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Centre for Policy on Ageing | |
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Pressure points
— learning from Serious Case Reviews of failures of care and pressure ulcer problems in care homes | | Author(s) | Jill Manthorpe, Stephen Martineau |
| Journal title | Journal of Adult Protection, vol 19, no 5, 2017 |
| Publisher | Emerald, 2017 |
| Pages | pp 284-296 |
| Source | http://www.emeraldinsight.com/loi/jap |
| Keywords | Elder abuse ; Protection [vulnerable adults] ; Injuries ; Leg ulcer ; Death ; Care homes ; Management [care]. |
| Annotation | Serious Case Reviews (SCRs, now Safeguarding Adults Reviews (SARs)) may be held at local level in England when a vulnerable adult dies or is harmed, and abuse or neglect is suspected, and there is cause for concern about multi-agency safeguarding practice. To date there has been no analysis of SCRs focusing on pressure ulcers. The purpose of this paper was to present findings from a documentary analysis of SCRs/SARs to investigate what recommendations are made about pressure ulcer prevention and treatment in a care home setting in the context of safeguarding. This analysis was presented in cognisance of the prevalence and risks of pressure ulcers among care home residents and debates about the interface of care quality and safeguarding systems. Following research, the authors located 18 relevant SCRs and one SAR covering pressure ulcer care in a care home setting. Most of these inquiries into practice, service communications and the events leading up to the death or harm of care home residents with pressure ulcers observed that there were failings in the care home, but also in the wider health and care systems. Overall the reports revealed specific failings in multi-agency communication and in quality of care. Pressure ulcers featured in several SCRs, but it was problems and inadequacies with care and treatment that moved them to the safeguarding arena. The value of examining pressure ulcers as a key line of inquiry is that they are `visible' in the system, with consensus about what they are, how to measure them and what constitutes optimal care and treatment. In the new Care Act 2014 context they may continue to feature in safeguarding enquiries and investigations as they may be possible symptoms of system failures. This analysis highlights that it is not inevitably poor quality care in a care home that gives rise to pressure ulcers among residents. Several SCRs note problems in wider communications with healthcare providers and their engagement. Nonetheless, poor care quality and negligence were reported in some cases. Various policies have commented on the potential overlap between the raising of concerns about poor quality care and about safeguarding. These were highlighted prior to the Care Act 2014 although current policy views problems with pressure ulcers more as care quality and clinical concerns. (JL). |
| Accession Number | CPA-171027218 A |
| Classmark | QNT: CA3G: CU: CRT: CW: KW: QA |
Data © Centre for Policy on Ageing |
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| ...from the Ageinfo database published by Centre for Policy on Ageing. |
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