Table 3 Summary of quotes from focus groups and semi-structured interviews

Identifiers: A -F represents each participating home; ‘Staff’ and ‘Family’ represents data from the focus groups and ‘GP’ represents data from a GP interview.

Initial assessment of the resident

Well they’d still be, you’d be going by their mobility, because they’d be off their feet, they’d be shaky, they’d be clammy confused, you know a lot of those symptoms. (…) We see a lot of changes in mobility or increased falls when somebody has an infection. (C: Staff)

They manifest like agitation, anxiety or different from what they are. For example, they are always pleasant to the staff and other patients and their families, they can be different when they come in and then the staff go ‘there’s something wrong, something’s not right’. (A: Staff)

Observation of the resident

I think I would be worried about the one to 4 h I would worry about the time, if the answer is no, I think it should be a shorter period of time. (…) Usually an increase in temperature is a good sign that there’s something going on? (A: Family)

You see there, the over- 65 with COPD and delirium is much more clinically urgent than someone with increased frequency of their urine. And yet the end result of that algorithm is phone GP. Now if you phoned the out of hours’ service at three o’clock in the morning [for COPD resident] that’s reasonable. If you call the out of hours’ service at three o’clock in the morning like that [for resident with increased frequency], that’s unreasonable (D: GP)

See where it says take the resident’s temperature we obviously can’t do that, step one. (…) That’s why we rely wholly on behaviour and that because we don’t have a lot of tools that we are allowed to use. (…) We would love to be able to take temperatures and things like that there but (Name of care home) frowns upon it. (C: Staff)

Additional signs and symptoms

We would notice a difference in their mood or the way they are, or confusion would be a big thing with elderly people (…) temperature would nearly be the last thing I would take. I would look at all the other things first and then I would take temperature, the GPs will always ask for the temperature. (B: Staff)

Urinary tract infections

Yeah and if someone is incontinent you don’t always know about the urgency of it because with dementia, not everyone can tell you when you need to go so it makes it quite difficult. And with the lower abdominal pain not everyone will tell you if they are in pain (F: Staff)

I don’t think anyone ever tells us that they’ve got that it’s burning. Because a lot of them are already incontinent, they are wearing incontinent pads, you’re not going to see the increased urgency or frequency or increased incontinence, so it’s rare that we actually see blood in the pad when they’ve had a urinary infection. A lot of them can’t tell you if they’ve got a lower abdominal pain okay, you could see the shaking and the rigors but that’s not a symptoms that we see often. (D: Staff)

Respiratory tract infections

See it’s not mentioning here the sputum, the colour of the sputum because COPD, every patient of COPD has sputum (…) you can see a lot from the colour. When it’s infection it’s yellowish, greenish. (A: Staff).

Skin and soft tissue infection

If they have pus draining from a wound, we always swab it and send the swab. Always. We would never leave that. (…) And then like one was done the other day and it goes back to the GP, the results and then the GP contacts us and then with the antibiotic and then it comes from the pharmacy, so we always swab a pussy wound. (B: Staff)

If we get someone with an abscess and we let the, once you let the pus out you don’t usually have to give the antibiotic cover, so it’s more the antibiotics needed here rather than whenever there actually is pus draining. (B: GP)

Well, if there’s a wound, we would do that if it’s localised redness heat or swelling or anything like that where there’s no abrasion or no wound then we go through the GP – if there’s a sore or the skin like moisture lesions we see. Or if it looks like breaking, then we go to through the district nurses. (F: Staff)

Action by care home staff

If they are not taking the paracetamol and not taking a drink, I’d be more inclined to contact the GP, because I know I will not get that down, if I can get that down with paracetamol and lots of drinks I would wait, usually. (B: Staff)