DC123-Pressure Ulcer Prevention and Management Policy

Registration Number: {{org_field_registration_no}}

Pressure Ulcer Prevention and Management Policy

1. Purpose

The purpose of this policy is to establish clear guidelines for the prevention, early detection, and effective management of pressure ulcers within {{org_field_name}}. Pressure ulcers, also known as pressure sores or bedsores, can have serious health implications for service users. This policy ensures that our care staff take a proactive approach to pressure ulcer prevention, delivering high-quality care that aligns with NICE Guidelines (CG179) and Care Quality Commission (CQC) Fundamental Standards.

By implementing structured prevention strategies and evidence-based management techniques, we protect service users from unnecessary pain, infections, and complications associated with pressure ulcers.

This policy also sets out how {{org_field_name}} will meet its responsibilities under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including safe care and treatment, person-centred care, dignity, consent, safeguarding, staffing, good governance, duty of candour and statutory notification requirements. In domiciliary care, pressure ulcer prevention is a shared responsibility between the service user, care staff, family or informal carers where appropriate, community nursing services, GPs, tissue viability services, commissioners and other health and social care professionals. Staff must act promptly where skin damage is identified or suspected, and must escalate concerns without delay to prevent avoidable deterioration or harm.

2. Scope

This policy applies to all employees, including care workers, nurses, managers, and any external healthcare professionals involved in the care of service users. It covers:

Risk assessment and identification of service users at risk.
Preventative measures to reduce pressure ulcer incidence.
Early intervention and management strategies.
Staff training and responsibilities.
Compliance with legal and regulatory requirements.
Monitoring, evaluation, and continuous improvement.
Consent, mental capacity and best-interest decision-making where a service user declines repositioning, skin checks, equipment or referrals.
Escalation to GPs, district nurses, tissue viability nurses, emergency services, safeguarding teams, commissioners and CQC where required.
Duty of Candour communication where a notifiable safety incident has occurred.
Statutory notifications to CQC where a pressure ulcer meets the threshold for serious injury or where abuse or neglect is suspected.
Use of body maps, wound charts, photographs where locally agreed and consented to, and clear contemporaneous records.

3. Legal and Regulatory Framework

This policy is written in line with the following legislation, regulations and statutory or best-practice guidance, as applicable to domiciliary care services in England:

Health and Social Care Act 2008.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including:
- Regulation 9: Person-centred care.
- Regulation 10: Dignity and respect.
- Regulation 11: Need for consent.
- Regulation 12: Safe care and treatment.
- Regulation 13: Safeguarding service users from abuse and improper treatment.
- Regulation 14: Meeting nutritional and hydration needs.
- Regulation 15: Premises and equipment.
- Regulation 17: Good governance.
- Regulation 18: Staffing.
- Regulation 20: Duty of Candour.
Care Quality Commission (Registration) Regulations 2009, Regulation 18: Notification of other incidents.
Care Act 2014 and Care and Support Statutory Guidance, including adult safeguarding duties under section 42 where abuse or neglect is suspected.
Mental Capacity Act 2005, including capacity assessment and best-interest decision-making where a service user may be unable to consent to pressure ulcer prevention or treatment interventions.
NICE Clinical Guideline CG179: Pressure ulcers: prevention and management.
NICE Quality Standard QS89: Pressure ulcers.
Department of Health and Social Care: Safeguarding adults protocol – pressure ulcers and raising a safeguarding concern, updated 18 June 2025.
NHS England/National Stop the Pressure Programme guidance on pressure ulcer definition and measurement.
Local Integrated Care Board, local authority safeguarding adults board, tissue viability service and community nursing pathways.

3.1 Definitions and Categorisation of Pressure Ulcers

A pressure ulcer, also known as pressure damage, pressure injury, pressure sore or bedsore, is localised damage to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear. Pressure ulcers may also be associated with medical devices or other equipment that remains in contact with the skin.

{{org_field_name}} will use current nationally recognised terminology and local tissue viability guidance when recording and escalating pressure damage. Staff must not rely only on the terms “grade 1–4”. Records should refer to category/stage where required locally and must include suspected deep tissue injury and unstageable pressure ulcers.

For operational purposes, staff must treat the following as significant or severe pressure damage requiring urgent escalation to a senior member of staff and appropriate health professional advice:

Any category/stage 3 or category/stage 4 pressure ulcer.
Any unstageable pressure ulcer.
Any suspected deep tissue injury.
Multiple category/stage 2 pressure ulcers.
Any pressure damage that deteriorates, becomes painful, appears infected, produces discharge or odour, or is associated with systemic illness.
Any pressure damage that may have arisen because of neglect, poor care, omission of care, refusal or inability to access equipment, or failure to follow the care plan.

Where there is uncertainty about categorisation, staff must record the concern, protect the affected area from further pressure, and seek advice from a district nurse, tissue viability nurse, GP, NHS 111 or emergency services according to the urgency of the situation.

4. Risk Assessment and Identification

{{org_field_name}} will identify people at risk of pressure ulcers as early as possible and will ensure that risks are reflected in the service user’s care plan, daily records and staff instructions.

A pressure ulcer risk assessment must be completed:

before or at the start of the care package, where pressure ulcer risk is known or suspected;
during the initial care planning assessment;
whenever the service user’s mobility, continence, nutrition, hydration, cognition, skin condition, medication, pain, general health or level of independence changes;
following discharge from hospital, respite care or another care setting;
after a fall, acute illness, infection or period of reduced mobility;
when a service user starts using new equipment, including a wheelchair, hoist sling, recliner chair, hospital bed, mattress, cushion, splint, catheter tubing, oxygen tubing or other device that may create pressure;
after any pressure ulcer, moisture lesion, skin tear, blister, redness, bruising, pain or suspected pressure damage is identified.

The assessment must include, as relevant:

mobility and ability to reposition independently;
skin condition, including redness, discolouration, warmth, swelling, pain, hardness, blistering or broken skin;
history of previous or current pressure ulcers;
continence, moisture, sweating, wound leakage and skin hygiene;
nutrition, hydration, weight loss, swallowing difficulties and appetite;
cognition, communication, mental capacity and ability to report pain or discomfort;
sensory impairment, including reduced pain sensation;
long-term conditions such as diabetes, vascular disease, neurological conditions, frailty or end-of-life care needs;
medicines that may affect skin integrity, alertness, mobility, nutrition or hydration;
suitability and correct use of pressure-relieving equipment;
environmental factors in the person’s own home;
involvement of family, informal carers and external professionals.

A validated tool, such as Waterlow, Braden or another locally agreed tool, may be used to support assessment. The tool must not replace professional judgement. Staff must escalate concerns even where a score does not appear high but the person’s presentation indicates risk.

Where a service user is assessed as being at risk, the care plan must set out the specific interventions required, including frequency of skin checks, repositioning support, equipment, nutrition and hydration support, continence care, escalation arrangements, and who is responsible for each action.

Where the service user refuses any part of the assessment or prevention plan, staff must record the refusal, explain the risks in a way the person can understand, consider whether a mental capacity assessment is required, inform the manager, and seek professional advice where risk remains significant.

5. Pressure Ulcer Prevention Strategies

Pressure ulcer prevention must be person-centred, proportionate to risk and clearly recorded in the service user’s care plan. Staff must follow the care plan and must report immediately if the plan is not achievable during visits.

Repositioning and mobility

Staff must encourage and support the service user to change position in line with the care plan and professional advice.
The frequency of repositioning must be based on assessed need, skin condition, comfort, tolerance, mobility, tissue viability advice and any moving and handling plan.
Staff must not drag or slide the service user across surfaces. Moving and handling equipment must be used where required.
Where the service user is unable to reposition independently, the care plan must state what support is required, how often, by whom, and what action staff must take if repositioning cannot be completed.
Repositioning must be documented where it forms part of the care plan.

Skin inspection and care

Staff must observe exposed pressure areas during agreed care tasks, including personal care, continence care, dressing and moving and handling, while maintaining dignity and consent.
Staff must report any redness, discolouration, pain, swelling, heat, hardness, blistering, broken skin, moisture damage, bruising or marks from equipment.
Staff must pay particular attention to heels, sacrum, hips, buttocks, elbows, shoulders, spine, ankles, ears and any area in contact with medical devices or equipment.
Skin must be kept clean and dry. Barrier products must be used only where included in the care plan or advised by a healthcare professional.
Staff must not massage reddened or damaged skin.

Continence and moisture management

Where incontinence or moisture is present, the care plan must include timely continence care, skin cleansing, appropriate products, laundry or clothing arrangements, and escalation if skin damage develops.
Moisture lesions must be reported and recorded, as they may coexist with pressure damage and increase the risk of deterioration.

Nutrition and hydration

Staff must encourage food and fluid intake in line with the care plan and the person’s preferences, dietary needs and swallowing guidance.
Concerns about reduced appetite, weight loss, dehydration, swallowing difficulty, vomiting, diarrhoea or inability to access food and fluids must be reported promptly.
Referral to the GP, district nurse, dietitian or speech and language therapist must be requested where indicated.

Equipment and environment

Pressure-relieving equipment must be used only as assessed and prescribed or agreed by the relevant professional.
Staff must check during visits that equipment is available, clean, correctly positioned and being used as intended.
Concerns about faulty, unavailable, unsuitable or refused equipment must be reported immediately to the office and relevant professional.
Staff must record when equipment is not in use and the reason, including refusal, discomfort, breakdown, power failure or environmental barriers.

Service user and carer information

Service users and, where appropriate, family or informal carers must be given information about pressure ulcer risks, early warning signs, repositioning, nutrition, hydration, equipment use and when to seek help.
Advice must be provided in a format the person can understand and must take account of communication needs, cognition, capacity, language and sensory impairment.

6. Early Intervention and Management

If pressure damage is identified or suspected, staff must act immediately to reduce further harm.

Immediate action

Staff must:

relieve pressure from the affected area where safe to do so;
check the service user’s comfort and pain;
report the concern to the senior person on duty or manager before leaving the visit, unless emergency action is required sooner;
contact or request contact with the district nurse, GP, tissue viability nurse, NHS 111 or emergency services according to the seriousness of the concern;
record the concern in the daily care record and incident system;
update or request an update to the care plan;
inform family or representatives where appropriate and in line with consent, confidentiality and best interests.

Emergency escalation

Staff must seek urgent medical advice or emergency assistance if the service user appears acutely unwell, has signs of sepsis, rapidly deteriorating skin damage, spreading redness, severe pain, fever, confusion, unusual drowsiness, foul-smelling discharge, black tissue, exposed bone or tendon, or any other urgent clinical concern.

Wound care

Care workers must not undertake wound assessment, categorisation, cleansing, dressing selection, debridement or clinical treatment unless this is within their role, training, competency and the care plan. Wound care must be directed by an appropriate healthcare professional. Staff must follow infection prevention and control procedures and must not apply creams, dressings or treatments unless instructed in the care plan or by an authorised healthcare professional.

Classification and professional assessment

Pressure damage must be categorised by an appropriately competent healthcare professional wherever possible. Where staff are not clinically qualified to categorise the wound, they must describe what they see, record the location, size if trained to do so, appearance, pain, odour, discharge and surrounding skin condition, and escalate for clinical review.

Care plan review

Following any pressure ulcer or suspected pressure damage, the manager or delegated senior must ensure that the care plan is reviewed. The review must consider repositioning, visit duration and frequency, double-up care, moving and handling, continence care, nutrition and hydration, pressure-relieving equipment, staff competency, communication with professionals, and whether the current package of care remains safe.

Investigation and learning

Any pressure ulcer that develops, deteriorates or is identified while {{org_field_name}} is providing care must be reviewed to identify contributory factors, actions taken, whether care was delivered as planned, whether escalation was timely, and what learning is required. Findings must be recorded and shared through supervision, team meetings, training and audit.

6.1 Safeguarding Adults and Pressure Ulcers

Pressure ulcers do not automatically mean that abuse or neglect has occurred. However, pressure damage may indicate neglect, acts of omission, poor care, failure to follow a care plan, failure to escalate concerns, lack of suitable equipment, poor nutrition or hydration support, or organisational abuse.

Staff must raise an immediate concern with the manager where:

pressure damage may have resulted from neglect, poor practice or omission of care;
the care plan has not been followed;
required repositioning, continence care, nutrition, hydration support or equipment has not been provided;
there has been a delay in reporting or seeking clinical advice;
the service user has multiple category/stage 2 pressure ulcers, a category/stage 3 or 4 pressure ulcer, an unstageable pressure ulcer or suspected deep tissue injury;
the service user or representative alleges neglect or poor care;
staff are concerned that family, informal carers or professionals are not providing agreed support;
the service user is unable to protect themselves and has care and support needs.

The manager must consider the Department of Health and Social Care pressure ulcer safeguarding protocol, local safeguarding adults board procedures and local authority referral thresholds. Where abuse or neglect is suspected, a safeguarding concern must be raised with the local authority without delay and CQC must be notified where required.

Where there is immediate risk of serious harm, staff must contact emergency services and take immediate steps to protect the person.

6.2 CQC Notifications and Duty of Candour

The registered manager or nominated senior person must review every pressure ulcer incident to decide whether a statutory notification to CQC is required.

CQC must be notified without delay where the incident meets CQC notification criteria, including serious injury, allegation of abuse, or any other notifiable event under the Care Quality Commission (Registration) Regulations 2009. This includes pressure damage that may have occurred while regulated activity was being provided or as a consequence of how care was provided.

As a minimum, the manager must consider CQC notification where:

a category/stage 3 or 4 pressure ulcer develops after the person started receiving the service;
an unstageable pressure ulcer or suspected deep tissue injury is identified;
multiple category/stage 2 pressure ulcers are identified;
the pressure ulcer causes, or is likely to cause, prolonged pain, impairment or significant deterioration;
abuse, neglect or acts of omission are suspected;
the incident meets the threshold for a notifiable safety incident under Duty of Candour.

Where the Duty of Candour applies, {{org_field_name}} must act in an open and transparent way. The service user and/or relevant person must receive a truthful explanation of what is known at the time, an apology, information about further enquiries, reasonable support, and written follow-up in line with Regulation 20.

All decisions about CQC notification and Duty of Candour must be recorded, including the rationale where a notification is not made.

6.3 Consent, Mental Capacity and Refusal of Care

Staff must seek the service user’s consent before carrying out skin checks, personal care, repositioning, use of equipment or sharing information, unless another lawful basis applies.

Where a service user refuses care or support that is required to prevent or manage pressure ulcers, staff must:

respect the person’s decision where they have capacity;
explain the risks and benefits in a way the person can understand;
offer alternatives where possible;
record the refusal, the information given and any action taken;
report the refusal to the manager;
escalate to the GP, district nurse or tissue viability nurse where risk remains significant.

Where there is reason to believe the service user may lack capacity to make a specific decision about pressure ulcer prevention or treatment, the manager must ensure that the Mental Capacity Act 2005 is followed. A decision-specific capacity assessment must be arranged, and any best-interest decision must involve the person as far as possible, relevant representatives and professionals.

Refusal of care must not be ignored. Repeated refusal, inability to understand risk, or refusal that places the person at serious risk must trigger management review and professional escalation.

7. Staff Responsibilities and Training

Care workers must:

follow the service user’s care plan, moving and handling plan and pressure ulcer prevention instructions;
observe skin condition during agreed care tasks while maintaining privacy, dignity and consent;
report any concern about skin integrity, pain, equipment, continence, nutrition, hydration, refusal of care or inability to complete planned care;
record observations clearly, factually and promptly;
encourage repositioning, mobility, food and fluid intake in line with the care plan;
use pressure-relieving equipment only as instructed;
escalate immediately if pressure damage is suspected or if equipment is missing, faulty or not being used;
never undertake wound care unless trained, competent, authorised and instructed within the care plan.

Senior care staff, coordinators and managers must:

ensure pressure ulcer risks are assessed and reflected in care plans;
ensure staff have enough time, information, equipment and competency to deliver planned care safely;
review incidents, missed visits, late visits, refusals of care and changes in condition;
liaise with district nurses, GPs, tissue viability nurses, commissioners, local authority safeguarding teams and CQC where required;
decide whether safeguarding, CQC notification and Duty of Candour requirements apply;
ensure learning from incidents is shared and embedded.

Registered nurses, where employed or commissioned by {{org_field_name}}, must:

work within their professional competence and registration requirements;
undertake or support clinical assessment, wound care planning and escalation as appropriate to their role;
ensure wound care documentation is accurate, contemporaneous and communicated to relevant staff.

Training

All relevant staff must receive pressure ulcer prevention training at induction and thereafter at intervals determined by role, risk, competency and service need. Training must include:

causes and risk factors for pressure ulcers;
early signs of skin damage, including signs on darker skin tones;
moisture damage and pressure damage;
repositioning and moving and handling principles;
continence, nutrition and hydration risks;
equipment use and escalation of equipment problems;
recording and reporting;
safeguarding and neglect indicators;
Duty of Candour and CQC notification awareness;
consent, mental capacity and refusal of care.

Staff competency must be checked through supervision, spot checks, care record audits, observed practice and incident review.

8. Record Keeping and Compliance

Accurate, factual and contemporaneous records must be maintained for all pressure ulcer prevention and management activity.

Records must include, where applicable:

risk assessments and reassessments;
skin observations and body map entries;
care plan instructions and updates;
repositioning support provided or declined;
continence care, nutrition and hydration support;
equipment checks, concerns and actions taken;
communication with the service user, family, representatives and professionals;
referrals and escalation to GP, district nurse, tissue viability nurse, NHS 111, emergency services, safeguarding team, commissioner or CQC;
incident reports and investigation findings;
photographs, where used lawfully and in line with consent, confidentiality and local procedures;
mental capacity assessments and best-interest decisions where relevant;
Duty of Candour actions;
CQC notification decisions and confirmation of submission where required.

Records must be clear enough to show what was observed, what action was taken, who was informed, when escalation occurred, what advice was received, and how the care plan was updated.

Staff must not use vague wording such as “skin fine” where risk is present. Records must describe the actual observation, for example: “no redness seen on heels during personal care” or “red non-blanching area observed on left heel; pressure relieved; office informed at 09:20; district nurse contacted.”

All records must be stored securely and processed in line with confidentiality, data protection and organisational record keeping procedures.

9. Monitoring, Evaluation, and Continuous Improvement

{{org_field_name}} will monitor the effectiveness of this policy through regular governance activity. This will include:

monthly audits of pressure ulcer risk assessments, care plans, daily records and incident reports;
review of all pressure ulcers identified while the service is being provided;
checks that care plans contain clear instructions for repositioning, skin checks, continence care, nutrition, hydration and equipment;
checks that staff have reported and escalated concerns promptly;
review of missed, late or shortened visits where pressure ulcer prevention care may have been affected;
review of equipment delays, faults or refusal;
monitoring of CQC notifications, safeguarding referrals and Duty of Candour actions;
analysis of themes, trends and repeat concerns;
service user and family feedback;
action plans with named leads and completion dates.

Learning from audits, incidents, complaints, safeguarding enquiries, CQC feedback and professional advice must be shared with staff and used to improve practice. Where shortfalls are identified, the registered manager must ensure prompt remedial action, including care plan review, staff supervision, retraining, disciplinary action where appropriate, and escalation to commissioners or professionals where the package of care is no longer safe.

10. Policy Review and Updates

This policy will be reviewed at least annually, or sooner where there are changes in legislation, CQC guidance, NICE guidance, DHSC safeguarding guidance, NHS England pressure ulcer guidance, local safeguarding procedures, tissue viability pathways, commissioning requirements, or following any serious incident, safeguarding concern, complaint, audit finding or CQC feedback relating to pressure ulcer prevention or management.

The registered manager is responsible for ensuring that staff are informed of policy updates and that any required training, competency checks or care plan changes are completed.

11. Conclusion

{{org_field_name}} is committed to preventing avoidable pressure damage through early identification of risk, person-centred care planning, timely escalation, effective communication, accurate records, staff training and strong governance. Pressure ulcer prevention is an essential part of safe care and treatment, safeguarding, dignity, nutrition, hydration, consent and quality assurance. Where pressure damage occurs or is suspected, staff must act promptly to reduce harm, seek appropriate clinical advice, update the care plan, consider safeguarding, consider CQC notification and comply with Duty of Candour where applicable.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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