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Registration Number: {{org_field_registration_no}}

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Catheter Care Policy

1. Purpose

This policy ensures that catheter care at {{org_field_name}} is managed safely, effectively, and in compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (including, where applicable, Regulations 9, 10, 11, 12, 13, 14, 15, 17, 18 and 20), the Care Quality Commission (Registration) Regulations 2009 (including notification requirements), and the Health and Social Care Act 2008: Code of practice on the prevention and control of infections and related guidance. This policy also supports compliance with the CQC assessment framework (Safe/Effective/Caring/Responsive/Well-led) and the Fundamental Standards.

Catheter care must be delivered in a way that maintains dignity, comfort and health, while minimising avoidable infection risk, trauma, blockage and other catheter-related harm.

2. Scope

This policy applies to all staff involved in the assessment, insertion, maintenance, monitoring, and removal of urinary catheters. It includes guidance on infection prevention, documentation, staff training, and person-centred approaches to catheter care.

This policy applies to permanent, bank and agency staff, and to any external clinicians working in the home. Insertion/re-insertion and catheter changes must only be undertaken by a registered healthcare professional or clinician who is trained and assessed as competent. Care staff may provide day-to-day catheter support (for example hygiene, positioning/emptying drainage bags, observation and escalation) only where trained and signed off as competent and where this is within their role and the person’s care plan.

3. Related Policies

• Infection Prevention and Control Policy (CH17)
• Safe Care and Treatment Policy (CH11)
• Risk Management and Assessment Policy (CH18)
• Person-Centred Care Policy (CH07)
• Confidentiality and Data Protection Policy (CH34)

4. Policy Statement

{{org_field_name}} is committed to ensuring that catheter care is carried out safely, with respect for individual dignity, and in line with best practice guidelines. We aim to prevent catheter-associated urinary tract infections (CAUTIs), ensure optimal hygiene, and support people to maintain as much independence as possible.

5. Definitions and catheter safety essentials

Closed drainage system: A sealed connection between catheter and drainage bag/valve that is not disconnected except for clinical reasons.

Catheter passport: A document (paper or electronic) held with the person’s records that includes catheter type/size, balloon volume, insertion date, planned review/change date, allergies (e.g., latex), typical urine output, usual symptoms, and escalation contacts.

Catheter review: A documented review at agreed intervals (and at least monthly, or sooner if clinically indicated) confirming ongoing need and considering alternatives.

6. Indications for Catheterisation

A urinary catheter must only be used when there is a clear clinical indication, it is the least restrictive/most appropriate option, and the decision is documented in the care plan with a review date. The ongoing need for catheterisation must be reviewed at agreed intervals and whenever the person’s condition changes.

Common indications include:

• Acute or chronic urinary retention.
• Management of bladder dysfunction due to neurological conditions.
• Monitoring of urinary output in critically ill individuals.
• Support for individuals with severe mobility limitations.
• End-of-life care to improve comfort.

7. Types of Catheters and Selection

The type of catheter used should be based on individual needs and medical advice:

• Intermittent catheters – used for short-term or temporary catheterisation.
• Indwelling catheters – either urethral or suprapubic, requiring regular monitoring and care.
• Condom catheters – non-invasive options for male individuals where appropriate.

8. Catheter Insertion and Initial Care

• Catheter insertion must be performed only by a trained healthcare professional.
• Aseptic technique must be used to prevent infection.
• The individual must be fully informed and give consent before insertion.
• The correct catheter size and type should be chosen to minimise discomfort and reduce complications.
• A detailed record must be made in the individual’s care plan, including the reason for catheterisation, type, and insertion date.

Prior to insertion, staff must:

• confirm capacity and consent (or complete a Mental Capacity Act best-interest decision where required) and record this in the notes;
• complete and record a risk assessment (infection risk, trauma risk, known strictures, anticoagulants, latex allergy);
• record baseline observations relevant to CAUTI/sepsis screening where appropriate;
• ensure a sterile closed drainage system is used from insertion and that the catheter is secured to reduce traction/urethral trauma.

9. Ongoing Catheter Maintenance

• Catheter care must be person-centred, ensuring the comfort and dignity of people we support.
• The catheter site should be cleaned daily using warm water and mild soap.
• The drainage bag should be kept below bladder level to prevent backflow and infection.
• Staff must check for signs of blockages, leakage, or infection, including pain, fever, or cloudy urine.
• Individuals should be encouraged to drink sufficient fluids to promote urinary health.
• Maintaining a closed system: Do not disconnect the catheter from the drainage bag/valve unless there is a clear clinical reason (for example, changing equipment in line with manufacturer’s instructions or clinical need).
• Drainage bag positioning: Keep the bag below the bladder and off the floor, ensuring tubing is not kinked and urine flows freely.
• Emptying: Empty the bag using a clean container dedicated to the person, when it is around two-thirds full (or sooner), and avoid the outlet tap touching any surfaces.
• Securement: Ensure the catheter is secured and the person is comfortable, to reduce traction and urethral/suprapubic site trauma.
• Hydration/constipation: Support adequate hydration (where not contraindicated) and manage constipation, as constipation can contribute to retention and catheter problems.

10. Preventing and Managing Catheter-Associated Urinary Tract Infections (CAUTIs)

• Strict hand hygiene must be followed before and after handling a catheter.
• Avoid unnecessary catheter use to reduce the risk of infection.
• Encourage regular emptying of the drainage bag to prevent stagnation.
• Staff must monitor and record any symptoms of infection, including:
  • Fever, chills, or back pain.
  • Increased bladder discomfort.
  • Cloudy or foul-smelling urine.
  • Blood in the urine (haematuria).
• If an infection is suspected, staff must report it immediately and seek medical advice.
• Antibiotics must not be requested solely for cloudy or foul-smelling urine in the absence of symptoms. Bacteria are commonly present in urine with catheters; antibiotic treatment is indicated only where the person has symptoms/signs consistent with CAUTI and a clinical assessment supports infection.
• Urine specimens: If a urine sample is required, it must be obtained using aseptic technique from the sampling port (if present) after disinfecting the port, and never from the drainage bag. The sample must be labelled, documented, and sent according to local pathology instructions.
• Where CAUTI is suspected/confirmed and the catheter has been in place for 7 days or more, a clinician should consider changing or removing the catheter as part of treatment planning, in line with prescribing guidance and the person’s care plan.

11. Catheter Changes and Removal

• Catheter changes must be individualised and carried out only by a competent clinician in line with the person’s assessed needs, the catheter passport/care plan, and manufacturer instructions. Catheters must not be changed “routinely” without a documented clinical rationale; however, planned changes may be scheduled where clinically indicated (for example long-term catheter management) and must be recorded with a review date.
• Unscheduled changes should occur if:
  • The catheter is blocked or leaking.
  • The individual experiences persistent pain or discomfort.
• Where appropriate, catheter removal should be encouraged, and bladder retraining initiated.
• All catheter changes or removals must be documented in the care plan.

12. Documentation and Record Keeping

• Each individual with a catheter must have a detailed care plan outlining:
  • The reason for catheterisation.
  • Type and size of catheter used.
  • Date of insertion and planned removal or change date.
  • Any observed issues, including infection symptoms or discomfort.
  • Fluid intake and output monitoring where necessary.
• Any deviation from the care plan must be recorded and reported.

Records must also include:

• daily (or per care plan) checks of urine flow, leakage, discomfort, securement and bag position;
• catheter hygiene provided and any skin integrity concerns;
• bag/valve changes (date/time, reason, equipment batch if relevant);
• escalation actions taken (GP/111/999 contacts), advice received and outcomes;
• urine specimens taken (how/when/from where) and results;
• incidents/near misses (e.g., accidental traction/removal, bleeding, suspected sepsis) and learning actions.

13. Person-Centred Approach and Dignity in Catheter Care

• People we support must be involved in decisions about their catheter care whenever possible.
• Privacy and dignity must be respected at all times during catheter care procedures.
• Staff should encourage individuals to maintain independence in their catheter care if they are able.
• Alternative continence support options should be explored where appropriate.

14. Training and Staff Responsibilities

• All staff involved in catheter care must complete specialist catheter training.
• Staff must be competent in:
  • Aseptic techniques and infection control measures.
  • Recognising and managing catheter-related complications.
  • Supporting individuals with dignity and sensitivity.
• The Registered Manager is responsible for ensuring compliance with catheter care guidelines and staff competency.

15. Emergency Situations and Escalation Procedures

• Staff must recognise and respond to catheter-related emergencies, including:
  • Blocked or dislodged catheters causing severe pain or urinary retention.
  • Acute infections with high fever or sepsis risk.
  • Severe bleeding from the urinary tract.
• In any urgent case, staff must seek immediate medical attention and document the incident.

Following any catheter-related serious incident (for example suspected sepsis, emergency hospital transfer, serious bleeding, or traumatic catheter removal), staff must:

• complete an incident report and ensure immediate clinical review;
• consider whether Duty of Candour applies and follow the service Duty of Candour procedure;
• notify CQC without delay where a notifiable event has occurred, in line with the CQC Registration Regulations notification requirements (including serious injury notifications where applicable).

16. CQC notifications and external reporting

The Registered Manager (or delegated senior) must ensure that CQC notifications are submitted in line with the Care Quality Commission (Registration) Regulations 2009 and CQC guidance, including (where applicable) notifications of serious injury, allegations of abuse, and other notifiable safety incidents arising from catheter care. The decision to notify, the date/time submitted, and any reference number must be recorded in the incident record.

17. Quality Assurance and Compliance Monitoring

• Regular audits of catheter care practices will be conducted to ensure compliance with best practices.
• Audits must include (as a minimum): catheter passports/care plans in place, evidence of ongoing need review, documentation completeness, infection prevention practices (hand hygiene/PPE/aseptic technique), closed system compliance (unnecessary disconnections), and learning from incidents/UTIs. Audit findings, actions, owners and deadlines must be recorded and reviewed through governance meetings.
• Feedback from people we support and their families will be actively sought to improve catheter care procedures.
• Non-compliance will be addressed through additional training, performance monitoring, and corrective action where necessary.

18. Policy Review

This policy will be reviewed annually or sooner if changes in CQC regulations, NICE Guidelines, or operational needs require an update.

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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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