The Care Home Manager’s clinical support guide

Pressure ulcers

What you need to know as Registered Manager / Care Home Manager

A pressure ulcer is damage to the skin and the deeper layer of tissue under the skin. This happens when pressure is applied to the same area of skin for a period of time and cuts off its blood supply.

It is more likely if a person has to stay in a bed or chair for a long time. Pressure ulcers are sometimes called 'bedsores' or 'pressure sores’.

They form when constant pressure on a part of the body shuts down the blood vessels feeding that area of skin (this is why repositioning is needed).

Areas vulnerable to pressure sores include the lower back and buttocks, and bony protruding areas such as shoulders, hips, knees, heels, and ankles. Without care, pressure ulcers can become very serious.

They may cause pain, or mean a longer stay in hospital. Severe pressure ulcers can badly damage the muscle or bone underneath the skin, and can take a very long time to heal.

The definitions of pressure ulcer and categories (rough and ready guide)

an open wound or blister – a category two pressure ulcer

a deep wound that reaches the deeper layers of the skin – a category three pressure ulcer

a very deep wound that may reach the muscle and bone – a category four pressure ulcer.

Though the language is technical, simply put the Category 3 and 4 are CQC reportable – they are full skin loss and full tissue loss.

Category 3 and 4 are serious wounds. Ways to stop pressure ulcers getting worse and help them heal include:

• applying special dressings that speed up the healing process and may help to relieve pressure

• moving and regularly changing position – repositioning – it can be up to every 2 hours

• using specially designed static foam mattresses or cushions, or dynamic mattresses and cushions that have a pump to provide a constant flow of air

• eating a healthy, balanced diet

• a procedure to clean the wound and remove damaged tissue (debridement)

Simply put, most pressure ulcers are preventable and are from neglect or lack of coordinated good practice and care:

– neglect of diet and hydration

- neglect of repositioning the resident with a wound

- neglect of treating the wound effectively

- neglect of using equipment to help the wound heal, give the person relief.

For that reason, the registered manager would need to report it in as serious neglect.

Clearly, it’s a area that needs co-ordination – but simply put if the skin breaks down, all the care home / nursing tools of body mapping, skin inspections, effective personal care planning, using appropriate creams, pressure relieving equipment, repositioning all need to be used intelligently, with input from nurses / GP’s / Tissue viability team to stop it progressing to a pressure sore.

It’s a complex area but hopefully that gives you an idea!

Pressure Ulcers / Know your residents

Know the residents, understand that anyone living in a care home is at risk of developing a pressure ulcer, however there will be certain residents at greater risk and therefore the Home Manager should have oversight of such residents and their own particular risk factors.

Pressure Ulcers / High risk factors

The most obvious risk factors to be aware of are, restricted mobility which may require assisting the resident with changing position on a frequent basis, any previous pressure ulcer, any current pressure ulcer, loss of sensation and feeling in parts of the body, skin that is dry and weak, poor nutrition and dehydration are also key factors in the development of pressure ulcers.

Pressure Ulcers / Getting a risk assessment / first 6 hours

Depending on whether the role of Registered Manager is in a Nursing or Residential Home risk assessment will vary in terms of who or how it is carried out.

For example in a Nursing Home a trained Nurse should be able to carry out a risk assessment for anyone who moves into a nursing home, good practice dictates that the risk assessment should ideally be carried out within the first six hours of moving in.

Decubitus sacrum - severe bed sore in the sacral region

Pressure Ulcers / Managing the risk in a residential home

In a Residential Home if a person has one or more risk factors and they have been referred to a community nurse it is wise to advise the community nurse that the resident will require a risk assessment on the first community nurse visit followed by a fully documented plan of care for the staff within the care home.

Depending on which local authority the Residential home is located, it may be that District Nurses will visit the person in the home to apply clinical care as per care plan.

If there is no previous or pending referral to a community nurse and there are concerns that the residents skin integrity may be deteriorating then consider calling the GP who can put you in touch with specialist services.

Each local authority will have their own route to referral. It may be that the GP or the Community or District Nurse is the first point of contact, whichever way ensure that the correct contact details documented in the Homes protocol.

Explaining how and when to make a referral if concerns are raised in regards to potential development of pressure ulcers.

Pressure Ulcers and the care plan

There will need to be a care plan for anyone who has been assessed as being high risk of developing a pressure ulcer and the care plan must be reviewed regularly, the Home manager will need to audit the care plan on frequent basis to ensure that the care plan is being adhered to, if it is not then the Home manager must address this with members of staff with immediate effect.

Depending on the reasons why it is not being adhered the Home Manager will need to address the reasons by methods such as training, performance review and so forth but it is the responsibility of the Home Manager to make sure that the care plan is delivered exactly as it is written as there is no room for delay or error.

If the Home Manager is not familiar with pressure ulcer management then it is wise to access the relevant level of training for themselves.

Pressure Ulcers and Safeguarding concerns

If you do become aware of a pressure ulcer on a resident then it is imperative that you as the Home Manager understand the local safeguarding policy and at what level it is expected that a person with a pressure ulcer should be safeguarded, read the care homes in house safeguarding policy and apply the principles within to ensure that best practice is carried out at all times.

What a Care Home Manager needs to know about Medication Management

Medication is such a huge area of compliance within a care home therefore this paragraph can only provide a snapshot of ‘how to’ for the Registered Manager. Visit NICE for the full guidelines

It is advised that every Care Home Manager is fully up to date with the care home medication policy along with the NICE guidelines for ‘Managing medicines in care’ in order to fully understand what is required from care homes in the area of medication administration and management.

Be aware that over time the guidelines may be updated and under the Home managers duty of care updating oneself on a regular basis makes good sense and affords good practice.

• Checks to make with staff management / medication management.

• Ensure that all staff who administer medication are up to date with the correct level of medication training.

• Ensure that all staff delivering medication understand the process.

• Ensure that all staff administering medication receive regular competency testing including the intervals between formal training.

• Ensure that all medication trained staff know how to order medications and what day to place an order for medication so that residents do not run out of their medicine.

• Ensure that all medication trained staff know how to receive, store and dispose of medication and the safe systems of disposal.

• Ensure that all medication trained staff know how to support residents who self administer their own medicine.

• Ensure that medication administration charts are filled in correctly with the correct code

• It is useful for medication trained staff to sit in on medication reviews with community staff.

Use the six R’s of medication!

Be aware of and conversant with the six R’s of medication. Ensure that the staff in the care home are familiar with them and can in time recite and understand the 6 Rs of medication...

1 Right client

2 Right route

3 Right drug

4 Right dose

5 Right time

6 Right documentation

Other considerations around best practice / reducing risk with medication management

Consider whether spot checking staff on the six R’s is a worthy exercise which can easily be carried out on a walk around the home.

Consider as the Care Home Manager whether it would be useful to complete an advanced level medication course yourself, many do.

Consider appointing a medication champion

Carry out regular audits, part audits and full audits covering all shifts over all days, you cannot audit medication administration enough.

Utilise any pharmacy professionals that may be located within the wider organisation or consider getting to know the local clinical commissioning teams pharmacist, as they can be a great source of support and help.

Only buy in good quality medication training.

Use NICE resources: Care home staff administering medicines

Know and share the guidance from the CQC for providers in regards to controlled drugs.

Continence Care – what you need to know as a Registered Care Home Manager

Continence care is paramount within care home because reduces healthcare related harm and promotes the well being of the resident, preserves dignity showing that value is placed upon the person and their needs.

It is essential that the Care Home Manager is fully aware of the needs of their residents and has sufficient depth of knowledge about good practice with continence care to manage those needs effectively. Click here to learn more.

Firstly a let’s get a better understanding of incontinence before we explain good practice in managing the symptoms:

Urinary incontinence is more common than inability to control bowel movements.

Urinary incontinence is more common in older people, especially women. Incontinence can often be cured or controlled.

What causes incontinence of the bowels?

Injury to the nerves that sense stool in the rectum or those that control the anal sphincter can lead to fecal incontinence.

The nerve damage can be caused by childbirth, constant straining during bowel movements, spinal cord injury or stroke.

What are the risks urinary incontinence? How are they categorised?

For older women, pelvic surgery, pregnancy, childbirth, and menopause are major risk factors.

Types of urinary incontinence include stress incontinence, overflow incontinence, urge incontinence or overactive bladder, functional incontinence, mixed incontinence, total incontinence, bedwetting.

What happens in the body to cause bladder control problems?

The body stores urine in the bladder. During urination, muscles in the bladder tighten to move urine into a tube called the urethra.

At the same time, the muscles around the urethra relax and let the urine pass out of the body.

When the muscles in and around the bladder don’t work the way they should, urine can leak. Incontinence typically occurs if the muscles relax without warning.

What are the causes of Urinary Incontinence?

Incontinence can happen for many reasons. For example, urinary tract infections, vaginal infection or irritation, constipation.

Some medicines can cause bladder control problems that last a short time.

When incontinence lasts longer, it may be due to:

• Weak bladder muscles

• Overactive bladder muscles

• Weak pelvic floor muscles

• Damage to nerves that control the bladder from diseases such as multiple sclerosis, diabetes, or Parkinson’s disease

• Blockage from an enlarged prostate in men

• Diseases such as arthritis that may make it difficult to get to the bathroom in time

• Pelvic organ prolapse, which is when pelvic organs (such as the bladder, rectum, or uterus) shift out of their normal place into the vagina. When pelvic organs are out of place, the bladder and urethra are not able to work normally, which may cause urine to leak.

How does incontinence effect men?

Most male incontinence is related to the prostate gland and may be caused by: • Prostatitis—a painful inflammation of the prostate gland

• Injury, or damage to nerves or muscles from surgery

• An enlarged prostate gland, which can lead to Benign Prostate Hyperplasia (BPH), a condition where the prostate grows as men age.

Is incontinence linked with dementia?

Urinary incontinence, or unintentional urination, is common in people who have dementia.

It can range from mild leaking to unintentional urination.

Less commonly, it also refers to unintentional bowel movements, or faecal incontinence.

Incontinence is a symptom that develops in the later stages of dementia. Between 60 – 70% of those with Alzheimer's will go on to suffer from incontinence issues.

What incontinence aids are available?

Pads, pull up pants, male continence sheaths, bed pads,waterproof mattress protectors, catheter.

What is involved in good continence care?

Good continence care involves having the right aid for the right person with costs managed appropriately. The following points will help you provide good quality continence care:

1. Pads

Ensure that all staff know and understand that residents who are prescribed pads as part of their continence care wear the right product at all times, ie light flow, heavy flow, day and night pads. By doing so you are promoting dignity and independence, reducing the need for overflow and spillage and promoting comfort.

2. Training

Ensure that staff have been trained in the correct level of continence care and particularly understand the different types of pads, sizes and times of day, ie day or night pads.

Audit the care plan regularly to ensure that staff are following it as directed.

Training is key to good continence management, a method you may wish to employ is to nominate one person who has a special interest to act as a continence champion and a resource for other staff when needed.

3. Catheters

If a resident uses a catheter, ensure that the care plan is up to date and is followed to the exact letter. Ensure that all staff understand and have been trained in catheter care according to their level of responsibility, ie nursing or residential home.

4. Contact details

Ensure that the contact details for specialist staff and advice is available to all staff and if assessment is required there is usually a clinical nurse specialist in the community who can make a referral for continence support if necessary. This may differ in areas of the UK, depending on the location of the home.

5. As the Home Manager attend a continence course yourself.

What is involved in continence planning?

Residents in care homes have their own unique special needs, but consider the following when continence care planning:

• Personalised assessment of need for each resident who displays urinary symptoms or incontinence.

• Community/District support from specialist services.

• Regular management audits improving care by acting on the findings without delay.

• Policies and protocols that support the promotion of good continence care for residents.

Clinical Observations for Care Home Managers

The broad sense of observations refers to the physical assessment of a patient, including assessment of wounds, intravenous therapy, wound drains, pain and vital signs collection and specialised assessments such as neurological observations.

What are vital signs?

Vital signs are used in the collection of cluster of physical measures including pulse, temperature and blood pressure and respiration.

Why do care home staff take obs? (observations)

Observations are a useful tool to gauge a resident / patients health – especially for those what are very poorly.

For nursing home residents, the observations for the patient / resident are taken regularly.

If a resident deteriorates, the change in the observations reveal it. In some cases the deterioration will lead to death.

By capturing the timing and degree of change, it gives the nurse information to assess and make an informed decision about what best to do.

If it is serious, options will include calling for an ambulance, speaking to an on call doctor etc.

In residential homes, the ambulances will be called more often as there are no qualified clinicians onsite.

In nursing homes, the nurse will take the vital signs and interpret based on their clinical knowledge, with a deeper understanding what may be occurring.

Clinical observations in nursing homes

Within Nursing homes all nurses should know how to take and understand clinical observations and they should be up to date with any relevant clinical and mandatory training.

It is the role of the Care Home Manager to ensure that all nurses are competent and properly trained in taking accurate observations and making correct decisions and onward referral based on findings.

Clinical observations in residential homes

In Residential homes staff will likely make general observations during the course of their work, they may notice a change in a resident’s condition such as fluid intake measures are low, fluid output is low, loose bowels, high body temperatures, change in mood or behaviour, change in skin integrity such as red areas or bruising when assisting with personal hygiene and or general deterioration overall.

Residential care home staff will also benefit from training in taking specific observations so that they understand the importance of observation and how to act upon any concerns that observations communicate.

However, if the observation is of a clinical nature such as the taking of blood pressure then the appropriate course must be resourced in order to train the care assistant how to carry out such a task competently.

It is usually at this point that the advice of the resident General Practitioner is sought for ongoing intervention and care planning.

Any of the above should also be reported to the Care Home Manager so that he/she can take the appropriate action to ensure that future care and support is delivered.

The Care Home Manager’s clinical support guide

In this handy support guide for Care Home Managers we asked a Qualified Nurse to detail the key clinical information every Home Manager will need to know to run their home successfully.

Topics covered in this guide

What are the main responsibilities of any nurse?

Part 1

Part 2

Part 3

Part 4

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