What to do when new pressure damage is found in a care home

Act on the skin finding before deciding what to call it

A worker sees a new red or darker area on a resident's heel during personal care. The skin may be intact, and the person may have little pain or may not be able to describe it. A manager should not wait for a category label before protecting the resident and seeking a trained clinical assessment. Early pressure damage can be harder to recognise on darker skin, and redness is not the only sign.

Check the resident's immediate condition and comfort. Record the location, appearance, pain or discomfort, whether the skin is intact and any change from earlier observations. Follow the home's escalation route to a nurse, community nursing team, GP or tissue viability service as appropriate. Staff should work within their training. They should not diagnose the category, prescribe a dressing or decide that the area is harmless from a photograph alone. If the resident is unwell or there are signs that require urgent care, use the urgent clinical route.

Protect the affected area while advice is obtained. Review how pressure reaches the site and whether the person can reposition, move or request help. Use the resident's existing plan and clinically approved equipment. A person left on the same surface while staff debate paperwork can experience further harm. At the same time, do not improvise a turning schedule or device that conflicts with clinical advice, skin condition or the person's wishes. Seek a clear interim plan from the responsible professional.

NHS England's Enhanced Health in Care Homes framework calls for care homes to maintain a pressure-ulcer policy, help staff recognise and prevent damage, refer residents for individualised wound care and implement the local wound team's plan. NICE CG179 provides clinical recommendations on risk and skin assessment, prevention and management within its scope. The care home's first obligation is a prompt, coordinated response to the resident, not an automatic classification by an untrained worker.

Establish a reliable baseline and timeline

Check when the area was last observed intact or different. Review recent skin checks, personal-care notes, hospital transfer information, mobility changes and any prior pressure damage. If the resident has just returned from hospital, compare the discharge skin information and arrival assessment. Do not assume where the damage developed merely because it was first documented in the home. Record “first observed here at this time” when origin is uncertain. That is a factual statement, not a conclusion about cause.

Ask the resident how the area feels and whether they noticed it earlier. Involve them in inspection and care decisions with dignity and consent. A person may report pain before staff see an obvious break in the skin. They may also explain that an aid, shoe, splint or device rubs at the site. Keep their account in the clinical record. If they cannot communicate easily, consider non-verbal signs and advice from people who know their normal presentation.

Document the site's appearance using the home's approved clinical process. NICE CG179 recommendations 1.4.1 to 1.4.3 address surface area, estimated depth and validated classification by appropriate clinicians. Photographs may help when taken with consent, privacy and secure handling. A blurred image sent through an informal personal phone channel is not a safe substitute for a clinical record. Label observations and review dates so later teams can see change.

Identify possible contributors without rushing to blame. Has the resident become less mobile after illness or a fall? Are they sitting longer? Is the mattress or cushion suitable and functioning? Was a repositioning plan in place and delivered? Has nutrition or hydration changed? Is moisture affecting skin? Does a medical device press on the area? The first review should gather facts and organise a professional assessment, not declare that a single missed turn caused the ulcer.

Obtain a clinician-led risk and wound assessment

The clinician should assess the skin damage and the person's overall pressure risk. NICE CG179 calls for reassessment when clinical status changes and skin assessment for adults at high risk by a trained healthcare professional. It notes that colour change or discolouration can be a sign, including on darker skin, and that heat, firmness and moisture may matter. A validated scale can support clinical judgement but should not replace it.

The plan should cover the pressure site, category if appropriate, likely contributing factors, pain, risk of further damage, wound care and review frequency. Ask who is responsible for each part. In a residential home, community nursing or tissue viability services may direct wound care while home staff deliver agreed daily support. In a nursing home, the local division of responsibility may differ. The provider should make the handover explicit rather than assuming another team will handle the whole case.

Ask about support surfaces and positioning. NICE discusses high-specification foam mattresses and, where needed, dynamic surfaces for adults with a pressure ulcer, as well as seating needs. The choice and configuration require clinical and equipment assessment. A mattress order is not the same as a mattress installed and suitable for the resident. Check delivery, fit, settings, power, maintenance and whether staff know how to use it. Do not treat an equipment label as proof that pressure is being relieved.

Review nutrition and hydration with qualified input. NICE recommends a nutritional assessment by a dietitian or another appropriately skilled professional for adults with pressure ulcers and says supplementation should address identified deficiency. Care staff should not prescribe supplements solely because an ulcer is present. Record intake concerns and the professional plan. Pain, illness and personal preferences can affect eating and repositioning, so the response should be individual.

Make the prevention plan deliverable on every shift

Translate clinical advice into actions staff can perform. If repositioning is recommended, the plan needs the person-specific frequency, safe method, equipment, comfort measures and what to do if the resident declines. If a heel needs offloading, identify the approved equipment and how to check its position. If a cushion is required, specify which chair and who checks it. The home should not substitute a generic “two-hourly turns” schedule for the clinician's individual plan. The plan must respect the resident's condition and choices.

Test the rota and environment. Can staff provide the agreed support overnight and during meals? Is the required equipment available when the person transfers between bed and chair? Are replacement covers or supplies ready? Does an agency worker know the plan? A beautiful care plan that cannot be delivered on a busy shift is not an effective control. Escalate resource or equipment gaps to the manager and clinical team promptly.

Preserve mobility and meaningful activity. NHS England's care-home framework emphasises care plans that empower residents to remain active while promoting healing. Pressure prevention should not automatically mean keeping someone in bed. The clinical team can balance offloading with movement, seating, falls risk and the person's goals. A fall prevention measure may affect skin risk, and a pressure-relieving device may affect transfers. Coordinate rather than treating each risk in isolation.

Record delivered care accurately. If a position change, skin check or equipment inspection was missed, document it and escalate according to policy. Do not complete a chart retrospectively to make it appear that every action occurred. The clinical reviewer needs reliable information to judge whether the plan is working. A pattern of missed support requires a staffing or process response, not a cleaner spreadsheet.

Review change rather than waiting for a scheduled audit

Set a clinical review point and escalation triggers. The area may enlarge, deepen, become more painful or show signs of infection. Staff should know whom to contact if the skin changes before the scheduled visit. A wound that is not improving under a documented plan needs reassessment, not just another week of the same care. The separate future owner for a worsening wound would focus on that failure-to-improve decision.

Compare observations in a consistent way. Use the clinician's measurement and classification method. Record changes in colour, size, depth, pain, exudate and surrounding skin as directed. Do not compare photographs taken in different lighting as the only evidence of progress. An apparent improvement in a score is not enough if the resident's pain or function is worse.

Review whether the controls happened. Was the mattress installed and functioning? Were repositioning and skin checks delivered? Was the resident able to use the cushion? Did the nutrition referral occur? Were staff trained in the new plan? If an action was recorded as complete but not observed in daily care, correct the process. A clinical review should have the information needed to decide whether treatment or prevention needs changing.

Ask the resident about comfort and preferences. A device may be effective on paper but unacceptable to the person, leading them to move out of position or avoid sitting. The plan can be adjusted with professional input. Avoid labelling a resident “non-compliant” without understanding pain, sleep, cognition or the burden of the intervention.

Consider safeguarding without using a category as the whole test

A pressure ulcer can arise despite appropriate care, or it can reveal neglect, missed support or unsafe systems. DHSC's safeguarding adults pressure-ulcer guidance provides an England process that prioritises clinical harm reduction and asks whether an adult safeguarding response is needed. It includes an adult safeguarding decision guide and body map. The manager should follow the current local authority route and use the national protocol with clinical and safeguarding input.

Do not wait for the internal investigation to finish before making a referral where a safeguarding concern is present. Equally, do not assert that every pressure ulcer proves neglect. The review should consider the person's condition, origin and timing, previous risk assessment, agreed care, actual delivery, equipment, professional advice and whether there was a failure to act on deterioration. Record the reasoning and who was involved. The clinical response continues regardless of whether a safeguarding threshold is met.

Communicate openly with the resident and, according to their wishes and lawful sharing arrangements, family or representatives. Explain what has been found, what care and assessment are arranged and what remains uncertain. Do not promise a cause before investigation. If the case meets the statutory duty of candour threshold, follow the required process with specialist advice. General openness should not wait for a formal threshold decision.

CQC notification is a separate decision. CQC's serious-injury guidance addresses serious injury connected with regulated activity. An allegation of abuse has its own route. A manager should assess the actual ulcer, circumstances and current guidance, and document the decision. Avoid a universal rule that a particular wound category always has one reporting outcome without checking the current regulatory criteria and facts.

Investigate the prevention system fairly

Once the resident's care is secured, reconstruct the care pathway. What was the pressure risk before the new finding? Was the skin assessed at admission and after health changes? Were repositioning, equipment and nutrition actions specified? Did staff have time and skill to deliver them? Were early warning signs recorded and escalated? Did a hospital transfer provide the necessary information? The investigation should distinguish a weak plan, a delivery failure, a delayed clinical response and unavoidable disease factors.

Review a sample of relevant records, not just the chart for the day the ulcer was found. Look at previous skin entries, shift handovers, equipment requests and incidents. Speak with staff and the resident. A missing signature may represent a missed task or a record problem; investigate rather than assume. A complete chart is also not conclusive proof that support was provided effectively. Observe the current process and compare it with what the plan requires.

Identify service-wide issues when appropriate. Are several residents waiting for pressure-relieving equipment? Does the night shift have enough trained staff for repositioning plans? Are community nursing referrals delayed? Does the home have a clear process for changes in mobility after hospital discharge? A resident-specific action may need a wider governance response. Keep individual clinical details confidential while sharing the operational lesson with the team.

Set actions that can be tested. If the problem was an unprocessed equipment request, track request, delivery, installation and staff use. If staff did not recognise darker-skin colour changes, provide practical training and verify understanding. If shift handover lost a new plan, test the next few handovers. The incident should not be marked closed simply because a new policy was uploaded.

Example: new heel damage after reduced mobility

A resident returns from hospital walking less than before. Two days later, a worker notices a darker, warm area on the heel. The worker records the finding and tells the senior, who arranges clinical assessment through the local wound-care route. The team checks the hospital discharge information and discovers that the resident's mobility and skin risk were not fully incorporated into the care plan. Staff provide interim pressure protection under professional advice and ensure the next shift knows what to observe and whom to call.

The clinician assesses and records the area, risk factors and plan. The manager checks whether a suitable mattress or heel device is required and follows delivery through to actual use. The resident participates in deciding how to remain active comfortably. The safeguarding lead applies the DHSC and local process to the facts rather than drawing a conclusion from the wound alone. The registered person considers CQC notification criteria separately and records the decision.

The home reviews the transfer process and finds that admission skin information reached a general inbox but not the shift team. A new handover check is introduced and tested on later returns. The example shows a response sequence. It does not categorise the ulcer, prescribe a dressing or set a universal repositioning interval.

Where Complys may fit

The live Complys care home guide discusses policies, training, incidents and actions. Public material does not verify wound assessment, pressure-ulcer classification, clinical care planning, mattress settings or automated safeguarding decisions. A product owner must confirm any proposed administrative workflow before publication.

If supported, a compliance system could hold the pressure-ulcer policy review, staff training evidence, incident action owner, equipment service record or governance audit. The resident's wound photographs, clinical assessment and treatment plan belong in the authorised clinical care system. A manager may track that a referral or equipment action was completed without duplicating sensitive wound images in a general compliance tool. Information governance and product teams should review the use case.

CTA: Review Complys for Care and ask which current policy, training, incident and action workflows can support skin-integrity governance alongside clinical records. Related tool opportunity: A new-pressure-damage response worksheet covering discovery, clinical escalation, interim protection, source and timeline, equipment, resident communication, safeguarding decision and tested action. It must not categorise a wound or prescribe treatment. Suggested internal links out: First-fall response, hospital-return medicines reconciliation, care home CQC guide. Suggested links in: Care home clinical safety cluster page, broad CQC evidence guide and future worsening-pressure-ulcer owner. Cannibalisation boundary: This page owns discovery of new pressure damage and the initial clinical, prevention and safeguarding response. A later worsening-wound owner would address failure of an existing treatment plan. A general pressure-ulcer policy or anatomy article should not duplicate this incident decision journey.