Registration Number: {{org_field_registration_no}}

Assisting with Personal Care Policy

1. Purpose

The purpose of this policy is to ensure that all personal care provided within {{org_field_name}} is delivered safely, effectively, compassionately and consistently in line with the Fundamental Standards under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended) and current Care Quality Commission (CQC) guidance. This includes CQC’s single assessment framework and related quality statements for Safe, Effective, Caring, Responsive and Well-led services. The policy sets out how we will protect people’s dignity, rights, choices and independence while meeting our legal duties under the Care Act 2014, the Mental Capacity Act 2005, the Equality Act 2010 and other relevant legislation and guidance.

2. Scope

This policy applies to:

All domiciliary care staff, including care workers, coordinators, and managers.
Service users receiving personal care services.
Families and representatives involved in care planning and decision-making.
Regulatory bodies, ensuring compliance with statutory and ethical standards.

It covers:

Definition and principles of personal care.
Service user consent and choice.
Safe and respectful personal care practices.
Infection prevention and hygiene.
Training and staff competency.
Monitoring and continuous improvement.

3. Legal and Regulatory Framework

This policy aligns with, and must be read alongside, the following current legislation, regulations, statutory requirements and regulatory guidance, as amended:

Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including the Fundamental Standards:
- Regulation 9 – Person-centred care.
- Regulation 10 – Dignity and respect.
- Regulation 11 – Need for consent.
- Regulation 12 – Safe care and treatment.
- Regulation 13 – Safeguarding service users from abuse and improper treatment.
- Regulation 14 – Meeting nutritional and hydration needs.
- Regulation 17 – Good governance.
- Regulation 18 – Staffing.
- Regulation 19 – Fit and proper persons employed.
- Regulation 20 – Duty of Candour.
Care Quality Commission (Registration) Regulations 2009 – including applicable requirements concerning the Statement of Purpose and statutory notifications.
CQC’s current assessment framework, including the five key questions of Safe, Effective, Caring, Responsive and Well-led and the quality statements relevant to person-centred care, dignity, consent, safeguarding, infection prevention and control, safe care and treatment, staffing and governance.
Health and Care Act 2022, Section 181, which introduced the statutory requirement for persons working for the purposes of a CQC-registered regulated activity to receive training on learning disability and autism appropriate to their role.
Sections 20(5ZA) and 21A of the Health and Social Care Act 2008, as inserted by the Health and Care Act 2022, establishing the statutory learning disability and autism training requirement and associated Code of Practice.
Oliver McGowan Code of Practice on statutory learning disability and autism training, which sets the standards that relevant training must meet. The Oliver McGowan Mandatory Training on Learning Disability and Autism is the Government’s preferred and recommended training package. Alternative training may be used where {{org_field_name}} can demonstrate that it meets the statutory requirements and standards in the Code and is appropriate to the person’s role.
Care Act 2014 and Care and Support Statutory Guidance – including wellbeing, prevention, personalisation and safeguarding duties.
Mental Capacity Act 2005 and current Code of Practice – including the statutory principles, supported decision-making, decision-specific capacity assessment, best-interests decision-making and least restrictive practice.
Applicable legal requirements concerning deprivation of liberty, including the current interpretation of Article 5 of the European Convention on Human Rights and the appropriate lawful-authorisation process where restrictive care arrangements may amount to a deprivation of liberty.
Equality Act 2010 – including non-discrimination and the duty to make reasonable adjustments.
UK General Data Protection Regulation and Data Protection Act 2018, as amended by the Data (Use and Access) Act 2025 – governing the lawful, fair and secure processing of personal and special category data, including records concerning intimate and personal care.
Applicable national infection prevention and control guidance issued by the Department of Health and Social Care, UK Health Security Agency and other relevant national bodies.
Relevant NICE guidance applicable to the person’s needs and the care being provided.

{{org_field_name}} will ensure that personal care is planned and delivered in accordance with current legislation, statutory guidance, CQC requirements and the person’s assessed needs, wishes, preferences and rights.

4. Definition and Principles of Personal Care

Personal care includes assisting service users with activities of daily living such as:

Personal hygiene – Washing, bathing, oral care, shaving, and grooming.
Dressing and undressing – Supporting service users to choose and wear appropriate clothing.
Toileting support – Assistance with continence care, catheter/stoma care, and use of mobility aids.
Assistance with eating and drinking – Encouraging adequate nutrition and hydration.
Skin and pressure care – supporting people with skincare, pressure area care and continence management in line with individual risk assessments and care plans.
Medication support – Assisting with medication only where authorised and in accordance with the person’s care plan, our Medicines Policy, staff competence, and Regulation 12 (Safe care and treatment), including clear recording of any support provided.

Key principles:

Dignity and Respect – Ensuring service users’ privacy and treating them with sensitivity.
Independence and Empowerment – Encouraging self-care where possible.
Personal Choice – Honouring service users’ preferences, routines, and cultural/religious beliefs.
Safety and Comfort – Adhering to best practices for hygiene, positioning, and risk management.
Reasonable adjustments and accessible communication – Ensuring that information and explanations about personal care are provided in ways the person can understand, and that any sensory, cognitive, cultural, language or communication needs are met, in line with the Equality Act 2010 and CQC’s expectations for person-centred care.

5. Service User Consent and Choice

All personal care must be delivered with explicit, informed consent. Our approach includes:

Seeking consent before each care intervention.
Respecting service users’ right to refuse assistance.
Ensuring decisions align with the Mental Capacity Act 2005 for those unable to consent.
Documenting all consent discussions and preferences in the care plan.

When there is doubt about a person’s capacity to consent to a specific aspect of personal care, staff must follow the Mental Capacity Act 2005 by:

applying the five statutory principles, including presuming capacity and supporting the person to make their own decision wherever possible;
carrying out and recording a decision-specific capacity assessment using the two-stage test;
where the person lacks capacity for that decision, making and documenting a best interests decision, involving the person as far as possible and consulting family, friends or any attorney or deputy where appropriate; and
choosing the least restrictive option that still meets the person’s needs and keeps them safe.

Staff must pay particular attention to how consent is obtained from people with communication difficulties, a learning disability, autism, dementia or sensory impairments. Non-verbal communication, behaviour and known preferences must be taken into account, and reasonable adjustments made so that people can understand and express their choices.

6. Safe and Respectful Personal Care Practices

To ensure safety and dignity, care workers must:

Respect service users’ privacy by using screens, closing doors, and covering exposed areas.
Maintain hygiene and infection control – Using gloves, aprons, and following hand hygiene protocols.
Use appropriate manual handling techniques – Avoiding undue discomfort or risk of injury.
Communicate clearly and sensitively – Explaining each step of the process and ensuring comfort.
Encourage autonomy – Allowing service users to participate as much as possible.
Follow the person’s risk assessments and personal care plan, including guidance on moving and handling, falls prevention, pressure area care and skin integrity, and escalate any concerns promptly.
Be alert to and immediately report any actual or suspected abuse, neglect or unexplained injuries observed during personal care, in line with {{org_field_name}}’s Safeguarding Adults policy and local safeguarding procedures.
Record personal care provided, including any refusals, changes in the person’s condition or concerns identified, in the care record on the same day, in line with our governance and record-keeping requirements (Regulation 17).

7. Infection Prevention and Hygiene

Hygiene standards must be maintained through:

Use of PPE (personal protective equipment) – Gloves, aprons, and masks where required.
Frequent handwashing and sanitisation before and after care tasks.
Proper disposal of waste materials including incontinence pads, gloves, and wipes.
Adherence to infection control policies, especially for service users with specific health conditions.
Carry out and follow individual infection prevention and control (IPC) risk assessments for each person, including any additional precautions needed due to wounds, catheters, stomas, respiratory infections or immunosuppression.
Follow current national IPC guidance (for example UKHSA or DHSC guidance) relevant to domiciliary care, including any outbreak management measures communicated by the local authority or health protection team.
Ensure that reusable equipment used in personal care (for example, hoists, slings, washbowls, commodes) is cleaned and stored safely in line with IPC guidance and manufacturer’s instructions.

8. Training and Staff Competency

All staff assisting with personal care must:

Complete and keep up to date with mandatory training in personal care, infection prevention and control, dignity and respect, safeguarding adults, Mental Capacity Act, and any role-specific training required (for example, moving and handling or medicines support).
Receive refresher training on an annual basis or as needed.
Be observed and assessed regularly to ensure competence and adherence to best practices.
Complete mandatory training on learning disability and autism appropriate to their role and responsibilities, in line with section 181 of the Health and Care Act 2022. {{org_field_name}} will use the Oliver McGowan Mandatory Training on Learning Disability and Autism, or an equivalent programme that meets the Oliver McGowan Code of Practice.
Apply the knowledge and skills from learning disability and autism training when planning and delivering personal care, including communication, sensory needs, reasonable adjustments and supporting people’s rights.

9. Monitoring and Continuous Improvement

To maintain high standards of care:

Care plans are reviewed regularly to align with changing needs.
Supervisory visits and spot checks ensure compliance with best practices.
Service user feedback is actively sought to improve care quality.
Incident reporting and investigations help to identify and address any concerns.
Use audits, spot checks, supervision, feedback and incident learning to generate evidence that personal care is safe, effective, caring, responsive and well-led, and to map this evidence to the relevant CQC quality statements under the single assessment framework.

10. Duty of Candour and Incident Reporting

{{org_field_name}} is committed to an open, transparent and learning culture and will comply with Regulation 20 – Duty of Candour.

The general duty to act openly and transparently applies in relation to care and treatment provided to service users.

Where an incident meets the statutory definition of a notifiable safety incident, the specific Duty of Candour procedure must also be followed.

Notifiable Safety Incident

For {{org_field_name}}, as a registered provider other than an NHS health service body, a notifiable safety incident is an unintended or unexpected incident that occurs in respect of a service user during the provision of a regulated activity and which, in the reasonable opinion of a healthcare professional:

Appears to have resulted in:

The death of the service user, where the death relates directly to the incident rather than to the natural course of the person’s illness or underlying condition.
An impairment of the person’s sensory, motor or intellectual functions which has lasted, or is likely to last, for a continuous period of at least 28 days.
Changes to the structure of the person’s body.
Prolonged pain.
Prolonged psychological harm.
A shortening of the person’s life expectancy.

Or requires treatment by a healthcare professional in order to prevent:

The death of the service user; or
An injury which, if left untreated, would lead to one or more of the statutory outcomes listed above.

For this purpose, prolonged pain and prolonged psychological harm mean pain or psychological harm experienced, or likely to be experienced, continuously for at least 28 days.

A pressure injury, fall, medication error, missed visit, injury or other personal-care incident must therefore be assessed against the statutory criteria. It must not automatically be treated either as a notifiable safety incident or as falling outside the Duty of Candour requirements solely because of the type of incident.

Duty of Candour Procedure

Where the statutory threshold is met, {{org_field_name}} will, as soon as reasonably practicable:

Notify the relevant person that the incident has occurred.
Provide reasonable support to the relevant person.
Provide a factual account which, to the best of the organisation’s knowledge, is true of all the facts known at the time.
Explain what further enquiries or investigations are considered appropriate.
Provide a sincere apology.
Give the relevant person an opportunity to ask questions and raise concerns.
Take account of communication, accessibility, capacity and reasonable-adjustment needs.

The initial notification will normally be made in person by an appropriate representative of {{org_field_name}}.

The notification will be followed by written communication containing:

The factual information provided.
Details of further enquiries or investigations considered appropriate.
The outcome of further enquiries where available.
A written apology.

{{org_field_name}} will maintain a secure written record of:

The incident.
The assessment of whether the statutory threshold was met.
The healthcare professional opinion relied upon where applicable.
Communications with the relevant person.
The apology provided.
Support offered.
Investigation findings.
Follow-up correspondence and actions.

Where the relevant person cannot be contacted or declines to speak with {{org_field_name}}, the organisation will maintain a written record of reasonable attempts made to contact or communicate with them.

Incident and Near-Miss Reporting

All incidents, near misses and concerns relating to personal care must be reported promptly through {{org_field_name}}’s incident-reporting arrangements.

This includes, where applicable:

Falls.
Pressure damage.
Skin injuries.
Medication errors.
Missed or significantly shortened care visits.
Moving and handling incidents.
Infection-control incidents.
Failures to follow the care plan.
Refusal of essential care where a significant risk arises.
Actual or suspected abuse or neglect.
Equipment-related incidents.
Any unexpected deterioration or harm potentially associated with the care provided.

Staff must take immediate action to protect the person from further harm and obtain medical assistance where required.

Safeguarding

Where an incident raises an actual or suspected safeguarding concern, staff must immediately follow {{org_field_name}}’s Safeguarding Adults Policy and applicable local safeguarding arrangements.

Duty of Candour, safeguarding and incident investigation are separate processes and one must not delay another.

CQC Statutory Notifications

The Registered Manager will separately assess each relevant incident against the Care Quality Commission (Registration) Regulations 2009.

Where the statutory threshold for a CQC notification is met:

The notification will be made without delay or within the other applicable statutory timeframe.
The current CQC statutory notification route will be used.
Completion of an internal investigation must not delay a notification that is legally required without delay.
Confirmation or reference details will be retained.

For serious injury notifications under Regulation 18, the actual statutory injury criteria must be considered rather than relying solely on the description or name of an incident.

A pressure injury, for example, must be assessed against the applicable CQC notification criteria. CQC guidance identifies a pressure sore of grade 3 or above that develops after the person starts using the service as an example relevant to the serious-injury notification provisions.

Investigation and Learning

Following an incident or near miss, {{org_field_name}} will consider whether it is necessary to:

Review the person’s care plan.
Review relevant risk assessments.
Review Mental Capacity Act or consent arrangements.
Review staffing or visit arrangements.
Review staff competence.
Provide additional supervision or training.
Review equipment.
Make a safeguarding referral.
Notify CQC.
Notify or consult other relevant professionals or authorities.
Implement corrective or preventative action.

Learning from incidents, Duty of Candour cases, safeguarding concerns, complaints and near misses will be incorporated into governance, training and quality-improvement arrangements.

11. Policy Review and Updates

This policy will be reviewed at least annually, or sooner where necessary, to ensure that it remains accurate, effective and consistent with current legislation, CQC requirements, statutory guidance and the operational arrangements of {{org_field_name}}.

An earlier review will be undertaken where:

The Health and Social Care Act 2008 or Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 are amended in a way relevant to personal care.
CQC requirements relating to person-centred care, dignity, consent, safe care and treatment, safeguarding, infection prevention and control, staffing or governance materially change.
CQC statutory notification requirements change.
Mental Capacity Act legislation, guidance or relevant case law materially changes.
Learning disability and autism training requirements or the Oliver McGowan Code of Practice change.
Infection prevention and control guidance relevant to domiciliary care materially changes.
Data protection legislation materially affecting personal-care records changes.
A serious incident, safeguarding concern or Duty of Candour case identifies weaknesses in the delivery of personal care.
Audits, spot checks or competency assessments identify unsafe or inconsistent practice.
Complaints, service-user feedback or family feedback identify required improvements.
New equipment or methods of providing personal care are introduced.
The policy is found to be unclear, inaccurate or ineffective.

The Registered Manager is responsible for ensuring that this policy remains current and is implemented effectively.

As part of the review process, {{org_field_name}} will consider:

Personal-care records.
Care plans and risk assessments.
Consent records.
Mental Capacity Act and best-interests records.
Safeguarding concerns.
Incidents and near misses.
Pressure damage and skin-integrity concerns.
Infection-prevention incidents.
Medication incidents associated with personal care.
Missed or shortened visits.
Duty of Candour cases.
CQC statutory notifications.
Complaints and compliments.
Service-user and representative feedback.
Staff feedback.
Spot checks and supervisory observations.
Staff training and competency records.
CQC inspection or assessment findings.
Changes in legislation and national guidance.

Any amendments made to this policy will be:

Recorded with the date of review and, where appropriate, a summary of material changes.
Approved by the appropriate responsible person.
Communicated to relevant staff.
Reflected in care-plan templates, personal-care procedures and associated documentation where necessary.
Incorporated into staff training, supervision or competency assessment where required.
Monitored to ensure that revised arrangements are implemented effectively.

This policy must be read alongside {{org_field_name}}’s relevant policies and procedures, including:

Safeguarding Adults.
Medicines Management.
Infection Prevention and Control.
Moving and Handling.
Mental Capacity and Consent.
Complaints.
Incident Reporting.
Duty of Candour.
Confidentiality and Data Protection.

All staff delivering personal care must follow the current versions of these policies and the individual’s current care plan and risk assessments.

{{org_field_name}} will use learning from incidents, audits, complaints, safeguarding concerns, feedback and regulatory findings to continuously improve the safety, dignity and quality of personal care.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

DC40-Assisting with Personal Care Policy