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Registration Number: {{org_field_registration_no}}

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Pressure Ulcer Prevention and Management Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} takes a proactive, evidence-based approach to preventing and managing pressure ulcers. Pressure ulcers (also known as pressure sores or bedsores) can cause serious harm, pain, and infection, and their prevention is a key indicator of high-quality care.

This policy ensures:

• Early identification and prevention of pressure ulcers in people we support.
• Effective risk assessments and personalised care planning.
• Rapid intervention and wound management to prevent deterioration.
• Compliance with CQC Fundamental Standards and best practice guidelines from NICE, NHS England, and Tissue Viability Services.

2. Scope

This policy applies to:

• All staff responsible for delivering personal care, including care assistants, nurses, and senior care staff.
• People we support who are at risk of developing pressure ulcers.
• Management and leadership teams, responsible for ensuring compliance with this policy.
• External healthcare professionals, including GPs, district nurses, and tissue viability specialists.

3. Legal and Regulatory Compliance

This policy aligns with:

CQC Regulations (Health and Social Care Act 2008, Regulated Activities Regulations 2014)

• Regulation 9 (Person-Centred Care) – Ensures that care plans reflect individual needs, including pressure ulcer prevention​.
• Regulation 10 (Dignity and Respect) – Requires that care is delivered with dignity, minimising discomfort and pain​.
• Regulation 12 (Safe Care and Treatment) – Mandates the prevention, detection, and treatment of pressure ulcers​.
• Regulation 13 (Safeguarding) – Protects individuals from avoidable harm caused by untreated or poorly managed pressure ulcers​.
• Regulation 17 (Good Governance) – Ensures systems are in place for monitoring and improving care quality​.

Other Relevant Guidelines

• NICE Clinical Guidelines (CG179) on Pressure Ulcers – National best practice for prevention and treatment.
• Tissue Viability Nursing (TVN) Guidelines – Evidence-based strategies for wound care.
• National Wound Care Strategy Programme (NWCSP) – Guidance for reducing avoidable pressure ulcers.
• Manual Handling Operations Regulations 1992 (MHOR) – Safe repositioning techniques for immobile individuals.

4. Pressure Ulcer Prevention Strategies

4.1. Risk Assessment for Pressure Ulcers

All individuals must have a pressure ulcer risk assessment completed:

• On admission, using an approved tool (e.g., Waterlow Score, Braden Scale).
• Every week for high-risk individuals or monthly for lower-risk individuals.
• After any change in health condition (e.g., hospital admission, infection, reduced mobility).

Risk assessments must consider:

• Skin integrity, identifying any early signs of redness, swelling, or skin breakdown.
• Level of mobility, identifying individuals unable to reposition themselves independently.
• Nutritional status, as poor nutrition increases ulcer risk.
• Continence care, ensuring that moisture-related skin breakdown is prevented.
• Medical conditions, such as diabetes or vascular disease, which increase susceptibility.

Individuals identified as high risk must have preventative interventions implemented immediately.

4.2. Preventative Measures

To reduce the risk of pressure ulcers, staff must:

• Reposition individuals regularly, based on individual risk assessments:
  • Every 2 hours for high-risk individuals.
  • Every 4 hours for moderate-risk individuals.
• Encourage movement, where possible, using gentle mobility exercises.
• Use pressure-relieving equipment, such as:
  • Specialist pressure-relief mattresses and cushions.
  • Heel protectors and positioning aids.
• Ensure proper skin care, including:
  • Daily skin checks for high-risk individuals.
  • Moisturising dry skin to prevent cracks.
  • Avoiding excessive moisture from sweat, incontinence, or wound exudate.
• Support optimal nutrition and hydration, including:
  • Encouraging high-protein diets to support tissue repair.
  • Hydration monitoring to maintain skin elasticity.
• Promote continence management, ensuring that:
  • Individuals are kept clean and dry.
  • Barrier creams are applied where needed.

4.3. Staff Training in Pressure Ulcer Prevention

All staff must receive mandatory training, covering:

• How to recognise early signs of pressure ulcers (Grade 1-4).
• Correct repositioning and manual handling techniques.
• Use of pressure-relieving equipment.
• Nutritional strategies for skin integrity.
• Infection prevention and control in wound care.

Refresher training is conducted annually or as required following incident reviews.

5. Managing Pressure Ulcers

5.1. Identifying and Documenting Pressure Ulcers

If a pressure ulcer develops, staff must:

• Document the ulcer immediately, including:
  • Size, depth, and location.
  • Colour and presence of exudate.
  • Pain levels and signs of infection.
• Photograph the wound (with consent) for monitoring and assessment.
• Notify a senior nurse or manager immediately for escalation.
• Complete an incident report, ensuring lessons are learned and recorded.

5.2. Wound Care and Treatment Plans

Pressure ulcer treatment must follow an individualised wound care plan, which includes:

• Cleaning the wound with sterile saline or appropriate antiseptic solutions.
• Applying suitable dressings, based on the ulcer severity (e.g., foam, hydrocolloid, antimicrobial).
• Regular dressing changes, as per wound care guidelines.
• Pain management, using appropriate analgesia.
• Monitoring for signs of infection, including redness, heat, swelling, or odour.

5.3. Escalation and External Referrals

If a pressure ulcer does not improve, becomes infected, or reaches Grade 3 or 4, it must be urgently escalated:

• GP or district nurses should be contacted for medical review.
• Tissue viability nurses (TVNs) should be involved for advanced wound care.
• Hospital admission may be required for severe cases.

All referrals must be documented, and staff must continue monitoring the ulcer during treatment.

6. Infection Prevention and Control in Pressure Ulcer Care

• Strict hand hygiene must be maintained before and after dressing changes.
• Sterile wound care techniques must be followed.
• Infected wounds must be closely monitored, with immediate action taken to prevent sepsis.
• Clinical waste procedures must be followed for used dressings.

7. Monitoring and Compliance

7.1. Quality Assurance and Audit

• Monthly wound care audits to track pressure ulcer prevalence and management effectiveness.
• Regular case reviews for all individuals with Grade 2 or higher pressure ulcers.
• Annual training compliance checks to ensure staff remain competent.
• Lessons learned reviews following severe cases or safeguarding alerts.

7.2. Incident Reporting and CQC Notifications

• All Grade 3 and 4 pressure ulcers must be reported to CQC as serious incidents.
• Root cause analysis (RCA) must be conducted for avoidable ulcers.
• Action plans must be implemented to prevent reoccurrence.

8. Related Policies

This policy should be read alongside:

• CH11 – Safe Care and Treatment Policy​.
• CH17 – Infection Prevention and Control Policy​.
• CH16 – Health and Safety at Work Policy​.
• CH27 – Staff Supervision, Training, and Development Policy​.

9. Policy Review

This policy will be reviewed annually or earlier if regulatory updates or incidents require changes

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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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