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Registration Number: {{org_field_registration_no}}

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Aseptic Technique Policy

1. Purpose

The purpose of this policy is to ensure that all clinical procedures involving an aseptic technique at {{org_field_name}} are performed safely, effectively, and consistently to prevent the introduction of harmful microorganisms and reduce the risk of infection. This policy sets out the principles, responsibilities, and practices required to maintain asepsis in accordance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, and the latest guidance from Public Health Wales and Care Inspectorate Wales (CIW). It supports our commitment to high standards of infection prevention and control, safeguarding the health and wellbeing of individuals using our service.

2. Scope

This policy applies to all staff at {{org_field_name}} who are involved in any clinical or care procedure where aseptic technique is required. This includes nurses, senior carers trained in wound care or catheterisation, and any other personnel performing procedures such as dressing wounds, inserting or managing urinary catheters, managing PEG sites, or handling sterile equipment. It also applies to staff supervising or auditing these practices, including the Registered Manager and Infection Control Lead.

3. Related Policies

This policy should be read in conjunction with:
CHW11 – Safe Care and Treatment Policy
CHW17 – Infection Prevention and Control Policy
CHW18 – Risk Management and Assessment Policy
CHW21 – Medication Management and Administration Policy
CHW24 – Management of Accidents, Incidents, and Near Misses Policy
CHW40 – Assisting with Personal Care Policy

4. Policy Statement and Definitions

Aseptic technique is a method used during clinical procedures to prevent the contamination of wounds, equipment, and susceptible body sites by pathogenic microorganisms. It involves using practices that ensure the area remains sterile throughout the procedure. At {{org_field_name}}, we are committed to maintaining asepsis in all appropriate procedures to reduce the risk of healthcare-associated infections (HCAIs). We distinguish between standard aseptic technique (used for procedures such as catheter care and dressing clean wounds) and surgical aseptic technique (used rarely in care homes, for complex procedures requiring a sterile field).

5. Key Principles of Aseptic Technique

The core principles observed in all aseptic procedures at {{org_field_name}} are:

• Effective hand hygiene before and after every procedure
• Use of sterile gloves, equipment, and appropriate PPE
• Preparation of a clean or sterile field depending on the nature of the procedure
• Maintaining a non-touch technique where possible
• Disposing of waste and contaminated items immediately and safely
• Ensuring the environment is clean, well-lit, and interruption-free

All procedures must be risk-assessed and performed in accordance with current evidence-based practice. Deviation from these principles must be justified, recorded, and escalated to a senior member of staff.

6. Staff Competence and Training

Only staff who have been assessed as competent in aseptic technique are authorised to carry out such procedures. Competency is assessed at induction (for relevant clinical staff) and re-evaluated annually. Training includes:

• Principles and rationale of aseptic technique
• Hand hygiene and glove use
• Use of sterile equipment and supplies
• Infection risks and transmission routes
• Legal and professional accountability

Records of training and competency assessments are maintained and monitored by the Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, and the Infection Control Lead, {{org_field_infection_control_lead_name}}.

7. Procedures Requiring Aseptic Technique

Procedures requiring the use of aseptic technique at {{org_field_name}} include, but are not limited to:

• Wound care and dressing changes (especially for surgical wounds or pressure ulcers)
• Urinary catheter insertion and care
• PEG site cleaning and tube changes
• Application of sterile dressings
• Subcutaneous or intramuscular injections (where applicable)
  Each procedure must follow a specific care protocol documented in the personal care plan and updated following any clinical review. Staff must prepare equipment using sterile packs or trays and follow the principles of aseptic field management.

8. Environment and Equipment

Procedures requiring asepsis should be carried out in a clean, clutter-free environment. Where possible, care should be delivered in a dedicated treatment area or the individual’s room, ensuring surfaces are cleaned with an appropriate disinfectant prior to and after the procedure. All sterile equipment is stored in designated clean areas, within its use-by date, and disposed of immediately after single use. Sterile dressing packs, gauze, and catheters are used only once per procedure. Staff ensure no contact is made between sterile and non-sterile items during preparation or administration.

9. Documentation and Care Planning

All aseptic procedures must be documented clearly and in real-time. Records must include:

• Date, time, and name of staff performing the procedure
• Type of procedure and any observations or complications
• Products and equipment used
• Pain level and response of the individual
• Follow-up required or next scheduled procedure
  Care plans must detail the need for aseptic technique, including wound status, catheter care needs, and specific risks. Any variation from usual practice must be documented and reviewed by a senior clinician.

10. Monitoring, Audit, and Compliance

The Infection Control Lead is responsible for auditing aseptic procedures monthly to ensure compliance with best practice. Audits include:

• Observation of technique
• Review of documentation
• Storage and expiry of sterile items
• Staff feedback and self-assessment
  Findings are reported to the Registered Manager and discussed at team meetings. Any non-compliance is addressed through supervision, retraining, or disciplinary action where appropriate. The outcomes of audits form part of our Quality of Care Review and are available for CIW inspection.

11. Infection Control and Waste Disposal

All waste generated from aseptic procedures is treated as clinical waste. Sharps are disposed of in appropriate sharps containers immediately. Gloves, aprons, and dressings are placed in orange clinical waste bags and disposed of in accordance with our Infection Prevention and Control Policy (CHW17). Spillages are cleaned using approved disinfectants and reported in accordance with the CHW24 policy. The safety of individuals, staff, and visitors is our priority.

12. Communication and Consent

Before carrying out an aseptic procedure, the individual is informed of what the procedure involves, why it is necessary, and how their privacy and dignity will be maintained. Informed consent is obtained and documented. Where an individual lacks capacity, a best interest decision is made following the Mental Capacity Act 2005, involving family members or advocates as appropriate. Procedures are carried out respectfully and with sensitivity to cultural, spiritual, and personal needs.

13. Policy Review

This policy is reviewed annually, or sooner if prompted by new legislation, guidance from CIW or Public Health Wales, audit findings, or after an infection control incident. Staff are informed of changes through team briefings, training, and internal communications.

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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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