CH147-Wound Care and Management Policy
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Registration Number: {{org_field_registration_no}}
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
Every wound care episode must be clearly documented, including date, time, staff member, type of dressing used, wound appearance, and any changes or concerns. Photographic records may be used with the individual’s consent. Wound care charts must be kept up to date and matched against the care plan. Body maps and wound measurement tools (e.g. tracings or digital measurements) are to be used to support objective monitoring. Good documentation is essential for continuity of care and safeguarding. Records must be accessible for audits and reviews.
8. Escalation and Referral
Staff must escalate wound care concerns promptly to ensure safe care. Indications for escalation include increased redness or swelling, purulent discharge, foul odour, increased pain, non-healing, signs of systemic infection (e.g. fever), or any concern that a wound is deteriorating. Wounds not improving within the expected timeframe must be referred to the community nurse or GP. Complex or non-healing wounds must be referred to the Tissue Viability Nurse. In any case of suspected abuse, neglect or pressure ulcer of category 3 or 4, safeguarding procedures and Regulation 13 guidance must be followed immediately.
9. Pressure Ulcer Prevention and Management
People we support who are immobile, malnourished, or with reduced sensation are at risk of developing pressure ulcers. These individuals must be assessed regularly, repositioned according to care plans, and provided with appropriate pressure-relieving equipment. All staff are trained to identify early signs of skin damage (e.g. non-blanching erythema) and take preventative action. Pressure ulcers must be graded according to NHS guidelines and recorded with appropriate treatment plans. Category 3 and 4 ulcers must be reported to CQC under Regulation 18 – Notification of Other Incidents.
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.
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
In line with Regulation 20 and CH35 – Duty of Candour Policy, if a significant wound-related incident occurs (e.g. missed care resulting in pressure ulcer development), the affected individual and/or their representative must be informed in an open and transparent way. A written apology is provided, and a full investigation is undertaken. We use such incidents to reflect, learn, and prevent recurrence.
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.
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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