Preventing pressure sores at home

The NHS describes the first signs as discoloured patches of skin that do not change colour when pressed, skin that feels warm, spongy or hard, and pain or itchiness. On white skin the patch is usually red. On black or brown skin it is more likely to look purple or blue, which is one reason a mark can go unnoticed for days on darker skin. The NHS guidance on pressure ulcers sets out the signs and the risk factors in full.

The test is simple enough to do while you help your relative wash. Press the patch gently with a fingertip and let go. If it goes pale and then colours up again, blood is still reaching the skin. If the colour does not change, the damage has started, and it is a nursing matter rather than a household one.

The NHS says sores usually develop gradually but can sometimes appear over a few hours, which is why one long afternoon asleep in a chair after a discharge matters. The risk is higher if your relative has problems moving, has had a pressure ulcer before, has been seriously ill in intensive care or has recently had surgery, is underweight, has swollen, sweaty or broken skin, has poor circulation or fragile skin, or cannot feel pain normally. Where several are true at once, NICE treats the person as being at high risk, and so should you.

Skin checks belong in the same part of the day as washing and dressing, so nobody makes a separate event of them. What personal care covers and a day in the life of a personal carer describe where the check fits, and the personal care guide covers the rest.

The route to a district nurse is your relative's GP surgery. Ring, say you think there is a pressure ulcer, and ask for a district nursing referral and a home visit. If your relative is still on a ward, ask the ward to refer them before they come home. If a district nurse already visits for something else, tell that nurse. NICE's quality standard says a person with a risk factor who is referred to community nursing services should have a pressure ulcer risk assessment at the first face to face visit, so the referral is what opens that door.

NICE asks that an adult at risk of a pressure ulcer changes position at least every 6 hours, and an adult at high risk at least every 4 hours. If they cannot move themselves, the guidance is to help them and to write down how often it is being done. Those figures are in NICE's guideline on pressure ulcers and in the NICE quality standard on help with repositioning, which applies in people's own homes as well as in hospitals.

Two things go against instinct. NICE says not to massage or rub the skin to prevent a pressure ulcer, so a rub with cream on a red heel is the wrong move, kind though it is. And turning is not always a hoist manoeuvre. It can be pillows behind the back and lengthways under a calf so the heels lift clear of the bed, which is how Kent Community Health NHS Foundation Trust describes it in its five steps to prevent pressure ulcers. Ask the district nurse to show you and the carer once, on your relative's own bed. If your relative cannot help at all with the move, read transfers, hoists and when two carers are needed first.

If the mornings and the evenings both need somebody there, you can search for carers near you and compare their rates before committing to anything, and the needs to hours guide turns the tasks above into a number of visits. Nights are a separate question. Visits end when the carer leaves, so if your relative needs turning at two in the morning, that is overnight care or live-in care rather than a longer evening visit.

Two routes exist and both are worth using. The district nurse's assessment is what unlocks a mattress or an air surface. The council route is a home assessment from adult social services, and if it finds your relative needs equipment or a change to the home costing less than £1,000, the NHS guide to care and support you can get for free says the council must provide it free of charge. A council worker or an occupational therapist does that visit. The right equipment to aid an older person covers what else comes out of it, and local authority funding explains the rest.

The distinction NICE draws on food is a useful one for a family being sold things. Supplements are not recommended purely to prevent a sore in somebody whose eating is adequate. Once there is an ulcer NICE asks for a nutritional assessment by a dietitian, and for supplements where there is a deficiency, which is a decision for the GP or the dietitian rather than a shelf in a chemist. If eating is already a worry, nutrition for older people and hydration for older people cover the ordinary ways of getting more into somebody.

Moisture is the other half. Incontinence makes skin softer and quicker to break down, and the answer is prompt changes, careful drying and a barrier preparation where a nurse or GP has suggested one. Managing incontinence at home covers the routine, and catheter and stoma care at home covers it where equipment is involved.

PrimeCarers is an introductory service rather than a care agency. We check a carer's identity and right to work, run an enhanced DBS check on the Update Service, and interview every carer online before they appear in a search. Qualifications, training and references are not checked by us and sit on a carer's own profile, so if experience with pressure care matters, ask the carer directly. Carers are self-employed and are insured while they work. How we vet every carer sets out what the checks cover.

Prevention needs somebody there at both ends of the day, so the cost question is one of hours. Two one-hour visits a day, seven days a week, is 14 hours: £252 to £350 a week on PrimeCarers, against £392 to £490 through an agency. If turns are needed at night too, a sleeping night starts at £130 and a waking night at £150, and past about 35 hours a week live-in care from £1,050 a week costs less than the visits it replaces. If your relative is coming out of hospital with skin already at risk, how hospital discharge works is the page to read next.