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Recognising and managing deterioration

Introduction 

An essential part of supporting any resident within a care home is ensuring they are safe and well and that any changes in their presentation is recognised early and responded too in a timely way.

Deterioration can present in many ways. These changes are sometimes referred to as soft signs of deterioration. Soft signs are early indicators that the person you support might be becoming unwell. This could be anything such as a change in physical presentation or behaviour or changes in mental state. They are the early indicators that someone may be becoming unwell.  For residents with learning disabilities or with dementia it is particularly important that carers can identify soft signs of deterioration that the resident may not be able to communicate verbally. Any sign that a person is not their normal self should be taken seriously.


Not every illness can be prevented, but good quality daily care will reduce risks and minimise the times a resident experiences a deterioration in their health and support early identification of concerns. Some steps should be taken for every resident to reduce the risk of illness:

  • Ensure residents are drinking enough, particularly at times of heightened risk of dehydration such as in hot weather
  • Support residents to eat well and consume an appropriate balance of nutrients. Particular attention should be given to those with specific dietary needs e.g. diabetics, or residents needing reduced consistency or food fortification
  • Promote movement and activity, encouraging overall mobility
  • Monitor bladder and bowel movements and keep a bowel chart
  • Monitor residents’ height, weight and BMI. It is good practice to calculate a MUST score
  • Encourage residents to sleep well, with good sleep hygiene
  • Complete regular scheduled healthcare eg Dentist, opticians, hearing, vaccinations
  • Follow any planned treatment and medications, and respond to new needs early by seeking a clinical assessment
  • Undertake regular skin checks and treat any wounds promptly

 

Managing the environment in the care home can also help keep residents well by reducing the causes of illness and injury:

  • Keep rooms clean and tidy, and remove any trip hazards
  • Regularly clean common touch points
  • Maintain good infection prevention techniques
    • hand washing / using hand gel
    • wearing a mask when appropriate
    • opening windows for fresh air and ventilation
  • Maintain good kitchen and meal management
  • Ensure toilets and bathrooms are regularly and thoroughly cleaned

 

Similarly staff need to maintain good hygiene practices for themselves, to avoid spreading infection to residents. These include 

  • Staying bare below the elbow when supporting residents
  • Keeping nails clean, short and not wearing false nails
  • Minimising jewellery, especially any that might dangle or has stones
  • Only wearing uniform when inside the care home and ensuring it is kept clean
  • Not attending work when unwell so residents are not infected 
     

All staff should undertake training to recognise and respond to signs of deterioration, such as recognising and managing deterioration -elearing for healthcare

It is important to recognise the early signs of deterioration in residents. These ‘soft signs’ are an indicator that someone is becoming unwell. Someone who knows the resident well may start by thinking the resident is ‘not themselves today’. This may be due to: 

  • Changes in their physical presentation such as becoming more breathless, being too hot or cold, being unsteady or not passing urine
  • Changes in their behaviour or abilities such as reduced alertness levels, agitation, changed habits, reduced mobility or restlessness
  • Changes in their mental state such as new or worsening confusion or becoming more withdrawn

All concerns that a resident is not their usual self should be taken seriously. A deterioration tool should be used to support an assessment of the signs of deterioration and help with good communication with a health care professional if this is needed. Examples of deterioration tools are:

It is helpful wherever possible to take the resident’s blood pressure, pulse, oxygen levels, temperature and respiratory rate to support good decision making on the right care.

If a resident does become unwell timely care is important. A sudden and noticeable change in condition during a day or since the previous day should trigger an immediate response.

If a resident has a slow deterioration over a number of days or weeks this should be raised at the next care home round for review, or by contacting the resident’s GP if there are concerns.

  • Call 999 for any life threatening concerns e.g. severe shortness of breath, signs of sepsis, FAST positive (signs of a stroke), chest pain, significant reduction in responsiveness, broken bones unless the resident’s care plan indicates they do not wish for this kind of treatment
  • Call UCR 8am – 6pm if a resident has a sudden but not life threatening deterioration, shows signs of infection, or they have had a fall  

Coventry UEC: 0300 200 0011, option 3
Warwickshire UCR: 01926 600818

  • Overnight contact rapid response for end of life care needs and blocked catheters.

Coventry: 0300 200 0011, option 3

Warwickshire North: 07584 557366

Rugby area: 07740 803855

South Warwickshire: 07775 016618

Call 111 for any other urgent matters out of hours

  • Call the resident’s GP for a gradual deterioration and/or it is related to a known health condition that they are already being treated for. Consider referring to the next care home round if the need is not urgent. 

You should always consider any advance care plan and respect form the resident has in place to understand their wishes for treatment.

 

In the event of an outbreak (incident in which at least one or more people affected by the same infectious disease are linked by time, place, or common exposure – UKHSA definition) this should be reported to the appropriate agency in a timely way. If you suspect you have an Acute Respiratory Infection (ARI) outbreak, including Covid-19, unidentified ARI (e.g. chest infection), single case AND outbreaks of influenza - please notify UKHSA using Care OBRA on the link below:

For notifications of any other outbreak e.g. diarrhoea and or vomiting, scabies etc please contact UKHSA, Public Health local authority or ICB Infection Prevention & Control Team via:

More information on common conditions can be found in the Coventry and Warwickshire Care home information pack: Care Home Information Pack  

React to Deterioration videos and resources

Comprehensive Geriatric Assessment Resources | British Geriatrics Society

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