{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Catheter Care Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} provides safe, effective, person-centred and dignified support to residents who have, or may require, a urinary catheter. Catheter care will be delivered in a way that protects, promotes and maintains each resident’s safety, well-being, privacy, dignity, independence and personal outcomes.

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and the Welsh Government statutory guidance for service providers and responsible individuals. In particular, it supports the requirements relating to personal plans, standards of care and support, continuity of care, language and communication, staffing, staff training, infection prevention and control, health and safety, medicines, monitoring, review and improvement.

Catheter care will be provided in accordance with current evidence-based guidance, including relevant NICE guidance on healthcare-associated infections and catheter-associated urinary tract infection, Public Health Wales infection prevention and control resources, local Health Board continence guidance, and any instructions or care plans provided by GPs, district nurses, continence specialists or other relevant healthcare professionals.

The aim of this policy is to minimise avoidable catheter use, reduce the risk of catheter-associated urinary tract infection, blockage, trauma, pain, leakage, skin damage and avoidable hospital admission, and ensure that residents receive timely clinical advice and treatment when concerns arise.

2. Scope

This policy applies to all staff employed or engaged by {{org_field_name}} who support residents with catheter care, including registered nurses, care staff, agency staff, volunteers where applicable, and managers responsible for oversight of care. It also applies to the coordination of care with external healthcare professionals, including GPs, district nurses, community nurses, continence services, pharmacists, infection prevention and control teams, out-of-hours services and emergency services.

This policy covers the day-to-day support, monitoring, documentation and escalation of concerns relating to:

• indwelling urethral urinary catheters;
• suprapubic catheters;
• intermittent catheterisation, where this is included in the resident’s assessed needs and personal plan;
• catheter drainage bags, catheter valves, night bags and related equipment;
• catheter hygiene, infection prevention, hydration, comfort, dignity, skin integrity and continence support.

Only staff who are trained, assessed as competent, and authorised within their role may undertake catheter-related tasks. Registered nurses remain accountable for nursing assessments and nursing interventions. Care staff must not insert, remove, change or flush catheters unless this has been formally delegated by an appropriate registered healthcare professional, is within local Health Board guidance, is included in the resident’s personal plan, and the member of staff has been trained, assessed as competent, and authorised to perform the task.

Where a resident lacks capacity to make a specific decision about catheter care, staff must act in accordance with the Mental Capacity Act 2005, the resident’s best interests, any valid and applicable advance decision, and any lawful representative or attorney arrangements.

3. Principles of Catheter Care

Person-Centred, Rights-Based and Dignified Care

Catheter care must be provided in a way that respects the resident’s dignity, privacy, choices, cultural needs, religious needs, language needs and communication needs. Staff must explain catheter care before it is provided and seek the resident’s consent wherever the resident has capacity to consent.

Residents must be supported to participate in decisions about their catheter care as far as they are able. Information must be provided in a way the resident can understand, taking account of communication needs, sensory impairment, cognition, language preference and whether the resident wishes to receive care or information in Welsh.

Catheter care must be reflected in the resident’s personal plan and must support the resident’s personal outcomes, including comfort, independence, continence, hydration, mobility, sleep, social participation, dignity and avoidance of unnecessary hospital admission.

Assessment and Individualised Care Planning

Each resident who has a catheter, or who may require catheterisation, must have their needs assessed and recorded in their personal plan. The personal plan must clearly state:

• the reason for catheterisation;
• the type of catheter and drainage system used;
• the date of catheter insertion or last catheter change, where known;
• the planned review date and expected duration of catheter use;
• the resident’s usual urine output pattern and any monitoring required;
• the resident’s hydration needs and any fluid restrictions;
• the resident’s level of independence with catheter care;
• the support required from staff;
• the resident’s preferences, dignity needs and communication needs;
• risks relating to infection, blockage, bypassing, leakage, trauma, falls, skin damage, pain, delirium, dehydration or hospital admission;
• when and how staff must escalate concerns;
• the healthcare professional or service responsible for catheter changes, reviews and specialist advice.

Catheter use must be reviewed regularly and must not continue without a clear clinical reason. Alternatives to catheterisation, including continence assessment, toileting support, continence products or other bladder management options, must be considered with the resident and relevant healthcare professionals where clinically appropriate.

The resident, and where appropriate their representative, family, advocate, GP, district nurse, continence specialist or other relevant professional, must be involved in care planning and review. Where there is a change in catheter care needs, the personal plan and risk assessments must be updated promptly.

Where available, the resident should have a catheter passport or catheter record, and staff must ensure it is kept up to date and shared with relevant healthcare professionals, especially during hospital admission, discharge, out-of-hours review or transfer of care.

Infection Prevention and Control

Catheter care must be provided using standard infection control precautions and, where required, transmission-based precautions. Staff must follow current infection prevention and control guidance, including hand hygiene, appropriate use of PPE, safe handling of body fluids, safe disposal of clinical waste, safe cleaning of reusable equipment and safe management of the care environment.

Staff must decontaminate their hands before and after any contact with the catheter, drainage bag, catheter valve, urine, catheter equipment or the resident’s intimate care area. Disposable gloves and aprons must be worn where there is a risk of contact with urine, body fluids, mucous membranes, non-intact skin or contaminated equipment. Gloves and aprons must be changed between tasks and residents, and hand hygiene must still be performed after glove removal.

All catheterisation undertaken by healthcare workers must be an aseptic procedure. Catheter-related procedures must only be carried out by staff who are trained and assessed as competent for the specific procedure. The catheter drainage system must remain closed wherever possible to reduce infection risk.

Catheter bags must be positioned below bladder level and kept off the floor. Tubing must be positioned to avoid kinks, traction, pressure damage or trip hazards. Drainage bags must be emptied using a clean container, avoiding contact between the drainage tap and the container. Drainage bags must be emptied when clinically required and before they become overfull, usually when around two-thirds full, to reduce backflow and maintain comfort.

Routine disconnection of the catheter drainage system must be avoided. Catheter bags, valves and night bags must be changed in line with manufacturer instructions, local Health Board guidance and the resident’s personal plan.

Catheter Maintenance and Hygiene

Staff must support the resident to maintain personal hygiene while preserving privacy, dignity and independence. Catheter care must be explained to the resident before it is provided, and the resident must be encouraged to do as much for themselves as they are safely able to do.

The catheter site, surrounding skin and drainage system must be observed during personal care for signs of redness, swelling, discharge, pain, bleeding, leakage, pressure damage, skin breakdown, odour or discomfort. Concerns must be recorded and reported promptly to the nurse in charge, manager or relevant healthcare professional.

Perineal hygiene must be provided as part of normal personal care and after episodes of incontinence or soiling. Staff must use gentle hygiene methods and avoid unnecessary antiseptic cleaning unless specifically advised by a healthcare professional.

Catheters must be secured appropriately, where clinically indicated, to reduce traction, urethral trauma, pain, accidental removal and tissue damage. Staff must ensure that straps, fixation devices and bag supports do not restrict circulation or cause pressure damage.

Residents must be supported to maintain adequate hydration unless clinically contraindicated. Where a resident is at risk of dehydration, has recurrent blockage, has concentrated urine, or has reduced intake, staff must monitor and escalate concerns in accordance with the resident’s personal plan.

Used catheter equipment, drainage bags and urine containers must be disposed of in accordance with the home’s infection prevention and control, waste management and health and safety procedures.

Monitoring and Early Detection of Complications

Staff must monitor residents with catheters for signs of complications and must report concerns promptly. Possible catheter-related concerns include:

• no urine draining or reduced drainage;
• catheter blockage or suspected blockage;
• bypassing or leakage around the catheter;
• lower abdominal pain, bladder discomfort or flank pain;
• new or worsening confusion, delirium, agitation or deterioration;
• fever, chills or feeling systemically unwell;
• blood in the urine;
• cloudy urine, strong-smelling urine or visible sediment where accompanied by symptoms or deterioration;
• pain, redness, swelling, discharge or bleeding at the catheter site;
• accidental catheter removal;
• signs of dehydration;
• skin damage from tubing, straps, fixation devices or urine leakage.

Staff must not rely on urine smell, cloudiness or dipstick/urinalysis alone to diagnose catheter-associated urinary tract infection. If catheter-associated UTI is suspected, staff must seek clinical advice from the GP, district nurse, community nurse, out-of-hours service or other relevant healthcare professional.

Urine samples must only be obtained where clinically indicated and must be collected in accordance with clinical guidance. Where a sample is required, it must be taken from the catheter sampling port using an aseptic technique, or from a newly changed catheter if the catheter has been changed. Samples must not be taken from a drainage bag unless specifically instructed by a healthcare professional.

Catheter-associated UTI, suspected sepsis, blockage, haematuria, severe pain, absence of urine output, accidental removal, trauma or rapid deterioration must be escalated without delay. Staff must follow the resident’s escalation plan, local Health Board guidance and emergency procedures.

Antimicrobial Stewardship and Catheter-Associated UTI

Antibiotics must only be used when prescribed by an authorised prescriber. Staff must not request antibiotics solely because a resident has cloudy, strong-smelling or bacteria-positive urine without symptoms or clinical deterioration.

Where catheter-associated urinary tract infection is suspected, staff must seek clinical advice and provide accurate information about the resident’s symptoms, catheter type, catheter change date, allergies, current medicines, hydration, observations, urine output, pain, confusion, fever, deterioration and any previous urine culture results.

Staff must monitor the resident’s response to any prescribed treatment and report any deterioration, adverse effects, allergy concerns or lack of improvement. Where antibiotics are prescribed, administration must follow the home’s Medication Management and Administration Policy and the prescriber’s instructions.

Staff must support antimicrobial stewardship by avoiding unnecessary urine testing, avoiding inappropriate requests for antibiotics, encouraging hydration where appropriate, supporting catheter removal where clinically indicated, and maintaining catheter hygiene and closed drainage.

Catheter Removal and Trial Without Catheter (TWOC)

Catheters must be removed as soon as clinically appropriate. Long-term catheter use must be reviewed regularly with the resident and relevant healthcare professionals to confirm that catheterisation remains necessary and that alternatives have been considered.

A Trial Without Catheter (TWOC) must only be undertaken where it has been planned and authorised by an appropriate healthcare professional and where the care home has the staff competence, equipment, monitoring arrangements and escalation plan required to support the resident safely.

The resident’s personal plan must state the TWOC plan, including who authorised it, when the catheter is to be removed, what monitoring is required, what fluid intake/output monitoring is required, what symptoms must be reported, and when urgent clinical advice must be sought.

Following catheter removal, staff must observe and record urinary output, discomfort, abdominal pain, urinary retention, incontinence, agitation, deterioration or other concerns. Prompt clinical advice must be sought if the resident is unable to pass urine, develops pain, becomes distressed, deteriorates or shows signs of retention or infection.

Decisions about long-term catheter use, catheter removal, recatheterisation or alternative bladder management must be made collaboratively with the resident, and where appropriate their representative, GP, district nurse, continence specialist and other relevant healthcare professionals.

4. Consent, Mental Capacity and Best Interests

Staff must seek the resident’s consent before providing catheter care, where the resident has capacity to make the relevant decision. Consent and refusal must be respected and recorded where appropriate.

Where there is concern that a resident may lack capacity to make a specific decision about catheter care, the Mental Capacity Act 2005 must be followed. Capacity must be considered decision-specifically and time-specifically. Residents must be supported to make their own decisions as far as possible, including through accessible information, communication aids, advocacy, family involvement where appropriate, and Welsh language support where this is the resident’s preference.

Where a resident lacks capacity to make a specific decision, any decision or act in relation to catheter care must be in the resident’s best interests, must be the least restrictive option, and must take account of the resident’s wishes, feelings, beliefs, values, advance decisions, lasting power of attorney arrangements, deputyship arrangements and the views of relevant people.

Any restriction, restraint or deprivation of liberty linked to catheter care, including preventing a resident from removing a catheter, using clothing or equipment to restrict access, or close supervision for the purpose of preventing removal, must be lawful, necessary, proportionate, documented, reviewed and escalated in accordance with the home’s Mental Capacity, Deprivation of Liberty Safeguards and Restrictive Practice policies.

5. Staff Training, Competency and Responsibilities

The service provider will ensure that staff involved in catheter care are suitably trained, competent, supervised and supported for the tasks they undertake. Training and competency must be proportionate to the staff member’s role and the needs of residents using the service.

All staff who support residents with catheter care must receive training appropriate to their role, including:

• dignity, privacy and person-centred catheter care;
• hand hygiene and standard infection control precautions;
• safe use of PPE;
• safe positioning and emptying of drainage bags;
• maintaining a closed drainage system;
• recognising catheter complications;
• recognising possible CAUTI, sepsis and deterioration;
• hydration and UTI prevention;
• skin integrity and pressure damage prevention;
• documentation and escalation;
• consent, mental capacity and best interests;
• safe waste disposal;
• the limits of their role and when to seek clinical advice.

Registered nurses and any staff undertaking delegated catheter-related clinical tasks must receive task-specific training and competency assessment before undertaking those tasks. This includes, where relevant, catheter insertion, catheter removal, catheter change, catheter valve management, catheter specimen collection, bladder scanning, catheter flushing/washout or supporting TWOC. Staff must not undertake any catheter-related clinical procedure unless it is within their role, authorised, documented, and supported by training and competency assessment.

The registered manager is responsible for ensuring that staff training records, competency assessments and refresher training are maintained. Competency must be reviewed where practice concerns arise, following incidents, when guidance changes, when a resident’s needs change, and at intervals determined by the service provider or local Health Board guidance.

Staff must work within their professional boundaries and must seek advice from a registered nurse, GP, district nurse, continence specialist, pharmacist, out-of-hours service or emergency service where catheter care needs are complex or where the resident deteriorates.

6. Documentation and Records

Accurate, timely and factual records must be maintained for all catheter care. Records must be completed in accordance with the home’s record keeping, confidentiality and data protection procedures.

The following information must be recorded in the resident’s care records and/or catheter record, where applicable:

• reason for catheterisation;
• catheter type, size and balloon volume, where known;
• route of catheterisation, such as urethral or suprapubic;
• date of insertion or last catheter change;
• next planned review or change date;
• drainage system used;
• catheter fixation or support device used;
• daily catheter care provided;
• urine output monitoring, where required;
• fluid intake monitoring, where required;
• catheter site and skin observations;
• signs of pain, discomfort, leakage, blockage or infection;
• urine samples requested or obtained, including reason and method;
• advice received from healthcare professionals;
• actions taken following concerns;
• resident consent, refusal or best-interest decision where relevant;
• communication with family, representatives or advocates where appropriate.

Where a catheter passport is used, staff must ensure it is updated and accompanies the resident when attending appointments, being admitted to hospital, returning from hospital, or transferring between services.

7. Escalation, Incidents and CIW Notifications

Staff must escalate catheter-related concerns promptly in accordance with the resident’s personal plan, clinical advice, local Health Board guidance and the home’s incident reporting procedures.

Urgent clinical advice must be sought where a resident has no urine draining, suspected blockage, severe pain, haematuria, suspected catheter-associated UTI, suspected sepsis, fever, rigors, acute confusion, deterioration, accidental catheter removal, trauma, or any other concern that may place the resident at risk of harm.

Catheter-related incidents must be recorded, investigated and reviewed. This includes catheter-associated infection, avoidable blockage, accidental removal, trauma, avoidable hospital admission, medication or antibiotic-related concerns, delayed escalation, documentation failures and any care that did not follow the resident’s personal plan.

The registered manager and responsible individual must ensure that incidents are reviewed for learning and that action is taken to reduce recurrence. Themes must be considered as part of quality assurance, infection prevention and control audits, staff supervision, training and the quality-of-care review.

CIW must be notified, using CIW Online, where a catheter-related incident meets the threshold for notification, including serious injury, serious illness, death, an outbreak of infectious disease, or any event that prevents or could prevent the service from continuing to be provided safely. The Health Board and other relevant agencies must also be notified where required.

8. Related Policies

• CHW07 – Person-Centred Care Policy
• CHW11 – Safe Care and Treatment Policy
• CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CHW17 – Infection Prevention and Control Policy
• CHW18 – Risk Management and Assessment Policy
• CHW21 – Medication Management and Administration Policy

9. Monitoring, Audit and Review

This policy will be reviewed at least annually, or sooner where there are changes to legislation, Welsh Government statutory guidance, CIW expectations, NICE guidance, Public Health Wales guidance, local Health Board guidance, incidents, audit findings or identified learning.

The registered manager will ensure that catheter care is monitored through the home’s governance, audit and quality assurance systems. Monitoring will include, where applicable:

• review of catheter care plans and personal plans;
• review of catheter records and catheter passports;
• infection prevention and control audits;
• hand hygiene and PPE audits;
• review of catheter-associated infections;
• review of urine sampling practice;
• review of antibiotic prescribing themes where information is available;
• review of catheter blockages, bypassing, leakage and accidental removal;
• review of avoidable hospital admissions linked to catheter care;
• review of staff training and competency records;
• review of incidents, complaints, safeguarding concerns and lessons learned;
• feedback from residents, representatives, staff and visiting professionals.

Audit findings must be recorded and used to improve practice. Where shortfalls are identified, the registered manager must ensure that an action plan is developed, implemented and reviewed. Learning from audits, incidents, complaints and professional advice must be shared with staff through supervision, team meetings, training and policy updates.

The responsible individual must maintain oversight of the quality and safety of catheter care as part of the service’s monitoring, review and improvement arrangements.

---

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.