Jasmine is a student nurse who while on her third-year community placement was deemed competent to attend a residential home unsupervised to dress Mrs John’s leg ulcer.

When she got to Mrs John’s room she found the room was cold with the window open and that it was dark with poor lighting. Mrs John was complaining of feeling freezing cold, had back pain and wanted to go to the toilet but was laying down in the bed and requested support to sit up. As Jasmine switched all the lights on she noticed Mrs John’s poor oral hygiene due to a build-up of food in her oral cavity and also dribbles of something on her face and dried fluid from her eyes. Jasmine observed that it looked as though Mrs John’s personal care had not been attended to.

Mrs John said that she wanted to die and be left alone. When Jasmine mentioned this to the care staff and the home manager their attitude was dismissive and they referred to Mrs John as a ‘stubborn lady’.

Jasmine was also concerned that on several visits she had observed broken furniture in the home that had not been fixed and which could be a hazard to the residents. She had also observed another resident undressed on their bed with the bedroom door left open.

When Jasmine returned to the community nurse office she shared her concerns with her mentor. She also raised them with her personal tutor. As a result of this a safeguarding referral was made and an appropriate plan of care was put in place to reduce the risk of Mrs John coming to harm. The risks to other residents were also reduced by monitoring of care standards by the Local Authority Contracting Team.