Waterlow and MUST Assessments in Domiciliary Care: A Complete Guide

Risk assessment is fundamental to delivering safe, person-centred care in domiciliary settings. Two assessments stand out as essential tools for identifying vulnerable clients: the Waterlow Scale for pressure ulcer risk and the MUST (Malnutrition Universal Screening Tool) for nutritional concerns. Understanding when and how to use these instruments helps care agencies prevent serious complications, improve outcomes, and maintain regulatory compliance with CQC (England) and CIW (Wales) standards.

What is the Waterlow Scale?

The Waterlow Scale is a widely recognised pressure ulcer risk assessment tool used across healthcare settings in the UK. Developed by Judy Waterlow in 1985, it remains the gold standard for identifying clients at risk of developing pressure sores (pressure ulcers or bedsores).

Pressure ulcers develop when sustained pressure compromises blood flow to the skin and underlying tissues, typically over bony prominences like heels, hips, and sacrum. In domiciliary care, where clients may spend extended periods in chairs or beds, this risk is particularly acute. The Waterlow assessment helps care teams identify who needs preventative interventions before damage occurs.

How the Waterlow Scale Works

The tool evaluates multiple risk factors across different categories:

• Mobility status – immobility significantly increases risk
• Skin condition – presence of existing damage, oedema, or moisture
• Age and build – elderly and underweight clients face higher risk
• Continence issues – moisture from incontinence breaks down skin barrier
• Appetite and food intake – nutritional status affects skin integrity
• Sensory perception – inability to feel pressure or reposition
• Tissue malnutrition – protein deficiency weakens skin resilience
• Medications – certain drugs affect healing and sensation

Scores are calculated as low risk (under 10), medium risk (10–14), high risk (15–20), or very high risk (above 20). The higher the score, the more intensive preventative measures required.

Implementing Waterlow in Home Care Settings

Domiciliary care agencies must incorporate Waterlow assessment into their initial client review and reassess regularly – typically monthly or when circumstances change (illness, immobility increase, medication changes).

Practical Steps for Care Managers

1. Complete assessment at first visit – gather information from client, family, GP records, and hospital discharge summaries
2. Document carefully – record exact scores and factors contributing to risk level
3. Develop individualised care plans – specify pressure relief strategies, frequency of repositioning, equipment needs
4. Ensure carer training – staff must understand why interventions matter and how to execute them correctly
5. Monitor and reassess – track skin condition, mobility changes, and update assessments accordingly
6. Communicate findings – share results with clients, families, GPs, and relevant healthcare professionals

Care agencies should maintain clear records of all Waterlow assessments. Management software like CareCallAI allows you to store assessments securely, set automatic reassessment reminders, and flag high-risk clients so care teams stay alert.

Understanding MUST (Malnutrition Universal Screening Tool)

The MUST is a five-step screening tool designed to identify adults at risk of malnutrition. Developed by the British Association for Parenteral and Enteral Nutrition (BAPEN), it's straightforward to administer in community settings and requires no special equipment.

Malnutrition in older adults and those with chronic conditions carries serious consequences: slower wound healing, increased infection risk, weakened immunity, frailty, falls, and poor mental health. In domiciliary care, where nutrition may be compromised by difficulty cooking, swallowing problems, loss of appetite, or medication effects, MUST screening is critical.

The Five Steps of MUST Assessment

The tool evaluates three key measurements:

Step 1: Body Mass Index (BMI) Calculate using height and weight. Score ranges from 0 (BMI 20.1–24.9) to 2 (BMI below 16.0).

Step 2: Unintentional Weight Loss Ask about weight change over 3–6 months. Score 0 for no loss, up to 2 for loss exceeding 10%.

Step 3: Acute Illness Effect If the client has had no nutritional intake for more than 5 days, score 2.

Step 4: Overall Risk Category Add scores together: 0 = low risk, 1 = medium risk, 2 or more = high risk.

Step 5: Management Guidelines Provide appropriate actions based on risk level: monitoring for low risk, dietary review for medium risk, referral to dietitian for high risk.

Why Both Assessments Matter in Domiciliary Care

These two tools are complementary – poor nutrition directly increases pressure ulcer risk, whilst immobility and poor skin integrity affect appetite and ability to eat. A client scoring high on both Waterlow and MUST requires integrated interventions addressing mobility, skin care, and nutritional support.

Regulatory bodies including CQC and CIW expect care agencies to demonstrate systematic risk assessment and appropriate response. Using recognised, validated tools like Waterlow and MUST shows auditable evidence of safe, evidence-based practice.

Integrating Assessments into Your Care Processes

Initial assessment interview should include both Waterlow and MUST screening. Use this opportunity to gather comprehensive health information, understand the client's circumstances, and identify support networks.

Care plan development must detail specific preventative actions:

• For high Waterlow scores: pressure-relieving equipment, repositioning schedules, skin inspection protocols
• For high MUST scores: dietary modifications, fortified foods, fluid intake monitoring, GP or dietitian referral

Staff training ensures carers understand why these measures prevent serious harm. Regular team updates on pressure ulcer prevention and nutritional support reinforce best practice.

Reassessment schedules should be documented and automated where possible. Client conditions change; scores that were low risk may increase with new illness, reduced mobility, or medication changes.

Documentation and Compliance

Both assessments must be documented thoroughly in client records with:

• Completed assessment tools showing all scores
• Date of assessment and reviewer name
• Resulting care plan changes
• Reassessment dates
• Evidence of sharing findings with relevant professionals

Using integrated care management software simplifies this process. CareCallAI allows care teams to complete assessments directly within client records, generate automatic alerts for high-risk clients, and ensure reassessment schedules are met without administrative burden.

Common Pitfalls to Avoid

• One-off assessment only – risk changes; regular reassessment is essential
• Completing forms without action – assessments mean nothing if findings don't drive care changes
• Failing to communicate – GPs, district nurses, and families need to know assessment outcomes
• Poor documentation – vague notes make it impossible to track changes or defend practice decisions
• Insufficient carer training – staff must understand the clinical reasoning behind interventions

Taking Action

If your domiciliary care agency isn't systematically using Waterlow and MUST assessments, now is the time to embed these tools into your practice. They're evidence-based, quick to administer, and directly prevent serious complications that harm clients and damage agency reputation.

Starting with clear processes, training, and documentation demonstrates regulatory compliance and delivers genuinely safer care. Automated reminders and integrated record-keeping reduce administrative friction and keep high-risk clients visible to your team.

Ready to streamline risk assessment and care planning? CareCallAI's integrated platform supports Waterlow and MUST screening, flags at-risk clients automatically, and keeps comprehensive records organised and accessible. Start your free trial today at carecallai.co.uk/signup and see how simplified assessment processes can improve client safety and agency efficiency.