{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Identifying and Managing Sepsis Policy

1. Purpose

This policy sets out {{org_field_name}}’s arrangements for recognising, assessing, responding to and escalating suspected sepsis in people using the service. It is intended to ensure that possible infection and deterioration are recognised promptly, that people at risk of severe illness or death from sepsis receive timely medical assessment or emergency treatment, and that care is provided safely.

The policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 12, Safe care and treatment, Regulation 17, Good governance, and Regulation 18, Staffing, and the Care Quality Commission (Registration) Regulations 2009 where statutory notifications are required.

Recognition, risk assessment and escalation of suspected sepsis must reflect current NICE guidance, including NICE NG253, Suspected sepsis in people aged 16 or over: recognition, assessment and early management, together with any applicable local NHS clinical deterioration and escalation arrangements.

Staff must treat suspected sepsis as a potentially life-threatening clinical emergency and must act promptly in accordance with the person’s presentation, assessed level of risk, care plan, clinical instructions and the escalation requirements contained within this policy.

2. Scope

This policy applies to all healthcare professionals, nursing staff, care assistants, and other employees at {{org_field_name}} involved in the care of individuals at risk of sepsis. It covers the recognition, management, escalation, and documentation of sepsis cases within our care home.

3. Understanding Sepsis

• Definition: Sepsis is a life-threatening response to an infection that causes organ dysfunction.
• Common Causes: Bacterial, viral, or fungal infections, particularly in the lungs, urinary tract, skin, or gastrointestinal system.
• High-Risk Groups:
  • Older adults
  • Individuals with weakened immune systems
  • People with chronic conditions (e.g., diabetes, COPD, kidney disease)
  • Those with indwelling medical devices (e.g., catheters, PEG tubes)
  • Post-surgical individuals or those with open wounds

4. Recognising and Assessing Possible Sepsis

Staff must consider the possibility of sepsis whenever a person has symptoms or signs suggesting infection, particularly where there is an unexplained deterioration in their physical condition, mental state or usual functional ability.

Sepsis may present in a non-specific way. A person may feel or appear seriously unwell without having a high temperature. Staff must therefore not exclude sepsis solely because a person’s temperature is normal or because fever is absent.

Where staff are trained and competent to undertake observations, assessment should include, as appropriate:

• temperature;
• respiratory rate;
• heart rate or pulse;
• blood pressure;
• oxygen saturation;
• level of consciousness and mental state;
• changes in behaviour;
• urine output;
• skin colour and appearance;
• signs of infection;
• recent deterioration in mobility or functional ability; and
• comparison with the person’s normal or baseline observations where known.

For adults aged 16 or over in a care-home or other community setting, the following NICE community-setting criteria must inform escalation.

High-risk criteria

A person with suspected infection must be treated as being at high risk of severe illness or death from sepsis if they meet any applicable high-risk criterion, including:

• objective evidence of a new altered mental state;
• respiratory rate of 25 breaths per minute or more;
• a new requirement for 40% inspired oxygen or more to maintain an oxygen saturation above 92%, or above 88% where the person has known chronic hypercapnic respiratory failure;
• systolic blood pressure of 90 mmHg or less;
• systolic blood pressure more than 40 mmHg below the person’s normal level;
• heart rate above 130 beats per minute;
• no urine passed during the previous 18 hours;
• for a catheterised person, urine output below 0.5 ml/kg/hour;
• mottled or ashen appearance;
• cyanosis affecting the skin, lips or tongue; or
• a non-blanching petechial or purpuric rash.

Moderate-to-high-risk criteria

A person with suspected infection must be treated as being at moderate-to-high risk of severe illness or death from sepsis if they meet any applicable moderate-to-high-risk criterion, including:

• a new change in behaviour or mental state reported by the person, a relative, representative or member of staff;
• an acute deterioration in functional ability;
• an impaired immune system because of illness or medication, including oral steroids;
• trauma, surgery or an invasive procedure during the previous six weeks;
• respiratory rate of 21 to 24 breaths per minute;
• systolic blood pressure of 91 to 100 mmHg;
• heart rate of 91 to 130 beats per minute or a new-onset arrhythmia;
• no urine passed during the previous 12 to 18 hours;
• for a catheterised person, urine output between 0.5 ml/kg/hour and 1 ml/kg/hour;
• tympanic temperature below 36°C; or
• signs of a potential infection such as redness, swelling or discharge from a surgical site or wound breakdown.

Staff must also take account of clinical concern and the person’s usual presentation. A person who appears seriously unwell or whose condition is deteriorating must be escalated even where individual observations do not appear to meet a numerical threshold.

Where observations cannot be obtained reliably, this must not delay medical assessment or emergency escalation when the person’s condition gives cause for concern.

Pulse oximeter readings must be interpreted alongside the person’s overall clinical condition. Staff must recognise that pulse oximeters can give inaccurate readings and that an apparently reassuring oxygen saturation must not override clear evidence of deterioration.

5. Immediate Response to Suspected Sepsis

Staff must respond immediately when infection and possible sepsis are suspected. The response must be proportionate to the person’s assessed clinical risk and must not be delayed while waiting for routine reviews, relatives or managerial authorisation.

High-risk suspected sepsis

Where a person with suspected infection meets any high-risk criterion described in Section 4:

• call 999 for emergency medical assistance and state clearly that sepsis is suspected;
• provide the ambulance service with the person’s symptoms, observations, relevant medical history and reason for concern;
• arrange immediate transfer for emergency medical care unless the ambulance clinician or other appropriately qualified healthcare professional gives a different clinical direction;
• ensure relevant information accompanies the person, including their current medicines information, allergies, care plan, emergency healthcare plan where applicable, treatment escalation information where applicable and relevant recent observations; and
• inform the person in charge of the service or Registered Manager without delaying emergency treatment.

Where appropriate, ambulance or secondary-care services must be pre-alerted through the arrangements used by the ambulance service, GP or other healthcare professional.

Moderate-to-high-risk suspected sepsis

Where a person with suspected infection meets one or more moderate-to-high-risk criteria but no high-risk criterion:

• obtain prompt assessment by an appropriate healthcare professional capable of assessing the person’s condition, establishing a diagnosis and deciding whether the person can safely be treated outside hospital;
• provide the healthcare professional with the person’s observations, clinical changes, baseline condition, relevant medical history and reason for concern;
• follow any clinical directions provided;
• continue to monitor the person’s condition while awaiting assessment; and
• escalate immediately to emergency medical care if the person’s condition deteriorates or a high-risk criterion develops.

If a definitive diagnosis cannot be established, or the healthcare professional determines that the person’s condition cannot safely be treated outside an acute hospital setting, the person must be referred urgently for emergency medical care.

Suspected infection without high-risk or moderate-to-high-risk criteria

Where a person with suspected infection does not currently meet high-risk or moderate-to-high-risk criteria:

• seek appropriate clinical advice according to the person’s symptoms and clinical needs;
• monitor for deterioration;
• ensure staff know the symptoms and changes requiring further escalation; and
• escalate promptly if the person’s condition changes or causes increasing concern.

Care while awaiting emergency or clinical assessment

Staff must:

• remain with or closely supervise the person according to their condition;
• position the person safely and comfortably;
• maintain their airway and provide first aid within the member of staff’s competence;
• continue appropriate observations without allowing repeated observations to delay emergency transfer;
• provide oxygen only where this is within the member of staff’s training and competence and is authorised by an appropriate prescription, clinical direction or emergency protocol applicable to the service;
• not give food, drink or oral medication where the person has reduced consciousness, unsafe swallowing, significant vomiting or another clinical reason making oral intake unsafe;
• follow existing fluid restrictions, dysphagia plans and clinical instructions unless an appropriately qualified healthcare professional directs otherwise; and
• record the person’s presentation, observations, time of deterioration, advice obtained, decisions made and action taken.

Concern about possible sepsis must never be downgraded solely because one observation is within the normal range.

6. Ongoing Monitoring, Escalation and Handover

Where a person has suspected infection or suspected sepsis and remains within the service while awaiting medical assessment or emergency transfer, appropriately trained and competent staff must continue to monitor the person’s condition.

Observations should include, where clinically appropriate and within staff competence:

• respiratory rate;
• oxygen saturation;
• heart rate or pulse;
• blood pressure;
• temperature;
• level of consciousness;
• mental state and behaviour;
• skin colour and appearance;
• urine output;
• signs of infection; and
• any change in mobility, function or general condition.

Observations must be considered in relation to:

• the person’s usual or baseline observations;
• the direction and speed of deterioration;
• known long-term conditions;
• medicines that may alter the person’s physiological response;
• the person’s immune status; and
• any clinical advice already received.

Any deterioration, development of a high-risk criterion or significant increase in staff concern must result in immediate reassessment and escalation.

Staff must not allow repeated observations, completion of paperwork, contacting relatives or contacting managers to delay a necessary 999 call or emergency transfer.

When care is handed over to ambulance clinicians, the member of staff must provide an accurate and structured handover containing all relevant information, including:

• the person’s name and relevant personal details;
• known or suspected source of infection;
• time symptoms or deterioration were first identified;
• current and previous observations;
• the person’s normal baseline where known;
• changes in mental state, behaviour or functional ability;
• relevant medical history;
• recent surgery, trauma or invasive procedures where applicable;
• immunosuppression where applicable;
• current medicines and known allergies;
• urine output where relevant;
• treatment, medicines or first aid already provided;
• clinical advice already obtained;
• treatment escalation plan, advance care plan, advance decision to refuse treatment or emergency healthcare plan where applicable; and
• any relevant communication, capacity, mobility, sensory or behavioural support needs.

The time of all observations, escalation decisions, healthcare contacts and transfer must be recorded accurately in the person’s care record.

7. Preventing Sepsis in Care Home Settings

{{org_field_name}} will take appropriate measures to reduce the risk of infection and infection-related deterioration.

Infection prevention and control

Staff must:

• follow the organisation’s infection prevention and control procedures;
• perform hand hygiene in accordance with current infection prevention requirements;
• use personal protective equipment where indicated;
• follow appropriate wound-care and aseptic procedures within their role and competence;
• manage urinary catheters, enteral feeding devices and other invasive devices in accordance with the person’s care plan and clinical instructions; and
• ensure equipment and the care environment are cleaned and decontaminated appropriately.

Vaccination and preventative care

People using the service will be supported to access vaccinations for which they are eligible, in accordance with current national vaccination programmes and individual clinical advice.

People will also be supported with appropriate oral care, nutrition, hydration, continence care, skin care and mobility in accordance with their assessed needs and care plans.

Early recognition and management of infection

Staff must recognise and report signs of possible infection promptly, including signs associated with:

• urinary tract infection;
• respiratory infection;
• wound or skin infection;
• infected pressure damage;
• gastrointestinal infection;
• dental or oral infection; and
• infection associated with a catheter, enteral feeding device or other invasive device.

Changes from the person’s normal presentation, including deterioration in mental state, behaviour, appetite, continence, mobility or functional ability, must be taken seriously and escalated where clinically indicated.

Staff training and competence

The service provider must ensure that staff receive training, support, supervision and competency assessment appropriate to their roles and responsibilities.

Staff whose duties include monitoring people who may deteriorate must have sufficient knowledge and competence to:

• recognise signs of infection and deterioration;
• recognise possible sepsis;
• undertake any observations required by their role safely and accurately;
• understand the escalation criteria contained within this policy;
• obtain appropriate clinical assistance; and
• make an emergency 999 call without avoidable delay when high-risk criteria or other signs of serious deterioration are present.

Training must be refreshed or repeated where necessary to maintain competence, following changes to guidance, where monitoring identifies a knowledge or competency gap, or following an incident or identified learning need.

8. Staff Responsibilities

All care and nursing staff

All staff involved in direct care must:

• remain alert to signs of infection, deterioration and possible sepsis;
• know the person’s usual presentation where reasonably practicable;
• recognise and respond to the high-risk and moderate-to-high-risk criteria described in this policy;
• undertake observations only where trained and competent to do so;
• report and escalate concerns promptly;
• call 999 without avoidable delay where high-risk suspected sepsis or other life-threatening deterioration is identified;
• follow advice provided by ambulance clinicians, GPs, NHS 111 or other appropriately qualified healthcare professionals;
• provide an accurate handover when the person’s care is transferred; and
• make accurate and contemporaneous records of observations, concerns, advice and actions.

Staff do not require prior authorisation from the Registered Manager, senior staff, relatives or representatives before calling 999 where emergency medical assistance is required.

Registered nurses, where employed

Registered nurses must practise within their professional scope of practice and must:

• undertake appropriate clinical assessment;
• interpret observations in the context of the person’s baseline condition and clinical presentation;
• escalate suspected sepsis appropriately;
• follow current clinical guidance and authorised local pathways;
• administer prescribed medicines and oxygen in accordance with legal, professional and organisational requirements; and
• ensure appropriate clinical documentation and handover.

Registered Manager

The Registered Manager must:

• ensure effective systems are in place for recognition and escalation of clinical deterioration and suspected sepsis;
• ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed;
• ensure staff receive training, support, supervision and competency assessment appropriate to their roles;
• ensure appropriate equipment required for observations is available, maintained and used by competent staff;
• ensure incidents are recorded, reviewed and investigated where appropriate;
• ensure learning from incidents is identified and implemented;
• ensure CQC statutory notifications are submitted where the statutory notification criteria are met; and
• monitor compliance with this policy through the service’s governance arrangements.

9. Documentation, Incident Reporting, Duty of Candour and CQC Notifications

Care records

All suspected or confirmed episodes of sepsis, infection-related deterioration and related escalation must be documented accurately and contemporaneously in the person’s care record.

Records must include, as applicable:

• the symptoms or changes identified;
• the date and time concerns first arose;
• relevant observations and the time they were taken;
• the person’s normal baseline where relevant;
• changes in mental state, behaviour or functional ability;
• the suspected source of infection where known;
• the name or role of each healthcare professional contacted;
• the time each contact was made;
• advice and clinical instructions received;
• whether 999, NHS 111, the GP or another healthcare service was contacted;
• treatment or first aid provided;
• the person’s response;
• details and time of any transfer to hospital;
• information handed over to ambulance or hospital clinicians; and
• any subsequent actions required by the service.

Records must be accurate, complete, legible, secure and contemporaneous in accordance with the service’s record-keeping requirements.

Internal incident reporting

A suspected or confirmed episode of sepsis must be recorded through the organisation’s incident reporting system where it constitutes an incident under the organisation’s reporting procedures, including where there has been:

• unexpected or significant deterioration;
• avoidable delay in recognition or escalation;
• a medicines-related issue;
• a failure to follow an agreed care or escalation plan;
• equipment failure;
• an infection prevention and control concern; or
• another event requiring investigation or organisational learning.

Incidents must be reviewed proportionately and any identified learning or required improvement must be acted upon.

CQC statutory notifications

A hospital admission for suspected or confirmed sepsis is not automatically a statutory notification to CQC.

The Registered Manager or other authorised person must assess the circumstances against the Care Quality Commission (Registration) Regulations 2009 and submit a notification where the statutory criteria are met.

Under Regulation 18, Notification of other incidents, the service must notify CQC of an event where it falls within a category specified by that regulation, including where applicable a qualifying serious injury, abuse or allegation of abuse, an incident reported to or investigated by the police, or another specified notifiable event.

Where a person using the service dies, the Registered Manager or other authorised person must consider and comply with the separate requirements of Regulation 16, Notification of death of a person who uses services.

The fact that sepsis was suspected, diagnosed or resulted in hospital admission does not in itself determine whether a Regulation 18 notification is required. The circumstances and statutory criteria must be considered.

Notifications must be made without delay and in the manner required by CQC where the applicable regulation requires this.

Duty of candour

Where an incident associated with the person’s care or treatment meets the statutory definition of a notifiable safety incident under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, {{org_field_name}} must follow the statutory duty of candour requirements.

This includes:

• acting in an open and transparent manner;
• notifying the relevant person as soon as reasonably practicable;
• providing a truthful account of the known facts;
• explaining what further enquiries or investigations are appropriate;
• providing an apology; and
• providing the required written follow-up.

A diagnosis of sepsis or hospital admission does not automatically constitute a notifiable safety incident for the purposes of Regulation 20. The statutory criteria must be considered in each case.

Audit and organisational learning

Sepsis-related incidents and episodes involving significant deterioration must be reviewed where appropriate through the service’s governance arrangements.

The Registered Manager must ensure that:

• concerns about delayed recognition or escalation are investigated;
• relevant actions are identified;
• lessons are shared with appropriate staff;
• care plans, risk assessments, procedures or training are updated where required; and
• improvements are monitored to establish whether they have been effective.

10. Related Policies

• CH11-Safe Care and Treatment Policy
• CH17-Infection Prevention and Control Policy
• CH18-Risk Management and Assessment Policy
• CH27-Staff Supervision, Training, and Development Policy
• CH34-Confidentiality and Data Protection (GDPR) Policy
• CH25-Notification of Other Incidents Policy

11. Policy Review

This policy will be formally reviewed at least annually and sooner where required.

An earlier review must be undertaken where relevant because of:

• a change in applicable legislation or regulations;
• a change in CQC requirements or regulatory guidance;
• a material change to NICE sepsis guidance or other authoritative national clinical guidance relevant to the service;
• a significant sepsis-related incident, serious deterioration or identified failure in escalation;
• findings from an audit, investigation, safeguarding process or complaint demonstrating that the policy is ineffective or requires amendment; or
• changes to the services provided by {{org_field_name}} that affect the management of infection, clinical deterioration or sepsis.

The Registered Manager must ensure that amendments are communicated to relevant staff and that any necessary changes to training, care documentation, escalation pathways or practice are implemented.

Audits and incident reviews must be used, where appropriate, to monitor whether staff recognise deterioration, obtain appropriate clinical assistance, escalate emergencies without avoidable delay, maintain adequate records and follow the requirements of this policy.

---

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.