After a full assessment for NHS Continuing Healthcare Funding (CHC), it is the Multi-Disciplinary Team’s role to make a recommendation to the NHS Integrated Care Board (ICB) as to whether or not an individual has a ‘Primary Healthcare Need’.

If the recommendation is positive and the individual is found eligible for CHC Funding, the NHS is obligated to pay for all their healthcare and social care needs in full – free of charge.

Establishing A Primary Health Care Need

Is your relative entitled to free NHS Funding for their care?

Where CHC Funding has been awarded, the ICB should take the lead role in implementing the approved care package. It is the ICB’s primary responsibility to plan, procure, commission and case manage a suitable package of care to meet that individual’s assessed healthcare needs and desired outcomes – which includes all their social care needs and accommodation. This is usually done via an appointed Case Manager. Then, once commissioned, the ICB also have ongoing responsibility for reviewing, monitoring and reassessing that care package to ensure that it still remains appropriate to meet and support the individual’s needs and agreed outcomes.

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (updated July 2022) stipulates that the individual is to be the centre of focus at all times (‘person centric’). As such, the personalised package of care should be specifically tailored to meet their needs. It is up to the ICB how they source that package of care. Often, they will have to look outside the ICB.

Paragraph 193 of the latest revision of the National Framework, indicates that where CHC Funding is awarded, care planning should be considered as a whole, and not in isolation to other needs the individual may have; and furthermore, those needs should, wherever possible, form part of a single care plan. In theory, this should make it easier and simpler to manage.

Joint packages of care

Sometimes, care packages can involve combined elements of both healthcare and social care needs (referred to as a “joint package of care” with health needs being provided by the ICB, and social care needs being the responsibility of the Local Authority (subject to means-testing).  In practice, where there is potential for overlap, the NHS National Framework suggests carrying out a 24/48 hour analysis to help identify those needs which are: (a) clearly healthcare related, and are therefore the sole responsibility of the ICB (as they are beyond the local authority’s legal powers); (b) those needs which fall across both health and social care and; (c) those needs which are clearly social care and the responsibility of the local authority.

Although the core tenet of CHC Funding is that ‘NHS care is free at the point of delivery’, i.e. the package of care should be sufficient to meet the individual’s needs, that does not necessarily mean the NHS have an open cheque book! Of course, inevitably, cost can be a determining factor, especially where the individual requests more expensive support services and/or a more expensive placement than the NHS are willing and/or able to provide.

Where NHS CHC Funding involves commissioning care resources from another body, such as the local authority, these organisations should work in collaboration and partnership together.

However, this can potentially lead to conflict between the two bodies as to which side of the dividing line the care falls and who pays! For example, the NHS could arguably, perhaps, seek to downplay some care needs in order to pass the cost directly over to the local authority. Conversely, the local authority could seek to pass the cost of care back to the NHS if the proposed services are beyond their legal authority e.g. where services by a registered nurse are involved (see the Coughlan case and Section 18-20 Care Act 2014).

The Coughlan case

In the meantime, the individual should not be held ‘hostage’ or used as a ‘ping pong ball’ – batted back and forth between the NHS and the local authority whilst any inter-agency battle lines are being fought behind the scenes. Where CHC is awarded, it remains the responsibility of the ICB to maintain the assessed package of care, regardless of any ongoing dispute, so that there is no gap in the provision of care.

The ICB and local authority should have in place an agreed formal process to resolve any disputes over jointly-funded services. Remember, the individual is at the heart of the CHC Funding process and their needs are paramount and take priority.

That said, the ICB shouldn’t have to pay for any additional ‘life-style’ choices or private services the individual specifically wants e.g. beauty treatments, hairdressing or a better room than standard in a care home – unless, of course, the additional cost of such niceties are reasonably justified as part of the assessed healthcare package.

Funded Nursing Care

Where an individual does not qualify for CHC Funding but nevertheless has some healthcare or nursing care needs, the National Framework provides that, “the NHS may still have responsibility to contribute to that individual’s health needs  – either by directly commissioning services or by part-funding the package of support. Where a package of support is commissioned or funded by both a local authority and an ICB, this is known as a ‘joint package of care’.’’ One such example of this is Funded Nursing Care which provides a set weekly sum payable to the Nursing Home to cover the cost of limited nursing input, usually care planning, oversight and monitoring of an individual’s needs. The balance of the weekly fee is payable by either the individual or the Local Authority (subject to means-testing).

In addition to Funded Nursing Care, an individual may be assessed as needing a split between health and social care, eg. 60% social care/40% health care.

If, all or any part of the assessed care package is passed over to the local authority, it will mean that the individual has to undergo a means-tested assessment which could see them end up paying for part or all of their care package if their income and savings exceed £23,250 (current threshold as at the time of print).

Important: If a joint package of care is awarded, and the ICB are contributing at least 50% of the jointly funded package, then you can argue that the health needs must outweigh the social needs, and therefore, it follows that the individual should be reassessed as having a Primary Health Need. If correct, funding will pass into the ICB’s sole remit for free funded care, not the local authority (where means-testing applies).

Top-up fees

Top-up fees may be unlawful and are generally not permitted if an individual is assessed as eligible for  full CHC funding.

This can cause difficulties when the NHS contract rate paid to the nursing home for a CHC patient is less (sometimes significantly less) than that paid by a privately self-funding resident. This funding gap can often leave the Nursing Home substantially out-of-pocket if they are receiving less for the CHC funded resident than they were receiving previously for the same resident on a self-funding basis; and yet providing the same, or indeed, a higher level of nursing care.

To plug this funding deficit, the Nursing Home may try to charge the resident or their family, a top-up fee, in an attempt to recoup any shortfall. However, the Nursing Home cannot lawfully do so unless there are exceptional circumstances.

However, top-up fees are lawful if a resident is funded by the Local Authority, who will only fund up to a certain level. If the resident wishes to reside in a more expensive Care Home, and the Local Authority consider that needs can be adequately met in the cheaper home, then a top-up fee is permissible. However, it is important to remember that such top-up fees cannot be paid by the resident themselves – responsibility for payment of these top-up fees would lie with a family member or other third party.

Have you been coerced into paying unlawful care home top-up fees?

Formal assessment of an individual’s eligibility for NHS Continuing Healthcare Funding (CHC) is conducted by an NHS Multi-Disciplinary Team using the Decision Support Tool (DST).

The DST is a screening tool used by Multi-Disciplinary Team (MDT) assessors to record assessed levels of healthcare needs across all 12 Care Domains in one document – based on the frequency and/or severity of the care requirements in each Care Domain (namely: Breathing, Nutrition, Continence, Skin, Mobility, Communication, Physical/Emotional Needs, Cognition, Behaviour, Drugs/Medication /Symptom Control, Altered State of Consciousness and Other).

Focusing on whether an individual is displaying challenging behaviour can be a pivotal point in determining their eligibility for CHC.

Challenging behaviour can impact upon many Care Domains and this should not be forgotten when completing an assessment for eligibility.

Often the NHS Clinical Commissioning Group’s assessor will compartmentalise the needs in Behaviour and will fail to cross-reference them with the other Care Domains. This can have a prejudicial effect on the whole case. So, make sure that the details of behaviour are well recorded in the Behaviour section on the DST and also in the four Key Characteristics.

In the Behaviour section (section 9) of the DST it states;

‘Behaviour: Human behaviour is complex, hard to categorise, and may be difficult to manage. Challenging behaviour may be caused by a wide range of factors including extreme frustration associated with communication difficulties or fluctuations in mental state.

Challenging behaviour in this domain includes but is not limited to:

• aggression, violence or passive non-aggressive behaviour
• severe disinhibition
• intractable noisiness or restlessness
• resistance to necessary care and treatment (but not including situations where an individual makes a capacitated choice not to accept a particular form of care or treatment offered.)
• severe fluctuations in mental state
• inappropriate interference with others
• identified high risk of suicide’.

The DST also gives the following descriptions against the different levels of need that can be selected:

To select the correct level of need, there needs to be a close study of all the aspects of the behaviour. There needs to be a degree of clinical judgment to consider the impact of the behaviour on the individual, on the people providing their care, and on the people sharing the care setting.

Firstly, the specific detail of the behaviour needs to be recorded. If there is a list of incidents recorded with the date, duration, what happened and what action was needed, it is imperative that such matters are noted on the DST.

TIP: If your relative is living at home, you could start keeping a record of any incidents on a list, spreadsheet or in a diary. This will be helpful when completing the DST. If your relative is living in a care setting, hospital or rehabilitation type setting, the care provider will likely start recording incidents on purpose printed behaviour recording sheets (sometimes referred to as ABC’s  i.e. an Antecedent (what happens before the behaviour i.e. what might have triggered it, a Behaviour and a Consequence). You can ask the manager of the care setting to do this if they are not doing it already.

TIP: It is a good idea to regularly check that the care records are up to date and accurately reflect details of behaviour.

Do Care Homes Play A Part In Preventing Successful Outcomes For CHC Funding?

Here are some key details that ought to be noted in the care records and which will be important to record on the DST:

What is actually happening?

• Is the individual just being verbally aggressive or are they being physically aggressive, too, and if so, what are they doing? An individual who is feebly pushing a carer away will not be as difficult to care for as another who is lashing out and directing punches at carers or using a weapon (such as a walking stick or handbag).
• Is the individual doing things that could attract negative behaviour from other users of the care service? For example, an individual that invades the personal space of other residents in a care home or shouts in their faces. These actions could create risks for the person displaying the behaviour, particularly where there are other residents with cognitive problems that do not understand what is happening, as they can retaliate, causing risks to safety.

How often does the behaviour happen?

• Is it daily, weekly or monthly or less frequent? Behaviour can be sporadic, frequent or occasional.

How long does each incident last?

• For example, is it an instant response that ends quickly, like lashing out when care is given? Or is it longer lasting, for example, an individual that is constantly being noisy or constantly being aggressive?
• It is relevant to consider how often carers need to manage the behaviour and how much of their time it takes up.

Is there a trigger to the behaviour?

• If there is, it can make it easier for carers to anticipate or avoid.
• If there are no identifiable triggers, conversely, this can make it harder to give care safely.
• Consider what led to the behaviour happening. Is it likely that it will keep happening?
• What measures have been taken or can be taken to prevent that trigger?

How is the behaviour managed?

• What do carers need to do to calm the situation down? For example, do they have to isolate the person?
• Do they need to restrain the individual? Are there any other special techniques needed?
• Does the individual need to be given medication to manage their behaviour – and does this need to be overseen by a specialist?
• How many carers need to be called to manage the behaviour? For example, does it need just one person to guide the individual away from a situation, or are two or three people needed to resolve it?
• Is there anyone with specialist training involved in managing their behaviour? For example, a psychiatrist or other member of a mental health team.

How much risk is involved in the behaviour?

• Is it likely that the individual might injure themselves or others?
• Have they injured themselves?
• Could they injure someone else?
• How strong are they?
• Are they able to move around or are they confined to a chair or bed (this can limit the risks to others)?

Other considerations could include:

• Is there a past history of very aggressive behaviour, and if so, is the behaviour still happening in a similar form?
• Has the individual caused previous injury to others or themselves due to the behaviour?
• Have there been lots of types of medication tried? Has the medication dose been changed a lot? Does the medication cause any side effects?
• Is the behaviour happening at night when there are few carers around to manage it?
• Are there any reports from specialists about the behaviour?
• Does the behaviour impact on other areas of care, for example does it make it harder to provide continence care?
• How does the behaviour affect the person’s psychological and emotional needs?
• It is important to reflect on the incidents of behaviour also in the Psychological and Emotional Needs section, as often, an individual displaying challenging behaviour will be anxious, distressed or agitated at the same time.

It would be expected that the Multi-Disciplinary Team completing the DST will take into account all the appropriate factors, including the above, in order to arrive at the correct level of assessed need.

It would normally be expected that physical aggression would be given a higher level of need than verbal aggression. Similarly, frequently displayed behaviour would be given a higher level of need than infrequent behaviours.

Essentially, it is important to consider the risk versus the frequency. However, one very aggressive episode with serious consequences could be enough to warrant a ‘Severe’ or ‘Priority’ level of need in the DST.

Summary:

As can be seen, there are lots of factors to consider and it is important to understand the clinical opinion of the appointed assessors. The DST should record all the considerations of the MDT so that family members and other people reading the DST can understand why one level of need was chosen over another.

The needs reflected in the Behaviour section should be reflected also in the four Key Characteristics and should examine how the behaviour impacts on other areas of care.

It is a tricky subject and can give rise to differences of opinion between one clinician and another, as well as family members, care givers and advocates. Getting the right information and detail is key.

For more reading about MDTs and assessments, here’s a selection of previous blogs to help you…

Can The MDT Panel Refuse To Proceed If I Have An Advocate

Preparing for the Multi-Disciplinary Team Assessment

What Happens At The Multi-Disciplinary Team Meeting?

Don’t let the Decision Support Tool become a ‘tick box’ exercise

What Is The Role Of The MDT Coordinator?

Learning valuable lessons prior to your MDT Assessment and how to avoid pitfalls

What to expect when you attend a Continuing Care assessment

Attending the Multi-Disciplinary Team meeting – some useful guidance

Preparation, Preparation, Preparation! Never Take MDT Outcomes For Granted

If you need help with an MDT assessment, appeal or advocacy support don’t hesitate to contact us or get help from one of our specialist Advice Lines to discuss your case today.

Plus, don’t forget, there is plenty of free information and resources to help you on our Care To Be Different website.

If there is a particular topic you would like us to cover, we’d love to hear from you! Just send an email via our “Contact Us” page with the subject “blog request” and we’ll do our best to cover your suggested topic.

If your local NHS Clinical Commissioning Group has rejected your application for NHS Continuing Healthcare funding, you always have the option to appeal to an NHS England Independent Review Panel (IRP).

A few years ago, if you attended an Independent Review Panel (IRP), you might have expected to be there for – well, as long as it took to deal with your complaints and to give you the opportunity to discuss all the needs of your family member. This would be a face-to-face meeting with a representative from the CCG, the panel members, and a clinical adviser, you, and possibly your advocate.

Everyone had a hard copy of the document file, and the IRP members could discuss the file with you whilst everyone turned to the relevant pages together.

Everything changed with the onset of COVID-19. The NHS had a period of about 6 months where no IRPs were held. When they were eventually up and running again, IRPs were all done online (remotely) – the indication is that this way of working will continue indefinitely going forward, even with the lifting of COVID-19 restrictions.

So now, if you are invited to an IRP, you will receive your documents, likely via secure email, and you will be invited to a Microsoft Teams Meeting, online. Some people find this daunting, and although we believe that face-to-face meetings are better for families, the good thing about MS Teams is that you can take part in the IRP from the comfort of your own home. And, because more meetings can be held, it has enabled the NHS to clear a long backlog of cases.

As a result, you will get to attend an IRP within a reasonable time frame, possibly 3-6 months, rather than waiting 18 months to 2 years, which was the norm in the past.

If you have never used MS Teams before, the NHS will send you instructions, and you can always ask for the help of a friend or family member.

The NHS has also started to restrict the amount of time that IRPs run, now aiming to complete within 2 hours.  This is a tall order given there are 12 areas of need (care domains) to discuss, then there are the 4 key characteristics, and also any complaints that you might have about the process so far.  That’s a lot to cram into just 2 hours!

In order to use your time wisely, we would recommend that you think carefully about how long you spend talking about each item.

So here are some handy hints:

• Set out your complaints and everything that you want to say in writing in advance of the meeting and send this to the CCG or NHS England as requested – you should be asked to do this as a matter of course. You should make sure that you say which levels of need you disagree with and why – and try to back this up with examples from the clinical evidence if you can. If you have an advocate such as a solicitor, they will likely send in the written submissions on your behalf some weeks in advance of the IRP.
• If you have not got 2 computer screens, it can be difficult to look at the emailed IRP documents at the same time as taking part in the meeting. You might want to print key documents or key pages to help you refer to them during the IRP, or make a written note of the page number, dates and content, ready to be able to quote to the IRP members.
• During the meeting, focus more on the levels of need and the 4 key characteristics than the process, as this is where you can get the eligibility decision changed. Any complaints about the process will more than likely just be acknowledged by the IRP and the CCG told to get it right next time. Whereas changes to the levels of need and 4 key characteristics are more likely to lead to changes to the decision to award CHC funding.
• Spend more time discussing needs that are Moderate, High and Severe, than on needs that are Low – but don’t forget that even Low needs, particularly if they take up a lot of time in terms of care needed, can change the decision from ineligible to eligible!
• There will be some levels of need that you have agreed with, and others that you haven’t. Spend more time discussing the levels of need that you disagree with, but don’t ignore levels of need that you do agree with, if key care details have been missed or underestimated. For example, there might be practical considerations around the care needs that have not been taken into account; such as, in ‘Mobility,’ the original decision might not have considered the frequency or times of any falls. Falls might have been happening frequently at night when less carers were available to assist. Or, the original decision might not have looked at needs that overlapped. For example, there might be a Moderate or High in ‘Behaviour’, impacting on care needs in other areas of needs (domains), such as ‘Continence’ care, making it more difficult or more time-consuming for carers to provide the care in those other areas of need – you should discuss or emphasise these links.
• The 4 key characteristics – this is perhaps the most difficult part of the IRP for families to understand. It is the part of the IRP where you need to look at all the needs and how they interact with each other and then consider how this affects the Nature, Intensity, Complexity and Unpredictability of the needs. This comes at the end of the IRP, when you might be feeling a bit tired, so our tip is to have your points written out in advance, and submit them to the IRP in advance (you should be requested to do so by the CCG or NHS England), also have them printed out and in front of you during the IRP meeting; use a highlighter pen to pick out the most important points before the IRP starts, and use your highlights to help you to summarise concisely.
• During the IRP, keep your eye on the time and try to apportion your time well – aim to have no longer than 20 minutes at the start to discuss any complaints you have about the process. When discussing the areas of need (domains) aim for about 5-7 minutes per area of need – increase this slightly for higher-level needs and reduce it slightly for lower-level needs. Don’t forget there are 12 areas of need, so the time soon mounts! You need to leave time for the IRP members to ask you questions on each of the areas of need. At the end of the IRP, take about 20 minutes to discuss the 4 key characteristics and for the NHS to make their closing statements.
• The Chair of the IPR will likely set the pace for the meeting, but it is worth keeping an eye on the time yourself, so you don’t have to rush any of your points. Some IRP Chairs will let the time overrun, if needed.
• The MS Teams meeting will end for you and the CCG’s representative, but the rest of the IRP members will carry on discussing the case after your 2 hours is up, in order to make their decisions and conclusions.
• Make good use of your time in the IRP and maximise your chances of being successful!

Conclusion

Good preparation and use of time is paramount with such dramatically reduced appeal hearing slots.

Don’t get side-tracked into discussing matters which are irrelevant, waste precious time and could even undermine your case.

Focus on the good points you want to make to support your case.

As the IRP really is considered the last realistic chance to get valuable CHC funding awarded, many families use the opportunity to seek professional advocacy support to ensure that their appeal has the best chance of success. A good advocate will analyse the evidence, prepare detailed written appeal submissions and take the stress and strain off your shoulders. If you need legal help, visit our 1-2-1 page or get in contact via our website.

For additional reading around the subject, look at these helpful blogs:

Rejected for CHC Funding? Part 2: How to appeal the Local Resolution Decision

An exclusive Q & A interview with an IRP Chair – a rare insight into conducting your appeal and knowing what to expect on the day

Preparation, Preparation, Preparation! Never Take MDT Outcomes For Granted

June’s feature on flawed CHC assessments and the importance of good record keeping

PART 1- Looking At The 4 Key Indicators: Unlocking the basics

PART 2 – Looking At The 4 Key Indicators: Gathering pieces of evidence

PART 3 – Looking At The Four Key Indicators: Completing the Jigsaw

PART 4 – Looking At The Four Key Indicators: Drafting Your Conclusions

This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the second two descriptors in the Skin domain, to help you assess your or your relative’s “level of need” in this important domain.

Don’t miss parts one, two, three, four, five, six and seven of this series!

Get Help Breaking Down The Decision Support Tool: An Overview

Get Help Breaking Down the Decision Support Tool: Breathing Part 1

Get Help Breaking Down the Decision Support Tool: Breathing Part 2

Get Help Breaking Down the Decision Support Tool: Nutrition Part 1

Get Help Breaking Down the Decision Support Tool: Nutrition Part 2

Get Help Breaking Down the Decision Support Tool: Continence

Get Help Breaking Down the Decision Support Tool: Skin (including tissue viability), Part 1

Following the 2018 revisions of the DST, Skin moved “up” from number 8 to number 4. As in the 2012 version, it still follows the Continence domain, highlighting the interaction between skin integrity and incontinence. Unlike the 2012 version, however, in the 2018 DST the Skin domain is followed by Mobility, emphasising the significant impact of immobility on skin integrity. Any interrelation between domains (complexity), and its potential impact on the delivery of care (intensity/unpredictability), should be considered in the analysis of the four Key Characteristics.

The assessed levels of need in the Skin domain range from ‘No Needs’ to ‘Severe’. There is no descriptor for a ‘Priority’ level of need in this domain, indicating that an issue with skin integrity is unlikely to present an immediate risk to life, in and of itself.  That being said, the complications arising from pressure damage or other skin wounds can certainly be life threatening and swift. Skilled treatment is essential to prevent rapid deterioration. The vast majority of people being assessed for CHC will fall into the descriptors for a ‘Low’ or ‘Moderate’ level of need. The ‘High’ and ‘Severe’ levels of need are reserved for those suffering from extensive or non-healing wounds, which will usually require specialist treatment by the Tissue Viability Nurse (TVN), or vascular team.

The following clinical factors are relevant to the assessment of ‘High’ and ‘Severe ‘level needs in this domain:

• What is the extent of any existing skin damage – i.e., how deep are the wounds**?
• What treatment regime is required and who delivers it?
• Is the treatment effective – i.e., are the wounds responding/improving?
• Are any specialist dressing techniques required, e.g. compression?
• Is there any evidence of necrosis (white slough and/or dead, blackened tissue)?

**NOTE – Wounds are “graded” from 1-4 using a wound chart. Grade1 describes very superficial damage to the top layer of skin (epidermis), such as reddening or blanching. Grade 4 describes extensive damage to all three layers of the skin (epidermis, dermis, hypodermis). Extensive skin damage puts the underlying bones and joints at risk.

The main difference between the descriptors for a ‘High’ and ‘Severe’ level of need in this domain is the grading of the wound (depth/extent of damage) and whether it is showing signs of healing (“responding to treatment”).

Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for ‘High’ and ‘Severe’ levels of need. For each level of need, we provide a case study to give you a better understanding of how the descriptors of need might be applied at your or your relative’s assessment.

HIGH

CASE STUDY – HIGH

Care Home Skin Care Plan

Mrs. X remains very fragile, immobile and requiring nutritional supplements, impairing skin healing. Waterlow assessment tool score 32, very high risk. Air-flow mattress and pro pad cushion provided for pressure relief. Pressure wound on right foot plantar of first metatarsal head referred to tissue viability nurse for appropriate support and dressing advice, which is ongoing.  At high risk of skin breakdown due to incontinence, poor mobility and advanced age. Requires regular monitoring and repositioning to promote healing and prevent further skin breakdown. Barrier cream administered as needed to prevent skin breakdown and promote healing and protection. Repositioned every 2 to 3 hours. Make sure there is a cushion pad when seated on chair or wheelchair. Always ensure booties on both feet.

Tissue Viability Nurse Review

Wound on right foot 1cm x 1.5cm, grade 3. Centre of wound is sloughy but minimal exudate; Hydrogel dressing to aid debridement and healing. Edges of the wound are pink and epithelising. No sign of infection. Wound appears to be healing well and decreasing in size.

Mrs. X presents with a ‘High’ level of need as she has pressure damage or open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’, which is/are responding to treatment.

SEVERE

CASE STUDY 1 – SEVERE

Care Home Skin Care Plan

Mrs. X remains very fragile, immobile and requiring nutritional supplements, impairing skin healing. Waterlow assessment tool score 32, very high risk. Air-flow mattress and pro pad cushion provided for pressure relief. Pressure wound on right foot plantar of first metatarsal head referred to tissue viability nurse for appropriate support and dressing advice, which is ongoing. At high risk of skin breakdown due to incontinence, poor mobility and advanced age. Requires regular monitoring and repositioning to promote healing and prevent further skin breakdown. Barrier cream administered as needed to prevent skin breakdown and promote healing and protection. Repositioned every 2 to 3 hours. Make sure there is a cushion pad when seated on chair or wheelchair. Always ensure booties on both feet.

Tissue Viability Nurse Review

Wound on right foot 1cm x 1.5cm, grade 3. Centre of wound is sloughy, exudating and wet. Outer aspect of right big toe is black. Wound black/necrotic but looks white and appears to be infected. Swab taken. Smell is also offensive, referred to GP for antibiotics. Hydrogel dressing to aid debridement and healing. Wound does not appear to be healing well and is not decreasing in size.

Podiatrist Review

Right first metatarsophalangeal joint wound with infection 15mm diameter with surrounding callous. Seems painful as Mrs. X pulls away when touched. Already commenced antibiotics but suggest a check for diabetes due to rapid deterioration.

Mrs. X presents with a ‘Severe’ level of need as she has open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’ which are not responding to treatment and require regular monitoring/reassessment.

NOTE – This Mrs. X has the same wound, with the same treatment regime, as the Mrs. X in our example above for a ‘High’ level of need. However, in this case, the wound is not responding to treatment, has not reduced in size and has become infected. Blackened tissue indicates necrosis and Mrs. X shows signs of pain when the joint beneath the wound is touched. These factors make the difference between the ‘High’ and ‘Severe’ levels of need, although the location, size and grade of wound are the same. This is not a large wound, only 1 x 1.5cm, but the absence of healing and involvement of the underlying joint greatly increase the risk. If the joint becomes infected, there may be no option but to amputate the toe, or even the foot, to prevent the spread of infection which could rapidly lead to sepsis and death.

CASE STUDY 2 – SEVERE

Care Home Skin Care Plan

Mr. X is cognitively impaired, immobile and doubly incontinent, placing him at very high risk of skin breakdown. He is nursed in bed 24-hours a day; he is occasionally hoisted into a chair for a few hours. He is nursed on an alternating air pressure mattress and is dependent on staff to reposition him every 2 hours to reduce the risk of skin breakdown. Mr. X is prescribed barrier cream which staff apply to his skin following each episode of incontinence in order to reduce the risk of excoriation and moisture related lesions.

Relevant History

A rash was first documented to have been noticed on his back. It was initially treated as a fungal infection with numerous courses of topical and oral treatments to try to manage the symptoms. However, none of the treatments were effective and, over the following few months, the rash spread from his back to his shoulders, torso, arms and down his legs. What began as a florid rash became round scaly circular patches which were believed to be ringworm. These continued to grow and spread, with lesions joining together. They then began to breakdown, splitting open, scaling off and resulting in extensive areas of exposed flesh across his back, torso, arms and down his left leg, which have not responded to treatment. Despite numerous referrals to dermatology services, the GP has been unable to secure a domiciliary assessment of Mr. X’s skin, and he was considered too frail to attend an outpatient appointment. Mr. X was eventually admitted to hospital with extensive open skin from shoulder to wrist. He was discharged hours later with more topical creams which were applied with no effect.

Current Wound Care Plan

Mr. X’s skin on his back, shoulders and arms remains open and excoriated. The areas bleed periodically, and often ooze serous, yellow or green exudate. Staff try to manage this as best they can, under the supervision of Tissue Viability Service. As no viable treatment has been found, care centres on prevention of infection and excellent pain management. Mr. X is prescribed a Fentanyl patch 25mcg/hour, with as-required Oramorph for breakthrough pain/prior to dressing changes and repositioning.

In addition to the skin rash, Mr. X also suffers with numerous grade 2/3 wounds to both heels, left ankle, left knee and left elbow. All these wounds continue to be present, sometimes being noted to be ‘healing’ and other times with larger dimensions noted again and with purulent exudate. Currently dressed with Comfeel Plus and Hydrogel, depending on depth and amount of exudate. The Tissue Viability Nurse has been asked to review to see if there are any other treatments available.

Mr. X requires a very high level of care and management to prevent further tissue breakdown and ensure his pain is well-managed.

Mr. X presents with a ‘Severe’ level of need as he has multiple wounds which are not responding to treatment.

We hope this has helped you to understand the second two descriptors in the Skin domain.  Don’t miss the next part of this series, Mobility, coming very soon!

For further reading around the subject on pressure sores:

The dangers of pressure sores, pressure ulcers and bed sores

Take a holistic approach to improve your chances of getting CHC Funding

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NICE Guidelines – Pressure ulcers: prevention and management https://www.nice.org.uk/guidance/cg179

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