The signs were there all along
What if the most important opportunity to improve outcomes comes before the incident itself? Thomas Tredinnick, CEO and Co-Founder, Ally Cares explores why recognising change earlier may be the future of preventative care.
Why everything looks obvious in hindsight
One of the phrases I hear most often when speaking to care providers is also one of the most revealing.
“Looking back, the signs were there.”
It usually emerges during conversations about a fall, a hospital admission, an infection or a period of deterioration that seemed to arrive more quickly than anyone expected. As teams reflect on what happened, review the timeline and piece together the events that led to the outcome, somebody will often observe that the warning signs were present long before the issue became obvious.
It is rarely said as a criticism of staff or an admission that something was missed. More often, it reflects the reality that events can look very different once the outcome is known.
The resident who developed a chest infection may have been coughing more frequently throughout the previous week. The resident who experienced a fall may have been sleeping poorly, becoming increasingly restless or showing subtle changes in mobility that appeared insignificant at the time. The resident who was admitted to hospital may have been displaying small shifts in behaviour, routine or wellbeing that only became meaningful once viewed alongside everything that happened afterwards.
The challenge for care providers is that they are not working with hindsight. They are working in real time, supporting residents whose needs are constantly changing and trying to distinguish between normal variation and the earliest signs that something more significant may be developing.
That has always been one of the most difficult aspects of delivering good care.
The difference between an incident and a deterioration
Care providers are rightly encouraged to investigate incidents because incidents create opportunities for learning, improvement and accountability. Falls are reviewed. Hospital admissions are examined. Safeguarding concerns are analysed. Governance systems are designed to help organisations understand what happened and reduce the likelihood of it happening again.
What interests me, however, is that incidents are often the point at which a problem finally becomes visible rather than the point at which the problem actually began.
A resident who experiences a fall may have been becoming increasingly fatigued, unsettled or sleep deprived for several days beforehand. A resident who develops an infection may have already been displaying subtle changes in behaviour or movement patterns. A resident whose wellbeing deteriorates may have been showing signs of discomfort, anxiety or disruption long before anybody would have considered them to be at immediate risk.
The reality is that deterioration rarely arrives all at once.More often, it develops through a series of small changes that appear unrelated when viewed individually but become much more significant when viewed together.
The difficulty is that those changes are often hard to see, particularly during the hours when residents are alone in their rooms and much of their experience remains hidden from view. In many ways, this challenge begins before residents even settle for the night. A growing number of providers are taking a closer look at the transition between daytime activity and overnight care and asking whether opportunities to support wellbeing are being missed during those crucial twilight hours.
What providers are beginning to see
One of the most interesting things we have observed across care homes is how quickly conversations change once teams gain greater visibility into the resident experience.
Instead of focusing solely on incidents, providers begin paying closer attention to patterns.
At Jackmans Lodge, the team found themselves gaining a much deeper understanding of residents through overnight behaviour, movement and routines. Changes that would previously have gone unnoticed became visible, enabling staff to build a clearer picture of individual needs and identify potential concerns earlier.
Reflecting on the impact they said:
“We spend more time with the people who are awake and need us, and leave the people who are asleep to rest.”
That comment captures something important. The value was not simply having more information. The value was understanding residents well enough to direct attention where it would have the greatest impact.
A similar lesson emerged at Charnwood Country Residence, where overnight coughing patterns contributed towards earlier intervention and treatment before deterioration became more serious. The breakthrough was not the treatment itself. The breakthrough was recognising that something had changed before the resident’s condition worsened.
At The Grange Nursing Home, unusual overnight sounds prompted further investigation and ultimately contributed towards a Speech and Language Therapy referral relating to swallowing difficulties. What initially appeared to be a relatively minor observation became clinically significant because the pattern was recognised early enough to act upon.
None of these examples began with a crisis, but with a change.
When better understanding changes care
Some of the most valuable outcomes providers describe are not necessarily reductions in incidents, but changes in the way care is delivered.
At Azalea Court, gaining a clearer understanding of resident experiences during the evening and overnight periods helped the team review existing approaches and make adjustments that contributed towards calmer nights and improved outcomes. The most important insight was not what happened during an incident. It was understanding what residents were experiencing beforehand.
When you start to really understand residents differently, things start to get interesting. At Court House, gaining visibility into what residents were actually experiencing overnight challenged assumptions that had existed for years and ultimately changed the way the team approached care.
When providers can’t see what is happening, they often have little choice but to intervene more frequently in order to gain reassurance. When understanding improves, care can become more personalised, more targeted and less disruptive. That is not about doing less, but focusing on doing what matters most.
The future of prevention is understanding change
The care sector talks increasingly about prevention, and rightly so.
Health and social care systems are under pressure to reduce avoidable admissions, prevent deterioration and support people to remain healthier for longer. Yet prevention is often discussed as though it is simply a matter of intervening earlier.
In reality, intervention is only possible when change is recognised as providers cannot act on changes they cannot see.
This is one of the reasons programmes such as the Dorset programme are so significant. Across participating homes, providers achieved a 49% reduction in falls, a 64% reduction in ambulance callouts and a 79% reduction in hospital transfers. Those outcomes are impressive, but perhaps the more interesting question is what providers were able to understand earlier that enabled those improvements to occur.
Because falls do not reduce by accident. Hospital transfers do not reduce by chance. More often than not, better outcomes emerge because somebody recognised that something was changing and had the opportunity to act before a situation became more serious.
That may ultimately be one of the most important opportunities facing the sector.
Not simply responding more effectively when incidents occur, but becoming better at recognising the subtle changes that often precede them.
The signs were there all along
The phrase continues to appear in conversations with providers because it captures something that feels increasingly relevant to the future of care. The signs are often there. The challenge is recognising them while the story is still unfolding rather than after the outcome is already known.
As providers gain greater visibility into the resident experience, particularly during the hours that have historically been least understood, they are discovering that some of the most valuable opportunities to improve outcomes do not sit within the incident itself. More often, they sit within the small changes that came before it.
Learn more
The most valuable opportunities to improve outcomes often emerge before an incident occurs, when subtle changes in health, behaviour, sleep or wellbeing are just beginning to appear.
If you would like to explore how providers are gaining a clearer understanding of those early indicators and using overnight insight to support more proactive, personalised care, we’d be delighted to share what homes across the UK are learning when they start to see the night differently.
Speak to the Ally team to discover how providers are identifying change earlier and supporting better outcomes for residents, families and care teams.
Related articles
Why Care Homes Are Rethinking Twilight Hours
The Four Pillars of Good Health in Care Homes
Why Sleep Must Be a Priority in Care: New Report from Care England
Sleep-Positive Care Powered by Ally