Quality standard


This quality standard covers the prevention, assessment and management of pressure ulcers in all settings, including hospitals, care homes with and without nursing and people's own homes. It covers people of all ages: neonates, infants, children, young people and adults (including older people). For more information see the topic overview.

Why this quality standard is needed

Pressure ulcers are caused when an area of skin and/or the tissues below are damaged as a result of being placed under sufficient pressure or distortion to impair its blood supply. Typically they occur in a person confined to a bed or a chair most of the time by an illness; as a result they are sometimes referred to as 'bedsores', or 'pressure sores'.

All people are potentially at risk of developing a pressure ulcer. However, they are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility, poor posture or a deformity, compromised skin or who are malnourished. For adults with malnutrition, guidance on nutritional support can be found in the NICE guideline on nutrition support in adults. The use of equipment such as seating or beds that are not specifically designed to provide pressure relief can also contribute to the development of pressure ulcers. As pressure ulcers can arise in a number of ways, interventions for prevention and treatment need to be applied across a wide range of settings, including the community, care homes and hospitals. These interventions may require organisational and individual change and a commitment to ensure effective delivery. Staffing levels can also have an impact on the number of pressure ulcers. Guidance on safe staffing levels and the use of pressure ulcers as nursing red flags can be found in the NICE guideline on safe staffing for nursing in adult inpatient wards in acute hospitals.

Pressure ulcers represent a major burden of sickness and reduced quality of life for people and their carers. They can be debilitating for the patient, with the most vulnerable people being those aged over 75. Pressure ulcers can be serious and lead to life‑threatening complications such as blood poisoning or gangrene. Pressure ulcers are graded with increasing severity from category 1–4, according to the European Pressure Ulcer Advisory Panel classification system (EPUAP, 2009).

A review of death and severe harm incidents reported to the National Reporting and Learning System found that pressure ulcers were the largest proportion of patient safety incidents in 2011/2012, accounting for 19% of all reports. It has been acknowledged that a significant proportion of pressure ulcers are avoidable (NHS Stop The Pressure). The prevalence of pressure ulcers is 1 of the 4 common harms recorded in the NHS Safety Thermometer, a local improvement tool for measuring, monitoring and analysing patient harms across a range of settings, including care homes, community nursing and hospitals on a monthly basis.

The quality standard is expected to contribute to improvements in the following outcomes:

  • incidence of category 2 pressure ulcers

  • incidence of category 3 pressure ulcers

  • incidence of category 4 pressure ulcers

  • health‑related quality of life

  • length of hospital stay

  • discharge destination (such as a patient's home or care home).

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable quality improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1–2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16


Overarching indicators and improvement areas

3 Helping people to recover from episodes of ill health or following injury

Improvement areas

Helping older people to recover their independence after illness or injury

3.6i Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services*

4 Ensuring that people have a positive experience of care

Overarching indicator

4a Patient experience of primary care
i GP services

4b Patient experience of hospital care

4d Patient experience characterised as poor or worse
i primary care ii hospital care

Improvement areas

Improving children and young people's experience of healthcare

4.8 Children and young people's experience of inpatient services

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicator

5b Severe harm attributable to problems in healthcare

Improvement areas

Reducing the incidence of avoidable harm

5.3 Proportion of patients with category 2, 3 and 4 pressure ulcers

Alignment with Adult Social Care Outcomes Framework

* Indicator shared

Table 2 The Adult Social Care Outcomes Framework 2015–16


Overarching and outcome measures

2 Delaying and reducing the need for care and support

Outcome measures

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

2B Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services*

4 Safeguarding adults whose circumstances make them vulnerable and protecting them from avoidable harm

Overarching measure

4A The proportion of people who use services who feel safe

Outcome measures

People are free from physical and emotional abuse, harassment, neglect and self‑harm

People are protected as far as possible from avoidable harm, disease and injuries

4B The proportion of people who use services who say that those services have made them feel safe and secure

Aligning across the health and care system

* Indicator shared

Patient and service user experience and safety issues

Ensuring that care is safe and that people of all ages have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to pressure ulcers.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services, which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and are supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development source(s) for quality standards that impact on patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for pressure ulcers specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole pressure ulcer care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to people with pressure ulcers and to prevent the development of pressure ulcers in people at risk.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality pressure ulcer service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals and social care practitioners involved in preventing, assessing, caring for and treating people with pressure ulcers should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source(s) on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people with pressure ulcers. If appropriate, healthcare professionals and social care practitioners should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.