Waterlow score to repositioning chart: pressure ulcer prevention in care homes

Pressure ulcer prevention in a care home rests on three things: a Waterlow score that is completed on admission and repeated at the right intervals, a prevention plan built around the SSKIN bundle for anyone at risk, and a repositioning chart that shows the plan was actually carried out. When damage is found, it is graded, photographed where consent allows, referred to the district nurse or GP, and reviewed for cause. Category 3 and above acquired in your care is normally notified to CQC as serious injury.

The short answer

The Waterlow score puts every resident into one of three bands: 10 or more is at risk, 15 or more is high risk, and 20 or more is very high risk. Score everyone on admission, repeat weekly for anyone at risk and monthly for everyone else, and repeat straight away after any illness, hospital stay, fall or change in mobility or continence. For anyone at risk, write a plan under the five SSKIN headings, choose the right surface, set an individual repositioning interval, check the skin at every reposition and record what you saw. Treat any non-blanching redness as a category 1 ulcer and act the same day. Grade every ulcer, refer it, review it for cause and report it where the regulations require. Pressure ulcers are treated by inspectors and safeguarding teams as a marker of care quality, so the record has to be complete.

Why pressure ulcers are treated as a marker of care quality

Most pressure ulcers are preventable. That is the starting position of NICE guidance, of local safeguarding boards and of CQC inspectors, and it is why a single category 3 ulcer acquired in a home draws more scrutiny than a dozen falls. The assumption is that the ulcer happened because someone was not turned, not checked, not fed or not put on the right mattress, and the home has to show otherwise.

The evidence that rebuts that assumption is a complete record: the Waterlow assessment, the plan, the repositioning chart, the skin checks, the nutrition record and the referrals. Where that trail exists, an ulcer in a person at the end of life with multiple conditions is understood as unavoidable. Where it does not, the same ulcer is a Regulation 12 breach and often a safeguarding enquiry.

In learning disability and mental health services the risk is lower on average but not absent. A person who spends all day in the same armchair, a resident with a spinal injury, someone who is losing weight during a period of poor mental health, or a person who will not let staff look at their skin all need the same assessment and the same plan.

At a glance: pressure ulcer prevention

These are floors, not ceilings. The plan for each person is set by their skin, not by their band.

What is a Waterlow assessment

The Waterlow assessment is the pressure ulcer risk tool most widely used in English care homes. It was designed by Judy Waterlow, a nurse, in the 1980s and has been revised since. It adds points across a set of categories and produces a total that places the person in a risk band. It is a screening tool, not a diagnosis, and it is one input to clinical judgement rather than a replacement for it.

Its strength is that it is quick, consistent and understood by district nurses, hospitals and inspectors, so a score of 18 means the same thing to everyone reading the record. Its weakness is that it can be completed without looking at the person. A Waterlow score copied from last month with the same numbers in every box is a common finding and it tells an inspector that nobody looked.

Whoever completes it should have seen the resident's skin, know their weight and appetite, and know what medication they take. In nursing homes that is normally a nurse. In residential and learning disability services it is usually a senior carer trained in the tool, with the district nurse available for anything that is unclear.

Waterlow scoring: the categories

The Waterlow scale scores across the following areas. The exact points vary slightly between printed versions, so use the version your local district nursing team uses and keep a copy of the scoring key with your records.

Core categories

• Build and weight for height: average, above average, obese or below average, using BMI where available.
• Continence: fully continent or catheterised through to doubly incontinent.
• Skin type in the risk areas: healthy, tissue paper, dry, oedematous, clammy, discoloured, or broken.
• Mobility: fully mobile, restless or fidgety, apathetic, restricted, bedbound or chairbound.
• Sex and age: points rise with age and are slightly higher for women.
• Appetite and nutrition: using the MUST score or a nutrition screening question.

Special risks

• Tissue malnutrition: terminal cachexia, heart failure, peripheral vascular disease, anaemia, smoking.
• Neurological deficit: diabetes, multiple sclerosis, stroke, paraplegia, motor or sensory loss.
• Major surgery or trauma: orthopaedic surgery or time on a theatre table above two hours.
• Medication: steroids, cytotoxics and high-dose anti-inflammatories.

Waterlow score chart: what the bands mean in practice

A Waterlow score chart is only useful if each band triggers a change in what staff do. The total is 10 or more for at risk, 15 or more for high risk and 20 or more for very high risk. Write the band next to the score in the record and write the actions next to the band.

At risk means the person needs a written SSKIN plan, a skin check at least twice a day, a repositioning plan even if that is simply prompting to move, an appropriate foam mattress and monthly nutrition screening. High risk adds a shorter repositioning interval, a pressure-redistributing cushion for the chair, heel offloading in bed, weekly weights and the district nurse being told. Very high risk means considering a dynamic mattress, two-hourly repositioning or more often if the skin says so, and tissue viability advice where any damage is present.

Do not treat these as fixed. A resident scoring 12 who has a red sacrum needs the very high risk actions regardless of the number, and a resident scoring 21 who walks to the dining room three times a day may need less than the chart suggests. Record the reasoning either way.

When to score and how often to repeat

Complete a Waterlow risk assessment within six hours of admission for anyone with reduced mobility and within 24 hours for everyone else. Include a full skin inspection on the first day and record the findings on a body map, because damage that was present on admission needs to be documented as such. An ulcer discovered on day three with no admission body map will be assumed to have developed in your care.

Repeat weekly for anyone scoring 10 or more and monthly for everyone else. Repeat immediately after any hospital stay, infection, fall, new incontinence, a change in mobility, significant weight loss, a new medicine in the special risk groups, or any period of more than a day spent mainly in bed or a chair. Reassess at the end of life, because the risk rises sharply and the plan often needs to change from prevention to comfort.

Keep every version. A nursing home risk assessment that shows the score rising over three weeks and the plan being stepped up in response is exactly the evidence an inspector wants. A scored risk assessment with version history in your care records keeps that trail without any extra work.

SSKIN: turning the score into a plan

SSKIN is the prevention bundle used across the NHS and in most care homes. It covers the five things that stop ulcers, and the plan for anyone at risk should have a specific entry under each heading.

Surface

Which mattress and which cushion, chosen for the band, and who checks they are working. A dynamic mattress on the wrong setting or an alternating mattress with a flat cell is worse than a good foam mattress. Record the make, the setting and the date checked.

Skin inspection

How often, where, by whom and where it is recorded. Sacrum, heels, hips, elbows, shoulders, the back of the head and under any device such as oxygen tubing or a splint.

Keep moving

The repositioning interval in bed and in the chair, and what the person can do for themselves.

Incontinence and moisture

The continence plan, the barrier cream, and the change frequency for pads.

Nutrition and hydration

The MUST score, the weight schedule, any supplements, and the fluid target. Weight loss is one of the strongest predictors of skin breakdown and the two plans should be linked.

Choosing the right surface

For anyone at risk, a high-specification foam mattress is the minimum. For high and very high risk, or for anyone with existing damage, consider an alternating pressure or dynamic mattress and ask the district nurse or tissue viability service for advice on the choice. In a chair, a pressure-redistributing cushion matched to the person's weight matters as much as the mattress, because many residents spend more hours sitting than lying.

Surfaces need checking. Dynamic mattresses have weight settings and alarms; someone should confirm the setting weekly and after any weight change. Foam mattresses degrade, and a hand pressed into the mattress should not reach the bed base. Cushions need to be the right way up and not covered by a folded blanket that cancels the benefit.

Record what surface is in use in the care plan, and record the checks. When an ulcer is investigated, the first question will be what the person was lying on and whether it was working.

Skin inspection: what to look for and how to record it

Skin checks happen at every reposition and at every episode of personal care. Staff look at the pressure areas for redness, discolouration, heat, swelling, blistering, broken skin and any change from last time. In darker skin tones redness may not be visible, so look for purple or blue discolouration, feel for heat or coolness, and check for firmness or bogginess compared with the surrounding skin.

The finger test matters. Press a reddened area for a few seconds. If it goes white and then returns to red, the skin is blanching and the damage is not yet an ulcer. If it stays red, it is non-blanching and that is a category 1 pressure ulcer that needs action today.

Record each check with a time and a result, even when the result is skin intact. A chart with gaps reads as checks that did not happen. Where damage is found, mark it on a body map with size, colour and location, and photograph it if the person or their representative consents and your policy allows. Skin checks recorded in the daily log against the reposition make the trail continuous.

The repositioning chart

The repositioning chart is the document that either proves prevention happened or proves it did not. It needs to show the time, the position moved to, the skin check result and the initials of the staff member, at the interval the care plan sets. NICE says at least six-hourly for people at risk and four-hourly for high risk, but the interval is individual and should be shortened if skin checks show non-blanching redness.

Charts fail in predictable ways. Entries written at the end of the shift in one hand at identical intervals. Charts that show two-hourly turns through the night for a resident whose daily notes say she slept undisturbed. Charts that stop when the resident goes to the lounge, as if sitting does not count. Charts that show the same position twice in a row. Inspectors and safeguarding investigators know all of these patterns.

Fix them by recording at the time, on a device where possible, by including chair repositioning and by recording refusals honestly. A refused reposition, recorded with the reason and what was offered instead, is good care. A chart that pretends the turn happened is falsification.

Repositioning in practice

Repositioning means relieving pressure on the area that has been loaded, not simply moving the person a few inches. In bed, the 30 degree tilt using pillows is the standard technique because it takes the sacrum and hips off the mattress without putting full pressure on the trochanter. Keep heels free of the mattress with a pillow under the calves or a heel offloading boot. Avoid the head of the bed above 30 degrees for long periods because it increases shear at the sacrum.

In a chair, the person should shift their weight every 15 to 30 minutes if they can, and be helped to do so if they cannot. Limit uninterrupted sitting for anyone at high risk to two hours at a time. Slumped sitting, with the person sliding down the chair, loads the sacrum and causes shear and is a frequent cause of damage that nobody spotted because the resident was up all day.

Encourage movement for anyone who can walk. Ten steps to the toilet every two hours does more for the skin than any mattress.

Moisture, continence and skin care

Moisture from urine, faeces or sweat softens the skin and makes it far more vulnerable to pressure and shear. It also causes its own damage: moisture lesions in the skin folds that are often confused with pressure ulcers. The continence plan is therefore part of the pressure plan.

Use a pH-balanced cleanser rather than soap, pat the skin dry, and apply a barrier product where there is regular contact with moisture. Change pads promptly and choose the right absorbency rather than doubling pads, which creates a ridge under the person. Check the skin under the pad at each change. Avoid massaging red areas, which damages tissue rather than helping it.

Ask the district nurse to confirm whether any skin damage is a moisture lesion or a pressure ulcer and record the answer, because the treatment and the reporting differ.

Nutrition, hydration and skin

Skin that is not fed does not repair. Weight loss, low protein intake and dehydration all raise risk and all slow healing once an ulcer exists. The MUST score should sit alongside the Waterlow score, and a rising MUST should prompt a review of the pressure plan even if the Waterlow number has not changed.

For anyone at high risk or with existing damage, review intake against need with the GP or dietitian, consider supplements where intake is poor, and run a food and fluid chart for a defined period to find out what is actually being eaten rather than what is being served. See nutrition and hydration: fluid charts that get filled in for how to run those charts properly.

Record the link explicitly in the care plan. A sentence such as MUST 2, weight loss of 4kg since June, dietitian referral made, weekly weights, is exactly what a reviewer wants to see next to the Waterlow band.

Residents who refuse repositioning or skin checks

Some residents with capacity decline repositioning, particularly at night. Others, especially in mental health and learning disability services, will not let staff look at their skin. Both are common and both need a documented approach rather than a chart full of gaps.

For a resident with capacity, explain the risk plainly, ask what would make it easier, and offer alternatives: a better mattress, a smaller shift of weight, repositioning timed with a natural waking, or skin checks during a shower they already accept. Record each refusal with what was offered. Tell the GP or district nurse and update the care plan so the decision and the ongoing risk are visible to everyone.

Where the person lacks capacity for the decision, make a best interests decision with the people who know them, and consider the least restrictive way to achieve the check. Sometimes that is simply a different member of staff or a different time of day. Record the decision and review it.

Grading pressure ulcers

Every ulcer is graded using the international categories, and the grade determines treatment, reporting and the questions the home will be asked.

• Category 1: intact skin with non-blanching redness, or discolouration, heat or firmness in darker skin.
• Category 2: partial thickness loss of skin, presenting as a shallow open ulcer or an intact or ruptured blister.
• Category 3: full thickness skin loss; fat may be visible but bone, tendon and muscle are not.
• Category 4: full thickness loss with exposed bone, tendon or muscle.
• Unstageable: depth cannot be seen because the base is covered by slough or eschar.
• Deep tissue injury: purple or maroon intact skin or a blood-filled blister from damage to underlying tissue.

Care staff can identify and describe damage, but grading should be confirmed by a nurse, which in a residential service means the district nurse. Record who graded it and when. Never reverse-grade a healing ulcer: a category 3 that is healing is recorded as a healing category 3, not as a category 2.

What to do the moment you find damage

1. Relieve the pressure now. Move the person off the area and keep them off it.
2. Record it. Body map with size, location, appearance and category if known; photograph with consent; incident form.
3. Tell the nurse in charge or, in a residential service, the district nurse the same day. Ask for grading, a wound assessment and a treatment plan.
4. Check the surface. Confirm the mattress and cushion are right for the new risk level and change them if not.
5. Repeat the Waterlow score and step up the SSKIN plan: shorter repositioning interval, heel offloading, moisture management.
6. Review nutrition. Repeat MUST, start weights and a food and fluid chart, consider a dietitian referral.
7. Tell the person and their family what has been found and what is being done, and record the conversation.
8. Review for cause within 72 hours: was the plan right, was it followed, and was anything missed.
9. Report where required: category 3 and above, unstageable and deep tissue injury acquired in your care are notified to CQC as serious injury, and a safeguarding referral is made where neglect is possible.

Reporting: CQC, safeguarding and duty of candour

Pressure ulcers of category 3 and above, unstageable ulcers and deep tissue injury that developed while the person was in your care are normally notified to CQC as serious injury under Regulation 18 of the registration regulations. Category 1 and 2 damage is recorded and treated but not notified unless it forms part of a wider concern. Damage that was present on admission is not your notification but should be recorded as such, with the admission body map to prove it.

Where the ulcer could have been caused by a failure of care, a safeguarding referral to the local authority is required. Many local authorities have a pressure ulcer protocol that sets out a decision tool for this; use it and keep the completed tool with the record. The duty of candour applies where the ulcer is a notifiable safety incident, so the person and their representative are told, given an apology and a written account.

Keep the notification reference, the safeguarding reference and the candour letter with the incident. See CQC notifications: what to report and when for the wider rules.

Root cause review

Every category 2 and above ulcer acquired in the home gets a review by the manager or a nurse. The purpose is to find out whether the ulcer was avoidable and what the home will change. Look at the Waterlow assessments, the plan, the repositioning chart, the skin checks, the surface, the nutrition record and the staffing on the days before the damage appeared.

Write the conclusion plainly. Avoidable because repositioning was recorded four-hourly but the resident was in the lounge chair for seven hours on three consecutive days. Unavoidable because the resident was at the end of life, declined repositioning with capacity, and all measures were in place and recorded. Either conclusion is defensible if the evidence supports it; a review that reaches no conclusion is not.

Record actions with owners and dates, and check them at the next review. An incident review that captures root cause and carries a CQC-notifiable flag makes this a routine part of CQC compliance rather than an exercise you start from scratch each time.

Devices, heels and the places people forget

A growing share of pressure damage comes not from beds and chairs but from devices: oxygen tubing behind the ears, the bridge of the nose under a mask, catheter tubing against the thigh, splints, anti-embolism stockings, and even spectacles in someone who sleeps in them. Check under and around every device at every skin check and record it.

Heels are the second most common site after the sacrum and the easiest to protect. Keep them off the mattress entirely using a pillow lengthways under the calves or a purpose-made boot. Do not use ring cushions or water-filled gloves, which concentrate pressure rather than relieving it.

Other forgotten sites are the ears in side-lying, the elbows in people who push themselves up, the back of the head in bedbound residents, and the ischial tuberosities in anyone who sits for long periods. Add them to the skin check prompt so staff look every time.

End of life and skin changes

At the end of life the skin can fail as the body shuts down, and some damage is not preventable. That does not mean prevention stops; it means the plan shifts to balance comfort against pressure relief. A dying person who finds turning distressing should not be turned two-hourly by the chart. Record the decision, who was involved, and what is being done instead: a dynamic mattress, gentle shifts of weight, moisture care and pain relief before any move.

Document skin changes as they occur and involve the district nurse or palliative care team. An ulcer that develops in the last days of life with a clear record of the decisions made and the comfort measures in place will be understood by an inspector and by a coroner.

The person and family should be part of the conversation. Explain what is happening to the skin and why, and record that you did.

Learning disability and mental health services

Waterlow was designed for hospital and nursing populations, and in a learning disability or mental health home most residents score low. That is not a reason to skip it. The people who breach the threshold in these services are often not obvious: a young man with cerebral palsy who sits in the same wheelchair position for twelve hours, a resident with severe depression who has stopped eating, a woman with a spinal injury who cannot feel the damage, or someone on high-dose antipsychotics who has become sedentary and incontinent.

Skin checks in these services need consent work. Some residents will not tolerate being looked at, and staff need an approach recorded in the care plan that respects that while managing the risk. Use the times the person already accepts help, involve the people they trust, and explain in a way they understand.

Wheelchair cushions and seating assessments matter more here than mattresses. Ask the community team or the wheelchair service for a seating review for anyone who spends most of the day in a chair.

Skin check and prevention checklist for managers

• Waterlow score on admission, with a full skin inspection recorded on a body map the same day.
• Reassessment weekly for anyone at risk, monthly for everyone else, and after any change.
• A written SSKIN plan for everyone scoring 10 or more, with specific entries under each heading.
• The surface recorded by make and setting, and checked weekly.
• A repositioning chart that includes chair time and records skin checks and refusals.
• Heels offloaded for anyone at high risk in bed.
• MUST score and weight schedule linked to the pressure plan.
• Any non-blanching redness treated as category 1 and acted on the same day.
• Every category 2 and above acquired in the home reviewed for cause within 72 hours.
• Category 3 and above, unstageable and deep tissue injury notified to CQC and considered for safeguarding.
• Monthly count of ulcers by category, site and whether acquired in the home, reviewed at the governance meeting.

Common mistakes

• Waterlow scores copied from the previous month without a skin inspection.
• A score in the record with no plan, or a plan that is the same for every resident.
• Repositioning charts completed in one hand at the end of the shift, or that stop when the person is in a chair.
• Non-blanching redness described as a bit red and left until the next day.
• Dynamic mattresses on the wrong weight setting or cushions the wrong way up.
• No admission body map, so damage that was present on arrival is assumed to be the home's.
• Category 3 ulcers not notified because the manager assumed the district nurse would report it.
• Refusals of repositioning not recorded, leaving a gap that looks like neglect.

What good looks like on inspection day

An inspector will ask how many residents currently have pressure damage, how many ulcers were acquired in the home in the last year and what happened in each case. Have the number and the reviews ready. They will pick one or two residents at high risk and follow the trail: the Waterlow assessment and its history, the SSKIN plan, the surface in use, the repositioning chart for the last week, the skin checks, the weights and MUST score, and any referrals.

They will look at the mattress and check the setting matches the record, and they may ask a carer what they look for during a skin check and what they would do if they found a red area that did not fade. They will check that any category 3 ulcer in the last year was notified and that the safeguarding decision was recorded.

If your records are digital, be ready to open the resident's record and show the Waterlow history, the chart and the skin checks in one place. Kiwi keeps the scored assessment with its versions, the body map and the daily chart against the same resident, so the trail is on screen in a minute rather than spread across four folders. If you want to see it, book a demo.

Final conclusion

Pressure ulcer prevention is one of the clearest tests of whether a home does what its records say. The Waterlow score identifies who is at risk, the SSKIN plan says what will be done, and the repositioning chart and skin checks prove it happened. When damage appears despite all of that, the record shows it was unavoidable. When the record is incomplete, the same damage becomes a breach and a safeguarding enquiry. Score everyone, plan for everyone at risk, record at the time, act on the first red mark, and review every ulcer for cause. That is the whole discipline, and it is within reach of every home.

Frequently asked

What is a Waterlow assessment and what do the scores mean?

The Waterlow assessment is a scored tool for pressure ulcer risk. It adds points for build and weight, continence, skin type, mobility, sex and age, appetite, and special risks such as poor circulation, neurological conditions, major surgery and certain medicines. A total of 10 or more means at risk, 15 or more high risk, and 20 or more very high risk.

How often should the Waterlow score be repeated in a care home?

Repeat it weekly for anyone scoring 10 or above and monthly for everyone else. Reassess immediately after illness, a hospital stay, a fall, new incontinence, significant weight change or any period spent mostly in bed or a chair.

How often should a resident be repositioned?

There is no single correct interval. NICE says people at risk should change position at least every six hours and people at high risk at least every four hours, but the plan must be individual and based on the skin. If skin checks show redness that does not fade, the interval is too long for that person.

Do I have to report a pressure ulcer to CQC?

Category 3 and 4 pressure ulcers, unstageable ulcers and deep tissue injury that developed in your care are normally notified as serious injury. Where the damage suggests neglect, a safeguarding referral to the local authority is also required. Category 1 and 2 damage is recorded and treated but not normally notified.

What is the SSKIN bundle?

SSKIN is a five-part prevention bundle: Surface, Skin inspection, Keep moving, Incontinence and moisture, and Nutrition and hydration. It turns the Waterlow score into daily actions. Each part should have a specific plan in the care record for anyone at risk.

Can a resident with capacity refuse repositioning?

Yes. Record the refusal each time, explain the risk in a way the person understands, and offer alternatives such as a different mattress or smaller shifts of weight. Tell the GP or district nurse and update the care plan so the decision and the ongoing risk are visible.

What is the difference between a moisture lesion and a pressure ulcer?

A moisture lesion is skin damage caused by prolonged contact with urine, faeces or sweat, usually in the skin folds, and it is often shallow and irregular. A pressure ulcer sits over a bony prominence and is caused by pressure or shear. They are treated differently, so ask the district nurse to confirm which it is and record that.

Sources

• NICE CG179 Pressure ulcers: prevention and management
• NICE Quality Standard QS89 Pressure ulcers
• NHS England: Pressure ulcers: revised definition and measurement (2018)
• Waterlow pressure ulcer risk assessment tool
• NHS Stop the Pressure programme and React to Red Skin campaign
• CQC: Statutory notifications guidance for providers
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 Safe care and treatment