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‘What’ and ‘How’ to investigate your pressure ulcers in Nursing and Residential Homes under lock down and long term

Wound and pressure ulcer prevention are key quality indicators of nursing care (Sprakes & Tyrer 2010)

This guide will be helping with the following 3 key themes:

  • Establishing your teams current knowledge. In-house skills gap analysis
  • What to report
  • How to investigate (RCA)

Skill gap analysis – what is your, and your teams, current understanding on processes?

Staff in residential & nursing homes need to know the principles of preventing, managing and reporting skin damage. Understanding these processes under the safeguarding and mental capacity act is becoming increasingly necessary as the levels of the ageing population in the UK continues to rise.

(Ousey et al 2016)

Without mandatory pressure ulcer prevention educational programme in many settings it is paramount we have quality and governance structures in place.  

It is important to have a designated lead nurse to support the governance compliance as well as key links or champions to create improvement network within the home and create an open culture of learning and sharing.

A key formula for success was specified by Hartman et al 2016, in that where Leadership’s visible prioritisation of, and support for, PU prevention and the initiation of PU prevention activities through formal structures, were the most striking sites of improving performance.

Starting the process with an in-house review of practice is a great start.

Example of in-house skills gap could be as aSSKINg checks – with intentional rounding or spot checks.

With the idea to identify gaps and set actions to mitigate risk. This could be as simple as making sure ALL staff know what a category 1 pressure ulcer looks like, ways of checking e.g. blanching technique, and know what to do in identifying early pressure damage.

This may sound simple but remembering that all pressure ulcers start as a category 4 pressure ulcer, picking them up at category 1 is paramount.

Making our actions SMART are likely to make them more achievable.

What to report

After involving a range of stakeholders, in 2018 NHS Improvement published new guidance on definition and measurement of pressure ulcers, to reduce disparities in reporting. The implementation process launch for these updates were April 2019 and NHS organisation Tissue Viability Teams have been busy updating there reporting structures and training on the updates.

One of the key targets for these revised guidelines is to create more uniformed reporting of pressure ulcers and skin damage.

There has been, and still is, a variance on what is reported, measured and investigated across NHS organisations and a lack of guidance for long-term care and hospices. In the long-term care settings data may be collected in-house and not shared to a data porcine spine system such as the national reporting learning system or NLRS. Monitoring incident data patterns may also vary in each organisation, with some settings starting to use electronic incident reporting systems such as data text while other small organisations are reporting using other means. The revised definition guidance can be found here.

Current nursing care home and hospice reporting as requested by CQC.

When it comes to investigating our in-house pressure ulcers, guidance for long-term care on when and how to do this is also lacking.

Below are my recommendations for long-term care on how to investigate, report and refer a pressure ulcer.

At present long-term care settings are asked by CQC to report all category 3 and 4 pressure ulcers, this may include a prompt to the local safeguarding team who may ask for an internal investigation to identify any gaps in care and/or learning needs. 

In the NHS services the EPUAP 2015 updated categories on pressure ulcers, including unsustainable and suspected deep tissue injury which in most cases will be reported as an incident such as a category 3 or 4 and investigated as such. It is important to remember that monitoring pressure ulcer data in clusters of incidences is not about associating blame on the clinical area organisation but about identifying potential gaps and areas of improvement. This, in my experience, becomes most effective as a learning tool when multidisciplinary teams are involved in full transparency of the process and shared with your commissioners or CTC inspectors. Preventing pressure ulcers is multifaceted and ensuring compliance of key prevention standards can seem complicated. For those that haven’t heard of the aSSKINg bundle I would highly recommend to see if you would like to implement within your environment, this can be a key compliance audit and/or implemented care plan to ensure the key standards of preventing a pressure ulcer are covered for your residents.

Although CQC is not, at present, asking organisations to report their unstageable or suspected deep tissue injuries, I would still ask the advice of your local inspector and monitor and investigate these in-house through root cause analysis.

‘Moisture associated skin damage’ or ‘incontinence associated dermatitis’ (moisture lesions) can be extremely painful and uncomfortable for the resident, sometimes described as a burn like pain. In most cases these are preventable with good risk assessment as part of your skin care plan, good personal care and barrier cream or spray. As a result, monitoring these instances is also highly recommended and where there are re-occurring cases may prompt a discussion with your local incontinence nurse specialist for a product review and/or monitor skin care plan.

Note: Residential sections of care homes will likely have their pressure ulcers reported by a district nurse or tissue viability nurse teams, therefore fall under the remit of local NHS reporting systems.

Care home leads should use their initiative in reporting anything outside this remit, they may need investigating if they’re not sure.

MCA and Safeguarding protocol

Under the mental capacity act and duty of candour you must involve the resident or, if reduced capacity, who ever has lasting power of attorney or next of kin.

In England the safeguarding pressure ulcer protocol can be completed in conjunction with your local authority as not all pressure ulcers need to be escalated to full investigation. You can access this protocol here.

NHS reporting

This can vary on organisations. NHS improvement recommends all grades of pressure ulcers to be reported including modulations and stage goals, suspected deep tissue injuries, medical device injuries, modulations.

Multiple category 2s , category 3s, category 4, unstagable, suspect deep tissue injury, medical device injury will in general prompt an internal root cause analysis to identify key themes and any potential gaps in care.

To find out more about how organisations are monitoring and reporting their pressure ulcers and share any quality improvement work you may be involved in, don’t forget the OSKA Quality improvement Champion Facebook group here.

How to complete a root cause analysis (rca) 

In all Long-term Health and Care settings in the UK, we are encouraged to report on our acquired harms and report on our findings to the CQC/Care inspectorate, safeguarding leads and governance leads. Rather than this being a process to cross the T’s and dot the I’s, it is here you can identify key emerging themes and ensure proposed actions and changes are meaningful and measured.

Having said that if you are new to quality improvement models following incidences it can be a very daunting affair. As clinicians of all levels we are asked to investigate and for you care providers out there you may find you do this naturally.

An emerging theme that has come from all the RCAs I have been involved in over the years is around culture and behaviours of an area of practice. This often feels like opening Pandora’s box, as to challenge in-house behaviours positively can be delicate work. From practice however, the greatest changes I have seen are in well led organisations where whole staff involvement are included.

If gaps are identified from your RCA, it can be hard initially to know where to start with your improvement plans. We also need to demonstrate that any changes are effective. Tracking your emerging themes, actions next to the number of incidences over time should show the impact of your changes along with staff and resident feedback. All of this may be collected and shown to your inspector on their visits and likely to tick a lot of the key lines of enquiry!

To start this process, you do not need to investigate deep tissue injury’s only, indeed if you have a high number of reported moisture lesions or Category 2 Pressure ulcers, why not start here to deep dive in to your trends and emerging themes.

To identify which actions, you would like to take, it is recommended you have an initial staff feedback panel to discuss findings from the RCA from lead investigator. These actions set should be discussed and agreed by the whole panel. 

Use a RCA template that is clear with a chronological time line. 

There are some templates available online to undertake a RCA such as the fishbone diagram you can look up. I have an adapted a tool for long term care, if you would like the template either come on the Facebook support page or contact me and I will be happy to share with you.

Following your findings agree on 1 or 2 SMART actions.

While actions set may be practical such as education, audits, documentation, it is the sustainability plan that is increasingly being looked at by inspectors. From the paper ‘review of care services report’ published by the CQC in 2017 discusses ‘sustainability scrutiny’. Click here to view.

This doesn’t just mean a review audit of actions set following an incident and panel, but how you are involving staff, residents and the public in your journey.

For further information or support in any of the above contact OSKA.


Hartmann,C. Solomon, J. Palmer,J, VanDeusen, C(2016) Contextual Facilitators of and Barriers to Nursing Home Pressure Ulcer Prevention. Journal of Advanced Skin Wound Care. May; 29(5) pp.226-238. available online. accessed at:

Ousey,K. Kaye, V, McCormick, K. Stephenson, J (2016) Investigating staff knowledge of safeguarding and pressure ulcers in care homes. Journal of Wound care. 2016 Jan;25(1):5-6, 8-11 avaialble only accessed 4th May at

Sprakes,K. Tyrer,J. (2020) Improving wound and pressure area care in a nursing home. Nursing Standard. Nov 10-16;25(10):43-9. available online accessed 5th May 2020 at: