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Leg Ulcer Management and Prevention Policy

1. Purpose

This policy sets out the arrangements used by {{org_field_name}} for the prevention, identification, assessment, monitoring and management of leg ulcers and lower-limb wounds. Its purpose is to ensure that people we support receive safe, person-centred and evidence-based care and are referred promptly to an appropriate healthcare professional when assessment or treatment falls outside the competence or responsibility of care home staff.

Leg ulcers can have a significant effect on a person’s health, comfort, mobility and quality of life and may be associated with venous disease, arterial disease, diabetes, oedema, infection or other underlying conditions. Inappropriate treatment, including inappropriate use of compression therapy, may cause significant harm. Staff must therefore recognise the limits of their role and must not diagnose the cause of a leg ulcer, select clinical treatment or initiate compression therapy unless they are appropriately qualified, trained, competent and authorised to do so.

The aims of this policy are to:

• promote early recognition and prevention of skin breakdown and lower-limb ulceration;
• ensure that any new or deteriorating leg ulcer is promptly assessed and appropriately escalated;
• ensure that treatment follows an individualised care and treatment plan provided or agreed by an appropriately qualified healthcare professional;
• reduce the risk of avoidable harm, infection, pain, deterioration and delayed healing;
• ensure that compression therapy is used only following appropriate clinical and vascular assessment and in accordance with an authorised treatment plan;
• support adequate nutrition and hydration where these are relevant to skin integrity and wound healing;
• ensure that people’s consent, capacity, choices, preferences, dignity and privacy are respected;
• ensure accurate, complete and contemporaneous documentation of assessment, treatment, monitoring and escalation;
• promote effective multidisciplinary working with GPs, community nurses, tissue viability services, vascular services, podiatrists and other relevant professionals; and
• ensure that staff undertaking any aspect of wound care are appropriately trained, competent, supervised and working within the limits of their role.

This policy supports compliance with the Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including:

• 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; and
• Regulation 20 – Duty of candour, where applicable.

This policy applies to all staff involved in supporting people who are at risk of, or have, a leg ulcer or other lower-limb wound. Staff must work within their training, competence, professional registration where applicable, delegated responsibilities and the person’s agreed care and treatment plan.

2. Scope

This policy applies to:

• People we support who are at risk of developing leg ulcers or require treatment.
• Registered nurses, care staff, and senior carers, who are responsible for ulcer prevention and management.
• External healthcare professionals, including GPs, tissue viability nurses, podiatrists, and wound care specialists.
• Management staff, who must ensure compliance with this policy and support staff training.

3. Legal and Regulatory Compliance

{{org_field_name}} will manage the prevention, recognition and care of leg ulcers in accordance with applicable legislation, regulatory requirements and current evidence-based clinical guidance.

The principal requirements relevant to this policy include:

• Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:
  • Regulation 9 – Person-centred care: care and treatment must be appropriate, meet the person’s needs and reflect their preferences. Assessment and care planning relating to leg ulcers must take account of the person’s clinical needs, wishes, goals and individual circumstances.
  • Regulation 10 – Dignity and respect: wound assessment and treatment must protect the person’s privacy and dignity and support their autonomy and independence.
  • Regulation 11 – Need for consent: care and treatment must only be provided with valid consent unless another lawful basis applies. Where a person aged 16 or over lacks capacity to make the relevant decision, staff must act in accordance with the Mental Capacity Act 2005.
  • Regulation 12 – Safe care and treatment: risks to the person’s health and safety must be assessed and mitigated. Care and treatment must be provided safely by staff who have the qualifications, competence, skills and experience required for the task. Appropriate infection prevention and control arrangements must be followed.
  • Regulation 13 – Safeguarding service users from abuse and improper treatment: neglect, including failure to obtain appropriate assessment or treatment for a wound or failure to respond to avoidable deterioration, must be recognised and addressed through the organisation’s safeguarding procedures where the circumstances indicate abuse or neglect.
  • Regulation 14 – Meeting nutritional and hydration needs: people’s nutritional and hydration needs must be assessed and met where the regulation applies. Where nutrition or hydration may affect wound healing, concerns must be identified, documented and escalated to an appropriate healthcare professional.
  • Regulation 17 – Good governance: the service must maintain effective systems for assessing, monitoring and improving the quality and safety of care, managing risk, and maintaining secure, accurate, complete and contemporaneous records of care and treatment and associated decisions.
  • Regulation 18 – Staffing: sufficient numbers of suitably qualified, competent, skilled and experienced staff must be deployed. Staff must receive the training, supervision, support and professional development required to perform their duties safely.
  • Regulation 20 – Duty of candour: the service must act openly and transparently. Where deterioration, treatment or another event meets the statutory definition of a notifiable safety incident, the registered person must follow the organisational Duty of Candour procedure.
• Mental Capacity Act 2005: where there is reason to doubt a person’s capacity to make a particular decision about wound assessment or treatment, capacity must be assessed in relation to that specific decision. Where the person lacks capacity, any decision made on their behalf must comply with the Mental Capacity Act 2005, including the statutory best-interests requirements.
• Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance: wound care must be undertaken using infection prevention and control practices appropriate to the procedure, the person’s clinical circumstances and the environment.
• Current NICE guidance relevant to the individual person’s condition, including guidance concerning venous disease, leg-ulcer infection and clinically appropriate compression therapy.
• Current local NHS wound-care, tissue-viability and vascular pathways: where a person’s NHS healthcare professionals have issued an individual wound-care or treatment plan, staff must follow that plan within the limits of their role and competence and must seek clarification where instructions are unclear, contradictory, incomplete or appear unsafe.

Clinical guidance does not replace individual professional judgement. Where the person’s condition falls outside the scope or competence of care home staff, advice must be sought promptly from an appropriately qualified healthcare professional.

4. Leg Ulcer Prevention Strategies

4.1 Risk Assessment for Leg Ulcers

On admission, and subsequently in accordance with assessed need, people must have their skin integrity and relevant risk factors assessed as part of their overall care assessment.

The assessment must consider, where relevant:

• previous or current leg ulcers or other wounds;
• diabetes;
• peripheral arterial disease or other known vascular disease;
• varicose veins and chronic venous insufficiency;
• previous deep vein thrombosis;
• lower-limb oedema;
• reduced mobility or prolonged immobility;
• impaired sensation or neuropathy;
• skin condition and any redness, discolouration, dryness, eczema, leakage or skin breakdown;
• pain or changes in pain;
• nutritional and hydration risks;
• smoking history where clinically relevant;
• footwear and potential sources of trauma;
• the person’s ability to inspect and care for their own skin; and
• any previous treatment, compression therapy or specialist advice.

Where a person is identified as being at increased risk, this must be reflected in their individual care plan with appropriate preventive measures, monitoring arrangements and escalation instructions.

Any new break in the skin of the lower leg, suspected leg ulcer, unexplained deterioration, change in colour or temperature of the limb, increasing oedema, increasing pain or other concerning change must be promptly reported to the nurse in charge or senior person and referred for clinical assessment as appropriate.

A pressure-ulcer risk assessment or general skin assessment must not be used as a substitute for appropriate clinical assessment of a leg ulcer.

Where compression therapy is being considered, the person’s arterial circulation must be appropriately assessed by a suitably trained and competent healthcare professional in accordance with the relevant clinical pathway. This may include ankle brachial pressure index assessment or another vascular assessment where clinically appropriate.

Care home staff must not assume that an ulcer is venous solely from its appearance or from the presence of oedema or varicose veins.

4.2 Preventative Measures

Preventive measures must be based on the person’s individual assessment, underlying conditions, mobility, preferences and professional advice.

Staff must, where appropriate:

• support regular movement and mobility in accordance with the person’s abilities and care plan;
• avoid prolonged immobility where this can safely be reduced;
• support good skin hygiene and the use of prescribed or recommended emollients and skin-care products;
• monitor the legs and feet for skin damage, oedema, colour changes, pain, leakage or other deterioration and report concerns promptly;
• support adequate nutrition and hydration in accordance with the person’s assessed needs and care plan;
• follow recommendations from dietitians or other healthcare professionals where nutritional supplementation or specialist dietary support has been prescribed;
• support appropriate leg positioning where this has been advised as part of the person’s clinical care plan;
• reduce avoidable trauma to the lower limbs;
• support the use of appropriate footwear where relevant; and
• follow individual advice from community nurses, tissue viability services, vascular services, podiatrists or other relevant healthcare professionals.

Compression stockings, hosiery, wraps or compression bandaging used for the prevention, treatment or recurrence prevention of venous leg ulceration must only be used where clinically appropriate and in accordance with an assessment, prescription or treatment plan from an appropriately qualified healthcare professional.

Staff must not independently commence, increase, reduce or materially alter prescribed compression therapy unless they are appropriately qualified, trained, competent and authorised to make that clinical decision.

Any new pain, numbness, unusual coldness, marked colour change, swelling, skin damage or other deterioration associated with compression must be escalated promptly and managed in accordance with the person’s clinical treatment plan and local escalation procedure.

5. Managing Leg Ulcers

5.1 Identifying and Documenting Leg Ulcers

Where a new leg ulcer or lower-limb wound is identified, staff must ensure prompt clinical escalation and accurate documentation.

The initial record must include, as far as can be safely assessed within the staff member’s competence:

• the date and time the wound was identified;
• the anatomical location;
• the circumstances in which it was discovered;
• the person’s symptoms, including pain;
• observable wound and surrounding-skin characteristics;
• any bleeding, exudate, odour, swelling, redness, heat, discolouration or other concerning feature;
• relevant changes in the person’s general condition;
• action taken;
• the healthcare professional or senior staff member contacted;
• advice received;
• the treatment or monitoring plan; and
• the date or circumstances for further review.

Formal wound measurements, wound classification, vascular assessment or other clinical assessments must be undertaken only by staff who are trained, competent and authorised to undertake them.

Where the organisation uses wound photographs, valid consent must be obtained before photography unless another lawful basis applies. The person must be informed why the photograph is being taken, how it will be used and how it will be stored. Where the person lacks capacity to make the relevant decision, the Mental Capacity Act 2005 must be followed. Photographs must be taken, stored, accessed and shared securely in accordance with the organisation’s information-governance arrangements.

Wound assessment records must be accurate, complete and contemporaneous. Subsequent reviews must record whether the wound is improving, static or deteriorating and any changes to pain, wound characteristics, treatment or clinical instructions.

Any unexpected deterioration must be escalated promptly rather than waiting until the next routine wound review.

5.2 Wound Care and Dressing Application

Wound care must be provided in accordance with an individual clinical wound-care plan and within the competence and authorised role of the staff member undertaking the procedure.

Registered nurses and any other staff undertaking delegated wound-care procedures must have received appropriate training and must have been assessed as competent for the procedure concerned.

Staff must:

• confirm the person’s identity and explain the procedure;
• obtain valid consent before treatment, or follow the Mental Capacity Act 2005 where the person lacks capacity for the relevant decision;
• protect the person’s privacy, dignity and comfort;
• assess and manage pain in accordance with the person’s care plan and prescribed medicines;
• follow the wound-care plan regarding cleansing, dressings, topical products and frequency of dressing changes;
• use aseptic or other appropriate wound-care technique in accordance with the clinical procedure, local infection-prevention procedures and professional guidance;
• perform hand hygiene before and after the procedure;
• use appropriate personal protective equipment;
• use wound-care products only as directed within the person’s treatment plan or according to an appropriately authorised clinical decision;
• dispose of contaminated dressings and clinical waste safely;
• document the care provided and the condition of the wound; and
• escalate any deterioration or deviation from the expected healing plan.

Staff must not independently substitute dressings, commence antimicrobial dressings, apply topical antiseptics or alter prescribed treatment unless they are appropriately qualified, competent and authorised to make that decision.

The presence of a leg ulcer does not in itself establish that the ulcer is clinically infected. Staff must monitor for and promptly report signs and symptoms that may indicate infection, including:

• spreading redness or swelling beyond the ulcer;
• localised warmth;
• increasing or new pain;
• purulent discharge;
• rapidly increasing wound deterioration;
• fever or other systemic symptoms; or
• signs that the person is becoming acutely unwell.

Where infection is suspected, an appropriately qualified healthcare professional must assess the person and determine whether antimicrobial treatment or further investigation is required.

Staff must follow the person’s prescribed treatment and must monitor and report failure to improve, adverse effects or deterioration.

5.3 Referral and Escalation

Leg ulcers must be managed through appropriate NHS and specialist referral pathways according to their suspected cause, severity, duration, response to treatment and the person’s overall clinical condition.

Staff must seek assessment from the person’s GP, community nursing service or other appropriate healthcare professional when:

• a new leg ulcer or unexplained lower-limb wound is identified;
• an existing wound deteriorates;
• there is increasing or uncontrolled pain;
• infection is suspected;
• treatment is not producing the expected improvement;
• there is uncertainty about the wound-care plan;
• compression therapy is being considered and appropriate vascular assessment has not been completed; or
• the person’s clinical condition changes in a way that may affect wound healing or treatment.

A person with a venous leg ulcer, defined for the purposes of the relevant NICE vascular referral guidance as a break in the skin below the knee that has not healed within two weeks, must be referred through the appropriate vascular pathway. A person with a healed venous leg ulcer must also be considered for referral to a vascular service in accordance with current clinical guidance.

Relevant referrals may include:

• the GP;
• community nursing services;
• tissue viability services;
• a vascular service;
• podiatry, particularly where there is diabetes, foot pathology or other relevant foot-related risk;
• diabetes specialist services;
• dietetic services where nutritional risk is affecting or may affect wound healing; and
• other specialist services according to clinical need.

Referral must not be delayed solely because a wound is already receiving dressings or appears superficially stable.

Where a referral has been made, staff must document the referral, follow up outstanding appointments or advice where necessary, communicate relevant information to the receiving professional and update the person’s care plan following specialist assessment.

5.4 Consent, Mental Capacity and Best Interests

Care and treatment relating to a leg ulcer must not be provided without the person’s valid consent unless there is another lawful basis for doing so.

Before assessment or treatment, staff must provide information in a form the person can understand about the proposed care, including its purpose and any material risks, benefits or alternatives relevant to the decision.

A person must not be assumed to lack capacity because they make a decision that staff or healthcare professionals consider unwise.

Where there is reason to doubt the person’s capacity to make a particular decision about wound assessment, dressings, compression therapy, photography, referral or another aspect of treatment, a decision-specific capacity assessment must be undertaken in accordance with the Mental Capacity Act 2005.

Where the person lacks capacity for the relevant decision:

• any decision made on their behalf must be in their best interests;
• the person’s wishes, feelings, values and beliefs must be considered;
• appropriate family members, attorneys, deputies or others must be consulted where required and appropriate;
• any valid and applicable advance decision or lawful authority held by an attorney or deputy must be respected;
• the least restrictive appropriate option must be considered; and
• the assessment and best-interests decision must be documented.

Refusal of wound care by a person who has capacity must be respected. Staff must explain relevant risks, record the refusal and information provided, and promptly inform the appropriate healthcare professional where refusal may place the person’s health at risk.

5.5 Compression Therapy

Compression therapy is a clinical intervention and must be managed safely.

Compression bandages, hosiery or wraps intended to treat a leg ulcer or manage venous disease must only be commenced following appropriate assessment by a suitably qualified and competent healthcare professional and in accordance with the person’s authorised treatment plan.

Before therapeutic compression is commenced, the person’s arterial circulation must be assessed as clinically appropriate to identify whether arterial disease is present and whether the proposed level and type of compression are safe.

Staff applying compression must:

• be trained and assessed as competent in the specific compression system they are using;
• follow the prescribed or authorised treatment plan;
• use the correct product, size and application technique;
• monitor the person’s skin condition, comfort, circulation-related symptoms and tolerance;
• document application and relevant observations; and
• escalate concerns promptly.

Care staff who have not been trained and assessed as competent must not independently apply compression bandaging or alter a compression regimen.

Staff must seek urgent clinical advice where a person receiving compression develops new or worsening:

• severe or disproportionate pain;
• numbness or altered sensation;
• unusual coldness of the foot or limb;
• pallor, cyanosis or other significant colour change;
• significant swelling;
• skin damage caused by the compression system; or
• any other sign suggesting compromised circulation.

Compression must not simply be continued despite signs of possible circulatory compromise. Staff must follow the clinical treatment plan and obtain urgent professional advice.

5.6 Deterioration and Emergency Escalation

Staff must recognise that deterioration of a leg ulcer or lower limb can indicate a serious or time-critical condition.

Immediate emergency assessment must be sought through the appropriate emergency pathway where the person has signs or symptoms suggesting a life-threatening or limb-threatening condition, including:

• suspected sepsis or severe systemic infection;
• sudden or severe deterioration in the person’s general condition;
• signs of acute limb ischaemia, such as sudden severe pain, a cold or markedly pale or discoloured limb, new loss of sensation or new loss of movement;
• uncontrolled or significant bleeding;
• suspected deep vein thrombosis accompanied by symptoms requiring urgent medical assessment; or
• any other clinical emergency.

Urgent same-day clinical assessment must be obtained where there is rapidly spreading redness or swelling, rapidly worsening wound deterioration, significant new pain, suspected infection, suspected vascular compromise or another significant change that cannot safely wait for routine review.

Staff must not wait for a scheduled dressing change, routine GP round or weekly wound review where the person’s condition indicates that earlier assessment is required.

All deterioration, escalation, advice received and action taken must be documented contemporaneously and communicated to relevant staff at handover.

Where an incident may constitute a safeguarding concern, notifiable incident or notifiable safety incident, the registered manager must ensure that the relevant safeguarding, CQC notification and Duty of Candour requirements are considered and followed.

6. Staff Training and Responsibilities

The registered provider and registered manager must ensure that staff involved in the prevention, identification, monitoring or treatment of leg ulcers have the knowledge, skills, competence and support appropriate to their role.

All relevant care staff must receive training appropriate to their responsibilities in:

• maintaining skin integrity and recognising skin breakdown;
• recognising signs of deterioration in a leg ulcer or lower limb;
• recognising signs of infection and systemic deterioration;
• knowing when and how to escalate concerns;
• infection prevention and control;
• supporting nutrition and hydration;
• pain recognition and escalation;
• consent and the Mental Capacity Act 2005;
• accurate record keeping; and
• safeguarding, including recognition of neglect related to failure to obtain or provide appropriate wound care.

Registered nurses and any other staff undertaking clinical wound-care procedures must additionally receive role-appropriate education and competency assessment covering the procedures they perform.

Compression bandaging or other specialist compression procedures must only be undertaken by staff who have received appropriate training and have been assessed as competent in the relevant technique and product.

Competence must not be assumed solely because a person has previously undertaken the procedure or attended training. Competence must be assessed and reviewed in accordance with the organisation’s competency framework and when there is a change in procedure, equipment, clinical guidance or identified performance concern.

Staff must:

• work within their competence and professional scope of practice;
• follow the person’s current care and treatment plan;
• seek clarification where clinical instructions are unclear;
• report deterioration promptly;
• maintain accurate and contemporaneous records; and
• escalate any concern where they believe treatment is unsafe, delayed or inconsistent with the person’s assessed needs.

The registered manager must ensure that staff have access to appropriate clinical advice and that training, supervision and competency records are maintained.

7. Monitoring and Continuous Improvement

{{org_field_name}} will operate effective governance arrangements to monitor the quality and safety of leg-ulcer prevention and management and to identify and address avoidable risks.

For each person with a leg ulcer:

• the wound and associated care plan must be reviewed at the frequency specified by the relevant healthcare professional and additionally whenever the person’s condition changes;
• deterioration must trigger prompt reassessment and escalation and must not be left until the next scheduled review;
• records must show the condition of the wound, treatment provided, response to treatment, pain, relevant risks, professional advice, referrals and changes to the treatment plan;
• outstanding referrals, specialist advice and follow-up actions must be monitored to completion; and
• changes to clinical treatment must be incorporated promptly into the person’s care records and communicated to relevant staff.

The registered manager must ensure that governance systems are capable of identifying:

• new and existing leg ulcers;
• wounds that are deteriorating or not progressing as expected;
• delays in assessment, referral or treatment;
• infection-related concerns;
• inappropriate or unauthorised use of compression therapy;
• incidents of missed or incorrect wound care;
• concerns regarding staff competence;
• safeguarding concerns;
• hospital admissions associated with wound deterioration; and
• repeated or systemic failures in care.

Audits must be undertaken at a frequency determined by risk and the needs of the service. Where an audit, incident, complaint, safeguarding enquiry, professional concern or adverse outcome identifies a weakness, the registered manager must ensure that:

• the cause is investigated appropriately;
• immediate risks are addressed;
• an action plan is implemented where required;
• learning is shared with relevant staff;
• staff competence or training is reviewed where necessary; and
• completion and effectiveness of corrective actions are monitored.

People receiving wound care must be given opportunities to express their views about their care and treatment. Relevant feedback must be considered as part of service improvement.

Where an incident meets statutory reporting requirements, the registered manager must ensure that appropriate notifications, safeguarding referrals and Duty of Candour processes are completed.

All governance, audit and improvement records relating to leg-ulcer care must be maintained securely in accordance with the organisation’s record-retention and information-governance requirements.

8. Related Policies

This policy should be read alongside:

• CH11 – Safe Care and Treatment Policy​.
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy​.
• CH16 – Health and Safety at Work Policy​.
• CH17 – Infection Prevention and Control Policy​.
• CH27 – Staff Supervision, Training, and Development Policy​.

9. Policy Review

This policy will be reviewed annually or sooner if required due to updates in clinical guidelines or CQC regulations.

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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}}
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