A pressure ulcer — also called a pressure sore or bedsore — is localised damage to the skin and the tissue underneath, caused by prolonged pressure, or pressure combined with shear, usually over a bony area such as the heels, hips or base of the spine. Most are preventable with regular repositioning, skin checks, the right equipment and good nutrition. Here is the point many care teams get wrong: a pressure ulcer is not automatically a safeguarding matter. The Department of Health and Social Care’s national protocol treats pressure ulcers as “primarily an issue for clinical investigation rather than a safeguarding enquiry” — although some genuinely do signal neglect and must be raised.
At a glance: Nexis CPD’s £9 Pressure Ulcers course gives care staff a practical grounding in how pressure ulcers develop, who is at risk, how to prevent them and what to report. It is CPD accredited and 100% online with a verifiable e-certificate, and any three courses cost £18. It is awareness training — it does not make anyone competent to assess, categorise or treat wounds, which is the job of registered nurses and tissue viability specialists.
What is a pressure ulcer?
A pressure ulcer forms when skin and the tissue beneath it are squeezed between a bone and an external surface — a mattress, a chair, a wheelchair cushion or even a medical device — for long enough that blood flow is cut off and the tissue is starved of oxygen. Shear (skin being dragged in one direction while the underlying tissue moves in another, for example when someone slides down a bed) and friction make the damage worse.
They most often appear over bony prominences: the sacrum and buttocks, heels, hips, elbows, shoulder blades and the back of the head. They can also develop under medical devices such as oxygen tubing, catheters or tight splints — so-called device-related pressure ulcers. The National Institute for Health and Care Excellence (NICE) guideline CG179, Pressure ulcers: prevention and management, is the core UK clinical reference, covering risk assessment, prevention and treatment across children, young people and adults.
Pressure ulcers matter because they cause real pain, infection risk, longer hospital stays and loss of independence — and because damage that starts as an area of red skin can become a deep wound surprisingly quickly in a frail person.
Who is at risk of pressure ulcers?
Anyone who cannot move freely is at risk, but some people are at much higher risk. NICE advises carrying out and documenting a pressure ulcer risk assessment for adults being admitted to hospital or a care home, or receiving NHS care elsewhere, if they have risk factors such as:
- significantly limited mobility — for example people with a spinal cord injury, or who are confined to bed or a chair;
- significant loss of sensation;
- a previous or current pressure ulcer;
- nutritional deficiency;
- the inability to reposition themselves; and
- significant cognitive impairment.
Other factors add to the risk, including incontinence (moisture weakens the skin), poor circulation, diabetes, being very underweight, dehydration and serious acute illness. Risk is not fixed: it can change quickly after a fall, an infection or a hospital stay, which is why risk should be reassessed whenever a person’s condition changes, not just recorded once on admission.
What are the categories of pressure ulcer?
Pressure ulcers are described by category according to how deep the damage goes. The NHS uses the following descriptions:
- Category 1 — intact skin with a localised area of redness (or discolouration in darker skin) that does not blanch when pressed. The area may feel warmer, cooler, firmer or softer than the surrounding skin, and may be painful.
- Category 2 — partial loss of skin, appearing as a shallow open wound or a blister.
- Category 3 — full-thickness skin loss; fat may be visible but not bone, tendon or muscle.
- Category 4 — full-thickness loss with exposed bone, tendon or muscle.
- Unstageable — the depth cannot be seen because the base of the wound is covered by dead tissue.
- Deep tissue injury — purple or maroon discoloured intact skin, or a blood-filled blister, caused by damage to underlying soft tissue. It can look like a bruise, but there has been no knock.
A practical warning for care staff: category 1 damage can be harder to spot on darker skin tones, where redness may not show. Look for changes in colour compared with the surrounding skin, and feel for differences in temperature or firmness. The earlier damage is noticed, the more likely it is to be reversed.
How are pressure ulcers prevented?
Prevention rests on a handful of simple, consistent actions, often remembered with the NHS SSKIN framework:
- Surface — make sure the person is on a suitable pressure-redistributing mattress or cushion for their level of risk.
- Skin inspection — check the skin regularly, especially over bony areas, and report changes promptly.
- Keep moving — encourage and help the person to change position.
- Incontinence and moisture — keep skin clean and dry, and manage incontinence promptly.
- Nutrition and hydration — support a good diet and fluids, which skin needs to stay healthy and to heal.
Many services now use an extended version, aSSKINg, which adds assessment of risk at the start and giving information to the person and their family.
How often should someone be repositioned?
NICE is specific here. It recommends encouraging adults who have been assessed as at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours, and adults assessed as at high risk to change position frequently and at least every 4 hours. If a person cannot reposition themselves, they should be helped, using appropriate equipment where needed. These are minimums — many people need turning more often, and the plan should reflect the individual.
What should you avoid?
NICE is clear that you should not offer skin massage or rubbing to adults to prevent a pressure ulcer. Rubbing reddened, fragile skin can cause further damage through shear, and any benefit seen from massage is likely to come from the pressure relief rather than the rubbing itself. Dragging someone up a bed instead of using a slide sheet causes shear damage too — our guide to moving and handling people explains safe technique.
Is a pressure ulcer a sign of neglect?
Sometimes — but far less often than is commonly assumed, and treating every pressure ulcer as abuse does harm. The Department of Health and Social Care’s Safeguarding adults protocol: pressure ulcers and raising a safeguarding concern (most recently updated in June 2025) sets a national framework “identifying pressure ulcers as primarily an issue for clinical investigation rather than a safeguarding enquiry led by the local authority”. It replaced an earlier 2018 protocol that was withdrawn in 2023.
The reasoning is sensible. Some pressure ulcers develop despite excellent care, particularly in people who are very ill or at the end of life. Launching a safeguarding enquiry into a family or a care team every time can be distressing and does not solve what is usually a clinical problem needing a clinical response. But the protocol is equally clear that some pressure ulcers do arise from poor practice, neglect or an act of omission, and those must be raised.
To help staff decide, the protocol provides a decision guide built around questions such as whether skin has deteriorated to category 3 or 4 (or multiple category 2 ulcers) from previously healthy skin; whether there has been a recent change in the person’s clinical condition; whether a risk assessment and care plan were in place and followed; whether there is concern that a carer has wilfully ignored or prevented access to care; whether the damage is inconsistent with the person’s assessed risk; and whether risks were explained to a person with capacity, or best interests considered for a person who lacks it. Each answer is scored, and the protocol states that “the threshold for raising a concern is 15 or above in most instances. However, this should not replace professional judgement.”
If you ever suspect deliberate neglect or abuse, you do not need to wait for a score — raise it through your organisation’s safeguarding procedure straight away. Our guide to safeguarding adults explains how concerns are raised.
What does the law expect of care providers?
There is no single “pressure ulcer law”. The duty comes through the general requirement to provide safe, good-quality care. In England, providers registered with the Care Quality Commission (CQC) must meet the fundamental standards in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 — including regulation 12, safe care and treatment, which covers assessing and managing risks to people’s health, and regulation 13, which protects people from abuse and improper treatment, including neglect. Pressure ulcer prevention sits squarely within these standards, and inspectors look at risk assessments, care plans, repositioning records and equipment.
Records matter. If a repositioning or skin check is not written down, it is very hard to show it happened. Clear, contemporaneous records protect the person, support clinical decisions and protect staff who are doing the right thing.
What if a person refuses to be repositioned?
Adults with capacity have the right to make their own decisions, including decisions others think are unwise. Under the Mental Capacity Act 2005, capacity must be presumed unless an assessment shows otherwise. If someone with capacity declines repositioning or equipment, explain the risks clearly, explore why (pain, discomfort, fear, wanting to sleep), offer alternatives, and record the conversation and their decision. If a person may lack capacity for that decision, a capacity assessment and a best-interests decision are needed. Our guide to the Mental Capacity Act explains the principles, and person-centred planning — see what person-centred care means — often finds a routine the person is happy with.
What should care workers do if they spot skin damage?
Act promptly and do not keep it to yourself:
- Relieve the pressure — reposition the person off the affected area, using equipment and safe handling technique.
- Report it — tell the nurse, senior carer or manager on shift straight away, following your local procedure. Many services have a “react to red” approach for exactly this.
- Record it — note where the damage is, what it looks like, when you noticed it and who you told.
- Do not rub or massage it, and do not apply creams or dressings you have not been trained or instructed to use.
- Check the basics — mattress and cushion settings, continence care, fluids and diet — because the cause is often one of these.
Assessing and categorising the wound, and deciding on dressings and treatment, is a clinical task for a registered nurse or tissue viability specialist. Your job is to prevent, notice and escalate — and that is where most pressure ulcers are won or lost.
Which courses support pressure ulcer prevention?
Three £9 courses fit together naturally for care teams, each with a verifiable certificate for training records:
- Pressure Ulcers — causes, risk factors, categories, SSKIN and reporting.
- Moving and Handling People Awareness — repositioning without causing shear or injury to the person or yourself.
- Nutrition in Care — because diet and hydration are the “N” in SSKIN, and wounds cannot heal without them.
Those three together cost £18 rather than £27, because any three courses trigger the pay-for-2-get-3 offer. Add them to the cart and the discount applies automatically.
Frequently asked questions
What is a pressure ulcer?
A pressure ulcer, also called a pressure sore or bedsore, is localised damage to the skin and underlying tissue caused by prolonged pressure, or pressure combined with shear, usually over a bony area such as the heels, hips or base of the spine. They can also form under medical devices. Most are preventable with regular repositioning, skin checks, suitable equipment and good nutrition.
How often should someone at risk of pressure ulcers be repositioned?
NICE guideline CG179 recommends encouraging adults assessed as at risk to change position frequently and at least every 6 hours, and adults at high risk to change position frequently and at least every 4 hours, with help and equipment if they cannot move themselves. These are minimums; many people need repositioning more often, and the plan should be based on the individual’s assessment.
Is a pressure ulcer always a safeguarding concern?
No. The Department of Health and Social Care’s safeguarding protocol treats pressure ulcers as primarily an issue for clinical investigation rather than a safeguarding enquiry. It provides a decision guide with a scoring threshold of 15 or above in most instances, while stating that this should not replace professional judgement. Pressure ulcers that result from neglect, poor practice or omission should be raised, and suspected deliberate abuse should be raised immediately.
What are the categories of pressure ulcer?
Category 1 is intact skin with non-blanching redness or discolouration; category 2 is partial skin loss such as a blister or shallow wound; category 3 is full-thickness skin loss; and category 4 exposes bone, tendon or muscle. Unstageable ulcers are covered by dead tissue so the depth cannot be seen, and deep tissue injury appears as purple or maroon intact skin or a blood-filled blister.
Should you massage red skin to prevent a pressure ulcer?
No. NICE advises that skin massage or rubbing should not be offered to adults to prevent a pressure ulcer, because rubbing fragile skin can cause further damage through shear. Relieve the pressure instead by repositioning, report the redness, and keep the skin clean and dry.
What is the SSKIN framework?
SSKIN is a five-step prompt used across the NHS and care sector: Surface (the right mattress or cushion), Skin inspection, Keep moving, Incontinence and moisture management, and Nutrition and hydration. An extended version, aSSKINg, adds assessment of risk and giving information to the person and their family.
Can an online course make me competent to treat pressure ulcers?
No. An online awareness course helps care staff understand risk, prevention and reporting, and provides a certificate for training records, but it is not a clinical qualification. Assessing, categorising and treating pressure ulcers is a clinical task for registered nurses and tissue viability specialists.
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This article is general information, not legal or clinical advice, and is not a substitute for clinical assessment. Assessment, categorisation and treatment of pressure ulcers should be carried out by a registered nurse or tissue viability specialist. A Nexis CPD awareness course is CPD accredited but is not a regulated or clinical qualification and does not make anyone competent to treat wounds. The Department of Health and Social Care safeguarding protocol and the CQC regulations cited apply in England; Scotland, Wales and Northern Ireland have their own arrangements. Guidance cited is drawn from NICE, the NHS and gov.uk at the time of writing.