A Full assessment of your relative’s care needs is completed by the Clinical Commissioning Group’s assessors using the Decision Support Tool (DST).
The DST is a scoring ‘tool’ used at the MDT to build a picture of an individual’s health needs across the various Care Domains by reference to a description (otherwise known as a ‘descriptor’) as to what level of need constitutes a ‘Priority’, ‘Severe’, ‘High’, ‘Moderate’, ‘Low’ or ‘No needs’.
The DST consists of 12 headings or ‘Care Domains’, which are considered by the assessors in conjunction with your relative’s healthcare needs namely:
- Behaviour
- Cognition
- Physical/emotional needs
- Communication
- Mobility
- Nutrition (food and drink)
- Continence
- Skin integrity
- Breathing
- Drugs/medication/symptom control
- Altered state of consciousness
- Other significant care needs
You can access the updated version of the Decision Support Tool here:
https://www.gov.uk/government/publications/nhs-continuing-healthcare-decision-support-tool
See the table below which you will find set out in the DST:
Let’s now look at the Care Domains of Incontinence and Skin Integrity.
It may be alarming to hear, but some care facilities or local authorities probably find it easier (ie more commercially viable) to manage patients by ‘making’ them become or remain incontinent.
Understandably, neither the NHS nor Social Services have sufficient funding or staff availability to provide carers, 24 hours a day, for each needy individual. So, due to a lack of resources, some patients are being left in the incontinence wear provided to wait for next change – which could be some hours later.
We were contacted by a lady who visited her sick husband every day whilst he was a resident in a luxury care home, but one day she couldn’t get to see him until late in the evening. When she arrived, she was distressed and angry to find her dear husband had been left sitting in his waste all day long, unchanged. How often does this happen when family aren’t around to observe how their spouse or relative is being cared for?
Incontinence products and pads are designed to contain waste matter, but for a limited period. But, too often, a shortage of staff and budgets can mean only a specific number of prescribed checks or changes of a patient’s incontinence wear in a day. A patient may be changed, but a few minutes later have an accident, and then be left for long periods, in discomfort, until the next check/change. Sadly, some organisations and care facilities might be inclined to think that it is far cheaper to leave an incontinent patient lying or sitting in their waste, than to employ more staff to deal to carry out more frequent checks and pad changes.
Less mobile patients may need a number of carers to help them with transfers for toileting which can be quite time-consuming. In the meantime, other needy patients who require attention might be neglected. Another reason why a care facility may feel it’s easier to let a patient become incontinent.
Being ‘made’ incontinent deprives an individual of their dignity, causes embarrassment and distress, which could be avoided.
Is it ever acceptable to make someone incontinent?
Patients who cannot communicate their needs are likely to go for longer periods unchecked (unless someone notices an odour). Incontinence can lead to urinary tract infections (UTI’s) and catheterisation – both very unpleasant and uncomfortable for the patient.
Worse still, less frequent changes of incontinence products can lead to the skin becoming moist, wet or soggy. This in turn can cause skin damage leading to moisture lesions and pressure sores. Pressure sores, sometimes known as pressure ulcers or bed sores, can develop very quickly if skin integrity is not closely monitored.
Pressure sores are caused by neglect and are entirely avoidable!
For some experienced nurses, the mere mention of a pressure sore is equivalent to a ‘swear word’, as they are totally preventable with good care.
Deep pressure sores can be agonisingly painful, making it uncomfortable for the patient to move. The area may be red and inflamed, weeping or bleeding. Patients have described pressures sores feeling like a ‘hot burning sensation’.
Why should anyone who is incontinent be allowed to develop a pressure sore?
Whether in a hospital, care home setting or at home, if pressure sores are not monitored and managed swiftly, they can very quickly deteriorate and become extremely difficult to treat successfully; sometimes causing significant deep-tissue cavity damage that goes down to the tendon, muscle and bone. The most serious cases of deep infection can result in loss of limb or prove fatal.
Pressure sores commonly occur on bony prominences eg shoulders, elbows, knees, buttocks, ankles and heels.
Pressure sores are graded in severity:
Grade 1: Non-blanching erythema. When lightly pigmented intact skin is pressed for a few seconds it remains red. This is harder to see on darker skin tones.
Grade 2: There is damage to the top layer of skin
Grade 3: Skin damage spreads to the fatty layers under the skin causing a shallow cavity (ulcer)
Grade 4: A deep cavity that goes down to bone (muscles or tendons), often accompanied by a foul smell (like rotting flesh) and can be fatal.
Pressure sore prevention is an essential aspect of patient safety
Pressure sores can develop in a matter of hours if not identified and acted upon.
However, they can be prevented with proper risk assessment and regular monitoring.
Some patients will inevitably be at higher risk than others – perhaps due to their advancing age, inherent frailty, disability or immobility (eg following surgery). Patients who are wheelchair or bed bound, or else sit or lie in one position for extended periods of time are at greatest risk.
Having good systems for detecting the risk of pressure sores developing is essential. Staff should look out for pain, itching, discoloration, numbness, heat or hardness of skin.
Monitoring the patient closely and having more frequent and regular thorough inspections should quickly identify damage (or vulnerable areas) sooner.
Using assessment tools such as the Waterlow scale will identify those patients most likely to be at risk of developing a pressure sore.
Basic repositioning (or turning) a patient can alleviate the occurrence of a pressure sore developing.
Staff and cares need better training and awareness of prevention strategies. They need to be alert and be able to identify patients at risk and take rapid and timely intervention, such as repositioning the patient, or providing a pressure relieving mattress or cushion, to prevent the development of a pressure sore or its deterioration. Early intervention can reverse a Grade 1 pressure sore, but left unattended can result in serious complications which may become irreversible and lead to life-threatening complications.
Being at ‘end of life’ and not eating or drinking is still no excuse to allow a pressure sore to develop. Skin integrity is paramount. Skin should be kept free of damage at all times.
For more information, read our helpful articles relating to pressure sores:
The dangers of pressure sores, pressure ulcers and bed sores
Take a holistic approach to improve your chances of getting CHC Funding
What preventions are in place to look after your relative? Do they have an ‘S SKIN’ Bundle?
A care bundle “is a collection of interventions that may be applied to manage a particular condition or as a preventative measure to reduce the risks of developing complications.” Hospitals and care home should have a policy to adopt the ‘S SKIN’ bundle.
The S Skin Bundle Consists of 5 key elements for skin protection, namely:
- Skin Inspection/assessment
- Surface
- Keep Moving (Repositioning)
- Incontinence / Moisture
- Nutrition and Hydration
Care bundles can be divided into 2 categories – one bundle is for prevention, and the other for treatment.
The prevention bundle is used when the patient is assessed at being at risk, following the use of a recognised risk assessment tool and requires a prevention plan to be in place.
The treatment bundle must be used when the patient has at least one pressure sore.
S SKIN pressure ulcer care bundle – prevention
Many practitioners will use the S SKIN bundle to check for compliance against the 5 key elements:
Skin Inspection: Staff should check the skin and ensure its management e.g. using blanching techniques – pressing the vulnerable area with the thumb and forefinger for 2 seconds and releasing. If the area remains red, that indicates damage to the capillaries. The patient will need repositioning and the matter should be noted and reported immediately.
Ideally, the patient should have a ‘touch’ test each time they are seen by staff.
Surface: Staff should check how the patient is sitting, sleeping or lying and whether pressure relieving equipment, such as special mattresses or cushions, are required and to check they are working effectively.
Keep Moving: Staff should check and ensure that the patient is frequently mobilizing eg getting up at regular intervals to prevent skin sheering and undue pressure on vulnerable areas. Or, if not possible, the patient has a repositioning schedule/chart in place and to initiate frequent repositioning as required.
Incontinence/Moisture: Staff should keep the patient dry and clean and check that the skin is protected from moisture damage. Moisture on the skin is usually caused by incontinence of urine/bowels or sweat. Vulnerable areas, such as the buttocks, that become moist, wet or soggy are more likely to cause skin breakdown and lead to pressure sores developing. Staff should take preventative measures and ensure appropriate steps are taken to reduce the risk eg applying barrier creams.
Nutrition/Hydration: Staff should check and ensure that nutritional assessments eg the MUST Tool (Malnutrition Universal Screening Tool) is being used and completed to monitor diet and fluid intake, and appropriate instructions are being given to carers.
Tip: If you have any concerns about your relative’s skin integrity, we recommend that you check their care home records and see that this essential tool is being actioned.
Summary
The S SKIN care bundle forms part of the patient’s records and should be used in conjunction with their own care plan. Check your relative’s care records regularly to ensure it is included and updated.
Pressure sores usually develop as a result of poor basic staff awareness and training, poor risk assessment and ongoing regular checks and assessments, and monitoring.
We have created our own mnemonic for good pressure sore care – ‘PAM’.
Prevent Assess Manage
If your relative has developed a pressure sore we suggest seeking specialist legal advice as they may be entitled to claim for the suffering and pain caused by neglect.
For further reading around the subject, read these blogs:
Why is it important to check your relative’s care home records?
June’s feature on flawed CHC assessments and the importance of good record keeping.
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This is an excellent informative and clear article which will help those starting out on the process of CHC to understand the domains of the DST for skin integrity and continence.
But however understanding the domains isn’t enough to secure a successful outcome. For us, the difficulty was applying the key indicators.
You can argue endlessly about the level attributed to each domain within the DST but unless you have a robust argument in terms of the Nature, Complexity, Intensity and Unpredictability of your relatives needs and can prove they have a PHN using these Key Indicators then you are likely to be unsuccessful, even if your relative scores a severe and many highs.
The process of the DST is overridden by the KI and I would urge all readers who are appealing the process to focus on this area.
In the case of my late father his DST scores fell within the indicative guidelines as to the threshold set for eligibility but he was rejected, even with one crucial domain remaining unawarded (because of disagreement between the two assessors as to the level) throughout the entire process right up to IRP.
So, yes this is a very useful article and one that should now be expanded on to include how these two areas of need are dealt with in terms of applying the KI to demonstrate a Primary Healthcare Need.
As festivities are gearing up, I just want to say Merry Christmas to all those at CTBD and it’s readers. Take a well earned break and return in the New Year ready to fight on.
Thanks Michelle – all the best to you to. Kind regards
Couldn’t agree more Michelle. It is an excellent and clear article, so always apply the Key Indicators to every domain. Especially make the complexity point where two or more domains are affected. My relative’s incontinence was considerably impacted by his behaviour – shouting, hitting out and swearing when needing change of pads, clothing or sheets and refusal to move position. It was also affected by his Cognition, as he had no appreciation of his condition (Dementia) nor of danger and risk. It seems the staff didn’t either, because relative developed a grade 4 pressure sore, at which point he required daily nursing visits for a year and turning every hour until death. A request for CHC assessment at the time was ignored, as were many requests for a full psych assessment to assess capacity to decline interventions. It’s worth noting that the Skin Integrity team were required to complete a form confirming they had fully informed relatives and patients of their option to be treated in hospital and had been informed of all relevant assessments and benefits. Despite being appointed Attorney (both Health and Finance) I was frequently ignored by medical and nursing staff. I only saw the Skin Integrity checklist when I requested all notes for the Retrospective case. CHC was backdated to the date of the pressure sore, but not to dates when it was clearly recorded he declined to be changed or failed to co operate with toileting or moving from chairs where he sat for 12 hours at a time – often sopping wet or worse. Despite retrospectively awarding him a Severe in Cognition throughout this period and acknowledging he lacked capacity, refusal was his “choice” and the sore was not a direct consequence of that choice. Be prepared to challenge this special type of logic before the MDT stage and beyond.
Dads 86 has dementia was able to walk round the house and outside if he had his walking pole and me – he was urine incontinent – he got admitted to hospital – left on a trolley for 16 hours in incontinence pants on not changed and no pressure relief – he had a slight pink area on his bottom when he went in – 3 days later an open pressure sore, doubly incontinent, only walked to the toilet twice, no exercise, no pressure cushion or mattress , after 6 days , came out of hospital unable to walk on his own now has to use a walking frame around the house and unable to go outside , can’t get out of chair alone can’t get out of bed alone
Totally sympathize with you Fiona. Very similar circumstances for my late father. Almost four years later with successful outcomes from IRP and PHSO I am going to resurrect my complaint to NHS who said they weren’t to blame for dad’s immobility, pressure sores and malnutrition. It’s a disgrace how they treat the elderly and cover up the repeated failures in care. I hope you dad is getting the care he so entitled to. Kind regards M