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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Leg Ulcer Management and Prevention Policy

1. Purpose

The purpose of this policy is to establish safe, person-centred and evidence-based arrangements for the prevention, identification, assessment, treatment, monitoring and escalation of leg ulcers affecting individuals receiving care and support at {{org_field_name}}.

{{org_field_name}} will ensure that the care and support provided to an individual with, or at risk of developing, a leg ulcer protects, promotes and maintains the individual’s safety and well-being and is provided in accordance with their assessed needs and personal plan.

This policy supports compliance with:

• the Regulation and Inspection of Social Care (Wales) Act 2016;
• the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including requirements relating to personal plans, standards of care and support, access to healthcare, staffing, staff development, infection prevention and control and record keeping;
• the statutory guidance issued by the Welsh Ministers for service providers and responsible individuals on meeting the service standard regulations for care home services;
• the Mental Capacity Act 2005 and associated Code of Practice, where an individual’s capacity to consent to assessment or treatment is in question;
• current Public Health Wales requirements and guidance relevant to skin integrity;
• current Welsh infection prevention and control guidance; and
• current applicable NICE and nationally recognised wound-care guidance.

The aims of this policy are to:

• reduce avoidable deterioration in skin integrity;
• identify leg ulcers and associated complications promptly;
• ensure that appropriate healthcare professionals are involved when assessment, diagnosis or treatment is outside the competence of care home staff;
• ensure that compression therapy and other specialist treatments are undertaken only following appropriate clinical assessment and by staff who are competent and authorised to undertake them;
• support effective wound healing and symptom management;
• identify and respond promptly to deterioration, infection or other clinical concerns;
• ensure that treatment decisions, referrals, outcomes and reviews are accurately recorded in the individual’s records and personal plan; and
• ensure that individuals are involved in decisions about their care and are treated with dignity, respect and sensitivity.

2. Scope

This policy applies to all care and clinical staff at {{org_field_name}}, including nurses, healthcare assistants, and other team members involved in the prevention and treatment of leg ulcers. It covers risk assessment, early intervention, treatment strategies, infection control, training, and documentation. It ensures that residents at risk of or suffering from leg ulcers receive person-centred, evidence-based care.

3. Related Policies

This policy should be read in conjunction with:

• CHW11 – Safe Care and Treatment Policy: Ensuring safe clinical procedures are followed.
• CHW07 – Person-Centred Care Policy: Delivering tailored care to meet individual needs.
• CHW17 – Infection Prevention and Control Policy: Reducing the risk of infection in wound management.
• CHW18 – Risk Management and Assessment Policy: Identifying risks and implementing preventive measures.
• CHW27 – Staff Supervision, Training, and Development Policy: Ensuring staff receive appropriate training on wound care management.

4. Policy Statement

{{org_field_name}} is committed to providing high-quality, evidence-based care for residents at risk of or suffering from leg ulcers. Our goal is to prevent leg ulcers through effective risk assessment, promote early intervention, and ensure optimal treatment when ulcers occur. We strive to maintain a safe and supportive environment where residents receive care that promotes healing, reduces complications, and enhances overall well-being.

5. Risk Assessment and Prevention Strategies

{{org_field_name}} will take a proactive approach to identifying and managing risks to skin integrity and the development or recurrence of leg ulceration.

• Initial assessment: An individual’s skin condition and relevant risk factors will be considered as part of the provider assessment and development of the personal plan following admission to the service.
• Ongoing assessment: Skin integrity will be monitored in accordance with the individual’s assessed needs. A reassessment will be undertaken when there is a significant change in the individual’s health, mobility, circulation, nutritional status, skin condition or other relevant circumstances.
• Public Health Wales assessment requirements: Where a formal skin-integrity risk assessment is required, staff must use an assessment tool approved by Public Health Wales. Individuals identified as being at risk must be managed in accordance with the applicable Public Health Wales SKIN bundle and associated local clinical arrangements.
• Competent assessment: Skin-integrity assessments must be undertaken only by staff who have the necessary knowledge, skills, training and competence to undertake the assessment and recognise when specialist clinical assessment is required.
• Risk factors: Assessment and monitoring must take account, where relevant, of factors including:
  • previous leg ulceration;
  • venous disease or venous insufficiency;
  • peripheral arterial disease or suspected impaired arterial circulation;
  • diabetes;
  • reduced mobility;
  • oedema;
  • lymphoedema;
  • pressure damage;
  • poor nutritional or fluid intake;
  • smoking history;
  • impaired sensation;
  • frailty;
  • cardiovascular disease;
  • medicines or medical conditions that may affect circulation or wound healing; and
  • any other factor identified by an appropriately qualified healthcare professional.
• Preventive care: Preventive interventions will be proportionate to the individual’s assessed needs and may include appropriate skin care, support with mobility, repositioning where required, nutritional and hydration support, pressure-relieving equipment and implementation of treatment prescribed or recommended by an appropriate healthcare professional.
• Pressure-relieving equipment: Where pressure-relieving equipment is required, it must be appropriate to the individual’s assessed risk, available for use, correctly used and maintained in good working order.
• Compression therapy: Compression bandaging, compression hosiery or another compression system must not be initiated solely because a person is believed to have venous disease. The individual must first receive an appropriate clinical and vascular assessment in accordance with the relevant healthcare pathway to establish the cause of the ulcer and whether compression is safe and clinically indicated. Compression therapy must be prescribed or recommended by an appropriately qualified healthcare professional and applied or supported only by staff who are competent and authorised to undertake the intervention.
• Personal plan: Identified risks, preventive measures, prescribed treatment, monitoring requirements and escalation arrangements must be recorded in the individual’s personal plan and made available to the staff responsible for providing their care.

6. Identification, Clinical Escalation and Early Intervention

Staff must remain alert to deterioration in the condition of an individual’s legs and skin and must report concerns promptly in accordance with the individual’s personal plan and the service’s clinical escalation procedures.

Staff must recognise and report signs or symptoms including:

• new skin breakdown or ulceration;
• persistent redness or discolouration;
• swelling or increasing oedema;
• increased or new pain;
• increased wound exudate;
• bleeding;
• malodour;
• increasing warmth around a wound;
• spreading redness;
• changes in the colour or temperature of the foot or leg;
• deterioration in an existing wound;
• signs of infection;
• signs of reduced circulation; or
• any other unexplained or significant change in skin integrity.

Where a new leg ulcer is identified, or an existing ulcer deteriorates, an appropriately competent registered healthcare professional must be informed without avoidable delay so that the individual can receive the assessment, treatment or referral required.

The service must arrange or support timely access to a GP, tissue viability service, community nursing service, vascular service or other appropriate healthcare professional where the individual’s needs cannot safely be assessed or managed within the competence and scope of practice of staff at {{org_field_name}}. This reflects the requirement for care-home residents to have access to treatment, advice and healthcare services as necessary. Regulation 33 specifically requires care-home providers to put such arrangements in place.

Urgent or emergency clinical assistance must be sought where the individual develops signs or symptoms indicating a potentially serious complication, including suspected sepsis, rapidly spreading infection, acute limb ischaemia, severe or rapidly increasing pain, suspected deep-vein thrombosis, significant uncontrolled bleeding or any other acute deterioration requiring urgent assessment.

Any immediate actions taken by staff, clinical advice received, referrals made and changes to treatment must be documented in the individual’s records.

Following a significant change in the individual’s skin integrity or treatment requirements, the individual’s relevant risk assessments and personal plan must be reviewed and revised as necessary.

7. Leg Ulcer Assessment, Wound Care and Treatment

Where an individual develops a leg ulcer, {{org_field_name}} will ensure that care is based upon an appropriate clinical assessment and treatment plan.

• Clinical assessment and diagnosis: A new leg ulcer must be referred for assessment by an appropriately qualified healthcare professional to determine, as far as practicable, the likely underlying cause and the treatment required. Staff must not assume that a leg ulcer is venous in origin without appropriate clinical assessment.
• Wound assessment: Where wound assessment forms part of the role of nursing staff employed by the service, it must be undertaken only by a registered nurse or other healthcare professional who has appropriate wound-care knowledge, training, skills and competence. Assessment must include, where clinically relevant:
  • wound location;
  • wound dimensions;
  • wound-bed appearance;
  • surrounding skin condition;
  • exudate;
  • pain;
  • signs of infection;
  • oedema;
  • evidence of deterioration or healing; and
  • other observations required by the treating healthcare professional or local wound-care pathway.
• Vascular assessment and compression: Where compression therapy is being considered, the individual must receive the appropriate vascular assessment required by the relevant clinical pathway before therapeutic compression is commenced, unless an appropriately qualified clinician has documented an alternative clinical decision. Staff must follow the treatment plan provided by the responsible healthcare professional.
• Cleansing and dressing: Wound cleansing and dressing selection must follow the treatment plan or prescription provided by the healthcare professional responsible for the individual’s wound care and current evidence-based wound-care guidance. Staff must not independently change a prescribed wound treatment unless they are professionally competent and authorised to make that decision.
• Compression therapy: Compression bandaging, hosiery or another therapeutic compression system must be applied only following appropriate assessment and where it has been prescribed or recommended for that individual. Application must be undertaken by a healthcare professional or member of staff who has been assessed as competent to use the specific compression system.
• Monitoring: The wound must be monitored at the frequency specified in the individual’s treatment plan. Deterioration, failure to progress as expected, increased pain, changes in circulation or signs of infection must be reported promptly to the appropriate healthcare professional.
• Infection: Staff must distinguish between routine wound colonisation and clinical signs of infection and must seek appropriate clinical assessment where infection is suspected. Antibiotics must not be requested or used solely because bacteria may be present in a leg ulcer. NICE guidance states that antibiotics should be offered only where there are symptoms or signs of clinical infection.
• Pain management: Pain associated with the ulcer, dressing changes or compression must be assessed and reported. Prescribed analgesia must be administered in accordance with the individual’s medicines record, prescription and {{org_field_name}}’s medicines-management policy. Non-pharmacological measures may also be used where appropriate and agreed with the individual.
• Specialist involvement: Referral or re-referral must be made to an appropriate professional where specialist assessment or treatment is required. This may include the GP, community nursing service, tissue viability service, vascular service, podiatry service, diabetes team, lymphoedema service, dietitian or another appropriate service.
• Treatment plan and personal plan: The treatment prescribed or recommended by healthcare professionals, responsibilities for carrying it out, monitoring arrangements and escalation requirements must be clearly recorded and reflected in the individual’s personal plan where they affect day-to-day care.

8. Consent, Mental Capacity and Best-Interests Decisions

Individuals must be involved in decisions concerning the assessment, prevention and treatment of their leg ulcer and their wishes, preferences, dignity, privacy and right to make decisions must be respected.

Valid consent must be obtained before wound assessment or treatment is undertaken, except where treatment is otherwise lawfully authorised.

An individual must be presumed to have capacity to make a decision about their wound care unless there is reason to doubt their capacity in relation to the specific decision at the time it needs to be made.

Where there is reason to doubt an individual’s capacity to make a particular decision about assessment or treatment:

• staff must follow the Mental Capacity Act 2005 and its statutory principles;
• a decision-specific assessment of capacity must be undertaken by an appropriate person;
• all practicable steps must be taken to support the individual to make the decision themselves;
• a person must not be regarded as lacking capacity merely because they make a decision that others consider unwise;
• where the individual lacks capacity, any decision made or action taken on their behalf must be in their best interests and must be the least restrictive available option;
• any person with relevant lawful authority, including an attorney or deputy where applicable, must be involved in accordance with the scope of that authority; and
• capacity assessments, consultation, best-interests decisions and the rationale for the decision must be recorded.

Where an individual with capacity refuses wound assessment or treatment, staff must respect that decision, explain the reasonably foreseeable risks where appropriate, inform the relevant healthcare professional and document the refusal, information provided and action taken.

Where refusal or inability to provide essential care creates a significant risk to the individual’s health or safety, the matter must be escalated promptly for appropriate clinical and, where necessary, safeguarding or legal advice.

9. Infection Prevention and Control

All wound care must be undertaken in accordance with {{org_field_name}}’s Infection Prevention and Control Policy, current Welsh infection prevention and control guidance and the infection-control precautions appropriate to the procedure being undertaken.

Staff undertaking wound care must:

• perform hand hygiene at the appropriate points before and after wound care and after removal of personal protective equipment;
• use appropriate personal protective equipment following assessment of the risk of exposure to blood, body fluids, wound exudate or contaminated materials;
• use an aseptic technique or aseptic non-touch technique where required by the wound-care procedure, treatment plan or current infection prevention and control guidance;
• prepare and maintain a clean and suitable environment for wound care;
• use dressings, equipment and wound-care products in accordance with the manufacturer’s instructions and the individual’s treatment plan;
• prevent contamination of clean or sterile equipment;
• clean, decontaminate or dispose of reusable equipment in accordance with infection prevention and control procedures and manufacturer instructions;
• dispose of dressings, contaminated materials, sharps and other waste through the appropriate waste stream; and
• report promptly any signs of infection or breach in infection-control practice.

Where infection is suspected, staff must obtain appropriate clinical advice and follow any microbiological sampling or antimicrobial treatment plan prescribed by the responsible healthcare professional.

Standard infection prevention and control precautions must be applied consistently regardless of whether infection is known to be present.

10. Nutrition and Lifestyle Support

Good nutrition plays a vital role in wound healing. Residents with leg ulcers receive dietary support, including:

• Adequate Protein Intake: Essential for tissue repair and healing.
• Vitamin and Mineral Supplementation: Particularly vitamin C, zinc, and iron, where clinically indicated.
• Hydration Monitoring: Ensuring residents remain well-hydrated to support circulation and skin health.

11. Staff Training, Competence and Delegated Healthcare Activities

{{org_field_name}} will ensure that staff involved in the prevention, observation or treatment of leg ulcers have the knowledge, skills, training and competence appropriate to their role and the activities they undertake.

Training and competency requirements will be determined according to staff members’ responsibilities and the needs of individuals using the service.

Relevant training will include, where applicable:

• skin-integrity assessment and monitoring;
• recognition of leg-ulcer risk factors;
• use of Public Health Wales-approved skin-integrity assessment tools;
• implementation of the Public Health Wales SKIN bundle where applicable;
• recognition and escalation of skin deterioration;
• wound assessment;
• wound cleansing and dressing procedures;
• aseptic technique or aseptic non-touch technique;
• infection prevention and control;
• recognising signs of local and systemic infection;
• recognition of deterioration requiring urgent clinical assessment;
• pain recognition and management;
• safe use of pressure-relieving equipment;
• principles and risks associated with compression therapy;
• nutrition, hydration and wound healing;
• accurate clinical record keeping;
• consent and the Mental Capacity Act 2005; and
• person-centred wound care.

Staff must not undertake a clinical activity, including wound assessment, specialist dressing procedures or compression therapy, unless that activity falls within their role and they have received the necessary training and have been assessed as competent.

Where a registered healthcare professional delegates a healthcare activity to another member of staff, the delegation must be appropriate and lawful, the staff member must be trained and competent to undertake the activity, and the delegating professional retains the professional accountability applicable to that delegation.

Competency must be reviewed where there is a change in practice, equipment, treatment, national guidance or an identified concern about practice.

Training, competency assessment, supervision and relevant professional development must be documented.

Registered nurses must maintain their professional registration and practise in accordance with the requirements of the Nursing and Midwifery Council.

12. Documentation, Personal Plans and Record Keeping

Accurate, contemporaneous and complete records must be maintained to support safe treatment, continuity of care, clinical decision-making and regulatory oversight.

Records must be made in accordance with {{org_field_name}}’s record-keeping procedures and, where applicable, professional standards.

Depending upon the individual’s needs and the responsibilities of the service, records must include:

• relevant skin-integrity and leg-ulcer risk assessments;
• the date a wound or deterioration was first identified;
• the location and type of wound;
• wound measurements and clinical observations where these form part of the staff member’s role;
• pain assessment and any action taken;
• the condition of the surrounding skin;
• signs of infection or deterioration;
• photographs where clinically appropriate, consented to and taken and stored in accordance with organisational procedures and data-protection requirements;
• the prescribed or recommended wound-care treatment;
• dressings and other products used;
• compression treatment where prescribed;
• the date and outcome of dressing changes;
• referrals to healthcare professionals;
• clinical advice and instructions received;
• actions taken following deterioration;
• medicines administered in connection with wound care, recorded through the appropriate medicines record;
• consent or refusal of treatment;
• relevant mental-capacity assessments and best-interests decisions;
• information provided to the individual or their representative;
• changes to the individual’s personal plan; and
• progress towards the intended clinical and personal outcomes.

The individual’s personal plan must clearly identify:

• the leg-ulcer-related care and support that staff are expected to provide;
• identified risks and how they are to be managed;
• the treatment or preventive interventions to be undertaken;
• monitoring requirements;
• signs or symptoms requiring escalation;
• the healthcare professionals involved;
• relevant preferences of the individual; and
• any support required to maintain independence or participate in their care.

The personal plan and relevant risk assessments must be reviewed and revised when there is a significant change in the wound, treatment, clinical condition, assessed risk or care and support needs.

This is in addition to the statutory requirement for the overall personal plan to be reviewed as and when required and at least every three months.

13. Coordination and Continuity of Leg Ulcer Care

{{org_field_name}} will maintain arrangements to ensure that leg-ulcer care is coordinated, delivered consistently and reviewed appropriately.

These arrangements will include:

• ensuring that prescribed dressing changes, observations and clinical reviews take place at the frequency specified in the treatment plan;
• ensuring that sufficient appropriate wound-care supplies and personal protective equipment are available to provide the planned care safely;
• maintaining continuity of care so that staff providing wound care have access to the current treatment plan and understand the individual’s needs;
• ensuring that temporary or agency staff who are involved in the individual’s care have access to the relevant personal plan and treatment instructions and are competent to undertake any clinical activity allocated to them;
• maintaining effective communication with GPs, community nursing services, tissue viability services and other relevant healthcare professionals;
• arranging and supporting timely access to specialist assessment where required;
• acting upon instructions and recommendations from healthcare professionals;
• reviewing the personal plan and risk assessments following a significant change in the individual’s condition or treatment;
• providing the individual with information, in a format appropriate to their communication needs, to enable them to participate in decisions about prevention and treatment; and
• involving the individual’s representative where appropriate and lawful.

Where responsibility for wound care is shared between {{org_field_name}} and an external healthcare service, the respective responsibilities for assessment, dressing changes, monitoring, supplies, escalation and review must be clearly established and recorded.

14. Responsibilities

Service Provider

The Service Provider is responsible for ensuring that:

• the service is provided with sufficient care, competence and skill;
• appropriate policies and procedures are in place and kept up to date;
• sufficient suitably qualified, skilled, competent and experienced staff are available to meet individuals’ assessed needs;
• staff have access to the training, supervision, equipment and supplies necessary to provide safe leg-ulcer care;
• arrangements are in place for individuals to access appropriate healthcare professionals; and
• systems are in place to monitor the quality and safety of care provided.

Responsible Individual

The Responsible Individual is responsible for maintaining oversight of the management, quality, safety and regulatory compliance of the service in accordance with their statutory responsibilities.

Where issues relating to leg-ulcer care identify a wider concern about quality, staffing, training, equipment, clinical governance or compliance, the Responsible Individual must ensure that the matter is appropriately reviewed and that required improvements are monitored.

Registered Manager

The Registered Manager is responsible for:

• implementing this policy within the service;
• ensuring staff understand and follow the policy;
• ensuring appropriate clinical escalation arrangements are available;
• ensuring training and competency requirements are identified and met;
• monitoring the quality and completeness of care records;
• ensuring prescribed treatment and personal plans are followed;
• ensuring concerns, incidents and deterioration are appropriately escalated; and
• taking appropriate action where practice does not meet required standards.

Registered Nurses

Registered nurses employed by the service are responsible for:

• practising within their professional competence and scope of practice;
• undertaking wound-care activities for which they are appropriately trained and competent;
• following prescribed treatment and relevant clinical guidance;
• recognising and escalating deterioration;
• maintaining accurate clinical records;
• reviewing nursing interventions and communicating concerns to appropriate healthcare professionals;
• ensuring that delegated activities are appropriate for the staff member undertaking them; and
• complying with the Nursing and Midwifery Council Code and relevant professional standards.

Care Staff

Care staff are responsible for:

• observing the individual’s skin and legs as required by the personal plan;
• reporting changes or concerns promptly;
• carrying out only those wound-care or preventive activities for which they have been trained, assessed as competent and authorised;
• following the individual’s personal plan and treatment instructions;
• supporting nutrition, hydration, mobility, skin care and other preventive measures identified in the personal plan; and
• making accurate records of care provided and concerns identified.

External Healthcare Professionals

GPs, community nursing services, tissue viability services and other external healthcare professionals retain responsibility for the clinical assessment, prescribing, diagnosis or treatment decisions that fall within their respective professional roles.

The service will work collaboratively with these professionals and implement their treatment instructions within the competence and responsibilities of the care home.

15. Regulatory Compliance

This policy supports {{org_field_name}} in meeting the applicable requirements of the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

In particular, the arrangements within this policy support compliance with requirements relating to:

• preparation, implementation and review of personal plans;
• provider assessment and reassessment when needs change;
• provision of care and support in a manner that protects, promotes and maintains individuals’ safety and well-being;
• provision of care and support in accordance with the individual’s personal plan;
• timely access to treatment, advice and other healthcare services;
• sufficient numbers of suitably qualified, trained, skilled, competent and experienced staff;
• appropriate staff induction, supervision, training and development;
• hygiene and infection prevention and control;
• sufficient supplies and suitable equipment;
• accurate and appropriate records; and
• effective governance, monitoring and improvement of the quality and safety of care.

{{org_field_name}} will have regard to the statutory guidance issued by the Welsh Ministers under section 29 of the Regulation and Inspection of Social Care (Wales) Act 2016 when determining how these regulatory requirements are met.

Care Inspectorate Wales may use the statutory guidance when assessing whether the service is meeting its legal requirements. Where the service adopts an alternative approach to that described in statutory guidance, it must be able to demonstrate that the approach nevertheless meets the applicable regulatory requirements.

16. Policy Review

This policy will be formally reviewed at least annually and sooner where required.

An earlier review must take place where there is:

• a relevant change in legislation or regulations;
• revised statutory guidance issued by the Welsh Government;
• revised requirements or guidance issued by Care Inspectorate Wales;
• a material change to Public Health Wales or national wound-care guidance;
• a significant change in infection prevention and control guidance;
• a change to local NHS wound-care or tissue-viability pathways that affects the service;
• evidence from an incident, complaint, safeguarding concern, audit or investigation that the policy is no longer effective;
• an identified gap in staff competence or clinical practice; or
• a material change to the service’s statement of purpose.

Following revision, relevant staff must be informed of the changes and, where necessary, receive additional instruction, training or competency assessment before implementing revised practice.

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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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