Pressure Ulcer Prevention Training for Care Staff in England

Pressure ulcer prevention training for care staff should teach people who is at risk, how to spot early skin damage, how to reposition safely, how to use pressure-relieving equipment, and who to tell. In England no law names a specific pressure ulcer course or sets a refresher interval. The duty comes from the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and the content comes from NICE and NHS England guidance. This post covers England; check your own nation's rules if you work in Scotland, Wales or Northern Ireland.

What the law requires

Two regulations sit behind this training. Regulation 18 says people employed to provide a regulated activity must "receive such appropriate support, training, professional development, supervision and appraisal" as is necessary for their duties. Regulation 12 says care and treatment must be provided in a safe way, which includes assessing risks to people's health and safety, doing all that is reasonably practicable to mitigate them, and ensuring that the people providing care have the qualifications, competence, skills and experience to do so safely.

Neither regulation mentions pressure ulcers by name. In practice, if you provide personal or nursing care to people who are immobile, frail or recovering from illness, pressure damage is an obvious risk to assess and to train for. For a wider view of how inspectors look at staff training, see our guide to what training CQC expects healthcare staff to have.

What NICE says about training

NICE guideline CG179, Pressure ulcers: prevention and management, makes two training recommendations:

• Recommendation 1.3.4: train healthcare professionals on who is most at risk, how to identify pressure damage, what steps to take, and who to contact for further information and action.
• Recommendation 1.3.5: for staff who are in contact with people at high risk, provide further training on risk and skin assessment, repositioning, pressure redistributing devices, discussing prevention with patients and carers, and sources of advice and support.

NICE's page for CG179 shows a last review on 30 November 2018, which found no new evidence affecting the recommendations. The guideline is written mainly with NHS-funded care in mind. NICE's quality standard on pressure ulcers (QS89) is more specific about settings: its first statement, a risk assessment within 6 hours of admission, covers hospitals and care homes with nursing, and does not cover residential homes that provide no nursing care. That does not remove the Regulation 12 duty from other providers, but it is worth knowing which document applies to your service. Neither training recommendation sets a course length, number of hours or refresher interval.

What care staff should be able to do

The NHS describes pressure ulcers as areas of damage to the skin and the tissue underneath. They usually form on bony parts of the body, such as the heels, elbows, hips and tailbone, and can develop gradually or, sometimes, within a few hours. A good course turns the guidance into practical skills.

Recognise who is at risk

According to the NHS, risk is higher for people who have difficulty moving, have had a pressure ulcer before, have had a recent serious illness or surgery, have low body weight, have swollen, sweaty or broken skin, have poor circulation or fragile skin, or have reduced ability to feel sensation or pain. NICE says to reassess risk if there is a change in clinical status, for example after surgery, a worsening condition or a change in mobility. Where a risk scale is used, NICE names the Braden, Waterlow and Norton scales for adults, but as a support to clinical judgement rather than a replacement for it.

Spot early skin damage

The NHS lists early signs as discoloured patches of skin that do not change colour when pressed, a patch of skin that feels warm, spongy or hard, and pain or itchiness in the affected area. NICE adds that non-blanching redness may be harder to recognise in darker skin tones, and recommends finger palpation or diascopy to check whether redness blanches. If skin does not blanch, NICE says to start preventative action and to consider repeating the skin assessment at least every 2 hours until it resolves. Staff should be trained to report these signs promptly rather than wait for a scheduled review.

Reposition and use equipment

NICE recommends repositioning adults at risk at least every 6 hours, and adults at high risk at least every 4 hours, with the required frequency documented and help (including equipment) offered to anyone who cannot move themselves. Training should cover safe technique for the equipment your service uses. It should also cover pressure-redistributing surfaces. NICE recommends a high-specification foam mattress for adults assessed as high risk in primary and community care, and says to consider a suitable cushion for people who use a wheelchair or sit for long periods. Heel offloading should be discussed with high-risk people and, where appropriate, their family or carers.

Involve the person and escalate

NICE recommends timely, tailored information for high-risk people and their families or carers, and an individualised care plan. The NHS advises seeing a GP if you think someone has a pressure ulcer, and getting urgent help (an urgent GP appointment or NHS 111) if there is hot, swollen or red skin, pus, a high temperature, or severe or worsening pain. Staff need to know your escalation route, and how to recognise when an infection could be becoming serious; our post on sepsis recognition training for care staff covers that side.

A ready-made framework: the NHS core curriculum

NHS Improvement published a pressure ulcer core curriculum in June 2018, developed under the national Stop the Pressure programme. It is guidance for educators rather than a mandatory standard. Its main modules follow the "ASSKING" framework: Assess risk; Skin assessment and skin care; Surface; Keep moving; Incontinence; Nutrition; and Giving information. It also has core modules on anatomy and physiology, core concepts, and medical device-related pressure ulcers.

The curriculum describes three levels of content (fundamental, intermediate and advanced) and says these are not attached to any staff band, because staff arrive with different experience. That is useful when you are planning a mixed team: a new support worker might start at the fundamental level while a senior carer works through the intermediate material.

Quick reference

Frequently asked questions

Is pressure ulcer training mandatory for care staff?

No law names it as a mandatory course. Regulation 18 requires appropriate training for the duties staff perform, and NICE recommends training for staff who care for people at risk, so providers need to be able to show how they have covered it.

How often should it be refreshed?

The regulations and NICE do not set a refresher interval. Providers set their own, usually informed by a training needs analysis, and a training matrix helps you see when each person is due; our training matrix template is one way to do it.

Does it apply to care homes without nursing?

NICE's 6-hour risk assessment statement is written for hospitals and care homes with nursing. Regulations 12 and 18 apply to providers of regulated activities more widely, and the NHS risk factors apply to anyone.

Do care assistants need to use a risk scale?

NICE says a validated scale can support clinical judgement. Who completes it should follow your service's competence framework and care plans.

Putting it into practice

Start with the risk you actually have. List who is at risk in your service, check that staff can describe the early signs and your escalation route, and record who has been trained and when. If you are building a wider programme, the Learnsignal CPD hub is a place to start looking.

This article is general information, not regulatory, legal or clinical advice. Check the current NICE, NHS England and CQC guidance and follow your service's own policies and clinical advice.