CH174-Aseptic Technique Policy
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Aseptic Technique Policy
1. Purpose
The purpose of this policy is to outline clear procedures and standards for the use of aseptic technique in home care settings to prevent infection and ensure the safety of the people we support. Aseptic technique is essential during clinical procedures such as wound care, catheterisation, injection administration, and other interventions where there is a risk of introducing harmful microorganisms. This policy ensures compliance with Regulation 12 (Safe Care and Treatment), Regulation 15 (Premises and Equipment), and Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It also supports the application of NICE guidelines and infection control principles within a domiciliary care setting.
2. Scope
This policy applies to all clinical and care staff employed by {{org_field_name}} who are involved in carrying out procedures requiring an aseptic technique in the home care environment. This includes registered nurses, senior care workers trained in specific delegated tasks, and support staff observing or assisting with such procedures. It also applies to agency workers and visiting professionals where care is provided in partnership. The policy ensures all staff understand when and how to apply aseptic technique, the required standards, and their responsibilities for infection prevention and safe care delivery.
3. Related Policies
This policy should be read in conjunction with:
- CH11 – Safe Care and Treatment Policy
- CH17 – Infection Prevention and Control Policy
- CH18 – Risk Management and Assessment Policy
- CH21 – Medication Management and Administration Policy
- CH24 – Management of Accidents, Incidents, and Near Misses Policy
4. Definition and Principles of Aseptic Technique
Aseptic technique refers to a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimising contamination by pathogens. In home care, aseptic technique may be used during wound dressing changes, catheter care, suctioning, and administering injectables. Key principles include maintaining a sterile field, using sterile equipment, performing effective hand hygiene, avoiding contact with non-sterile surfaces, and maintaining good environmental hygiene. There are two main types used in home care: standard aseptic technique and aseptic non-touch technique (ANTT), both of which aim to protect key parts and sites from contamination.
5. Risk Assessment and Decision-Making
Before any procedure requiring aseptic technique, a clinical risk assessment must be carried out to determine whether aseptic or clean technique is required. The decision depends on the person’s condition, the nature of the procedure, and the environment. The care plan must reflect this decision and clearly document when aseptic technique is required. The assessment should also identify risks such as immunosuppression, existing infection, wound type, or recent surgery. Aseptic technique is the default for invasive procedures and for individuals at higher risk of infection.
6. Preparation and Environment
Home environments can vary in their cleanliness and suitability for clinical procedures. Staff must assess the environment and make necessary adjustments to reduce the risk of contamination. This may include:
- Asking for a clean, well-lit surface to set up equipment
- Reducing foot traffic during the procedure
- Ensuring pets or distractions are removed
- Using protective sheeting to create a clean area
If the environment is not suitable, staff must raise concerns with the Registered Manager and consider whether the procedure should be rescheduled or relocated.
7. Hand Hygiene and Personal Protective Equipment
All aseptic procedures begin with effective hand hygiene, using either soap and water or an alcohol-based hand rub in line with CH17 – Infection Prevention and Control Policy. Hands must be washed before and after the procedure. Gloves must be worn throughout and changed immediately if contamination occurs. Additional PPE such as aprons and masks may be required based on the procedure and individual risk assessment. Gloves do not replace handwashing and must be disposed of using clinical waste procedures after use.
8. Equipment and Sterile Field Management
Only sterile, single-use equipment must be used for aseptic procedures. All packs must be checked for expiry date and integrity of packaging before use. A sterile field must be created using appropriate sterile dressing packs or trays. Once opened, sterile items must be handled using non-touch technique or sterile gloves. Contaminated items must be discarded immediately. If the sterile field is breached at any point, the procedure must be paused and the field re-established. Equipment and waste must be disposed of in line with CH22 – Handling and Disposal of Hazardous Substances Policy.
9. Procedure Protocols
Each clinical procedure requiring aseptic technique must follow a documented protocol in the individual’s care plan. Staff must follow step-by-step guidance specific to the task, whether wound dressing, catheter care, or injectable administration. Clinical judgement must be used to adapt to the person’s needs while maintaining aseptic principles. Procedures must never be rushed or compromised. Communication with the individual is essential throughout to ensure consent, comfort, and understanding. The procedure is documented in full including time, staff name, equipment used, any issues, and the condition of the individual.
10. Training and Competency
Only trained and assessed staff may carry out aseptic procedures. Staff receive training in aseptic technique during induction and must undergo competency assessments prior to being signed off. Refresher training is provided annually or when there is a change in clinical practice. Observational audits are carried out by clinical leads or the Registered Manager to ensure that practice meets expected standards. Staff who do not follow protocol may be removed from clinical duties until further training and reassessment is completed.
11. Monitoring and Quality Assurance
All aseptic procedures must be documented in the care record and reviewed as part of routine care plan reviews. The Registered Manager conducts monthly audits of aseptic practice, including spot checks and reviews of incident logs. Any breaches of aseptic technique, infections following procedures, or concerns raised by staff or families are logged, investigated, and acted upon. Outcomes and learning are recorded and shared with staff as part of reflective practice and continuous improvement under Regulation 17 – Good Governance.
12. Safeguarding and Incident Reporting
If poor aseptic technique results in infection or harm, the matter is reviewed under CH24 – Management of Accidents and Incidents and may be escalated as a safeguarding concern under CH13 – Safeguarding Adults Policy. The individual and their family must be informed in accordance with CH35 – Duty of Candour Policy. Where a notifiable safety incident occurs, this is reported to CQC in line with CH25 – Notification of Other Incidents Policy.
13. Policy Review
This policy will be reviewed annually or sooner in response to new clinical guidance, changes in legislation, audit findings, or learning from incidents. The review will be led by the Registered Manager in consultation with the Infection Control Lead {{org_field_infection_control_lead_name}} and relevant care professionals. Staff will be informed of any changes and provided with updated training if required.
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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