The Noticing Model™ · Monitoring outcomes · Deterioration
The weight might have been wrong. But why was nobody checking?
What would happen in your service if someone’s weight was different from what you would normally expect? One record in a CQC inspection showed a person had lost 3.5kg in a month and was at high risk of malnutrition. The explanation later was that the weight may have been wrong. But the service had not checked the reading, confirmed the loss or sought further advice before inspection. The important question is not whether the number was ultimately right. It is what happened when the record first showed something that could have mattered.
Some risks in adult social care are immediately noticeable. When you see someone having a fall or you witness someone choking the risks are immediately obvious. Other risks develop slowly and can hide in plain sight. A person starts to eat slightly less; their weight drops and their clothes become looser.
The notes show that staff recorded reduced appetite and they are eating smaller portions. Another staff member notes that the person seems more tired. Someone else says, “Have you noticed their clothes are looking looser?”
In isolation these recordings may not look significant. That is why gradual deterioration is easy to miss, and the dots aren’t always joined up. If these observations are not connected, then something serious can go unnoticed.
One CQC assessment under Monitoring and improving outcomes shows the problem particularly clearly. Inspectors found that food and fluid records were not accurate or complete, which meant the provider could not demonstrate how changes in people's intake would be identified quickly enough to protect them.
The report identified one person whose records showed a 3.5kg weight loss in a month. Their recorded weight placed them at high risk of malnutrition.
When inspectors asked whether dietary advice had been sought, the Registered Manager said the latest weight had probably been incorrect or had been recorded in error.
However, the service had not checked. The comment was said with confidence not assurance. This is a comment where the CQC can distinguish the difference.
There had been no action to confirm whether the weight was accurate, and no further advice had been sought before the inspection. This generates another question: has weighing people and recording the outcome become another task, rather than a way of monitoring change and recognising potential concerns.
What the finding actually tells us
The most reassuring interpretation of this finding is that the service had a weight-recording problem. A staff member may have recorded the person’s weight incorrectly. The scales may have been inaccurate and needed recalibrating. Someone may have weighed the person differently from usual.
Any of the above could be true. But none of those reasons answer the more important question:
If nobody knew the weight was wrong at the time, why was nothing done when the record showed a potentially significant loss?
There is a significant difference between:
"The reading showed a significant loss in weight. We checked the weight and established that the reading was incorrect. We recorded the incorrect weight with the rationale and then the correct reading"
and:
"We think the reading must have been incorrect."
The first is evidence. The second is a plausible explanation without assurance. In governance, an explanation that has not been tested can become reassurance very quickly.
A wrong weight and a weight that goes unnoticed are not the same thing
A wrong or inaccurate weight is not automatically evidence of poor care. Records can contain mistakes. The scales used can be inaccurate. Calculations to allow for wheelchair weight may be miscalculated. These are all plausible human errors.
The problem begins when an unexpected reading could indicate a health risk and nobody explores whether it is true.
If a person appears to have lost 3.5kg in a month, there are two broad possibilities.
The person has lost that weight, in which case the service needs to understand why. Or the person has not, in which case the service needs to understand why the record is wrong.
Both possibilities require action. What should not happen is for the entry to be left recorded without action until somebody else asks about it or health deteriorates significantly.
This is the same distinction Carevia explores elsewhere between policy and practice in safeguarding . A document can exist and still fail to protect someone if nobody is testing what it means in practice.
Why gradual change is so easy to miss
Gradual deterioration is difficult because it rarely looks significant from one shift to the next. A person may begin by eating slightly less at breakfast. Then leave more of their lunch. The nutrition monitoring chart records both observations.
A support worker may notice they need more encouragement at mealtimes to eat their meals. A relative may comment that their clothes look looser. These both get a mention in the person’s monthly key worker meeting.
Another member of staff may record that they seem more tired than usual and is passed on at handover. A weight is entered that is lower than the previous month and recorded in the person’s weight chart.
Every one of those observations can be recorded correctly and still fail to create a response to the person’s gradual deteriorating health.
That is because the problem is not always missing information. Sometimes the information is all there. The changes have been noticed but the significance has not been recognised which means it hasn’t gone any further than a record in a document.
Nobody joins it into a single picture.
This is one reason daily notes and monitoring forms matter so much. They support services to connect dots and recognise significance. Without recognising the significance, it is impossible to respond correctly and take the required action.
The first place I go to when a service has a low number of incidents or safeguarding is the daily notes. This is because they often contain information that has been noticed but not recognised. This is because they can become the default location for recording something that has been noticed, even when it's significance has not been recognised. They’ve not been recognised as a near miss, or a sign of deteriorating health, or as a safeguarding concern. There can be an assumption from staff that an entry written in daily notes filters to where it needs to go. This could include a staff member writing that a person ate less at lunchtime, their jumper appeared looser, or they were more tired than usual. This can provide an opportunity to ask what action, if any, was taken following the recorded entries.
If the significance isn’t recognised, then the response is unlikely to be correct. Carevia's guide to person-centred daily notes makes the same point: records should help leaders understand the person's experience and notice change, not simply prove that tasks were completed.
However, daily notes should also record action taken not just what has been noticed and recognised. Otherwise, part of the chain has been broken.
The practical challenge is not simply to record more. It is to help teams recognise when ordinary entries stop being ordinary and require a response.
Recording a weight is not the same as monitoring it
Many services can answer the question:
"Are people weighed regularly?"
Far fewer can answer:
"Who reviews the trend, what triggers concern, and what happens when the result does not make sense?"
Those are different questions.
A monthly weight entry is data, or more precisely, proof that a task has taken place. Monitoring begins when somebody interprets that data. Assurance begins when the service can show what happened next.
A functioning system should be able to answer questions such as:
- Who reviews changes in weight?
- What counts as an unexpected or clinically significant change?
- What happens when a reading does not fit the previous pattern?
- Who checks whether the scales or entry are accurate?
- Are food and fluid records reliable enough to support the decision?
- Are changes in appetite, swallowing, mood, mobility or health considered alongside the number?
- When is clinical or dietary advice sought?
- Who checks that agreed actions actually happened?
When reassurance replaces assurance
Once an unusual result has been challenged, it is very easy to explain it retrospectively.
"The scales were probably wrong."
"Someone must have entered it incorrectly."
"Their weight fluctuates."
"They were wearing different clothes."
Any one of those explanations may be correct.
But the leadership question is:
What evidence do we have that this explanation is true?
If the answer is none, the uncertainty remains.
Carevia has written before about the difference between confidence and assurance in How Leaders Know What's Really Happening in Adult Social Care .
Confidence says the reading was probably wrong.
Assurance checks.
The Noticing Model™ in practice
This is exactly the type of situation The Noticing Model™ is designed to explore.
It begins from a simple principle:
People cannot respond to what they do not notice.
Notice
Something is different.
In this example, the record shows a 3.5kg weight reduction in one month.
Notice does not mean assuming the person is malnourished. It means recognising that this is a deviation from what we expect for this person.
Recognise
The next question is:
Why might this matter?
Weight loss may be associated with reduced intake, swallowing difficulty, illness, pain, medication, oral-health problems, low mood, reduced independence at mealtimes or other causes.
It may also be a measurement error.
Recognition is not diagnosis. It is understanding that the change may be significant enough to investigate.
Respond
What needs to happen now?
A proportionate response might include re-weighing the person, checking the equipment and previous weights, reviewing food and fluid information, checking recent daily notes and considering whether anything else about the person's health or behaviour has changed.
Where the change is confirmed or concern remains, appropriate clinical or dietary advice should be sought.
Report
Important information has to reach the people who can act on it.
- If a support worker notices reduced appetite, does the senior know?
- If the senior identifies an unexpected weight change, does the manager know?
- If the weight is rechecked, is the result communicated clearly?
- If professional advice is received, does it reach the staff delivering support?
Reflect
The final question is:
What will we notice sooner next time?
Reflection should move beyond correcting one weight entry.
Leaders should ask whether the same system could allow the same warning sign to be missed for somebody else.
Three things worth doing this week
- Pick one person whose weight has changed recently. Follow the record backwards and forwards. Who noticed the change, what did they do, and what evidence shows the issue was resolved?
- Read the food and fluid records alongside the daily notes. Do they tell the same story, or does one source show changes the other misses?
- Ask three staff what would make them escalate a weight change. Do not ask whether they know the policy. Give them a realistic scenario and see what they would actually do.
Where RAOF™ adds the assurance
The Noticing Model™ helps teams notice and respond to something that may matter.
RAOF™ helps leaders test whether the wider picture supports that response.
RAOF™ is explored in more depth in How Leaders Know What's Really Happening in Adult Social Care .
The real test for your own service
Most services can produce a weight chart. Most can produce a food and fluid form. Most will have a nutrition policy.
The questions that matter are:
Can you show what happened the last time something changed?
- Who noticed?
- Who recognised why it might matter?
- What happened next?
- Who was told?
- Was the change confirmed?
- Was advice sought where appropriate?
- Did the care plan change?
- Was practice checked afterwards?
Where Carevia can help
The Noticing Model™ is built into The Noticing Hub™ Membership by Carevia .
The Hub is designed to help teams build professional curiosity into the work they already do rather than create another layer of forms.
It includes practical tools built around:
- handovers
- supervisions
- leadership walkarounds
- scenario-based learning
- policy discussions
- care-plan review
- team reflection
Notice what matters sooner, recognise why it matters, respond appropriately, make sure the right people know, and reflect so practice improves.
For the governance side of the same problem, Carevia Pro+ uses RAOF™ to help managers triangulate evidence rather than rely on a single reassuring record.
The Noticing Model™ asks: What are we noticing, and what might it mean?
RAOF™ asks: How do we know what is really happening?
Frequently asked questions
Does one low weight automatically mean a person is malnourished?
No. One unexpected reading may be genuine, may reflect normal variation or may be inaccurate. A significant or unexpected change should be checked and interpreted in context rather than ignored.
What should a service do if a recorded weight appears wrong?
The reading should be checked promptly using an appropriate method, alongside previous weights and relevant information about the person's intake, health and presentation.
Why are food and fluid records important?
They can help show changes in intake over time and support decision-making where there are nutritional or hydration concerns. Their value depends on them being accurate, complete and reviewed.
How does The Noticing Model™ apply to weight loss?
It gives teams a simple sequence: Notice the change, Recognise why it might matter, Respond proportionately, Report what others need to know and Reflect on what could be noticed sooner next time.
How does RAOF™ add to The Noticing Model™?
The Noticing Model™ helps teams recognise and respond to a concern. RAOF™ helps leaders triangulate the wider evidence by reading records, asking people and staff, observing practice and feeding learning forward into improvement.
Is recording weight regularly enough?
Recording is only one part of monitoring. Leaders also need systems that identify meaningful change, trigger appropriate action and show that concerns were followed through.
Further reading from Carevia
- The Noticing Hub™ Membership by Carevia Practical tools that bring The Noticing Model™ into handover, supervision, walkarounds, scenarios and team learning.
- How Leaders Know What's Really Happening in Adult Social Care The wider RAOF™ approach to triangulating records, conversations and practice.
- Daily Notes in Adult Social Care: Are Yours Actually Person-Centred? Why everyday records should help leaders understand what is changing.
- Lessons Learned in Adult Social Care: 6 Myths to Avoid Why recording an event or closing an action does not necessarily mean anything changed in practice.
- Safeguarding: When the Policy Is Not the Practice Another example of the gap between a reassuring record and what is actually happening.
This article discusses a published CQC assessment finding in general terms and does not identify the service concerned. It is written to support reflective practice and is not clinical, dietetic, legal or regulatory advice. Unexpected weight loss or concerns about nutrition should be assessed in line with the person's needs, relevant professional advice, local procedures and clinical guidance.