This article is based on a review carried out by the Scottish Commission for the Regulation of Care (Care Commission) in 2007, which examined pressure ulcer prevention, care and treatment for older people living in care homes in Scotland. Inspection, complaints and enforcement activity from 2002 to 2006 revealed many aspects of poor practice, as residents were either at risk of developing a pressure ulcer, or existing pressure ulcers were not being managed appropriately. The review highlighted six key areas where care homes were consistently not meeting best practice and recommendations were made to improve care.