risks.
Matched on
terms: care
PFD report
69match
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: assessment, care
PFD report
69match
Derrick Plater
There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Matched on
terms: assessment, care
PFD report
69match
Ross Boyd
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
Matched on
terms: assessment, care
PFD report
69match
Harold de Mello
A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care needs, or consult relevant family.
Matched on
terms: assessment, care
PFD report
69match
Charles Lawrence
The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in immediate medical assessment for recurrent fallers.
Matched on
terms: assessment, care
PFD report
69match
Maria Silkin
The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to a dangerous delay in appropriate medical intervention.
Matched on
terms: assessment, care
PFD report
69match
Ian Morley
A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Matched on
terms: assessment, care
PFD report
69match
Peter Furness
The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.
Matched on
terms: assessment, care
PFD report
69match
Joanna Bowring
Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
Matched on
terms: assessment, care
PFD report
69match
Freda Cordy
A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
Matched on
terms: assessment, care
PFD report
69match
Micael McMonigle
Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments were not updated, and the response to the patient's absence was delayed and did not conform with procedures; staff knowledge of leave policy was inadequate.
Matched on
terms: assessment, failure
PFD report
69match
Dorethea Parr
Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about falls, leading to missed intervention opportunities.
Matched on
terms: assessment, care
PFD report
69match
Robert Cardwell
Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Matched on
terms: care, failure
PFD report
69match
Constance Connolly
The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up on a scan they ordered, and a breakdown in communication between different care teams resulting in a cancelled appointment and no further action.
Matched on
terms: care, failure
LGO / SPSO decision
69match
25-000-452 - Berkley Care Blenheim Limited
Summary: There was fault in the quality of care provided to Mr X’s late grandfather Mr Y by the care home. It failed to carry out a thorough pre-assessment, delayed taking action when Mr Y’s food and fluid intake reduced and failed to properly assess and respond to Mr Y’s risk of falls. It also delayed billing Mr...
Matched on
terms: assessment, care
Committee recommendation
69match
#9 - 79th Report - Supporting people with frailty outside hospitals
In 2024–25, 32 of 106 local NHS areas (known as sub-ICBs) assessed less than 10% of their registered patients aged 65 or over. However, nine of 106 local areas assessed 90% or more of this group of people, suggesting that good performance is possible within existing resources.18 The National Institute for Health and Care Excellence (NICE) guidelines specify...
Matched on
terms: assessment, care
Committee recommendation
69match
#7 - 79th Report - Supporting people with frailty outside hospitals
For all patients diagnosed with severe frailty, the GP contract requires GPs to do a clinical review. This includes a review of the patient’s medication, a falls risk assessment and a discussion with the patient of the benefits of having an enriched summary care record that provides healthcare professionals with access to core details about the patient (medications,...
Matched on
terms: assessment, care
Committee recommendation
69match
#3 - 79th Report - Supporting people with frailty outside hospitals
NHS England’s existing oversight arrangements are not improving GPs’ assessment and support of people with frailty. It is not clear exactly who is responsible for improving performance. NHSE considers that ICBs are responsible for commissioning services to meet the needs of their population; and that the service providers must ensure that the services they are commissioned to provide...
Matched on
terms: assessment, care
LGO / SPSO decision
68match
23-008-538 - Oxfordshire County Council
Summary: Ms X complained about Oxfordshire County Council, Oxford Health NHS Foundation Trust, and NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board. She complained about faults relating to aftercare under section 117 of the Mental Health Act 1983. We have upheld Ms X’s complaints about discharge, assessment, care planning and personal health budgets. We did not uphold...
Matched on
terms: assessment, care
Article 2 learning point
68match
CR — HMP Swansea - LP Healthcare 1
A range of information including that from assessment during custody and from court proceedings should be considered along with the presenting risk factors when undertaking an initial assessment of an individual’s risk of suicide/self-harm and the opening of a potential ACCT.
Matched on
terms: assessment, care
LGO / SPSO decision
68match
20-014-489 - Hertfordshire County Council
Summary: Ms C complains the Council failed to properly safeguard her mother or provide satisfactory information about funding for care homes. The Council is at fault for failing to carry out safeguarding, assessment, and complaint handling procedures correctly. It is also at fault for failing to properly advise Ms C about funding for care home placements. These failures...
Matched on
terms: assessment, care, failure
LGO / SPSO decision
68match
21-007-208 - Hertfordshire County Council
Summary: The Council’s failure to consider the needs and practicalities of the wider family before agreeing that a proposal by the Borough Council would meet Miss X’s disabled child’s needs was fault. The Council has agreed to complete a new assessment.
Matched on
terms: assessment, care, failure
Inquiry recommendation
66match
R68 - Cumulative risk assessment across protection plans
Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable adults within a single unit, cumulative risks arising from those individual protection plans across all residents must also be evaluated.
Matched on
terms: assessment
Inquiry recommendation
66match
R25 - Pressure damage risk assessment
Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score.
Matched on
terms: assessment
CQC action
66match
Continuity Healthcare Services Private Limited
The provider did not adequately assess and protect people against risks by doing all that was practicable to identify and mitigate such risks. The provider did not ensure staff had adequate qualifications, competence and skills to provide safe care. The provider did not ensure the safe management of medicines.
Matched on
terms: care
CQC action
66match
Westwood Care Home
The provider had not taken adequate steps to ensure safety risks, and incidents and accidents were assessed and mitigated. The provider had not ensured there was adequate governance of medicine administration or that staff competency was up to date.
Matched on
terms: care
PFD report
65match
Ernest Harper
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Matched on
terms: assessment