Author and Publication
Author: Ben Slater, Registered Social Worker, Founder and Managing Director of Nellie Supports
Reviewed by: Kerry Slater, Director of Operations
Last reviewed: 20 July 2026
Citation
1. Department of Health and Social Care (2022) National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. Available at: https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-and-nhs-funded-nursing-care
2. Department of Health and Social Care (2022) NHS Continuing Healthcare Decision Support Tool.
3. Department of Health and Social Care (2022) NHS Continuing Healthcare Checklist.
4. R v North and East Devon Health Authority, ex parte Coughlan [2000] 2 WLR 622.
Copywright
Copyright © 2026 Nellie Supports Ltd. All rights reserved.
This article is made available for general information, education and professional reference. It may be downloaded, printed and shared for non-commercial purposes, provided that it is reproduced in full, is not altered in any way, and is properly cited as the work of Nellie Supports Ltd. This material must not be edited, adapted, sold, republished, incorporated into commercial products, or used for commercial training, assessment, report-writing or advisory services without prior written permission from Nellie Supports Ltd.
This article does not constitute legal advice, clinical advice or a substitute for a decision-specific professional assessment. Where legislation, government guidance, court forms or external professional materials are referred to, those materials remain subject to their own copyright, licensing and re-use terms.
Abstract
This guide explains the skin and tissue viability domain of the NHS Continuing Healthcare Decision Support Tool. It covers pressure damage and its grading, wound care, prevention regimes including repositioning and pressure relieving equipment, the significance of risk that is being successfully managed, where needs are under-recorded, and the evidence that supports an accurate level.
The skin and tissue viability domain in the CHC Decision Support Tool
Skin is the domain where the well-managed need principle bites hardest. Intact skin achieved through two hourly repositioning, pressure relieving equipment and daily inspection is evidence of high need, not low need, and the record should say so.
What the domain covers
Skin condition and tissue viability, including pressure ulcers and their grade, moisture damage, skin tears, surgical or other wounds, leg ulceration, and the prevention and treatment regimes in place. It covers the equipment, repositioning, inspection and dressing regimes required, and the clinical skill needed to deliver and monitor them.
Prevention counts as need
This is the central point. A person at high risk of tissue breakdown whose skin remains intact because of a rigorous prevention regime has a significant need. Recording intact skin without recording the regime that maintains it misapplies the well-managed need principle. The record should describe the risk, the regime and what has happened historically when it lapsed.
Wound care and grading
Where damage exists, the grade, size, duration and treatment regime all matter. Frequent dressing changes, specialist dressings, negative pressure therapy, tissue viability nurse involvement and slow or non-healing wounds all point to higher levels. Recurrent breakdown in the same area is particularly significant because it demonstrates persistent underlying vulnerability.
Equipment and repositioning
Pressure relieving mattresses and cushions, specialist seating, repositioning schedules and the number of staff required to reposition all belong in the record. A two hourly repositioning regime requiring two staff is a substantial and skilled intervention, and its frequency and staffing should be stated rather than summarised as repositioning in place.
Interaction with other domains
Skin interacts with mobility, continence and nutrition more than almost any other domain. Immobility drives pressure risk, incontinence drives moisture damage, and poor nutrition impairs healing. Describing those interactions supports the complexity element of the four key characteristics analysis, which is where interaction is properly recognised.
Evidence that helps
Repositioning charts, body maps, wound assessment and photographic records, tissue viability nurse referrals and reviews, pressure risk assessment scores, dressing change records and district nursing notes. Records covering any period when repositioning or equipment lapsed and damage followed are the single most persuasive evidence in this domain.
Key takeaway
Intact skin maintained by an intensive prevention regime is evidence of need, not of its absence. Record the risk, the regime, its frequency and staffing, any history of breakdown, and the interaction with mobility, continence and nutrition.
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Frequently asked questions
Skin is intact, does that mean no need?
No. Where intact skin depends on repositioning, pressure relieving equipment and daily inspection, the underlying need remains significant. Record the risk and the regime, not just the outcome.
Does a grade 3 pressure ulcer mean a high level?
It points upward, and the level reflects the treatment regime, healing trajectory, clinical input required and whether damage is recurrent. Non-healing or recurrent damage is particularly significant.
Does a pressure mattress count as evidence?
Yes. Specialist equipment indicates assessed risk. Record why it was provided, what risk assessment supported it, and what the repositioning regime alongside it involves.
Related NHS Continuing Healthcare pages
These links take you to the most relevant Nellie Supports service page and to the supporting guides that explain the surrounding process.
Speak to an independent CHC specialist
Nellie Supports prepares independent needs evidence for NHS Continuing Healthcare assessments, reviews and appeals across England and Wales. Our reports are written by registered social workers on a permanent employed team, with internal peer review before release. Call 0333 987 5118 or send an enquiry and we will talk through where you are in the process.