What to do when a care-home pressure ulcer worsens despite a plan

Treat deterioration as a new decision point

A resident has had a documented pressure ulcer for two weeks. The wound is now larger, deeper or more painful. Staff say the care plan is in place and the repositioning chart is complete. The manager still needs a new clinical decision. Repeating the same plan because it exists in the file does not answer why the resident is deteriorating.

Start with the person. Check their immediate wellbeing, pain, temperature, behaviour and any other change that might indicate urgent illness. Ask a trained clinician to reassess the wound and the resident promptly through the locally agreed route. If the resident seems acutely unwell, use the urgent clinical pathway rather than waiting for a routine tissue viability visit. Care staff should report observations and provide support within their competence. They should not diagnose infection from appearance alone or start a treatment that has not been authorised.

Protect the affected site while advice is sought. Continue the current clinically agreed measures where safe, but report any reason they cannot be delivered. If a mattress has failed or the resident cannot tolerate the prescribed position, the team needs an interim plan from a responsible professional. A worsening wound makes the gap between an instruction and its delivery consequential. Record what actually happened rather than filling a chart to make it look complete.

This page addresses a wound that is deteriorating under an established plan. The separate new pressure-damage guide covers initial discovery and baseline assessment. Here the key questions are whether the clinical picture has changed, whether the plan still fits, whether each control was delivered and whether failures point to a wider safeguarding or governance concern.

Establish what changed, using comparable evidence

Make a timeline. Identify the last reliable assessment that described the wound and the first observation showing deterioration. Record who saw the change, when it was escalated, whom they contacted and what advice followed. If the change was first noticed on a weekend or night shift, include that period. Avoid writing a confident onset date when the observation interval does not support one.

Ask the assessing clinician to compare like with like. NICE CG179 recommends documenting surface area, estimating depth and repeating a validated category each time an adult pressure ulcer is assessed. It also identifies pain and other skin characteristics as relevant to assessment. A change in category can be important, but one number cannot tell the entire story. Compare the site, measurement method, image quality, pain, surrounding skin and the resident’s overall condition. A photograph taken in different light may mislead if it is treated as the only proof of change.

Preserve the resident’s account. Ask whether the wound feels more painful, whether they avoid a particular chair or position, and whether a device rubs or presses. A person who cannot speak may show discomfort through movement, facial expression, sleep disruption or distress. People who know their normal presentation may help staff recognise the change. Do not allow a reassuring chart to override the person’s experience.

Record uncertainty honestly. A wound may look different after a dressing change or assessment by a different clinician. If the clinical team thinks the appearance has changed but cannot yet establish the cause, document that judgement and the next review point. Avoid the extremes of declaring neglect from one image or dismissing deterioration because the category has not yet changed.

Request a whole-person clinical reassessment

The clinician should look beyond the wound surface. Has the resident become less mobile because of infection, injury or fatigue? Have they lost weight, eaten less, had new continence needs or spent longer in a chair? Has a medicine change affected alertness or movement? Has pain made repositioning difficult? The answer may be a combination of factors. A plan designed for the resident’s condition last month may now be inadequate even if every scheduled action occurred.

NICE CG179 says to reassess pressure ulcer risk when clinical status changes. It describes trained skin assessment, support surfaces, seating needs, nutritional assessment and wound management within its stated scope. In a care home without nursing, community nurses or a tissue viability team may direct wound treatment while home staff provide daily support. In a nursing home, responsibilities may be distributed differently. The manager should identify the named clinical decision maker and avoid assuming that a referral alone transfers every task.

Ask for a clear revised plan. It should state the wound-care treatment authorised by the clinician, how pressure will be reduced, what staff should observe, when review will occur and what would trigger earlier contact. It should address pain and the resident’s preferences. If the clinician recommends a different mattress, cushion or position, specify who will arrange it and what happens until it is available. A referral marked “sent” is not evidence that a resident has received the new support.

Consider whether infection is suspected. NICE recommendations on systemic antibiotics depend on clinical findings, including systemic sepsis, spreading cellulitis or underlying osteomyelitis. Care-home staff should not infer from a worsening wound that antibiotics are automatically indicated. They should communicate signs and obtain timely clinical assessment. If the resident has urgent symptoms, follow the local emergency route. Treatment decisions belong with qualified clinicians.

Test whether the existing plan was delivered

A signed plan and a completed chart are starting points for review, not proof of effective care. Trace the important controls across several shifts. Were position changes delivered at the specified intervals and in the agreed way? Were skin checks performed by someone with the required competence? Did staff know which site was at risk? Was the correct cushion used in the correct chair? Could the resident move independently or did they need help that was not available at the time?

Compare records with reality. Interview the staff who delivered care, inspect equipment and ask the resident where possible. A mattress might be present but not powered, incorrectly set, damaged or unsuitable for the person. A cushion might be available but left in another room. A turning chart might show activity, yet staff may have moved the resident back to the same pressure point because another risk was not addressed. The purpose is to identify what needs changing, not to blame a worker before the facts are known.

Check handovers. Did a hospital discharge summary identify new skin damage or a different support surface? Was a community nursing instruction copied accurately into the home’s care plan? Did agency and night staff receive the change? If a clinical recommendation was made by telephone, who recorded it and who confirmed the detail? A care plan can become stale when important advice stays in an inbox or a nurse’s separate record.

Look at refused or interrupted care. A resident may decline repositioning because of pain, cold, sleep disruption or fear of falling. Record the choice and the explanation offered. Ask a clinician to help find an acceptable alternative. Repeatedly writing “refused” without understanding the reason does not make the risk disappear. A person’s capacity and consent may need careful consideration, but staff should not treat refusal as permission to stop all efforts to protect the skin.

Ask whether the plan was suitable even if delivered

Sometimes every listed action happened and the wound still worsened. That calls for a clinical and operational review. Was the planned frequency sufficient for this resident’s current risk? Was the support surface appropriate for their weight, movement and wound site? Did the plan account for the hours spent sitting rather than lying? Did the person’s nutrition, hydration or pain need a new assessment? Did one intervention create a problem elsewhere?

Avoid turning general guidance into a rigid universal schedule. NICE gives recommendations about repositioning and pressure-redistributing devices, but an individual plan must be based on assessment and clinical judgement. A generic “two-hourly turns” line is neither a substitute for a personalised assessment nor evidence that the chosen approach works. If the current frequency or method is failing, ask the responsible clinician to decide what changes are needed and to explain them to staff.

Consider competing risks. A resident may need pressure relief but also have falls risk, breathing difficulty, contractures or discomfort in a proposed position. A different chair cushion may affect transfer safety. The teams should work together so the revised plan can be delivered safely. Staff should not improvise a device arrangement that creates another hazard. Record the agreed balance and review it when the resident’s condition changes.

The home also needs to ask whether its staffing and environment can support the revised plan. If one worker is expected to provide help that requires two people, or the required equipment is unavailable at night, the plan is not operational. Escalate the gap to the manager and clinical team. Arrange safe interim support and follow up procurement or staffing decisions to completion. Do not present an infeasible instruction as an implemented control.

Build a decision trail that survives handovers

A useful record links observation, decision, action and result. The first entry describes the deterioration and resident’s condition. The next shows when the clinical team was contacted, what they advised and what was done immediately. Later entries show the equipment, care and review actually delivered. The resident’s views and relevant family communication should appear where appropriate. Each change to the plan should have an owner and effective date.

CQC Regulation 17 guidance requires accurate, complete and contemporaneous care records and systems for identifying, monitoring and mitigating risks. It also expects action when risk increases. Records should help the next shift care for the person, not merely demonstrate that a form was completed. A vague instruction such as “continue pressure care” is weak if staff need to know a specific site, equipment, position, review date and escalation threshold.

Protect the integrity of the record. Correct an error transparently using the home’s policy. Do not backdate missing checks or rewrite an earlier assessment so it appears that worsening was anticipated. If care was missed, that fact helps clinicians decide what to do and helps the provider fix a system failure. Electronic systems can timestamp actions and remind staff, but they cannot prove that a wound was assessed correctly or that a resident accepted the care.

Set a review trigger that works in practice. Name the professional who will reassess the wound and the manager who will verify that new instructions reached every shift. Define what staff should do if the resident develops more pain, a new area of damage, systemic symptoms or a problem with equipment. A plan without a route for early escalation leaves the next worker to guess whether deterioration can wait.

Investigate wider care and safeguarding concerns separately

A wound can worsen despite reasonable care. It can also reveal avoidable omissions, inadequate staffing, equipment failure or repeated failure to act on advice. The manager should investigate facts without assuming either explanation. Ask what the resident experienced, whether expected care was offered and delivered, when concerns were first known and whether the service responded. Seek clinical and safeguarding advice when the facts require it.

DHSC’s pressure-ulcer safeguarding protocol applies in England. It is designed to support quick clinical harm reduction and a case-specific decision about whether an adult safeguarding response is needed. It includes a decision guide, body map and concern proforma. Wound category alone should not be used as a universal safeguarding rule. A lower-category wound alongside repeated missed care may raise a concern, while a severe wound may have a different clinical history. Apply the protocol and local authority procedure to the actual circumstances.

NICE NG189 identifies lack of care to protect skin integrity and deterioration without an adequate staff response among possible indicators relevant to safeguarding in care homes. If the manager is unsure whether the evidence reaches the threshold for a concern, they should consult their safeguarding lead and local authority route. They should not wait for an internal root-cause report to be finished before protecting the resident or asking for advice.

Keep the clinical review and safeguarding decision connected but distinct. The clinician needs reliable information to treat the wound. The safeguarding lead needs to understand whether neglect or another form of abuse may be involved. One process cannot replace the other. Record the decision, reasoning, people consulted and next steps, including a decision not to refer. If additional facts emerge, reconsider it.

Check CQC and other notification routes on the facts

Do not assume that every worsening pressure ulcer is automatically a CQC serious-injury notification or that no notification is needed because a wound was already known. The provider should review the relevant CQC notification guidance against the injury, the link to the regulated activity and the information available. Seek specialist advice where the application is uncertain. A safeguarding referral, CQC notification, duty of candour assessment and clinical incident record are different processes with different triggers.

The same caution applies to duty of candour. Be open with the resident and appropriate representatives about what is known, what care is being provided and what will be investigated. The specific statutory duty of candour requirements depend on the defined notifiable safety incident test. Do not use a generic wound category as a substitute for that test. The provider’s reviewer should record the assessment and any action required under its policy.

If the resident is transferred to hospital or another service, send a clear account of the wound, current treatment, risk controls, equipment and the recent deterioration. Record what was handed over and to whom. On return, reconcile any new clinical instructions before relying on the old care plan. A transition can introduce a second failure if each service assumes the other holds the latest information.

Learn from the case without turning it into a form exercise

Once the resident has a safe current plan, investigate why the earlier one failed or ceased to fit. Separate clinical change, equipment, delivery, communication and management oversight. A single cause may not explain the whole sequence. For example, illness may have increased risk, staff may have missed the change, and the cushion may have arrived late. Each factor needs a different corrective action.

Look for patterns across residents. Are wound reviews repeatedly delayed after weekends? Are mattresses unavailable while procurement waits for approval? Are staff documenting position changes in a way that hides refusals or discomfort? Are care plans updated in one system but not visible to agency staff? A useful audit follows a few real cases from assessment to action and outcome. Counting completed forms alone may miss whether residents received the support.

Assign actions to named owners with dates. Clinical treatment, equipment, staff briefing, documentation change and safeguarding review may have separate leads. Verify the action on a later shift and ask whether it changed the resident’s condition or the process that failed. If a control cannot be sustained, escalate it rather than closing the action because a policy was rewritten.

Communicate learning with care. Staff need to know the revised practice without sharing unnecessary personal details. The resident and their family or representative should receive appropriate information and a chance to ask questions. Be honest about what is established and what is still being reviewed. A strong response combines prompt care for the individual with a truthful account of system performance.

Questions managers can use in the first review

• What exactly changed in the wound and when was the change first observed?
• Is the resident unwell, in more pain or showing another reason for urgent clinical help?
• Who is the responsible clinician, and when will they reassess the wound and whole-person risk?
• What pressure relief and wound-care instructions apply now, and which need revision?
• Did the equipment, position changes, skin checks and referrals happen as recorded?
• Can the resident tolerate the proposed plan, and what alternatives have been discussed?
• Has illness, mobility, nutrition, seating or transfer changed since the plan was written?
• Does the evidence suggest neglect, a wider service failure or a safeguarding concern?
• Which CQC, candour or other routes require a separate case-specific check?
• Who will verify the revised plan on the next shift and at the next clinical review?

These questions structure a conversation. They do not replace clinical judgement or local safeguarding procedures. The answer may change as the wound is assessed and records are reconciled. Record the reason for decisions and return to them when new evidence appears.

What Complys can support, subject to product review

A compliance workflow can help a provider assign the clinical referral follow-up, equipment action, staff briefing and management review to named people. It can make deadlines and outstanding evidence visible across shifts. It cannot diagnose a wound, set treatment, determine a safeguarding threshold or decide whether a CQC notification is legally required. Any public claim that Complys automates these decisions needs product and specialist confirmation before publication.

For a service comparing its existing process with Complys, use a realistic case. Can the manager trace the first deterioration note to clinical advice, revised plan, equipment delivery and the next review? Can they see an overdue action without exposing confidential clinical details to people who do not need them? Can they distinguish a task marked complete from evidence that the resident actually received care? Those questions are more useful than a broad promise that software makes pressure care compliant.

Suggested CTA: Ask Complys to show how its current evidence and action workflows could support a care-home pressure-damage review. Confirm the available features and clinical-system boundaries in a product demonstration.

Related tool opportunity: A pressure-damage response and handover checklist may help managers capture a timeline, clinical contact, equipment gap, safeguarding decision and next review owner. It needs clinical and safeguarding review before release and must not score or diagnose wounds.