Is my resident well?

Is my resident well?

Ten everyday questions to ask yourself,
to help recognise when care home residents
are becoming unwell
Guide for care home staff and carers

How to use this guide

This guide includes ten questions (marked with this sign ? ) to go through and ask

yourself when caring for all residents.

It does not replace your everyday care home policies.

Answering these ? questions in order, (unless it is an emergency situation), each time

you visit a resident, will help you notice changes from what is normal for a resident, so
that you can act quickly if they become unwell.

Contents

Signs of being unwell Other things to Calling NHS services
consider for help
Breathing 4

Bowel habits 6 Sepsis Urgent clinical support 23
(infection in blood)
Hydration 7 17 Preparing for your
call - SBAR tool
Pain 9 Falls 18 25

Confusion 12 Care plans 20

Wellbeing 13 Last year of life 21

Skin 14

Look for questions with this sign ?
When answering the ? questions, be aware that:

GREEN AMBER RED
is normal you need to take action you must seek immediate help

Example of how to use

Score GREEN AMBER RED
colour Resident does Resident showing Resident is unwell and needs help
not show signs signs that they may immediately
of being unwell be unwell

What you Continue to Discuss any residents Contact the person in charge
should do monitor daily. who have amber scores immediately, so the right help and care
with the person in can be provided.
charge as soon as you If they are not immediately available
notice, so the resident follow the advice on pages 23 to 26
can be supported. about calling 111 or 999 for help.

Remember to see the person as a whole. Think about - what is important to the
resident about their care? Do they have an advance care plan? Make sure you are familiar with
their care plans, it may help you to decide what to do if they are unwell.

3

Signs of being unwell 4

Breathing

1. ? Is the resident breathless?

Score GREEN AMBER RED
colour No Yes – but this is usual Yes – they’re gasping for air
Yes – their lips are blue
Continue to Yes – breathing faster
monitor. than normal but not
gasping

What you Discuss with the person Contact the person in charge
should do in charge - note if it is immediately or call 999
different from normal. (Also check care plan for resident’s
Consider the possibility of wishes. Do they have an advance care
sepsis (infection spread to plan or DNACPR/ReSPECT form?)
the blood - see page 17).

2. ? Do they have a cough?

Score GREEN AMBER RED
colour No Yes – but this is usual Yes – they’re gasping for air
Yes – their lips are blue

Continue to Discuss with the person in Contact the person in charge
monitor. charge - make a note of immediately or call 999
the colour of the phlegm. (Also check care plan for resident’s
What you Consider the possibility of wishes. Do they have an advance care
should do sepsis (infection spread to plan or DNACPR/ReSPECT form?)
the blood-see page 17).
Note: cough can also
be a sign of swallowing
difficulties.

Signs of being unwell 5

Bowel habits Signs of being unwell 6

3. ? Have you noticed any changes in your resident’s
bowel habits?
Type 1 The Bristol Stool Chart
Type 2
Type 3 Separate hard lumps like AMBER
Type 4 nuts (hard to pass) Indicates constipation - encourage
Type 5 Sausage-shaped but drinking and monitor outputs.
Type 6 lumpy
Type 7
Like a sausage but with GREEN
cracks on its surface
Like a sausage or a snake, Indicates good bowel health - continue to
smooth and soft monitor.

Soft blobs with clear cut RED
edges (passed easily)
Fluffy pieces with ragged • Type 5&6 may have diarrhoea
edges, a mushy stool • Type 7 may have food poisoning
Watery, no solid pieces, • Less than 3 bowel movements a week
entirely liquid • Blood in stool
Discuss all with the person in charge and
encourage drinking.

Hydration - drinking

Urine infections can be serious in older people.

4. ? D oes your resident have any of the signs

of dehydration below?

• Change in urine colour (see page 8) • Dizziness
• Change in smell of urine • Reduced urine (less toilet visits or dry pads)
• Headaches • Confusion (see page 12)

What you Score GREEN AMBER RED
should do colour No If you answer yes to any of the above

Continue • Encourage drinking If there is no
to • M onitor drinking input and output improvement after a
monitor. • Test urine (if available). few hours discuss with
the person in charge.

Note: if the resident has swallowing difficulties discuss with the person in charge ways to
increase fluids.
Signs of being unwell 7

5. ? What colour is the urine? Signs of being unwell 8

Urine colour 1
2
GREEN 1, 2, 3 3
Continue to monitor. Well hydrated 4
5
AMBER 4, 5, 6 6
• Encourage drinking Hydrated, but could drink 7
• Monitor more 8
• Inform person in charge
6, 7, 8
Dehydrated, need to drink
more

Pain

If the resident cannot communicate their needs (e.g. advanced dementia).

6. ? D o they have any of the signs below that

might show they are in pain?

• Aggressive behaviour • Change in sleep pattern • Eating less
• New facial expressions e.g. • Avoiding certain • I ncrease in shouting, moaning,

frowning or moving away movements or moving less calling out or being quiet
when touched than normal

Score GREEN AMBER Yes - but this RED Yes - pain worse than usual or
colour No is usual new type of pain

What you Continue to Check if prescribed pain Contact the person in charge
should do monitor. relief can be given. immediately – look for the cause. Has
Is it worse than normal? something happened to the resident?
If yes, discuss with the e.g. a fall.
person in charge. If they have chest pain or other
severe pain, immediately call 999.

Signs of being unwell 9

Signs of being unwell 10

Pain

If the resident can communicate their needs

7. ? Are they in pain?

• If yes, ask where the pain is and whether it is new for them
• Ask them to describe their pain or give it a number 1-10, use the thermometer on page 11

(or use your care home pain scale).

Score GREEN AMBER RED
colour No pain Has pain score: 1,2,3,4,5 Has pain score: 6,7,8,9,10

What you Continue Check if prescribed pain relief Contact the person in charge
should do to can be given. immediately.
monitor. Is the pain worse than normal? Investigate if anything has happened
If yes, or pain is new, discuss to the resident e.g. a fall.
with the person in charge. If they have chest pain or other
severe pain, call 999.

Words used to
describe pain

10 Pain as bad
9 as can be

8

7 Extreme
pain
6

5 Moderate
pain
4

3

Signs of being unwell 11 2 Mild
1 pain

No pain

Signs of being unwell 12

Confusion

8. ? H ave you noticed a change in a resident, are

they more confused than normal?
Are they:

• Unable to concentrate • U pset, drowsy or irritated • Hearing or seeing things

Score GREEN AMBER RED
colour No to all If you answer yes to If you answer yes to any of the
any of the above above, but the confusion started
suddenly
What you Continue to Discuss with the person Speak to the person in charge.
should do monitor. in charge – reassure the Sudden confusion can be caused by
resident and go through (for example): stroke, chest pain, sepsis,
this guide to look for bleeding and low blood sugars, which
the possible cause for all require urgent attention and you
the confusion e.g. urine may need to call 999.
infection.

Wellbeing

9. ? Over the last few days or weeks, have you noticed
a change in your resident’s mood or wellbeing?

Check if:

• Something has happened to • Their sleep pattern has changed
change their mood
• They are eating less food or more food

Score GREEN AMBER RED
colour No to all If you answer yes to any of the above If very agitated and
you are worried about
the risk to themselves
or others

What you Continue to Take time to talk to the resident, discuss Inform the person in
should do monitor. their concerns and see if you can help. charge or call GP/111
If you cannot help or don’t see an for advice.
improvement speak to the person in
charge. Use this guide to look for other
reasons for change in mood e.g. pain.

Signs of being unwell 13

Signs of being unwell 14

Skin

10. ? D oes your resident have any signs

of skin damage?

• Redness • P ain • Hard areas
• Broken skin • Swelling • Hot or cold skin

Check possible pressure areas (common areas pictured in red)

Skin

Score GREEN AMBER RED
colour No Yes slightly red, hot or cold areas Yes very red, painful, swollen
appearing or broken skin

Continue • Do skin test on page 16 Discuss with the person in
to monitor • M ake sure resident is moved or charge immediately and assess
and keep skin using care home pressure
resident can move themselves with the ulcer assessment form.
moving. right equipment regularly Red skin found
• M ake sure they are clean and dry
What you • D iscuss with the person in charge
should do and monitor every few hours (if
your home has a policy – follow it).

Signs of being unwell 15

Signs of being unwell 16

Skin test

It is important to keep residents moving and reposition them so they do
not develop pressure ulcers.
If you see a red area of skin on a resident use the test below.

Press finger over red Remove your finger: RED
skin for 15 seconds AMBER If the skin stays red
Make sure you tell If the skin goes white when – your resident has a
the resident what your finger is removed, a stage 1 pressure ulcer –
you are doing – this pressure ulcer has not started to immediately speak with
may be painful. form, but make sure the resident the person in charge
is able to move to reduce the (see amber box on
redness - check this regularly, page 15).
so it does not get worse.

Sepsis (when infection spreads into blood)

This can be life threatening

AMBER RED
If a person has one or more of these
If a person has one or more of these symptoms, they might have severe sepsis:
symptoms, they might have sepsis:
• C annot feel a pulse at the wrist
• Feverish/hot with uncontrolled shaking • V ery fast breathing (more than one breath
• F ast or irregular breathing
• A fast heart beat every two seconds)
• Increased confusion or difficult to wake • B lue lips
• Responds only to voice or pain, or unresponsive
up • Skin rash or patchy skin
• Not passed urine in the past 12–18 hours • N ot passed urine in the past 18 hours
• U rine cloudy, smelly or painful to pass. • Sudden worsening.

This person needs a medical review. This person needs an urgent medical review.
1. Immediately inform the person in 1. Immediately inform the person in charge
2. Call 999, and state that they may have
charge
2. Contact the GP or call 111, and state ‘red flag’ sepsis.

that they may have sepsis.

Other things to consider 17

Other things to consider 18

What to do if a resident falls:

Obvious injury

A person has fallen or has been found lying on the floor:
• Check if it’s safe to approach the resident
• Check if the resident responds to you and look for an injury
• Ask the person in charge to assess the resident immediately and move them only if the

person in charge says you can.

You can see an obvious injury (e.g head injury, bleeding, broken bone)
• Call 999
• Keep the person warm and as comfortable as possible
• Get the resident’s notes (and the red bag if appropriate)
• Tell next of kin in line with their care plan
• Record the fall in the person’s notes and begin a falls investigation
• If the person is on blood thinners (e.g. warfarin, apixaban, dabigatran, rivaroxaban,

edoxaban) seek urgent medical advice.

What to do if a resident falls:

No obvious injury

A person has fallen or has been found lying on the floor:
• Check if it’s safe to approach the resident
• Check if the resident responds to you and look for an injury
• Ask the person in charge to assess the resident immediately and move them only if the

person in charge says you can.

You cannot see an obvious injury Remember if a
resident’s mobility
• Follow the care home’s policy to move the person to a safe place changes this could
• Keep them warm and as comfortable as possible also indicate they
• Observe the person frequently checking for any changes, especially are unwell – discuss
with the person in
if they are on blood thinners (see list on page 18). charge.
• Tell the person’s next of kin in line with their care plan
• Record the fall in the person’s notes and begin a falls investigation
• Call GP or 111 if you need advice or are unsure what to do

(see page 23/24).

Other things to consider 19

Other things to consider 20

Care plans

It is important to know your residents and what their wishes are.
Make time to read their care plans and update them if you see
any signs in this guide of them being unwell.

Make sure you know what is in your resident’s care plan as it may help
you decide what to do:

• Do they have an advance care
plan or urgent care plan?

• W hat are their known wishes?

• H as a decision been made about
resuscitation on a DNACPR/
ReSPECT form? (see example)

Example of DNACPR form

Last year of life
– things to consider

I s the resident in the last year of life?

Do they have an advance care plan that tells you
their priorities of care?

For example:

• D o they want to go to hospital?
• A re there other options for looking after them in the care home?

If there is not a plan in place, discuss this with the person in charge.
Early discussions with residents about their wishes may help you know
what to do when they are unwell. Page 22 gives indicators which may
show your resident has an advancing disease or is the last months,
weeks or days of their life.

Other things to consider 21

1. Advancing disease Other things to consider 22
• More hospital visits
• N eeds more assistance • Diagnosis of a condition • Weight loss
with activities of daily living that cannot be cured
• Increasing lack of
• Change to where they live • Depression concentration
(e.g move into care home)
• F atigue
2. Increasing decline • Weight loss

• R educed appetite • Not strong enough to • Reduced attention
• W ithdrawn/unsociable attend hospital visits • Changes to rhythm of
• Reduced mobility
• Sleeping more • Increased need for breathing
interventions • Irregular pulse
• Hearing or seeing things
• Slender appearance • Confused in time or place

3. Last days of life

• B ed bound • Needs assistance with all
• Little intake of food and care

drink • Semi-conscious or
• S leepy unconscious
• Bluish colour of skin
• Patchy skin • Very weak
• Difficulty swallowing

Urgent clinical support for care homes

Can’t Call 111 *6 Call 999 in
get your immediately an emergency
resident’s When you hear situation
GP on the Press 9 to continue. “This call is
phone? An automated recorded for • If your resident
message will ask is blue and
you to confirm *quality purposes”, gasping for
your location. breath
press wait for
the beep, then • You suspect a
press 6. stroke

You will be quickly • They have chest
connected to a pain or other
doctor or nurse. severe pain

• Or signs of
sepsis (infection
spread to blood
see page 17).

Calling NHS services for help 23

Calling NHS services for help 24

Preparing to call 111, a GP or 999

1. Sit somewhere quiet 3. Think about... ✔✔ Has this happened before
✔✔ If possible, in the resident’s ✔✔ Why are you calling? and is there a pattern? If
✔✔ What do you need advice so, what did you do and
room (so when you make what have you done so
the call you can say “I am on? far?
with Mr/Mrs…now”) ✔✔ What is the resident’s
✔✔ A follow up plan, what
2. Have all of the normal routine or to do if the advice is not
residents information behaviour? working?
available and ✔✔ Has anything changed and
something to take over what period? You will be asked a lot of
notes on ✔✔ What evidence can you questions, if you don’t
provide? know the answer
✔✔ The address and contact ✔✔ What are the resident’s don’t worry.
details of the home wishes/preferences? By preparing for your call
✔✔ Does the resident have a and following the SBAR
✔✔ Their name, date of birth decision on resuscitation? tool you will get the best
and GP information support and advice for
your resident.
✔✔ Evidence for the GP or
nurse to make the correct
judgement

SBAR handover tool

This tool covers: situation, background, assessment and recommendation (SBAR).
By following the SBAR tool, it will ensure that your call to a health service is clear and
purposeful – whether you are speaking to a GP, 111 or 999.

Situation My name is…, I’m calling from…..
What is going I am calling because I need your advice about...
on now? (Provide the resident’s name, date of birth and GP information)
Describe the symptoms as clearly as possible, explain what has changed
Background from their normal health.
What has Tell the health professional what you see.
happened?
Describe what is happening to the resident, say how long it has been
going on (if known) provide any relevant medical history (e.g. stroke,
dementia, falls).
What medications are they taking?
Have there been any recent changes to medication?
Does the resident have any allergies?

Calling NHS services for help 25

Calling NHS services for help 26

Background What actions have already been taken? - If so what for?
Is there an advance or urgent care plan in place for this resident?
What’s the Is there a DNACPR/ReSPECT form?
resident’s history?

Assessment If you suspect the resident has a particular condition e.g. urine
What do you infection, constipation, let the health professional know.
think is going on? How does the person look? - Are they in pain; breathless?
Call 999 if they are blue and gasping, or in severe pain.
Recommendation Have you been able to do any observations, if so what are the
What do you results?
want done?
Explain clearly what you need: advice, medical review etc.
Confirm what you have agreed with the health professional,
summarise and repeat back to them, so you can be sure.
Agree a timeframe for calling back if the resident does not improve.
Ensure you understand if a health professional will visit or call back,
and when.

Other useful contacts

More information

This booklet was produced by the North West London
Collaboration of Clinical Commissioning Groups (CCGs)
with the North West London health and care partnership.

Published May 2018, Review date May 2020