Martha's Rule in Adult Social Care: A Registered Manager's Guide to Implementation

Martha's Rule has changed how NHS hospitals respond when a patient, family member or member of staff is worried that someone's condition is deteriorating and isn't being taken seriously. It isn't a legal requirement in adult social care, but the principle behind it, that concerns about deterioration must be heard and acted on quickly, sits at the heart of what CQC expects from every registered provider. This guide sets out what Martha's Rule actually covers, why it matters for care homes and domiciliary services even though it doesn't formally extend to them, and a practical framework for building the same protections into your service.

What is Martha's Rule?

Martha's Rule is named after Martha Mills, a 13-year-old who died in 2021 after developing sepsis in hospital. A coroner ruled that her concerns, and her family's, about her deteriorating condition were not responded to promptly, and that she would probably have survived with earlier intervention. NHS England began rolling out Martha's Rule from April 2024, starting with around 100 acute sites and expanding to all adult and paediatric acute inpatient services, with full implementation targeted for 2026/27.

The scheme rests on three elements: round-the-clock access for patients, families and carers to request an urgent review from a separate critical care team; the same escalation route for staff who are worried a concern isn't being acted on; and accessible information so patients and families know how to raise a concern in the first place. NHS England's own figures show the scale of what this has already achieved: over 10,000 escalation calls were made in the scheme's first 16 months, with more than a third identifying rapid deterioration and hundreds of patients receiving potentially life-saving changes to their care.

Does Martha's Rule apply to adult social care?

Not directly, and it's worth being precise about that with your staff and families. Martha's Rule as designed by NHS England applies to acute inpatient hospital services only. It has not been extended, and there is no published timetable to extend it, to care homes, domiciliary care or supported living.

What does apply to adult social care is the thinking behind it. CQC, the Nursing and Midwifery Council and the General Medical Council issued a joint statement backing Martha's Rule, describing it as reinforcing "the fundamental principles of listening to people who use health and care services and their families, and acting on what they say." That statement makes the connection explicit: people's experience of being heard, and of concerns being acted on, is central to how CQC assesses safety and quality in every regulated service, including yours.

In practice, this means a provider who can show a clear, well-understood process for residents, families and staff to escalate concerns about deterioration is demonstrating exactly the kind of person-centred, responsive culture CQC looks for under its safe and well-led key questions, and under the duty of candour and complaints-handling requirements that already sit in your regulations. You don't need to wait for a mandate to build this.

The tool many care homes already have: RESTORE2

Adult social care doesn't need to invent a Martha's Rule equivalent from scratch. RESTORE2, developed by West Hampshire CCG and the Wessex Patient Safety Collaborative, is a physical deterioration and escalation tool designed specifically for nursing and care homes (a simplified version, RESTORE2mini, is also available where clinical observation equipment isn't in use). It combines three things:

• Recognising soft signs: a "what's normal for this resident" baseline, so staff can spot subtle changes, particularly valuable for residents with dementia or communication difficulties.

• NEWS2 observations: the same National Early Warning Score used across the NHS, so a care home's escalation call speaks the same clinical language as the ambulance service or GP on the other end of the phone.

• SBARD communication: a structured way (Situation, Background, Assessment, Recommendation, Decision) to hand over a concern so nothing gets lost or watered down.

RESTORE2 is recommended for care and nursing homes by the British Geriatrics Society and has been adopted across multiple NHS regions, including being offered to all CQC-registered care homes in some integrated care systems. If your service already uses Vital Signs and NEWS2 training, RESTORE2 is a natural extension: it gives your staff the escalation structure that sits around the observation itself.

For domiciliary care, where a full NEWS2 set isn't always practical, the same "soft signs" logic applies through simpler tools such as Stop and Watch, designed for families and carers to flag when something feels wrong, even before they can name why.

Not sure where your escalation processes stand against what CQC expects? Start with our CQC Readiness Assessment to see how your current systems compare.

A practical framework: adapting Martha's Rule's three elements

1. Give residents and families a clear, known route to raise a concern. Don't rely on staff remembering to mention it. Put it in the welcome pack, on a poster in communal areas, and repeat it at care plan reviews: who to speak to, what happens next, and that raising a concern won't affect the standard of care their relative receives. This mirrors the "accessible information" element of Martha's Rule and strengthens your existing complaints-handling and person-centred care practice.

2. Give staff the same permission to escalate, and a structure to do it with. Junior or night staff are often the first to notice something is wrong, and the least likely to feel able to challenge a senior colleague or on-call decision. A structured tool like RESTORE2's SBARD framework removes the guesswork: staff aren't asking permission to worry, they're following a defined process. Pair this with your Whistleblowing in Health and Social Care and Communication training so staff understand escalation is expected, not exceptional.

3. Close the loop, every time. Martha's Rule works because every call gets a response from someone outside the immediate care team. In a care home, that might mean a designated senior nurse, clinical lead, or on-call manager who isn't the person the concern is about. Log every escalation, what was found, and what changed. This record does double duty: it protects residents, and it gives you the evidence base CQC inspectors look for when assessing whether concerns are genuinely acted on rather than just received.

4. Train for it, don't just document it. A policy on a shelf doesn't change behaviour. Build RESTORE2 or an equivalent escalation tool into induction and refresher training, and run it alongside your Sepsis and Work in a Person-Centred Way modules so staff see the clinical and cultural sides of the same principle: listen, escalate, don't wait.

Why this matters beyond compliance

Martha's family's campaigning succeeded because it named something staff and families already knew: that a system only works if the people using it are heard, and the people running it are willing to act quickly on what they're told. NHS England's evaluation data backs this up in a hospital setting; there's no reason the same culture change wouldn't produce the same benefit in a care home, where residents and their families are often even better placed to notice subtle changes than a rotating hospital team.

For registered managers, building this now, ahead of any formal requirement, is both good governance and good care.

Verified sources

• NHS England, Implementation of first phase of Martha's Rule and Martha's Rule patient safety pages, england.nhs.uk

• NHS England, Over 10,000 calls to Martha's Rule in first 16 months, england.nhs.uk (March 2026)

• Joint statement on Martha's Rule from the NMC, GMC and CQC, cqc.org.uk

• Wessex Patient Safety Collaborative / Health Innovation Network, RESTORE2 resource pack and implementation guidance

• British Geriatrics Society, COVID-19: Managing the COVID-19 pandemic in care homes (RESTORE2 endorsement)