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CHC skin integrity rating down-rated because covered by continence rating?


Registered User
Sep 17, 2010
In a number of instances, the same "health defect" appears to cross over into several domains' rating. For example, inability to understand risks - cognition - may also be relevant to fall-risk - mobility).

In one instance at our CHC checklist meeting the consequences of the same "health defect" were treated as being entirely separate - and I'd appreciate TP views on whether (1) our assessor reached the right decision; and (2) whether other CHC assessors have gone down the same route.

The B rating on skin integrity states "Risk of skin breakdown which requires preventative intervention several times each day, without which skin integrity would break down".

The family claim the right rating for Mum is a B because "areas of skin likely to be at risk due to her incontinence are creamed every time [she] receives personal care [ie a number of times each day]".

The assessor said the right rating should be a C because "the preventative intervention several times each day, without which skin integrity would break down" was an aspect of the continence rating.

To my mind, the assessor's comments seem to clash with the description of the B rating (which doesn't say anything about where the skin needs to be on the body to "count").

I'd be interested to hear your views.


Registered User
Jun 4, 2010
West Midlands
No experience, but I have heard on here

A managed need is still a need

Sorry I can't be more helpful xx

Sent from my iPhone using Talking Point


Registered User
Sep 17, 2010
Thanks 2Jays.

I realise I'm asking help on a very narrow point - which doesn't make it easy for people to respond.:(


Registered User
Sep 17, 2010
Thanks again 2Jays. This is the bit you're highlighting isn't it?

Complexity: This is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs ….

It does seem relevant to the situation Mum's in ....


Registered User
Mar 26, 2011
Near Southampton
If the danger of skin breaking down is due to incontinence then that is surely different from skin that is in danger from merely sitting or lying or some other condition.

Many people with dementia who are incontinent would fall under the earlier catergory but would not be eligible for CHC funding.

Forgive me if I have misunderstood your query - which I may well have done.


Registered User
Sep 17, 2010
Hi Saffie

I agree that IF the skin integrity risk is caused by double incontinence (meaning the skin is likely to stay damp and in close contact from bacteria-laden faeces and urine for longer than would happen on other parts of the body) unless preventative action is taken, THEN many people with dementia would be entitled to at least a B rating (moderate risk) under this heading.

What I'm not at all sure about is whether this predictably increased skin integrity risk should be entirely discounted in the ratings BECAUSE IF there was no incontinence the skin integrity risk would be much lower. One could equally well argue that someone at particular risk of falls because of the high doses of anti-psychotic medication they need to take should have their falls risk discounted (I think ....:confused:).

Unless anyone else can provide more input I think I'll just raise the issue of inconsistencies and illogic and leave the multi-disciplinary DST panel to make what they will of the argument. Thanks for all contributions.

We wouldn't have rated Mum as being at high risk of skin integrity problems. It was the hospital that did - further enquiry suggests they give this warning almost as a matter of routine.


Registered User
May 20, 2009
It is the totality of health needs you need to look at.
You need to demonstrate how domains interact together showing that needs are complex.

Skin integrity could be affected by incontinence, but other elements would also effect skin integrity.
Certain drugs can thin the skin, nuitrition, and of course the likelyhood of pressure sores if your Mum is immobile or just has very fragile skin anyway.... you need to demonstrate it.
I did it from gp/hospital and nursing home notes

***** had very fragile skin prior to entering the nursing home in 2007.
On admission to **** he was admitted with MRSA to a skin tear on his arm.
Oliatum was applied to keep the skin moisturised.
Because of ***** lack of cognition, he has continued to receive skin tears and injurys during falls thus exacerbating the problem. Many are slow to heal, and some have required swab tests that have come back positive.
***** continues to get periodic sore scrotal area D-----cream is applied with effect.
Pressure sores on both heels in January, now healed but skin integrity still monitored.
Skin is still at risk of breakdown and needs careful monitoring.
Commenced on Prednisone in May. Skin at greater risk as a result.
***** is unable to wash himself, and meticulous washing and drying, and application of cream is required.
Needs regular drops for eye infections ie. Conjunctivitis

Risks –
 Infection ( fungal, bacterial )
 Pain,
 Reduced tissue viability.
 Pressure area damage.
 injury, skin tears.

4. Provide the evidence that informs the decision overleaf on which level is appropriate, such as the times and situations when intervention is likely to be performed across a range of typical daily routines and the frequency and duration of the intervention .Include the frequency and intensity of need, unpredictability, deterioration and any instability.
 ***** is unable to monitor any of his skin needs. He can neither keep his skin clean nor assess when he has an infection. He is dependant on staff to monitor all of his needs for him.
 See needs section.

5. Are the person’s support needs episodic (for example, requiring additional inputs for time limited periods) or long term?
 Long term.
 Skin should be monitored 24 hrs to avoid infection, exacerbation of any existing conditions, susceptibility to self injury, eyes cleaned regularly, therefore monitoring and treatment is intense.

 Skin damage is complex in nature as his existing conditions have been slow in healing. This requires input from several personnel ie. Dr, pharmacist, nurse, carers. Skin tears are problematic to manage and need skilled management to prevent or to treat.

 Skin tears are unpredictable, as are fungal infections and skin breakdowns.

6. Note any overlap with other domains.
 Behaviour – Deterioration due to anxiety, infection, pain.
 P&E – Anxiety/ distress caused by pain.
 Communication – Lacks capacity to inform anyone of pain or discomfort.
 Nutrition – Skin viability is absolutely reliant on good nutrition.
 Continence – Incontinence may contribute to skin damage.
 Drugs – Regular medication review in order to determine impact on skin.
 Mobility – Skin tears are a complication of damage that may occur during falls.

Deterioration – Repeated skin tears and lacerations due to falls. Skin tears not responding to medication as demonstrated in the past. Repeated eye infections due to close proximity to others.


Registered User
May 20, 2009
What I'm not at all sure about is whether this predictably increased skin integrity risk should be entirely discounted in the ratings BECAUSE IF there was no incontinence the skin integrity risk would be much lower.
As 2jays says, a managed need is still a need.


Registered User
Sep 17, 2010
Thanks geum.

Will copy out the wording you used because at least some of it's relevant to my Mum's case.

The nursing home said Mum's falls had damaged and would in future damage her skin integrity ... and Mum's at high risk of falls (in last 9 weeks has fallen 3 times even though the hospital and nursing home have done everything they can to safeguard her).

Mum picks at her skin for a variety of reasons .... it doesn't help.


Registered User
May 20, 2009
Goodluck AlsoConfused.
It's very stressful having to deal with an ill parent, let alone try to pick your way through the minefield of NHS Continuing Health Care. xxx

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