First reported 20 Aug 2013•Latest report 12 Mar 2026
Definition
What this concern includes
Includes failures of controls specifically dedicated to pressure-ulcer prevention and management, including risk assessment, prevention measures, clinical assessment, treatment, monitoring, specialist referral, equipment, repositioning and escalation across community and inpatient care.
Not included
Excludes generic wound-care deficiencies where pressure ulcers are not materially identified.
Excludes generic staffing, training, documentation or communication failures unless they directly impair pressure-ulcer prevention or management.
Excludes management of wounds caused by other mechanisms, including impact injuries, unless the report explicitly connects them to pressure-ulcer care.
Excludes unrelated delays, discharge or treatment failures where pressure-ulcer management is not the shared unsafe condition.
Reports
51
Distinct published reports
Individual concerns
106
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
135
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Care Quality Commission7
Department of Health and Social Care4
NHS Greater Manchester Integrated Care Board3
East Sussex Healthcare NHS Trust2
University Hospitals Birmingham NHS Foundation Trust2
Aneurin Bevan University LHB1
Angel Solutions (UK) Ltd1
Barchester Healthcare Limited1
Bargoed Care Home1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Beech Dene Residential Care Home1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Brunswick Ward at Lindridge1
Bryntirion Surgery1
Care First Homes1
NHS trust27
Health and social care service regulator7
Healthcare site7
Residential care home6
Integrated care board5
Private limited company5
Domiciliary care provider4
Ministerial department4
Type not available4
Care-home operator2
Company limited by guarantee2
English county council2
English unitary authority2
Executive non-departmental public body2
Local health board2
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
North London
Concerns raised2
Lack of appropriate training for doctors working in care homes when dealing with pressure sores
Lack of guidance supporting an interventionalist supervisory role when dealing with pressure sores
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NHS England is responsible for addressing concerns about pressure sore guidance and training for doctors working in care homes.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Routine pressure-ulcer assessment, treatment and dressing care ordinarily fall to appropriately trained nursing staff and other relevant clinicians, not GPs.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing NICE guidance applies to doctors in care homes and provides the primary national framework for pressure-ulcer prevention and management.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Sussex
Concerns raised1
Failure to provide adequate pressure sore care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Use the electronic pressure-ulcer audit tool for monthly ward audits and monitor compliance against prevention and management criteria.
Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Deliver mandatory and essential wound-care training, including pressure-ulcer prevention, human factors, and simulated patient-safety scenarios for relevant clinical staff.
Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2026.
Action
Continue targeted face-to-face pressure-ulcer training, circulate wound-care learning newsletters and webinars, and provide recurring ward study sessions.
Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Action
Undertake a formal evaluation of the Trust mandatory training framework during 2026–27 and seek approval for resulting training changes.
Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2026.
Action
Continue Trust-wide pressure-ulcer prevention work through category monitoring, monthly audits, CQUIN compliance oversight, and Pressure Ulcer Steering Group governance.
Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026.
Surrey
Concerns raised6
Failure to complete and audit improvements to pressure sore prevention and management
Failure to complete early and appropriate pressure sore risk assessment
Failure to provide appropriate pressure sore treatment
Failure to use pressure sore preventative measures
Failure to monitor residents' skin condition for pressure sores
Failure to record pressure sore risk, skin monitoring and treatment information
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.21
Action
Appoint a Regional Manager to provide increased management oversight.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Operate daily, monthly and bi-monthly audits of care documentation, skin integrity, risk assessments, equipment, interventions and follow-up actions.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Continue monitoring the safety and quality of care at Windmill Manor.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
Action
Consider whether criminal enforcement is appropriate in this case.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
Action
Carry out daily care-record sampling and monthly documentation audits, with management follow-up of identified actions.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Carry out monthly skin-integrity audits and additional Regional Manager reviews of high-risk residents’ interventions, equipment, care plans and Waterlow scores.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Hold bi-weekly clinical governance meetings to review high-risk residents, tissue-viability issues, referrals and clinical deterioration.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Introduce and embed the Enable electronic records and case-management system for care documentation and oversight.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Deliver reflective sessions and disseminate inquest learning to Home staff on pressure-injury risk, prevention, treatment and documentation.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Deliver staff training, supervision, knowledge checks and refresher sessions on pressure-area care, tissue-viability policy, risk assessment, prevention, skin monitoring, wound treatment and record keeping.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Provide weekly Clinical Development Nurse reviews of skin-integrity risks, care plans, wound assessments, categorisation, referrals and clinical concerns.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Provide dedicated management and clinical support, daily meetings and escalation of changes in residents’ clinical status through electronic notifications.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Deliver pressure-area, wound-management, tissue-viability, risk-assessment, prevention, skin-monitoring and record-keeping training with supervision and knowledge checks for staff.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Provide ongoing weekly Clinical Development Nurse reviews of skin-integrity risks, wound assessments, categorisation and care plans.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025.
Action
Review and update residents’ assessments, risk assessments and care plans monthly through the Resident of the Day process.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Maintain electronic notifications and management oversight of clinical-status changes, wound categorisation, care planning and treatment regimes.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Conduct operational observations, monitoring visits and staff supervisions addressing equipment, moving and handling, and regular repositioning.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Train staff on dynamic-air-mattress settings, regular equipment checks and obtaining replacement mattresses outside hours.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Conduct observations, staff supervisions and equipment-use support covering repositioning, moving and handling, mattresses and pressure-relieving equipment.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Train staff and maintenance personnel to set, check and replace dynamic air mattresses appropriately, including accessing out-of-hours replacements.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Action
Implement and embed the Enable electronic records and case-management system.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The registered provider is legally responsible for ensuring service users receive safe care and treatment, including pressure wound care.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised2
Lack of carer understanding of the need for repositioning to mitigate pressure sores
Lack of carer training on pressure sores, skin assessment or repositioning
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide further training in wound prevention.
Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.
Action
Conduct competency spot checks of staff after the training period.
Stated by Inspire You Care LtdStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Staff state that they understood the importance of repositioning bed-bound service users and had appropriate skills or training to support Celia.
Stated by Inspire You Care LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Gateshead and South Tyneside
Concerns raised1
Failure of positional-change documentation to record positional tilt relevant to pressure-damage prevention
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Add a 30-degree hip-tilt option to Nourish positional-change records.
Stated by Malhotra Care Homes LtdStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
South Wales Central
Concerns raised2
Failure to follow Tissue Viability Nurse dressing recommendations
Lack of nursing staff knowledge about podiatry referral rationale and possible interventions
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide additional Tissue Viability Nurse training on assessment, escalation, dressing management, and access to appropriate dressings, with attendance monitored through quality meetings.
Stated by Powys Teaching Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 8 September 2025.
Action
Provide ward-based and ward-leader education on the podiatrist’s role, scope, and service provision.
Stated by Powys Teaching Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 8 September 2025.
Nottinghamshire
Concerns raised2
Incorrect adjustment of airflow mattresses
Lack of clear guidance to staff when pressure damage is identified
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Check airflow mattresses daily for correct type, function and resident-weight setting, recording checks electronically.
Stated by Red Oaks Care HomeStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
Action
Use a documented Skin Integrity Protocol covering pressure escalation, family updates and duty-of-candour requirements.
Stated by Red Oaks Care HomeStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The strengthened systems and procedures for monitoring residents’ care arrangements are considered appropriate in all the circumstances.
Stated by Red Oaks Care HomeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Failure to properly inspect the skin of patients’ heels for pressure sores
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Reviews found no pressure damage before 15 October, when a blister was identified, documented, escalated and assessed.
Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Worcestershire
Concerns raised1
Failure to provide the Neighbourhood Team with direct access to hospital records for patients with pressure sores
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Obtain electronic patient-record access for two staff members per Neighbourhood Team, including evening and night community nursing teams.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2025.
Action
Review access uptake after all identified staff receive access and determine whether additional electronic patient-record licences are required.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 February 2025.
Somerset
Concerns raised1
Failure to adhere to repositioning care plans for patients at very high risk of pressure ulcer development
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Complete the Intentional Rounding quality-improvement project and roll out the new tool and training package organisation-wide by June 2025.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2025.
Action
Maintain mandatory pressure-ulcer-prevention eLearning and associated aSSKINg-based education, including Waterlow assessment resources and eAssessment tools.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 February 2025.
Action
Use education, audits and further ward-based quality-improvement projects to improve pressure-ulcer prevention and management.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2025.
Action
Review and align inpatient care-plan templates and documents using the aSSKINg framework.
Stated by Somerset NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2025.
Action
Review lateral-turning devices, assess available options and risks, and develop a standard operating procedure to support equitable access and safe repositioning.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2025.
Action
Have matrons work clinically on wards weekly to support training, identify high-risk patients, and lead ward rounds and safety huddles.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 February 2025.
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Includes failures of controls specifically dedicated to pressure-ulcer prevention and management, including risk assessment, prevention measures, clinical assessment, treatment, monitoring, specialist referral, equipment, repositioning and escalation across community and inpatient care.
