No or incomplete risk 15 What elements would have assessment and /or been expected to be in place care plan carried out but were not THIS IS SAFEGUARDING 4 Is there a concern that the No /Not Applicable 0 Pressure Ulcer developed as a result of Yes 15 the informal carer wilfully ignoring or preventing across to care or services 5 Is the level of damage to the Skin damage less 0 skin inconsistent with the severe than patient risk status for risk assessment patient’s pressure ulcer development? suggests is e.g low risk category /grade3 proportional or 4 pressure ulcer Skin damage more 10 severe than patient’s risk assessment suggests is proportional 6 Answer (a) if your patient has capacity to consent to every element of the care plan Answer (b) if your patient has been assessed as not having capacity to consent to ant part of the care plan or some capacity to consent to some but not all. a Was the patient compliant with Patient not compliant 0 the care plan having received with care plan (BHFT information regarding the risk of staff use non non- compliance and documented concordance forms) they been explained Patient compliant 3 with some aspect of care plan but not all Patient compliant 5 with care plan or not given information to enable them to make an informed choice. b Was appropriate care undertaken Documentation of 0 in the best interests, care being patient’s following the best undertaken in patient interest’s checklist in the Mental Capacity best interest Act Code of Practice? (supported No documentation of 10 by documentation, e.g. capacity care being and best interest statements and undertaken in the record of care delivered) patients best interest Total Completed by: Date: Circle decision below: Safeguarding Referral done Not for Safeguarding Referral Appendix 5.4: Body map Body maps must be used to record skin damage and can be applied as evidence if necessary at a later date. If two workers observed the skin damage they should both sign the body map.
No or incomplete risk assessment and /or care plan carried out 15 What elements would have been expected to be in place but were not THIS IS SAFEGUARDING 4 Is there a concern that the Pressure Ulcer developed as a result of the informal carer wilfully ignoring or preventing across to care or services No /Not Applicable 0 Yes 15 5 Is the level of damage to the skin inconsistent with the patient’s risk status for pressure ulcer development? e.g low risk category /grade3 or 4 pressure ulcer Skin damage less severe than patient risk assessment suggests is proportional 0 Skin damage more severe than patient’s risk assessment suggests is proportional 10 6 Answer (a) if your patient has capacity to consent to every element of the care plan Answer (b) if your patient has been assessed as not having capacity to consent to ant part of the care plan or some capacity to consent to some but not all. a Was the patient compliant with the care plan having received information regarding the risk of non- compliance and documented they been explained Patient not compliant with care plan (BHFT staff use non concordance forms) 0 Patient compliant with some aspect of care plan but not all 3 Patient compliant with care plan or not given information to enable them to make an informed choice. 5 b Was appropriate care undertaken in the patient’s best interests, following the best interest’s checklist in the Mental Capacity Act Code of Practice? (supported by documentation, e.g. capacity and best interest statements and record of care delivered) Documentation of care being undertaken in patient best interest 0 No documentation of care being undertaken in the patients best interest 10 Total Completed by: Date: Circle decision below: Safeguarding Referral done Not for Safeguarding Referral Appendix 5.4: Body map Body maps must be used to record skin damage and can be applied as evidence if necessary at a later date. If two workers observed the skin damage they should both sign the body map.
pressure-care-safeguarding-decision-guide-and-body-map.docx