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Registration Number: {{org_field_registration_no}}

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Wound Care and Management Policy

1. Purpose

The purpose of this policy is to ensure that all people supported by {{org_field_name}} receive safe, effective, person-centred wound care that promotes healing, prevents infection, and maintains dignity. This policy aligns with the requirements of Regulation 12 (Safe Care and Treatment), Regulation 9 (Person-Centred Care), and Regulation 13 (Safeguarding from Abuse and Improper Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Our goal is to deliver wound care that is holistic, responsive to clinical need, and based on current evidence-based best practice.

2. Scope

This policy applies to all staff involved in the observation, reporting, monitoring, or direct care of wounds in individuals receiving support from {{org_field_name}}. This includes qualified nurses, care assistants, support workers, and managers. The policy also provides guidance on escalation, partnership working with community health professionals, and documentation standards to support effective multidisciplinary wound management. The policy applies to both acute and chronic wounds, including pressure ulcers, leg ulcers, surgical wounds, traumatic injuries, and skin tears.

3. Related Policies

This policy should be read alongside the following policies:

• CH07 – Person-Centred Care Policy
• CH11 – Safe Care and Treatment Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH17 – Infection Prevention and Control Policy
• CH18 – Risk Management and Assessment Policy
• CH27 – Staff Supervision, Training, and Development Policy
• CH35 – Duty of Candour Policy
• CH36 – Initial Assessment and Care Planning Policy

4. Initial Assessment and Care Planning

All individuals receiving care with existing or at-risk wounds must have a comprehensive wound assessment completed by a suitably trained professional. The assessment must include the wound type, size, depth, exudate level, pain level, surrounding skin condition, and any signs of infection. Pressure ulcer risk assessments (e.g. Waterlow Score) must be used as standard. The resulting care plan must include dressing selection, frequency of review, escalation triggers, pain management, nutrition, and hydration needs. The care plan is personalised and reviewed regularly, and the person being supported (and their family, where appropriate) is involved in all decisions.

5. Roles and Responsibilities

Qualified staff (e.g., registered nurses) are responsible for undertaking wound assessments and delivering or delegating wound care safely. Care staff are responsible for observing, reporting, and documenting any changes to the wound or skin integrity and following the agreed care plan. All staff must know when and how to escalate concerns. The Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, oversees quality assurance, record audits, and training compliance. Collaborative working with GPs, community nurses, tissue viability services, and dietitians is essential for effective management.

6. Infection Prevention and Control

Wound care must always be delivered using infection prevention principles in line with CH17 – Infection Prevention and Control Policy. This includes effective hand hygiene before and after wound care, the use of appropriate PPE, safe disposal of clinical waste, and using aseptic techniques when indicated. Staff must be trained in wound hygiene principles and understand how to prevent cross-contamination between people we support. Equipment used must be clean, stored appropriately, and disposed of or decontaminated in accordance with infection control protocols.

7. Monitoring, Documentation, and Record-Keeping

All wound assessments, treatment, monitoring and care provided must be recorded accurately, completely, contemporaneously and in sufficient detail to demonstrate the care and treatment provided, the person’s response and any action taken. Records must be maintained securely and in accordance with the organisation’s record-keeping, confidentiality and data protection arrangements.

Every wound care episode must include, where applicable:

• the date and time of the assessment, treatment or dressing change;
• the name, role and signature or electronic identification of the staff member completing the record;
• the anatomical location and type of wound;
• the wound classification or category where applicable;
• objective measurements of the wound, including length, width and depth where clinically appropriate;
• the appearance of the wound bed and surrounding skin;
• the nature and amount of exudate;
• any odour;
• the person’s reported or observed level of pain;
• any signs or symptoms of local or systemic infection;
• the dressing or treatment applied;
• any change from the prescribed or agreed wound-care plan and the reason for that change;
• the person’s response to treatment;
• any concerns identified;
• any escalation, referral or professional advice sought or received; and
• any changes made to the person’s care plan or risk assessment.

Wound assessment charts, body maps, pressure-ulcer risk assessments and wound measurement records must be kept up to date and consistent with the person’s current care plan. Changes in wound condition must be clearly identifiable so that deterioration or failure to heal can be recognised promptly.

Where photographic monitoring is clinically appropriate, the purpose of the photograph must be explained to the person and the person’s consent obtained and recorded where they have capacity to make that decision. Where there is reason to doubt the person’s capacity to make the particular decision, capacity must be assessed in accordance with the Mental Capacity Act 2005. Where the person lacks capacity, any decision concerning clinical photography must be made lawfully and in the person’s best interests, taking account of any person authorised to make the relevant decision on their behalf.

Clinical photographs must be taken, transferred, stored, accessed, shared and deleted only through approved organisational systems and in accordance with applicable confidentiality, information-governance and data-protection requirements. Staff must not use personal mobile telephones, personal devices or unauthorised applications to take or store wound photographs.

Records relating to wound care must be available to authorised staff and relevant healthcare professionals where required for safe continuity of care and must be available for governance review, audit and regulatory inspection where appropriate.

8. Escalation and Referral

Any deterioration in a wound, unexpected change in skin integrity or concern regarding a person’s clinical condition must be escalated promptly to an appropriately qualified healthcare professional in accordance with the person’s care plan and the urgency of the situation.

Indicators requiring clinical review or escalation include, but are not limited to:

• increasing redness, heat, swelling or inflammation;
• increasing or unexplained pain;
• purulent or increased exudate;
• malodour;
• bleeding or tissue breakdown;
• increasing wound dimensions or depth;
• wound-edge or surrounding-skin deterioration;
• suspected spreading infection;
• signs or symptoms of systemic infection or sepsis;
• development or deterioration of pressure damage;
• unexpected necrosis;
• failure to progress towards healing within the expected clinical timeframe; or
• any other concern that the person’s condition is deteriorating.

Where there are signs of serious infection, sepsis or another acute deterioration, staff must seek urgent medical assessment or emergency assistance in accordance with the person’s clinical presentation and the organisation’s emergency procedures.

Non-healing, complex, deteriorating or clinically concerning wounds must be referred to the appropriate healthcare professional. This may include the GP, community or district nursing service, Tissue Viability Service, specialist wound-care service, podiatry service or other relevant professional. Referrals must be made without avoidable delay and followed up where necessary.

Where responsibility for wound care is shared between the care home and external healthcare professionals, staff must ensure that relevant information is communicated promptly, that professional instructions are incorporated into the person’s care plan and that responsibility for each aspect of care is clear.

A pressure ulcer must not automatically be treated as evidence of abuse or neglect solely because of its category. Where pressure damage is identified, staff must consider how the damage developed, the care and preventative measures that were in place, whether appropriate professional advice was sought and followed, and whether any act or omission, neglect, abuse or organisational failure may have contributed.

Where severe pressure damage is identified, or where there is concern that pressure damage may be associated with abuse, neglect, an act of omission or poor care, staff must immediately report the concern through the organisation’s incident and safeguarding procedures. The current national safeguarding adults protocol for pressure ulcers and the applicable local authority safeguarding procedure must be followed, including completion of the relevant safeguarding decision-making process where required.

Where there is reasonable cause to suspect abuse or neglect, a safeguarding concern must be raised with the appropriate local authority in accordance with the Care Act 2014, local safeguarding arrangements and the organisation’s Safeguarding Adults from Abuse and Improper Treatment Policy. Any applicable CQC statutory notification must also be submitted without delay.

All escalation, professional advice, referrals, safeguarding decisions and actions taken must be clearly recorded in the person’s care records.

9. Pressure Ulcer Prevention and Management

All people receiving care must have their risk of developing pressure damage considered as part of their assessment and ongoing care. A formal pressure-ulcer risk assessment must be completed where clinically indicated using an appropriate recognised assessment approach, together with professional judgement and assessment of the person’s individual circumstances.

Pressure-ulcer risk assessment must not be treated as a one-off exercise. The person’s risk and preventative care must be reviewed whenever there is a relevant change in condition, mobility, nutritional status, continence, cognition, skin condition, equipment, care setting or other factor that may affect the risk of pressure damage.

People identified as being at risk must have an individualised pressure-ulcer prevention plan. Depending on the person’s assessed needs, this must address relevant matters including:

• skin inspection and skin care;
• mobility and repositioning;
• the frequency and method of repositioning;
• pressure redistribution;
• appropriate mattresses, cushions and other pressure-relieving equipment;
• heel offloading where required;
• continence and moisture management;
• nutritional and hydration needs;
• pain;
• medical devices that may cause pressure;
• the person’s ability and willingness to reposition independently;
• any refusal of recommended preventative care and action taken in response; and
• when clinical review or escalation is required.

The frequency of repositioning must be based on an individual assessment and care plan rather than a routine interval applied to every person. Repositioning carried out, assistance offered and any refusal or inability to reposition must be documented.

Staff must inspect the person’s skin as required by their care plan and must recognise and promptly report early signs of pressure damage, including persistent or non-blanching erythema, changes in skin colour or temperature, pain, changes in tissue consistency and damage associated with medical devices.

Where pressure damage is identified, it must be assessed and classified by a healthcare professional with the necessary competence. The assessment, classification, location, dimensions and condition of the pressure damage must be recorded and an appropriate treatment and prevention plan implemented.

Pressure damage must be reviewed at clinically appropriate intervals and whenever deterioration is suspected. Any deterioration, unexpected development of pressure damage or failure to improve must be escalated promptly to the appropriate healthcare professional.

Where a pressure ulcer of grade/category 3 or above develops after the person has started using the service, the Registered Person must ensure that the incident is considered against the statutory serious-injury notification requirements and notified to the Care Quality Commission without delay where required under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Pressure damage present when a person is admitted or transferred into the service must be assessed and documented promptly, including its condition on arrival and any information available about when and how it developed. The receiving service must obtain relevant information from the transferring provider where necessary to ensure continuity of care and to establish the circumstances surrounding the damage.

The presence of a Category 3 or Category 4 pressure ulcer does not, by itself, establish abuse or neglect. Safeguarding action must be determined in accordance with Section 8 of this policy, current national pressure-ulcer safeguarding guidance and local safeguarding procedures.

All pressure-ulcer incidents must be subject to appropriate clinical review and organisational incident-management processes so that immediate risks are addressed and any necessary learning or improvement action is identified.

10. Pain and Holistic Support

Wound pain must be assessed and managed effectively. Staff must offer reassurance and treat the person with compassion and dignity at all times. Care must consider nutritional needs, hydration, mental wellbeing, and any fears the individual may have around treatment. Where appropriate, referrals to dietitians, occupational therapists, or psychological services may be made. The care approach must respect individual preferences, cultural beliefs, and consent. Dignity and privacy are upheld in every interaction, in line with CH08 – Dignity and Respect Policy.

10.1 Consent, Mental Capacity and Best Interests

Wound assessment, examination, dressing changes, treatment, photography and other wound-care interventions must only be undertaken with valid consent or other lawful authority.

Before seeking consent, staff must provide the person with information about the proposed wound care in a form and manner they can understand. Where relevant, this must include the purpose of the treatment, what it involves, foreseeable risks or discomfort, available alternatives and the potential consequences of refusing or delaying treatment.

Consent is an ongoing process and must not be assumed simply because the person previously agreed to wound care. Staff must continue to seek and respect the person’s consent during care and treatment. A person who has capacity may refuse or withdraw consent, even where staff or healthcare professionals consider the proposed treatment to be beneficial.

Where a person refuses wound assessment, repositioning, dressing changes or other recommended care, staff must:

• respect the person’s decision where they have capacity to make it;
• explain the relevant risks and potential consequences in a manner the person can understand;
• explore the person’s reasons for refusing;
• consider whether reasonable adjustments or alternative approaches could make the intervention acceptable;
• escalate significant clinical risk to the appropriate healthcare professional;
• update the risk assessment and care plan where required; and
• record the discussion, the person’s decision and the action taken.

A person must be presumed to have capacity unless it is established otherwise. A person must not be treated as unable to make a decision merely because they make a decision that others consider unwise. All practicable steps must first be taken to support the person to understand, retain, use or weigh the relevant information and communicate their decision.

Where there is reasonable doubt about a person’s capacity to make a particular wound-care decision, an assessment of capacity must be undertaken and recorded in accordance with the Mental Capacity Act 2005. Capacity assessments must relate to the specific decision that needs to be made at the relevant time.

Where the person lacks capacity to make the particular decision, any decision or act on their behalf must comply with the Mental Capacity Act 2005 and be in their best interests. Relevant wishes, feelings, beliefs and values must be considered and appropriate persons must be consulted, including anyone lawfully authorised to act on the person’s behalf, where applicable.

Any valid and applicable advance decision to refuse treatment, Health and Welfare Lasting Power of Attorney, Court-appointed deputy or relevant Court of Protection decision must be identified and respected within its lawful scope.

Where there is disagreement, significant uncertainty or a serious decision concerning treatment for a person who lacks capacity, staff must seek appropriate senior, clinical or legal advice in accordance with organisational procedures.

Consent, capacity assessments, best-interests decisions, refusals of care and any involvement of representatives must be clearly documented in the person’s records.

11. Training and Competency

Only trained and assessed staff are permitted to undertake wound care procedures. Training is delivered internally and through external clinical partners such as the local district nursing team. All care staff receive training in skin integrity, pressure ulcer prevention, and basic wound care principles. Competency checks are completed annually and more frequently where needed. Supervision and spot checks ensure quality and consistency. Records of training and competencies are maintained and audited by the Registered Manager.

12. Partnership Working

{{org_field_name}} maintains strong links with local NHS services and other professionals to ensure people receive high-quality, joined-up care. We work closely with GPs, community nursing teams, tissue viability nurses, palliative care teams, and local pharmacies. Referrals are timely and followed up, and joint care planning is undertaken where needed. Records of multidisciplinary involvement are kept in the individual’s care file and updated after every intervention.

13. Duty of Candour

{{org_field_name}} will act in an open and transparent way with people receiving care and treatment and with persons lawfully acting on their behalf.

Where a wound-related event may constitute a notifiable safety incident under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Registered Manager or other authorised senior person must ensure that the statutory duty of candour requirements are considered and applied.

A notifiable safety incident must be identified by applying the statutory criteria in Regulation 20. The fact that an adverse outcome has occurred does not, by itself, determine whether an incident is a notifiable safety incident. The circumstances of the incident and the applicable statutory harm threshold must be considered.

As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred, {{org_field_name}} must:

• notify the relevant person that the incident has occurred;
• provide the relevant person with reasonable support;
• give, in person where required by Regulation 20, an account of all facts known at that time that is truthful to the best of the organisation’s knowledge;
• explain what further enquiries or investigation the organisation considers appropriate;
• provide an apology;
• make a secure written record of the notification and discussion; and
• subsequently provide written notification containing the information provided, details of further enquiries, the results of those enquiries when available and an apology.

Where the relevant person cannot be contacted in person or declines to speak with the organisation’s representative, the requirements of Regulation 20 concerning attempted contact must be followed and a written record of the attempts made must be retained.

The statutory duty of candour does not prevent or replace immediate clinical treatment, safeguarding action, incident reporting, investigation, communication with healthcare professionals or any statutory notification to the Care Quality Commission.

Where an incident does not meet the statutory definition of a notifiable safety incident, staff must nevertheless continue to act openly and transparently with the person and/or their lawful representative in relation to the care and treatment provided.

Any wound-related incident associated with avoidable harm, missed care, delayed treatment, failure to follow a care plan or other potential service failure must be reported through the organisation’s incident-management procedures. Appropriate review or investigation must be undertaken to establish what occurred, identify contributory factors, take remedial action and reduce the risk of recurrence.

All duty of candour discussions, notifications, correspondence, apologies, support provided, investigations and resulting actions must be documented and retained securely.

14. Policy Review

This policy will be reviewed annually or sooner if national guidance, legislation, or local commissioning requirements change. The review will be led by the Registered Manager in collaboration with clinical leads and infection prevention officers. Feedback from staff, people we support, and inspectors will also inform the review.

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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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