Recognising Deterioration in Care Homes with RESTORE2

A resident does not have to collapse before staff can tell that something has changed.

It may be the person who normally comes down for breakfast but wants to stay in bed. Someone who is usually talkative may give one-word answers. A resident may need more help walking than they did yesterday, drink less than usual or appear unusually sleepy.

These changes can be easy to dismiss when none looks dramatic on its own. In a care home, however, staff often know residents well enough to notice deterioration before there are obvious clinical signs. The challenge is turning that concern into useful information and knowing what to do with it.

RESTORE2 is one approach used in care and nursing homes to support that process. It brings together recognition of soft signs, physiological observations using NEWS2 and structured communication using SBARD. It does not replace knowledge of the resident or clinical judgement. It gives staff a clearer way to recognise change, record what they have found and communicate concerns to the right healthcare professional.

What does deterioration look like in a care home?

Deterioration is not always obvious. Staff may notice a change in the resident before they can identify a clear clinical reason for it.

That might include someone:

• Being quieter or more withdrawn than usual
• Becoming unusually restless or agitated
• Sleeping significantly more
• Eating or drinking less
• Needing more help with mobility
• Appearing more breathless during normal activity
• Becoming newly confused or less responsive
• Having a noticeable change in continence or toileting
• Looking pale, flushed or generally unlike themselves

The important part is often the word change.

A resident with dementia may already experience confusion. Someone with chronic respiratory disease may normally become breathless with exertion. The question is not simply whether a symptom is present. Staff need to recognise when the person’s presentation is different from their usual baseline.

Start with what is normal for the resident

Knowing the person is one of the strongest advantages care-home staff have when deterioration begins.

A set of observations taken today is more useful when it can be considered alongside what is normal for that resident. The same applies to behaviour, appetite, mobility, alertness and communication.

Useful baseline information should therefore be easy for staff to find and understand. Depending on the home and the resident, this may include normal physiological observations, usual mobility, cognitive presentation, eating and drinking habits, communication needs and relevant personalised care or escalation plans.

Descriptions should be specific enough to help the next person understand what has changed.

For example, “not herself today” expresses genuine concern but gives little detail to somebody who does not know the resident. “Usually walks to the dining room with her frame but today needed two members of staff and stopped because she was breathless” gives a clinician something much more useful to work with.

What is RESTORE2?

RESTORE2 is a physical deterioration and escalation tool developed for care and nursing homes. Rather than relying on one score or one symptom, it helps staff move through a wider process of recognising that something has changed and communicating that concern.

The full RESTORE2 approach brings together three important elements:

• Soft signs that may indicate the resident is becoming unwell
• NEWS2 physiological observations where staff are trained and the tool is being used locally
• SBARD structured communication to help staff pass information to healthcare professionals clearly

This combination matters because deterioration is rarely captured by numbers alone.

A care worker may notice that a resident looks wrong before a significant change appears in their observations. Equally, physiological measurements may confirm that something more serious is developing even when the initial change seemed relatively minor.

Soft signs often come before a score

Soft signs are changes in how a person looks, behaves or functions that suggest they may be becoming unwell.

They matter particularly in care homes because staff see residents throughout ordinary daily activities. They know who normally eats well, who likes an afternoon sleep, who walks independently and who is usually keen to join a conversation.

That everyday knowledge can provide an early warning.

A staff member should not feel that concern is invalid simply because they cannot yet attach a diagnosis to it. “He isn’t normally like this” can be an important observation when it is followed by a closer look at what has changed.

The next step is to turn that instinct into facts that can be recorded, shared and acted upon.

Where NEWS2 fits into RESTORE2

Where a care home uses the full RESTORE2 tool and staff are appropriately trained, physiological observations can add another layer of information.

NEWS2 uses measurements including respiratory rate, oxygen saturation, blood pressure, pulse, temperature and level of consciousness to support recognition of acute illness.

The value is not simply in producing a number. Staff need to be able to obtain the observations correctly, record them accurately and follow the escalation process agreed for the home.

Trends also matter. A resident’s measurements may be more informative when compared with previous observations and their known baseline rather than viewed as an isolated set of figures.

Staff should not use a reassuring score to dismiss a clear change in the resident. If somebody who knows the person remains concerned, that concern still needs to be communicated through the appropriate route.

RESTORE2mini can support homes that do not take full observations

Not every care setting uses the full RESTORE2 process.

RESTORE2mini is a condensed version that places particular emphasis on identifying soft signs and communicating concerns using a structured approach. It can be useful in settings where staff are not routinely taking a full set of physiological observations.

The important point is not that every organisation should adopt the same tool. The home should use the deterioration and escalation approach agreed within its local arrangements and ensure staff are trained to use it properly.

NHS England guidance also recognises other approaches, including NEWS2 and locally adopted deterioration tools.

Taking observations needs more than knowing which button to press

Where staff are expected to take physiological observations, training should cover the practical skill rather than simply the paperwork.

A respiratory rate recorded inaccurately can affect the information being passed to a clinician. The wrong blood pressure cuff can affect a reading. Equipment that has not been maintained properly creates another source of uncertainty.

Staff need to understand:

• Which observations they are expected to take
• How to use the home’s equipment correctly
• Where results should be recorded
• What to do if a reading cannot be obtained
• How previous observations can be checked
• When results or concern need escalating

The aim is not to turn care workers into diagnosticians. It is to give the healthcare professional receiving the call reliable information on which to base the next clinical decision.

Use SBARD to make the escalation call useful

Recognising deterioration is only part of the job. The information then needs to reach somebody who can act on it.

RESTORE2 uses SBARD to help staff structure that conversation:

• Situation What is happening now?
• Background What relevant information does the clinician need to know?
• Assessment What have staff observed or measured?
• Recommendation What help or review is being requested?
• Decision What has been agreed?

This is particularly useful when staff are speaking to somebody who does not know the resident.

Instead of starting with a long history, the member of staff can say what has changed and why they are concerned, then provide the relevant background and observations.

The final part is easy to overlook. Staff should record what the healthcare professional advised, what is expected to happen next and what would trigger further escalation.

Know which escalation route applies

Using RESTORE2 does not mean that every deterioration follows the same pathway.

The appropriate response will depend on the resident’s condition, the urgency of the situation and the local services available. Depending on the circumstances, staff may need to contact a senior colleague, GP, community service, NHS 111, urgent community response service or 999.

The home should have clear arrangements for both normal working hours and nights, weekends and bank holidays.

Staff also need access to relevant personalised information. Advance care plans, treatment escalation plans and ReSPECT recommendations may affect the clinical decisions made for an individual resident, but they do not mean new deterioration should simply be ignored.

The role of care-home staff is to recognise the change, communicate it accurately and follow the agreed escalation process.

What should RESTORE2 training actually teach?

A useful training session should leave staff able to use the process on shift, not simply recognise the name RESTORE2 on a chart.

By the end of appropriate training, learners should understand how to:

• Identify soft signs that may indicate deterioration
• Describe what has changed from the resident’s normal presentation
• Find relevant baseline and care-plan information
• Take physiological observations correctly where this is part of their role
• Record observations accurately
• Use the home’s chosen deterioration tool
• Recognise when a finding or concern needs escalating
• Use SBARD or the locally agreed communication method
• Follow the correct in-hours and out-of-hours escalation route
• Record the advice and decision that follows an escalation call

Those are practical skills. Staff benefit from having a chance to use them with realistic examples rather than only reading through the tool.

Train with the residents your team actually supports in mind

The most useful examples are rarely dramatic textbook emergencies.

Consider a resident with dementia who has become unusually quiet and stopped eating. Another might have a new cough and gradually increasing breathlessness. A resident who normally transfers independently may suddenly need much more assistance.

Ask staff what they would notice first. What information would they look for? Would observations be appropriate? Who would they contact? What would they say?

The exercise can then move into the practical part of the process: finding the resident’s baseline information, completing the relevant documentation and making a structured handover.

This is different from practising a cardiac-arrest scenario. The skill being tested is whether staff can recognise a change that may otherwise have been lost during a busy shift.

Make deterioration visible at handover

One of the easiest places for early warning signs to disappear is between shifts.

If several staff members have noticed small changes, those observations need to be brought together. A vague instruction to “keep an eye on him” leaves the next shift to decide for themselves what that means.

A clearer handover might state:

• What has changed
• When it was first noticed
• What observations have been taken
• Who has been contacted
• What advice has been received
• What needs monitoring
• When further escalation is required

This helps prevent a new team from unknowingly starting the assessment again several hours later.

Review how the tool is working in the home

Introducing RESTORE2 should not end with distributing charts and sending staff on a course.

Managers should be able to see whether the process actually works in day-to-day care.

That might mean checking whether:

• Staff can find the tool when they need it
• Baseline information is current and accessible
• Observation equipment is available and maintained
• Staff know the escalation routes
• New employees are shown the local process during induction
• Records show clear decisions after escalation
• Near misses or incidents reveal recurring uncertainty

If staff understand the theory but repeatedly struggle with the same practical step, another full training course may not be the only answer. The problem may be where records are stored, how equipment is organised or whether the escalation route itself is clear.

RESTORE2 supports judgement rather than replacing it

The real value of deterioration training is not teaching staff to wait for a score before becoming concerned.

It is giving them a reliable process for acting on the changes they already notice.

Care-home staff often know when a resident is behaving differently long before an outside clinician sees them. RESTORE2 can help turn that knowledge into a clearer sequence: recognise the soft signs, gather appropriate information, communicate the concern and follow through on the decision.

Used well, the tool supports the judgement of the people who know the resident rather than replacing it.

RCMS Life Support’s care-focused training is built around that practical principle. Staff need to know what deterioration can look like in the people they support, what information they are expected to gather and how to raise a concern clearly when something has changed.

FAQs About RESTORE2 in Care Homes

Can RESTORE2 be used for a resident with a ReSPECT or end-of-life care plan?

Yes. A personalised treatment escalation or ReSPECT plan does not prevent staff from recognising and reporting deterioration. RESTORE2 can help identify that the resident’s condition has changed, while the response should take account of the individual’s documented wishes and agreed recommendations for emergency care and treatment. Staff should follow the resident’s current care plan and local clinical escalation arrangements.

What should staff do if a resident refuses physiological observations?

Staff should not automatically force observations because a resident appears unwell. If the person has capacity to make the particular decision, their wishes should be respected while staff explain the reason for concern and seek appropriate clinical advice. If there is doubt about capacity, the Mental Capacity Act and the organisation’s local procedures should be followed, including consideration of the person’s best interests where a decision needs to be made on their behalf.

Can RESTORE2 support residents with learning disabilities or limited verbal communication?

Yes. Recognising changes in behaviour, eating, drinking, sleep, mobility or mood can be particularly useful when a person cannot easily describe how they feel. RESTORE2mini has also been used to support carers of people with learning disabilities by helping them recognise soft signs and communicate concerns more clearly to healthcare professionals.

Can a care home change the RESTORE2 form to match its own paperwork?

The official RESTORE2 tool and its components should not be altered or amended. Care homes can develop local procedures around how the tool is used, stored and incorporated into their escalation processes, but the published RESTORE2 documentation itself should be used in accordance with the conditions set by Hampshire and Isle of Wight ICB.

Should completed RESTORE2 forms be kept in the resident’s care record?

This should follow the care home’s local documentation and records policy. Where RESTORE2 forms are used to record deterioration, observations or escalation decisions, the information should be retained in a way that supports continuity of care and provides an appropriate record of what was observed and communicated. Specific versions of RESTORE2mini are available for organisations that want to use the form as a legal record or an extension to existing documentation.