Pressure Areas and Safeguarding

1. Introduction

Safeguarding an adult from harm and exploitation is one of the key responsibilities of all care providers, and is a basic human right as laid down in the Human Rights Act 1998. All health and social care practitioners must ensure that adults are safeguarded against the risk of abuse or neglect by early identification of potential risks, prevention of risks and responding appropriately to any allegation or suspicion of abuse.

Older people and those with disabilities may be frail and have restricted mobility and will, therefore, be at higher risk of developing pressure areas, especially if they are towards the end of life. Pressure sores may start simply with skin changing colour but, if left untreated can become deep or infected. They can be life threatening if infections develop which are not treated.  With good management and care, they can be improved in many cases.

Staff must have an awareness of when tissue damage or pressure ulcers may be a result of poor practice or neglect, and what action to take. Not all pressure ulcers occur as a result of neglect by professionals, however, and care should be taken not to automatically make such assumptions.

Cases should be treated individually taking into account the person’s medical condition, prognosis, skin conditions, self-neglect, poor personal hygiene, living environment, poor nutrition and hydration and their own views on their care and treatment.

The police must be involved where there is a possibility the pressure sores are a result of wilful neglect by a family member or by a practitioner or service (see Taking Initial Action where there are Safeguarding Concerns).

2. Preventing Pressure Areas: Checklist

The following factors are a guide to identifying risk in relation to pressure sores, and to prevent them occurring wherever possible:

• all care staff should receive training on how to prevent and identify pressure sores;
• adults with care and support needs should be regularly assessed on their risk of developing pressure sores;
• individuals at risk of developing pressure sores should be assessed to ensure that appropriate equipment is provided promptly;
• timely referrals should be made to community health professionals in pressure sore management;
• body maps should be completed to identify and monitor pressure sores;
• care and support plans and action plans should be regularly reviewed by managers.

3. Pressure Area Assessment Checklist

If a pressure ulcer or tissue damage is at risk of occurring, or has already occurred, the following information should be obtained by the relevant practitioner from the adult, family member or carer.

3.1 History

Does the adult have any significant health history, including physical or mental health issues that would impact on their mobility or general physical health, for example?

Has there been a rapid onset or deterioration in the adult’s health? If so how has this affected them?

Does the adult have any issues related to mental capacity, compliance with practitioners, challenging behaviour, for example, that could impact on any required care and support interventions in related to tissue damage?

3.2 Care and support

Where was the adult living at the time the pressure ulcer was identified

Was the adult admitted with the pressure ulcer or has it developed since admission?

Were they receiving support from a regulated service?

What are the adult’s views of their condition? Are they in pain as a result of the ulcer? Do they have an infection or any other symptoms that may need immediate medical intervention?

What are the views of their carers or family members about the care and support the adult has received, and do they have any safeguarding concerns in relation to practitioners or service quality?

Are there any concerns that the adult’s pressure ulcer is related to the level of care from the service provider? If so, please see Taking Initial Action where there are Safeguarding Concerns.

Has a skin care assessment and care and support plan been completed? Was the assessment robust, for example were pressure areas identified as a risk and if so were specific of concern were noted; was a body map and a Waterlow score completed (see Appendix 1)? Was regular monitoring of the adult’s skin undertaken?

Does the adult’s care and support plan identify pressure area risks and appropriate measures to be taken to minimise risk, for example regular moving with the aid of staff?

Was specialist equipment in place and was it being appropriately used? If not, record the reason.

Were staff involved in the adult’s care and support adequately trained and competent in relation to skin care and pressure ulcer interventions? Was staff cover sufficient, both days and nights?

3.3 Mobility

What was the adult’s mobility just prior to identification of the pressure ulcer?

Does their care and support plan include needs relating to their mobility?

Have there been any changes to their mobility recently that are not reflected in the care and support plan?

Where the adult has mobility problems, do care and support staff regularly help them move – either in bed, in the chair or help them have a short walk for example?

3.4 Hydration and nutrition

What is the adult’s nutritional intake? Are there any concerns related to how much and the quality of the food they eat? Is there any concern they may be malnourished? Does their care and support plan reflect any such concerns?

Does the adult have an adequate, healthy intake of fluids? If not, does their care and support plan reflect this?

If they are in residential care or hospital are their food and fluid intake adequately recorded in their case notes?

Does the adult need a referral to a doctor or nutritionist?

Is the adult’s weight regularly recorded, monitored and concerns raised with the relevant health care professional?

3.5 Medication

Is the adult receiving any medication which may contribute to immobility, for example sedatives or medication that is making them feel nauseous?

If they are sedated, this may lead to the adult being immobile for extended periods of time.

Is their pain assessed and adequately managed?

3.6 General appearance

How does the adult present in relation to their appearance?

Are their hair and nails clean, their clothes clean, do they have any personal odour which suggests they may not have washed, bathed or showered recently?

Are they emaciated?

Is their oral care adequate?

3.7 Mental capacity

Are there any concerns about the adult’s ability to make informed choices? If so has a mental capacity assessment been completed?

If not, make arrangements for one to be completed (see Mental Capacity).

3.8 Equipment

Is relevant pressure relieving equipment in place, for example specialist mattresses, chair or feet cushions or beds? If not, and it is assessed as being required, make a referral to the relevant service.

3.9 Where the adult is living in the community

Where do they live?

Who is providing support?

What is the relationship to the adult of the person / people providing support to the care and support needs of the adult?

Provide the carer’s age, any disability and how they are coping.

What support networks do both the adult and the carer have?

Has the adult and the carer had care and support assessments conducted by the local authority? If not, do they need a referral?

Was support and help sought? If so, when and from whom?

Was support accepted – all, in part or none?

4. Assessment Outcome

Following completion of the assessment, including the above information, there are three possible outcomes:

• no further action – the assessment has concluded that the pressure ulcer was unavoidable due to the adult’s individual’s health issues. The service they have been receiving had taken all appropriate measures available to them in a timely manner;
• quality alert action required – the assessment has concluded that poor quality care may have contributed to the development of the ulcer and a Quality Alert Action required
• safeguarding referral required – the assessment has concluded that the pressure ulcer may have been avoidable – the result of neglect because the service and support they were receiving had not taken all appropriate measures available to them in a timely manner.  A safeguarding referral should be made to the local Safeguarding Adults Team; the police may also be notified where there are concerns of wilful neglect (see Taking Initial Action where there are Safeguarding Concerns).

Consideration should be given to any risks posed to other service uses, residents or patients, including gathering information as to the prevalence of other people who have developed pressure ulcers over a specified period of time.

Appendix 1: Resources

Waterlow score for grading pressure sores (click + button in bottom right corner to enlarge)

Waterlow resources