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Registration Number: {{org_field_registration_no}}

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Comprehensive Tracheostomy Care and Support Policy

1. Purpose

The purpose of this policy is to establish a clear and comprehensive approach to the safe management and support of individuals with a tracheostomy at {{org_field_name}}. This policy supports compliance with the Health and Social Care Act 2008 and the associated regulatory framework for registered providers, including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Fundamental Standards) and the Care Quality Commission (Registration) Regulations 2009. In particular, this policy is designed to evidence how the service meets Care Quality Commission (CQC) expectations relating to safe care and treatment, governance, staffing, openness and transparency following incidents, and statutory notifications to the CQC. It prioritises the safety, dignity, and well-being of service users while maintaining a high standard of care and promoting staff competence.

2. Scope

This policy applies to all staff members involved in the care and support of service users with a tracheostomy, including registered nurses, care assistants, and allied health professionals. It encompasses routine care, emergency management, training requirements, and collaboration with healthcare providers. This policy applies whether the tracheostomy is temporary or permanent, ensuring continuity of care across all stages.

3. Policy Statement

{{org_field_name}} is committed to providing safe, person-centred, and evidence-based tracheostomy care. All service users with a tracheostomy will receive individualised care plans, regular assessments, and appropriate interventions to maintain airway patency, prevent complications, and promote comfort and quality of life. This policy ensures that staff are adequately trained and competent in delivering tracheostomy care, including emergency procedures.

3.1 Regulatory requirements this policy evidences

This policy should be read alongside related organisational policies (including safeguarding, infection prevention and control, medicines management, complaints, governance, staff training and development, and record keeping). It is intended to provide evidence of compliance with relevant Care Quality Commission (CQC) requirements, including:

Regulation 12 (Safe care and treatment): Care and treatment is delivered safely; risks are assessed and mitigated; equipment is safe, available and used correctly; infection risks are controlled; and deterioration is recognised and escalated appropriately.

Regulation 17 (Good governance): Systems and processes are in place to assess, monitor and improve the quality and safety of care (including audits, competency sign-off, equipment checks, incident learning, and record quality).

Regulation 18 (Staffing): Sufficient numbers of suitably qualified, competent and skilled staff are deployed, including role-specific training, supervision and competency assessment for tracheostomy care.

Regulation 20 (Duty of candour): The service acts in an open and transparent way with the person using the service (and/or relevant person) following a notifiable safety incident, provides an apology, and keeps a clear written record of the actions taken.

CQC Registration Regulations 2009, Regulation 18 (Notification of other incidents): The service notifies the CQC of notifiable events within required timescales and keeps an auditable record of notifications made.

4. Best Practice Procedures

4.1 Initial Assessment and Care Planning

Upon admission of a service user with a tracheostomy, a comprehensive assessment will be conducted by a registered nurse. This assessment includes the reason for the tracheostomy, type and size of the tracheostomy tube, presence of a cuff, frequency of suctioning, and any associated risks or complications.

A personalised tracheostomy care plan will be developed in collaboration with the service user, their family or advocate, and healthcare professionals. The care plan will outline daily care routines, equipment requirements, medication needs, and emergency protocols. It will be reviewed regularly and updated based on the service user’s condition and healthcare recommendations.

Capacity, consent and best-interest decisions: Consent must be sought and documented for tracheostomy-related care wherever the person has capacity to consent to the specific decision. Where there is reason to doubt capacity for a particular decision, a decision-specific mental capacity assessment must be completed and recorded, and any best-interest decision must be made and documented in line with the Mental Capacity Act 2005 and associated guidance. Where restrictions are required to deliver safe care (for example, continuous supervision to prevent unsafe interference with the tracheostomy tube), the service must ensure the appropriate legal safeguards are in place, documented and reviewed.

Essential tracheostomy information (“airway plan / passport”): On admission and after any hospital review, staff must confirm and document: tracheostomy tube brand/type, size, length, cuffed/uncuffed status, presence/type of inner cannula, stoma maturity, ventilation/oxygen requirements, suction route and frequency, humidification method, emergency algorithm, and who to contact for urgent specialist advice. This information must be available at point of care (for example, a bedside emergency summary) and kept consistent with the care plan.

4.2 Daily Tracheostomy Care

Daily tracheostomy care will be provided by trained staff, ensuring cleanliness, comfort, and safety. This includes:

• Tube Cleaning and Maintenance: The tracheostomy site will be cleaned daily, and the tube will be inspected for signs of infection, blockage, or displacement. Inner cannulas, if present, will be changed or cleaned according to clinical guidelines.
• Suctioning: Suctioning will be performed as needed to maintain airway patency, following infection prevention and control practices. Suction pressure will be adjusted appropriately, and staff will monitor for signs of respiratory distress.
• Humidification: Appropriate humidification will be provided to prevent airway dryness and irritation, either through humidified oxygen, a heat and moisture exchanger (HME), or a nebuliser if prescribed.
• Cuff Management: If the tracheostomy tube has a cuff, it will be inflated and deflated according to clinical need, ensuring the pressure remains within safe limits.

4.3 Monitoring and Observation

Service users with a tracheostomy will be closely monitored for signs of complications, including infection, tube blockage, displacement, bleeding, or respiratory distress. Observations will include respiratory rate, oxygen saturation levels, and overall well-being. Any abnormal findings will be reported to the nurse in charge and documented in the care plan.

Regular multidisciplinary reviews will be conducted, involving the GP, respiratory specialist, speech and language therapist (if applicable), and the service user’s family. These reviews will ensure that care remains appropriate and responsive to changing needs.

4.4 Emergency Management

All staff must be trained in recognising and responding to tracheostomy-related emergencies, including tube blockage, displacement, and respiratory arrest. Emergency equipment, including spare tracheostomy tubes (same size and one size smaller), suction devices, oxygen, and airway adjuncts, will be readily available in designated locations.

Emergency readiness controls (must always be in place):

• A standardised emergency response guide must be used (aligned to recognised tracheostomy emergency principles) and must be immediately accessible at point of care.
• Emergency equipment must be checked at the start of each shift (or as defined locally) and after every use; checks must be recorded (date/time, name/signature of checker, items checked, and any action taken).
• Clear escalation criteria must be documented (for example: increased work of breathing, reduced oxygen saturations, bleeding, suspected displacement, repeated suction requirement, or signs of infection/sepsis) and linked to calling 999 and contacting relevant clinicians.
• Staff involved in tracheostomy care must complete regular scenario-based training/drills (including blockage and displacement), and learning must be recorded and acted upon through governance processes.

In case of a tracheostomy emergency:

• Staff will follow the emergency protocol outlined in the service user’s care plan.
• The nurse in charge will be alerted immediately, and emergency services will be contacted if needed.
• Basic life support will be provided if necessary, ensuring the airway is clear and oxygenation is maintained.

4.5 Infection Prevention and Control

Strict infection prevention measures will be followed to minimise the risk of infection. This includes hand hygiene, wearing appropriate personal protective equipment (PPE), and using sterile or single-use equipment for suctioning and tracheostomy care. The tracheostomy site will be inspected daily for redness, swelling, discharge, or other signs of infection.

4.6 Staff Training and Competency

All staff involved in tracheostomy care will undergo specialised training to develop the necessary skills and knowledge. This training includes:

• Anatomy and physiology of the airway.
• Tracheostomy tube types and functions.
• Routine and emergency tracheostomy care.
• Infection prevention and control.
• Communication strategies for service users with a tracheostomy.

Competency assessments will be conducted regularly to ensure staff maintain their skills. Only staff deemed competent will perform tracheostomy care without direct supervision.

Minimum competency governance requirements:

• Competency must be assessed against a documented competency framework covering routine care, suctioning, cuff management (where applicable), humidification, emergency response, escalation, and documentation standards.
• Staff must not provide unsupervised tracheostomy care until competency has been assessed and signed off by an appropriately qualified assessor.
• Competency must be refreshed at least annually and sooner following any tracheostomy-related incident, extended absence, or change in the person’s airway needs.
• The Registered Manager must maintain a training and competency matrix to evidence that sufficient competent staff are available on every shift to meet assessed individual needs (including nights).

4.7 Communication and Emotional Support

Service users with a tracheostomy may face communication challenges and emotional distress. Staff will use alternative communication methods, such as communication boards, writing pads, or speech valves, to facilitate effective interaction.

Emotional support will be provided through regular check-ins, reassurance, and involving the service user in decision-making about their care. Family members and advocates will be kept informed about the service user’s condition and involved in care planning when appropriate.

4.8 Equipment Management and Maintenance

All tracheostomy-related equipment will be maintained in good working order, with regular checks for functionality and cleanliness. This includes suction machines, humidifiers, oxygen supplies, and spare tracheostomy tubes. Expired or damaged equipment will be replaced promptly.

Equipment checks must be recorded on a standard checklist and include: suction device function and charge (where applicable), oxygen supply, humidification equipment availability, spare tracheostomy tubes (same size and one size smaller), inner cannulas where used, tracheostomy ties, dressings, lubrication, and any manufacturer-specific adjuncts. Emergency tracheostomy equipment must be stored together in a clearly labelled “tracheostomy emergency grab box/bag” located at point of care and must accompany the person for internal transfers where clinically required.

4.9 Documentation and Record-Keeping

Accurate and detailed documentation is essential for ensuring continuity of care. Staff will record all aspects of tracheostomy care, including daily care routines, suctioning frequency, observations, changes in condition, and any interventions provided. Care plans will be updated promptly to reflect any changes in the service user’s needs.

Documentation must be contemporaneous, attributable, and sufficiently detailed to evidence safe care and decision-making. Records must include: consent/capacity where relevant; tracheostomy tube details; suction episodes (including indication and outcome, and secretion characteristics where clinically relevant); cuff pressure checks where applicable; humidification method; skin integrity around the stoma; equipment checks; escalation and clinical advice sought; incidents/near misses; and updates to the airway plan/care plan following any change in needs.

4.10 Incident management, Duty of Candour and CQC notifications

Immediate actions and reporting: Any tracheostomy-related incident (including tube blockage, displacement, bleeding, aspiration event, hypoxic episode, unplanned hospital transfer, equipment failure, medication error related to respiratory care, or a near miss) must be made safe immediately, escalated to the nurse in charge without delay, and reported in the organisation’s incident reporting system as soon as possible and always before the end of the shift.

Duty of Candour (Regulation 20): Where an incident meets the definition of a notifiable safety incident, the service will act in an open and transparent way with the person using the service and/or the relevant person. This includes: informing them as soon as reasonably practicable, providing a truthful account of what is known at the time, offering a verbal and written apology, explaining the next steps (including investigation and review), and keeping a clear written record of all Duty of Candour actions and correspondence.

Learning and improvement: Tracheostomy-related incidents and near misses must be reviewed to identify root causes and contributory factors (for example: competency gaps, equipment availability, care planning deficits, documentation issues, or communication failures). Actions must be clearly recorded, time-bound, allocated to a named person, and reviewed for completion and effectiveness through governance processes.

CQC notifications (Registration Regulations 2009, Regulation 18): The Registered Manager (or nominated deputy) must ensure that the CQC is notified of notifiable incidents within required timescales, including incidents affecting the health, safety and welfare of people using the service. A notification log must be maintained showing the incident type, date/time, notification date/time, notifier, and outcome/reference number.

5. Communication

Effective communication is essential for service users with a tracheostomy, as the presence of a tracheostomy tube can significantly affect verbal communication. Staff will adopt alternative communication methods tailored to each service user’s needs. This may include the use of communication boards, writing pads, electronic devices, or non-verbal cues such as gestures and facial expressions.

Where appropriate, speech and language therapists (SLTs) will be consulted to assess the service user’s communication abilities and recommend suitable interventions, such as the use of speaking valves. Staff will be trained to use speaking valves safely, ensuring that the cuff is deflated before application and that the service user is monitored closely for signs of discomfort or respiratory distress.

All staff members will receive training on communication strategies to ensure that service users can express their needs, preferences, and concerns. Emotional support will also be provided, recognising the frustration and anxiety that communication barriers can sometimes cause.

6. Eating and Drinking

Eating and drinking require special consideration for service users with a tracheostomy, as there is an increased risk of aspiration. A multidisciplinary approach will be taken, involving speech and language therapists (SLTs), dietitians, and healthcare professionals to assess swallowing ability and recommend safe practices.

Service users will undergo a swallowing assessment before oral intake is introduced. If the service user is deemed safe to eat and drink orally, appropriate modifications will be made, such as adjusting food texture and fluid consistency to reduce the risk of aspiration.

For those unable to take food and fluids orally, alternative nutrition methods, such as enteral feeding, will be provided based on clinical recommendations. Staff will monitor for signs of aspiration, choking, or respiratory distress during and after meals, documenting all observations in the care plan.

Regular reviews of the service user’s nutritional status and swallowing ability will be conducted, ensuring that any changes in condition are promptly addressed and care plans updated accordingly.

7. Educating People Living with a Tracheostomy

Education is an essential part of empowering service users to manage their tracheostomy confidently and safely. At {{org_field_name}}, we ensure that individuals living with a tracheostomy, as well as their families and caregivers, are provided with comprehensive education tailored to their specific needs and abilities.

7.1 Individualised Education Plans: Each service user will receive a personalised education plan developed in collaboration with healthcare professionals, including respiratory specialists and speech and language therapists. This plan will cover:

• Understanding the purpose and function of the tracheostomy.
• Routine tracheostomy care, including cleaning, suctioning, and tube changes (where applicable and where it is safe for the service user to self-care).
• Recognising signs of infection, blockage, or other complications.
• Safe practices for eating, drinking, and communication.
• Emergency procedures in case of tube displacement or respiratory distress.

7.2 Practical Demonstrations and Resources

Hands-on training sessions will be provided to service users and their caregivers to build confidence in managing the tracheostomy. Educational materials, such as leaflets, videos, and step-by-step guides, will be made available to reinforce learning.

7.3 Ongoing Support and Review

Education will be an ongoing process, with regular reviews conducted to address any concerns, refresh knowledge, and adapt teaching as the service user’s condition or needs change. Staff will remain available to answer questions and provide additional training as required.

By equipping service users with the knowledge and skills they need, {{org_field_name}} ensures that individuals living with a tracheostomy can lead safe, comfortable, and empowered lives.

8. Related 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
• CH27: Staff Supervision, Training, and Development Policy

8.1 Governance, audit and assurance

The Registered Manager is responsible for ensuring ongoing assurance that tracheostomy care is safe, effective and consistently delivered. As a minimum, the service will complete and document:

• quarterly audits of tracheostomy documentation and airway plans;
• monthly checks of training and competency compliance for staff delivering tracheostomy care;
• monthly audit of emergency equipment check records and expiry dates;
• review of all tracheostomy-related incidents and near misses, including action tracking and sharing learning; and
• an annual review of this policy against current CQC guidance and relevant national clinical guidance for tracheostomy care in community settings.

9. Policy Review

This policy will be reviewed at least annually and sooner if there are changes to legislation, CQC guidance, or national clinical guidance, or following a significant tracheostomy-related incident, safeguarding concern, complaint trend, or audit finding. The review will be formally recorded with: version number, author, approver, review date, next review date, and a summary of changes. Superseded versions must be archived in line with the organisation’s document control procedure.

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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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