RELEVANT CHAPTER
RELEVANT INFORMATION
Safeguarding Adults Protocol: Pressure Ulcers and Raising a Safeguarding Concern (DHSC)
CONTENTS
1. Overview
The Department of Health and Social Care (DHSC) protocol on the process to be followed when it is identified that an adult has a pressure ulcer aims to promote awareness of pressure ulcers across the social care workforce, so that more can be done to prevent their occurrence and enable a speedy response. The protocol is clear that – in most cases – the appropriate response will be led by health practitioners, and not involve adult safeguarding processes.
The protocol is accompanied by Safeguarding Concerns Assessment Guidance which should be completed by a registered nurse. If responses to questions in the guidance give a total score of more than 15, then concerns should be shared with the local authority adult safeguarding team.
2. What are Pressure Ulcers?
Pressure ulcers (also called pressure sores or bed sores) are an injury that break down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They usually form on bony parts of the body, such as the heels, elbows, hips and tailbone (coccyx, at the base of the spine).
Signs of a pressure ulcer include:
- discoloured patches of skin that do not change colour when pressed – such patches are usually red on white skin, or purple or blue on black or brown skin;
- a patch of skin that feels warm, spongy or hard;
- pain or itchiness in the affected area of skin.
Pressure ulcers usually develop gradually but can sometimes appear over a few hours. They can become a blister or open wound. If left untreated, they can get worse and eventually reach deeper layers of skin, muscle and bone.
People are at more risk of developing pressure ulcers if they:
- have problems moving / are not very mobile;
- have had a pressure ulcer before;
- have been seriously ill in intensive care or have recently had surgery;
- are underweight or have issues with poor nutrition and hydration.
- have swollen, sweaty or broken skin.
- have poor circulation or fragile skin.
- have problems feeling sensation or pain.
Other issues which can contribute to pressure ulcers include:
- substandard care provided by staff;
- poor communication between carers and nurses;
- ineffective multi-disciplinary working;
- lack of access to required resources such as equipment and low staffing numbers.
Pressure ulcers can also occur because of neglect. This may be the deliberate or unintentional failure of a carer or member of staff to provide appropriate and adequate care and support, including:
- ignoring a person’s medical or physical care needs;
- failing to provide access to appropriate healthcare and support services;
- withholding essentials a person may need for good skin health, such as medication, adequate nutrition and regular changes of position.
3. Preventing Pressure Ulcers
Pressure ulcers cause distress to adults and their families, but most can be prevented. Treating and responding to pressure ulcers will mainly be health led, but preventing pressure ulcers is the responsibility of everyone involved, as many of those who are at risk of pressure ulcers will be receiving services and support from staff working across the social care sector.
To prevent pressure ulcers, all health and social care practitioners involved in the planning, commissioning and delivering of health and social care to adults, need to be able to spot the risks and take appropriate, speedy action.
Assessments of adults, including risk assessments, should look at the likelihood of pressure ulcers developing and describe actions that will be taken to prevent them. This applies to adults living at home as well in registered care home settings.
3.1 Providing information and advice
If a person who is at risk of pressure ulcers has mental capacity (see Mental Capacity chapter), they should be given advice and information about self-care and preventing skin damage. However, it is important to make sure the person:
- has understood the advice;
- can put the advice into practice;
- has the necessary equipment and knows how to use it;
- can understand what may happen if they do not follow advice.
Where the adult, for reasons that seem sensible to them, choose not to follow the advice given, practitioners should discuss alternatives and try to reach a compromise if possible. In this situation, practitioners should note the discussions in the adult’s records and make a note to revisit the conversation again.
If it appears that the adult is not looking after themselves or their environment, staff should ask their manager or safeguarding adults lead for advice (see also Self Neglect chapter).
Many people who develop pressure ulcers will not be receiving healthcare services but will be receiving care from family and friends or paid care workers. It is vital, therefore, that these paid and unpaid carers
are given training and information on how to prevent skin damage and pressure ulcers, and guidance on how to spot the signs that an ulcer may be developing, as well as how and when to contact relevant health practitioners about any concerns.
4. Taking Action when a Pressure Ulcer is Identified
Where there is concern that a pressure ulcer has developed, an appropriate member of staff should explain this to the adult and their family members and ask their views. Responses to pressure ulcers should always have the person at the centre and fully involve them (or their representative) and family.
Responding to pressure ulcers will mainly be an issue for health practitioners, rather than a safeguarding enquiry led by the local authority. It is not appropriate or necessary for adults with pressure ulcers to be routinely referred to the local authority (see Section 4.2, When safeguarding concerns should be raised with the local authority).
Where there are concerns about the quality of a service and possible poor practice, these should usually be raised with the service provider in the first instance, then escalated to the local authority, Integrated Care Board or Care Quality Commission (CQC) using existing local reporting systems.
4.1 Initial steps
If there are concerns that an adult has a pressure ulcer, the member of staff involved should (in discussion with the adult and their family) refer them to appropriate healthcare services so they can access the treatment they require to prevent further damage to their skin.
Pressure ulcers are given a category (or grade) from one to four to indicate the extent of the wound. with four being the most severe. Pressure ulcers in category one and two must be considered as requiring early intervention to prevent further deterioration or damage. For more information, see Categories of Pressure Ulcer and the Pressure ulcer recommendations document on the National Wound Care Strategy Programme website.
A clinician, usually a nurse, will document how the skin damage developed. If the adult has recently been transferred from another service, the organisation which identified concerns about the pressure ulcer should contact the previous care provider for information.
There should be a review within the organisation / service / provider, to identify if there are any lessons which could prevent the occurrence of pressure ulcers in the future. Very few cases will need a safeguarding concern to be raised with the local authority, most will not require such action (see Section 4.2, When safeguarding concerns should be raised with the local authority).
Where the pressure ulcer appears to be the result of unintentional neglect by an unpaid family or friend carer who is struggling to provide care, the most appropriate response will usually be to revise the package of care and ensure the carer has support and equipment to be able to care for the adult safely. Conversations with carers about this can be difficult, especially where carers have been dedicated in providing care but were not given – or have forgotten or otherwise not followed – advice and support to prevent pressure ulcers.
Most adults with pressure ulcers do not usually require a safeguarding referral / safeguarding processes as they require interventions and responses from health professionals.
The protocol requires that the Adult Safeguarding Decision Guide is completed for adults with ‘severe damage’, to assess whether it may be appropriate for staff to also share their concerns with the local authority adult safeguarding team.
4.2.1 Defining severe damage
A pressure ulcer might be classed as severe if there are multiple category two ulcers or single category three or four ulcers. However, severe damage could also be identified because of the impact the pressure damage has on the person affected (for example, they are experiencing pain).
Severe pressure ulcer damage can also be present, when it is not yet visible on the skin. Therefore, it is important to be alert for anything that indicates damage to the skin or underlying tissues, most commonly reports of pain or numbness, then changes in the tissue texture or turgor (tightness), change in temperature and finally changes in colour – remembering that not all skin tones show redness.
Skin damage that is established to be as a result of incontinence and / or other types of dampness alone should not be recorded in the notes as a pressure ulcer but should be referred to as ‘moisture association skin damage’ to distinguish it and be recorded separately. However, where this might be as a result of neglect or poor oversight, it should be explored – not ignored.
Skin damage that has been determined as combined, that is caused by both moisture and pressure, must be recorded in the notes as a pressure ulcer.
Skin damage that is a result of pressure from a device, such as from casts or ventilator tubing and masks, must be recorded as a pressure ulcer. These are known as medical device related pressure ulcers.
4.2.2 Action when there is severe damage
Within 48 hours of identifying a pressure ulcer which is classed as ‘severe damage’, the Adul Safeguarding Decisions Guide should be completed by a practising registered nurse with experience in wound management. The nurse completing the assessment should not be directly involved with the care of the adult.
The safeguarding adult decision guide contains six questions which give an initial score. This can be used to help inform decision making about whether to escalate safeguarding concerns. The threshold for raising a concern with the local authority is a score of 15 or above – but the score should be used alongside professional judgement.
The six questions in the adult safeguarding decision guide are:
- Has the person’s skin deteriorated to either category three or four, or multiple sites of category two ulceration from healthy unbroken skin, since the last opportunity to assess or visit?
- Has there been a recent change, that is within days or hours, in their clinical condition that could have contributed to skin damage? For example, infection, pyrexia, anaemia, end of life care (skin changes at life end), critical illness.
- Was there a pressure ulcer risk assessment or reassessment with an appropriate pressure ulcer care plan in place, and was this documented in line with the organisation’s policy and guidance?
- Is there a concern that the pressure ulcer developed as a result of the informal carer wilfully ignoring or preventing access to care or services? (see also Ill Treatment or Wilful Neglect chapter)
- Is the level of damage to skin inconsistent with the person’s risk status for pressure ulcer development? For example, low risk, category (or grade) three or four pressure ulcer.
Question 6 has two parts, which part is asked depends on the adult:
Answer question 6a if the person has capacity to consent to every element of the care plan:
6a. Were the risks and benefits explained and understood by the adult?
Was a plan of care agreed in line with shared decision-making and has the adult chosen to follow the relevant aspects of the plan?
Answer question 6b if the adult has been assessed as not having mental capacity to consent to any or some of the relevant aspects of the care plan:
6b. Was the relevant care undertaken in the adult’s best interests, following the best interests checklist in the Mental Capacity Act Code of Practice p65 – Quick Summary?
This should be supported by documentation, for example mental capacity and best interests statements and a record of the care delivered.
The Adult Safeguarding Decision Guide has example questions which practitioners can use.
A body map should be used to record skin damage. Photographs can also be taken, with consent from the adult or their representative. The photograph should only show the ulcer, not other uninvolved parts of their body; care and sensitivity must be taken to protect the adult when taking such images. A body map is available in Appendix 2 of the Protocol,
4.2.3 Assessment score and next steps
If the decision guide score is 15 or higher (which is a concern for safeguarding), then the following action is required:
- discuss with the person, family and / or carers that there are safeguarding concerns, explaining why and that a safeguarding enquiry has been raised;
- refer to the local authority, with completed safeguarding adults pressure ulcer decision guide documentation;
- follow local pressure ulcer reporting and investigating processes;
- record the decision in the person’s case records.
If the decision guide score is under 15, then the follow action is required:
- discuss with the person, family and / or carers and explain reason why it is not being referred for a safeguarding enquiry;
- explain why it does not meet criteria for raising a safeguarding concern with the local authority, but stress the actions which will be taken to treat the adult’s ulcer and prevent any further skin damage;
- action any other recommendations identified and put preventative or management measures in place;
- follow local pressure ulcer reporting and health investigation processes;
- record the decision in the person’s case records.
Once a safeguarding adults concern is raised with the local authority, staff in the safeguarding adults team will decide whether a section 42 enquiry is required and inform the adult, family members, organisation / provider of the next steps (see Safeguarding Enquiries section).
