Your Complete Guide to Pressure Ulcer Prevention in Care Homes

Pressure ulcer prevention is essential to providing safe, dignified, person-centred care. Care home residents may be particularly vulnerable because of limited mobility, frailty, dementia, reduced sensation, poor nutrition or complex health conditions. Their level of risk can also change quickly following an illness, fall, hospital admission or deterioration in their general health.

Effective prevention is therefore not a single assessment completed when someone enters a care home. It is an ongoing cycle of recognising risk, assessing individual needs, taking preventative action, monitoring the resident’s skin and responding promptly to changes.

This guide highlights how care home managers, nurses and caregivers can work together to reduce the risk of pressure damage and support better outcomes for residents.

What is a Pressure Ulcer?

A pressure ulcer, sometimes called a pressure sore or bedsore, is damage to the skin and underlying tissue caused by sustained pressure or pressure combined with shear.

When someone remains in the same position for a prolonged period, pressure can restrict blood flow to the affected tissues. Shear can occur when the skin remains in place while the body moves, for example, when a resident slides down a bed or chair.

Pressure ulcers commonly develop over bony areas, including the:

• Heels and ankles

• Sacrum and buttocks

• Hips

• Elbows

• Shoulders and spine

• Ears and back of the head

Pressure damage can also develop beneath or around medical devices such as oxygen tubing, catheters, footwear and continence products.

Not all skin damage is a pressure ulcer. Moisture-associated skin damage, incontinence-associated dermatitis and skin tears may look similar but require different management. Suspected damage should therefore be assessed by an appropriately trained healthcare professional.

Why Pressure Ulcer Prevention Matters

Pressure ulcers can have a significant physical and emotional impact on residents. They may cause pain, discomfort, disturbed sleep and reduced mobility, while affecting a person’s dignity, independence and confidence.

For residents with an existing wound, pain, lower mood or distress caused by wound odour may also reduce appetite. Poor nutritional intake can then make the healing process more difficult and potentially contribute to longer healing times. 

Pressure damage can also lead to:

• Infection and clinical deterioration

• Hospital admission or delayed discharge

• Increased dependence on caregivers

• Additional dressing changes and clinical appointments

• Disruption to rehabilitation and everyday activities

• Greater concern for relatives and loved ones

• Increased demands on care home staff, community teams and healthcare resources

Preventing pressure ulcers wherever possible is therefore important for resident wellbeing, care quality and the effective use of staff time and resources.

Which Care Home Residents are most at Risk?

All residents should be considered potentially at risk, but some will have factors that significantly increase their vulnerability.

These include:

• Limited mobility or an inability to reposition independently

• Frailty, thin skin or reduced tissue tolerance

• Dementia or cognitive impairment

• Reduced sensation or an inability to communicate pain

• A previous or existing pressure ulcer

• Poor nutrition, dehydration, weight loss or reduced appetite

• Incontinence or prolonged exposure to moisture

• Diabetes, poor circulation or neurological conditions

• End-of-life or palliative care needs

• Recent surgery, illness or hospital discharge

• A sudden deterioration in physical or mental health

• Medical devices remaining in contact with the skin

• A fall resulting in a prolonged period on the floor

Risk should never be viewed as static. A resident who was previously mobile and eating well may become vulnerable following an infection, fall, medication change or decline in appetite.

Recognising the Early Warning Signs

Early identification allows preventative action before more serious damage develops. 

Care staff should look and listen for:

• Persistent discolouration or colour change

• Skin that feels warmer or cooler than the surrounding area

• Unusual firmness, softness or a spongy texture

• Swelling

• Pain, tenderness, itching or numbness

• Blistering or broken skin

• Changes beneath medical devices or footwear

Pressure damage can be more difficult to identify visually on darker skin tones. Please watch our webinar, Achieving the Gold Standard in Lower Limb Offloading, for further information.

Discolouration may not be obvious, so staff should also compare the area with the surrounding skin and pay particular attention to changes in temperature, texture, firmness and reported discomfort. 

NICE recommends that skin assessment considers integrity, colour changes, heat, firmness, moisture, pain and discomfort.⁠

Risk Assessment and Reassessment

Pressure ulcer risk assessments should form part of the resident’s admission process and ongoing care.

The National Wound Care Strategy Programme (NWCSP) recommends using PURPOSE-T, or another validated tool containing the same minimum risk factors, alongside professional judgement. For residents admitted to a nursing home, complete a full risk assessment within six hours to identify any potential risk.

In a residential care home without a registered nurse on site, staff who identify a possible risk should take immediate preventative action and refer the resident through the home’s agreed pathway. This may involve a district nurse, GP, community nursing team or tissue viability service.

Risk should be reassessed whenever there is a change in the resident’s:

• Mobility or ability to reposition

• Skin condition

• Appetite, weight or hydration

• Continence

• Cognition or communication

• Medication

• General health

• Care environment or equipment

For residents whose condition remains stable, the NWCSP recommends a review at least monthly in community and care settings. Local policies may require more frequent reassessment. The result, agreed actions, and next review date should be clearly documented.

NWCSP Pressure Ulcer Recommendations and Clinical Pathway⁠

Using the aSSKINg Framework

The aSSKINg framework provides a practical structure for planning and delivering individualised pressure ulcer prevention.

A pressure redistributing mattress and repositioning alone cannot compensate for unmanaged moisture, poor nutrition or missed skin changes.

How often should Care Home Residents be Repositioned?

There is no single repositioning schedule that is suitable for every resident. Frequency should be based on the individual’s risk level, skin condition, mobility, comfort, sleep, medical needs and ability to change position independently.

For adults receiving care, EPUAP recommends that regular turning remains essential, but intervals (such as 2- or 3-hour schedules) must be tailored based on a clinical assessment of the patient's risk, skin tolerance, and support surface. An individual assessment, local policy or deterioration in the resident’s skin may indicate that more frequent repositioning is required. Document the prescribed frequency and support needed in the resident’s care plan.

EPUAP Reference

A good repositioning plan should consider:

·       Positions the resident can tolerate safely

·       Areas of the body requiring pressure redistribution

·       Whether the resident can reposition independently

·       Pain or discomfort during movement

·       Moving and handling requirements

·       The effect of repositioning on sleep

·       The mattress, cushion or other equipment in use

·       The resident’s preferences and normal routine

·       The outcome of each repositioning intervention

A pressure redistribution and reduction support surface does not remove the need for an individualised repositioning regime.

What if a Resident Declines Repositioning?

A resident may decline repositioning because it is painful, frightening, uncomfortable, or disrupts sleep. Someone living with dementia may not understand what is happening or may become distressed by physical contact.

Staff should try to understand the reason and consider whether the plan can be adapted. This might include:

• Explaining the purpose using appropriate language

• Providing reassurance and allowing more time

• Reviewing pain relief

• Trying a different position or technique

• Repositioning at a more suitable time

• Using equipment to automate and make movement gentler

• Involving someone familiar to the resident

• Seeking advice from the wider clinical team

• Introduce automated lateral turning systems

The discussion, the resident’s decision and any alternative actions should be documented. Where a resident cannot make the relevant decision, staff must follow mental-capacity legislation, local policy and an appropriate best-interests process.

Choosing Pressure Redistributing Equipment

Effective pressure redistribution and reduction support surfaces should be selected following an individual assessment rather than using the same solution for every resident. 

Consideration may need to be given to:

• Mattresses and mattress overlays

• Pressure redistribution cushions

• Wheelchairs, armchairs and riser recliners

• Heel offloading solutions

• Automated lateral turning systems

• Protection beneath medical devices

Any equipment provided should be:

• Appropriate for the resident’s level of risk and clinical needs

• Suitable for their weight, size and mobility

• Compatible with the bed, chair and other equipment

• Correctly installed and positioned

• Comfortable and acceptable to the resident

• Cleaned, inspected and maintained in accordance with instructions

• Used by staff who have received appropriate training

The resident’s skin and comfort should continue to be monitored after equipment is introduced.

Protecting the Skin from Moisture

Incontinence, perspiration, vomit, and wound exudate can leave the skin more vulnerable to damage.

Prevention may include:

• Responding promptly after episodes of incontinence

• Cleansing the skin gently and avoiding excessive friction

• Drying the skin carefully

• Using suitable continence products

• Applying an appropriate barrier preparation where indicated

• Reviewing continence needs and toileting plans

• Checking that bedding and clothing are dry and free from creases

Nutrition and Hydration

Good nutrition and hydration support skin health and the body’s ability to repair damaged tissue.

Care-home teams should monitor:

• Changes in appetite

• Unplanned weight loss

• Difficulties eating or swallowing

• Fluid intake

• Changes in mood affecting food intake

• The impact of pain, nausea or wound odour

• Whether assistance or adapted equipment is needed at mealtimes

Escalate reduced intake or unexplained weight loss for appropriate assessment, which may include referral to a GP and dietitian. Nutritional supplements should not be given solely to prevent pressure ulcers when someone’s nutritional intake is already adequate. They may be appropriate where a nutritional deficiency has been identified and professional advice has been obtained.

Keeping Prevention Person-centred

Pressure ulcer prevention should protect the resident’s quality of life as well as their skin.

Care planning should take account of:

• The resident’s preferred positions and routines

• Comfort, pain and sleep

• Dignity during skin checks and repositioning

• Their ability to move or participate in repositioning

• Communication or cognitive needs

• Personal goals and priorities

• End-of-life wishes

• The involvement of family members

For residents receiving palliative or end-of-life care, prevention plans may need to balance skin protection with pain management, comfort, sleep and dignity. Decisions should be made collaboratively and reviewed as the resident’s needs change.

What should Staff do if Pressure Damage is Suspected?

When a skin change or possible pressure ulcer is identified:

1. Relieve pressure from the affected area and record the position in which the resident was found.

2. Check that existing equipment is correctly positioned, functioning and being used as intended.

3. Do not rub or massage the affected skin.

4. Report the concern immediately through the home’s clinical escalation pathway.

5. Seek assessment from the appropriate nurse, GP, district nurse or tissue viability service.

6. Document what was observed and the action taken.

7. Photograph damaged skin only with appropriate consent and in accordance with local policy.

8. Update the care plan and communicate changes during handover.

Seek urgent clinical advice if skin is rapidly deteriorating, with increasing redness or discolouration, swelling, heat, pus, severe or worsening pain, fever, or possible signs of sepsis.

Documentation, Training and CQC Readiness

For care homes in England, good pressure ulcer prevention supports compliance with several CQC fundamental standards.

Regulation 12 requires providers to assess and mitigate risks, ensure staff are competent and make sure equipment is safe, suitable and used correctly. CQC Regulation 12: Safe care and treatment⁠

Regulation 17 requires effective governance and accurate, complete and contemporaneous care records. CQC Regulation 17: Good governance⁠

A care home should be able to demonstrate:

• Completed risk and skin assessments

• Individualised prevention plans

• Repositioning and skin-monitoring records

• Appropriate equipment selection and checks

• Documented refusals and alternative actions

• Prompt referral and escalation

• Effective handovers between staff and services

• Staff training and competency

• Regular audits, incident reviews and shared learning

Records should show not only that a task was completed, but also how the resident responded and whether the intervention remained effective.

Supporting “Surface” and “Keep Moving” with Repose and Toto

Frontier Medical Group offers pressure area care solutions that can support two important elements of the aSSKINg framework.

Repose – Surface

Repose is a range of reactive-air pressure redistribution and reduction support surfaces offering high levels of immersion and envelopment. The range includes surface solutions to protect residents while in bed, seating solutions for when seated, and foot care solutions to protect vulnerable heels.

Repose products can be considered following assessment as part of an individualised pressure ulcer prevention or management care plan. Products are suitable for multi-patient use when correctly cleaned, maintained and used in accordance with their instructions.

Toto Cradle – Keep Moving

Toto Cradle is an automated lateral turning system designed to deliver consistent, prescribed turning intervals during the day and night, including while the resident is sleeping.

It can support residents who require frequent repositioning or who find manual repositioning difficult, painful or disruptive. By supporting regular lateral turning, Toto Cradle can also help reduce the physical demands associated with manual repositioning for care staff.

A Prevention-first Approach

Pressure ulcer prevention depends on consistent everyday actions across the whole care team. By recognising risk early, using the aSSKINg framework, selecting an appropriate support surface, supporting effective and timely repositioning, and responding promptly to skin changes, care homes can help protect residents from avoidable harm while maintaining comfort, dignity, and quality of life.

Strengthen Pressure Ulcer Prevention in your Care Home

Discover how Repose and Toto can support your pressure area care pathway, or access further pressure ulcer prevention training through the FMG Learning HUB.

This article provides general educational information and does not replace professional clinical judgement, local policies, individual care plans or product instructions for use. References to CQC regulations apply to care services in England.

The contents of this article were supported by AI and fully reviewed by the Frontier Medical Group team before publication.