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Stoma Care and Management Policy

1. Purpose

The purpose of this policy is to ensure that residents at {{org_field_name}} who have a stoma receive safe, effective, dignified and person-centred care which protects and promotes their health, well-being, independence, privacy and personal outcomes.

Stoma care will be provided in accordance with:

• the Regulation and Inspection of Social Care (Wales) Act 2016;
• the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended;
• statutory guidance issued by the Welsh Ministers under the Regulation and Inspection of Social Care (Wales) Act 2016;
• relevant Care Inspectorate Wales requirements;
• the resident’s current provider assessment and personal plan;
• relevant healthcare professional instructions and specialist advice; and
• current infection prevention and control requirements and other applicable national guidance.

Stoma care must be individualised. Staff must not apply a standard routine where this conflicts with the resident’s assessed needs, personal plan, clinical instructions, appliance manufacturer’s instructions or advice from an appropriately qualified healthcare professional.

This policy aims to:

• ensure that stoma care protects, promotes and maintains each resident’s safety and well-being;
• ensure that stoma care is provided in accordance with the resident’s assessed needs, wishes, preferences and personal outcomes;
• promote independence and support residents to manage their own stoma wherever they are willing and able to do so safely;
• maintain residents’ privacy, dignity and choice during all aspects of stoma care;
• minimise the risk of infection, leakage, skin damage, dehydration and other avoidable complications;
• ensure that only staff who have the necessary knowledge, skills, training and competence undertake stoma care;
• ensure that staff recognise deterioration or complications and obtain appropriate healthcare advice or emergency assistance without avoidable delay;
• ensure that sufficient and suitable stoma supplies and infection prevention and control equipment are available;
• ensure that stoma care, observations, concerns, actions and professional advice are accurately recorded; and
• ensure effective collaboration with relevant healthcare professionals, including GPs, registered nurses, district nurses and specialist stoma care services.

2. Scope

This policy applies to:

• Residents who require stoma care, ensuring their needs are met in a dignified and professional manner.
• Care staff who provide direct or indirect support in stoma management.
• Nursing staff and external healthcare professionals, ensuring collaborative care planning.
• Relatives and advocates, who are involved in decision-making where appropriate.
• Record-keeping and regulatory compliance, ensuring the care provided meets CIW inspection standards.

3. Related Policies

This policy is closely aligned with the following:

• Infection Prevention and Control Policy (CHW17)​.
• Safe Care and Treatment Policy (CHW11)​.
• Dignity and Respect Policy (CHW08)​.
• Person-Centred Care Policy (CHW07)​.
• Medication Management and Administration Policy (CHW21)​.

4. Types of Stomas, Assessment and Personal Planning

A stoma is a surgically created opening through the abdominal wall which allows faeces or urine to leave the body.

The principal types of stoma include:

• Colostomy – an opening formed from the large bowel or colon through which faeces are passed.
• Ileostomy – an opening formed from the small bowel or ileum through which intestinal contents are passed.
• Urostomy – a urinary diversion through which urine is passed via a surgically created stoma.

The type of stoma alone must not determine the care provided. Care must be based upon the resident’s individual assessment, current needs, preferences, abilities, risks and professional advice.

4.1 Provider Assessment

Before or on commencement of the service, and subsequently whenever required, the resident’s stoma-related needs must be included within the provider assessment.

Where the resident has complex or specialist stoma care needs, the assessment must be undertaken by a person with appropriate skills, knowledge and competence or with advice from an appropriately qualified healthcare professional or specialist stoma care service.

The assessment must consider, as applicable:

• the type of stoma and relevant clinical history;
• the resident’s usual stoma management routine;
• the resident’s ability and wish to manage all or part of their own stoma care;
• the type of appliance and products prescribed, supplied or recommended for that resident;
• usual stoma appearance and output;
• peristomal skin condition;
• known complications and individual warning signs;
• hydration and nutritional requirements;
• any additional risks associated with the resident’s health conditions, medicines, cognition, dexterity, mobility or communication needs;
• psychological or emotional needs associated with living with a stoma;
• the level and type of staff assistance required;
• specialist instructions, including instructions from a stoma care nurse, registered nurse, GP, hospital team or other relevant healthcare professional; and
• action and escalation required where the resident’s condition changes or concerns arise.

4.2 Personal Plan

Each resident who requires support with stoma care must have the relevant arrangements clearly recorded within their personal plan.

The personal plan must identify, as applicable:

• the type of stoma;
• the resident’s personal outcomes, preferences and usual routine;
• what the resident can and wishes to do independently;
• exactly what assistance staff are required to provide;
• the normal pattern, amount and characteristics of stoma output where clinically relevant;
• the type of appliance and products used;
• instructions for emptying or changing the appliance;
• arrangements for monitoring the stoma and surrounding skin;
• individual hydration and nutritional requirements;
• identified risks and the measures required to reduce those risks;
• recognised signs of deterioration or complications specific to the resident;
• the actions staff must take if concerns arise;
• healthcare professionals or specialist services to be contacted and the circumstances in which they should be contacted;
• emergency arrangements where applicable; and
• any delegated healthcare activity and the staff authorised and assessed as competent to undertake it.

The resident must be involved in the preparation and review of their personal plan. A representative must also be involved where required or appropriate in accordance with the Regulations.

The personal plan must be reviewed whenever there is a change in the resident’s needs or circumstances and at least every three months. Any change in the resident’s stoma, output, skin condition, independence, appliance, professional instructions or clinical needs must prompt consideration of whether the provider assessment and personal plan require review and revision.

5. Stoma Care Procedure

All stoma care must be provided in accordance with the resident’s current personal plan, assessed needs, preferences, relevant professional instructions and the instructions applicable to the individual’s stoma appliance and associated products.

Staff must not introduce or alter an appliance, accessory, skin product, dietary restriction, fluid regimen or clinical treatment without appropriate authority or advice where this falls outside their role or the resident’s existing care arrangements.

5.1 Supporting Independence

Residents who are willing and able to manage all or part of their stoma care independently must be encouraged and supported to do so.

Staff must:

• respect the resident’s privacy, dignity and preferred routine;
• provide the level of assistance identified in the personal plan;
• avoid unnecessarily taking over activities that the resident is able to perform independently;
• ensure required equipment and supplies are accessible to the resident; and
• report and record any significant reduction or change in the resident’s ability to manage their stoma.

5.2 Infection Prevention and Control

Before undertaking or assisting with stoma care, staff must follow the service’s Infection Prevention and Control Policy and current infection prevention procedures.

Staff must:

• perform appropriate hand hygiene before and after providing care;
• wear disposable gloves and an apron where indicated by the activity and infection prevention procedures;
• prepare equipment and supplies in a manner that minimises contamination;
• prevent clean supplies from coming into contact with contaminated equipment or surfaces;
• deal with spillages promptly and in accordance with the Infection Prevention and Control Policy;
• dispose of used appliances, wipes, gloves, aprons and other waste in accordance with the service’s waste-disposal procedures and the classification of the waste concerned; and
• clean or decontaminate reusable equipment, where applicable, in accordance with the manufacturer’s instructions and infection prevention procedures.

Gloves do not replace hand hygiene.

5.3 Emptying and Changing the Stoma Appliance

The frequency and method of emptying or changing a stoma appliance must be determined by the resident’s individual needs, appliance type, personal plan, relevant manufacturer’s instructions and specialist healthcare advice.

Staff must not rely upon a fixed organisation-wide interval for appliance changes.

When assisting with an appliance change, staff must:

• explain the procedure and obtain the resident’s agreement before commencing;
• maintain privacy and dignity;
• assemble the products specified for that resident;
• remove the existing appliance carefully to minimise trauma to the skin;
• cleanse and dry the area in accordance with the resident’s personal plan, professional advice and the instructions for the appliance and products in use;
• observe the stoma and surrounding skin for changes;
• apply only those skin products, accessories and appliances which have been assessed as suitable for the resident;
• ensure that the new appliance is applied correctly in accordance with the resident’s individual instructions;
• make the resident comfortable and assist with clothing as required;
• dispose of waste safely; and
• record the care provided and any relevant observations or concerns.

Any unexplained change in the size, shape, colour or appearance of the stoma, repeated leakage, unexpected bleeding, significant skin damage or other concern must be reported and escalated in accordance with Section 7 of this policy and the resident’s personal plan.

5.4 Peristomal Skin Care

The skin surrounding the stoma must be observed whenever stoma care provides an appropriate opportunity to do so.

Staff must record and report relevant changes including:

• persistent redness;
• soreness or pain;
• broken or ulcerated skin;
• swelling;
• persistent moisture or excoriation;
• repeated leakage beneath the appliance;
• unexplained bleeding; or
• signs suggesting infection or another complication.

Products must not be applied routinely merely because a resident has a stoma. Barrier products, adhesive removers, powders, pastes, seals or other accessories must be used in accordance with the resident’s assessed needs, personal plan and relevant professional or product instructions.

Persistent or significant peristomal skin problems must be referred for appropriate clinical or specialist review.

5.5 Nutrition, Hydration and Stoma Output

Nutrition and hydration support must be individualised.

Staff must not apply a universal dietary or fluid regimen solely because a resident has a colostomy, ileostomy or urostomy.

The resident’s personal plan must record any dietary, fluid or electrolyte requirements identified through assessment or advised by an appropriately qualified healthcare professional.

Where applicable, staff must monitor and record food, fluid or stoma output in accordance with the personal plan and must promptly report:

• significantly increased or reduced output;
• absent output where this is unexpected;
• unusually watery or high-volume output;
• persistent vomiting;
• inability to maintain usual fluid intake;
• signs or symptoms suggesting dehydration; or
• any other significant change from the resident’s normal pattern.

Where nutritional or hydration concerns arise, appropriate healthcare advice must be sought without avoidable delay.

5.6 Stoma Appliances and Supplies

The service must ensure that sufficient and suitable supplies are available to meet each resident’s assessed stoma care needs.

Arrangements must include:

• monitoring available supplies;
• reordering supplies in sufficient time;
• ensuring products are stored appropriately;
• checking that the correct resident-specific products are available;
• ensuring products are within their expiry date where an expiry date applies; and
• contingency arrangements to prevent interruption of essential stoma care if normal supplies become unavailable.

Substitution of a resident’s usual appliance or specialist product must not occur without appropriate consideration of the resident’s needs and, where necessary, advice from the relevant healthcare professional or supplier.

6. Training, Competence and Delegated Healthcare Activities

Only staff who have received appropriate training and have been assessed as competent for the stoma care activities they are required to undertake may provide those activities without direct supervision.

Training must be appropriate to the resident’s needs and the duties undertaken by the member of staff and must include, where relevant:

• understanding the principal types of stoma;
• infection prevention and control;
• hand hygiene and appropriate use of personal protective equipment;
• safe disposal of waste;
• resident privacy, dignity, choice and independence;
• resident-specific appliance emptying and changing procedures;
• observation of the stoma and surrounding skin;
• recognising leakage, skin damage and other complications;
• recognising significant changes in stoma output;
• recognising possible dehydration or deterioration;
• the limits of the staff member’s role;
• reporting, recording and escalation requirements;
• when and how to obtain professional or emergency assistance; and
• any resident-specific specialist procedure the member of staff is expected to undertake.

Staff competence must be assessed before they undertake stoma care independently.

Competence must be reassessed at appropriate intervals and sooner where:

• the resident’s needs or stoma management arrangements change;
• a new appliance, product or technique is introduced;
• the member of staff has not undertaken the activity for a significant period;
• an incident, concern or practice issue identifies a need for reassessment; or
• the registered healthcare professional, manager or service provider considers reassessment necessary.

A record of relevant training and competency assessment must be maintained.

6.1 Delegated Healthcare Activities

Where any aspect of stoma care is a healthcare activity delegated by a registered healthcare professional, the service must ensure that:

• delegation is appropriate for the individual resident and activity concerned;
• there are clear written resident-specific instructions;
• the member of staff understands the activity and its limitations;
• the member of staff has received appropriate training;
• competence has been assessed and documented;
• the member of staff knows when the activity must not be undertaken;
• clear escalation arrangements are available;
• the delegation is reviewed when required or where the resident’s condition changes; and
• the activity is undertaken in accordance with relevant professional guidance and the resident’s personal plan.

Staff must not undertake a healthcare activity where they have not been trained, assessed as competent and appropriately authorised to do so.

Where registered nurses provide or delegate stoma care, they must work within their professional code, competence and scope of practice.

7. Recognition and Management of Stoma Complications

Staff must be alert to changes from the resident’s normal stoma appearance, output, skin condition, comfort and general health.

Any concern must be considered in the context of:

• the resident’s normal presentation;
• their current personal plan;
• any individual escalation or emergency plan; and
• instructions provided by the relevant healthcare professional or specialist stoma service.

Staff must not attempt to diagnose or independently treat a suspected stoma complication outside the limits of their role and competence.

7.1 Reduced, Absent or Changed Stoma Output

A significant reduction, absence or unexpected change in stoma output must not be managed by applying a fixed waiting period.

Staff must:

• check the resident’s personal plan for resident-specific instructions;
• assess and record relevant observations within the limits of their role;
• report the concern promptly to the appropriate senior member of staff or registered nurse, where applicable;
• obtain advice from the resident’s relevant healthcare professional or specialist service where required; and
• obtain urgent or emergency medical assistance where indicated by the resident’s symptoms, personal plan or professional advice.

Particular concern must be given to a change in output associated with symptoms such as:

• significant or worsening abdominal pain or cramping;
• abdominal distension;
• persistent nausea or vomiting;
• marked deterioration in the resident’s general condition;
• inability to maintain hydration;
• signs of significant dehydration;
• reduced consciousness, collapse or acute confusion; or
• any other symptom identified in the resident’s clinical or emergency plan.

Staff must not delay necessary medical assessment while attempting unapproved remedies.

7.2 Leakage and Peristomal Skin Damage

Where repeated leakage or skin damage occurs, staff must:

• check that care has been undertaken in accordance with the resident’s personal plan;
• record the condition of the skin and the nature and frequency of leakage;
• report persistent or significant concerns;
• avoid introducing unapproved creams, adhesives, appliances or other products; and
• seek advice from an appropriate healthcare professional or specialist stoma service where the problem cannot be promptly resolved within the resident’s established care arrangements.

A persistent leak must not simply be managed by repeated appliance replacement without considering whether the resident requires reassessment.

7.3 Bleeding, Infection and Changes in Stoma Appearance

Minor surface spotting may occur during some stoma care; however, unexplained, persistent or significant bleeding, an important change in stoma appearance or suspected infection requires appropriate assessment.

Staff must report and escalate concerns including:

• significant or persistent bleeding;
• increasing pain;
• increasing redness or swelling;
• purulent or unusual discharge;
• spreading inflammation;
• fever or systemic illness;
• a significant change in the colour or appearance of the stoma; or
• a marked change from the resident’s normal condition.

Healthcare advice must be obtained promptly and emergency assistance requested where the resident appears acutely unwell or where this is required by the resident’s emergency plan or professional advice.

7.4 Documentation and Review Following a Complication

Any significant stoma-related concern or complication must be documented, including:

• the date and time;
• observations made;
• symptoms reported by the resident;
• care or immediate action provided;
• the person to whom the concern was reported;
• professional advice sought or received;
• action taken following that advice;
• the resident’s response and outcome; and
• any further monitoring or follow-up required.

A significant or recurring complication must prompt consideration of whether the resident’s provider assessment, risk assessment, personal plan, staff competency arrangements or available supplies require review.

8. Record Keeping and Reporting

Stoma care records form part of the resident’s care records and must be accurate, clear, contemporaneous and sufficiently detailed to demonstrate the care provided and any action taken.

Staff must record information relevant to the care they provide, which may include:

• assistance provided with emptying or changing the appliance;
• the resident’s level of participation and independence;
• relevant observations of the stoma and surrounding skin;
• significant changes in output where monitoring is required by the personal plan;
• leakage, appliance problems or skin concerns;
• pain, discomfort or other symptoms reported by the resident;
• fluid or dietary monitoring where required by the personal plan;
• complications or deterioration;
• healthcare advice sought and received;
• action taken following professional advice;
• changes to appliances or stoma care arrangements authorised by an appropriate healthcare professional; and
• the outcome of any concern or intervention.

Staff must report significant changes or concerns promptly in accordance with the resident’s personal plan and the service’s reporting procedures.

Recurring concerns, incidents or significant changes must be brought to the attention of the manager or appropriate clinical lead so that consideration can be given to reviewing:

• the provider assessment;
• the resident’s personal plan;
• relevant risk assessments;
• healthcare professional involvement;
• staffing or competency requirements; and
• the suitability and availability of stoma supplies.

Records must be maintained, stored, accessed and retained in accordance with the service’s records management arrangements and the requirements of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

9. Psychological and Emotional Well-being

• Residents may experience emotional distress, body image concerns, or anxiety related to their stoma.
• Staff should provide reassurance, emotional support, and signposting to counselling services if required.
• Where appropriate, peer support groups or external organisations such as Colostomy UK can be recommended.

10. Governance, Monitoring and Regulatory Reporting

{{org_field_name}} will maintain effective arrangements for monitoring, reviewing and improving the quality and safety of stoma care provided to residents.

Monitoring will be proportionate to the number of residents receiving stoma care, the complexity of their needs, identified risks and any incidents or concerns.

The service will monitor, where applicable:

• whether residents receive stoma care in accordance with their personal plans;
• whether assessments and personal plans remain current;
• staff training and competency records;
• delegated healthcare arrangements;
• relevant care records;
• infection prevention and control practice;
• availability and suitability of stoma supplies;
• recurring leakage, skin damage or other complications;
• incidents, near misses, complaints or safeguarding concerns associated with stoma care; and
• whether healthcare advice and required follow-up actions have been completed.

Where monitoring identifies a concern, the service must take proportionate and timely action to protect residents and improve the service.

This may include:

• reviewing a resident’s provider assessment, risk assessment or personal plan;
• obtaining specialist or medical advice;
• reassessing staff competence;
• providing additional training or supervision;
• reviewing supplies or equipment;
• reviewing infection prevention and control practice; or
• amending this policy or associated procedures.

Relevant information arising from stoma care must contribute to the service’s wider quality assurance and quality-of-care review arrangements where appropriate.

10.1 Incidents and Notifications

Stoma-related incidents must be reported and recorded through the service’s incident reporting procedures.

Where an event meets the statutory criteria for notification to Care Inspectorate Wales or another authority, the required notification must be made in accordance with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and the service’s notification procedures.

The manager must not assume that every stoma-related complication is notifiable. Whether notification is required must be determined by the nature and consequences of the event and the applicable statutory notification criteria.

11. Policy Review

This policy will be kept under review and will be formally reviewed at least annually, or sooner where necessary.

An earlier review must be undertaken where:

• relevant legislation or statutory guidance changes;
• Care Inspectorate Wales requirements relevant to the policy change;
• applicable national clinical or infection prevention guidance changes;
• the service’s Statement of Purpose changes in a way that affects stoma care;
• new stoma care practices, appliances or delegated healthcare arrangements materially affect service delivery;
• an incident, complaint, safeguarding concern, audit or quality review identifies that the policy may no longer support safe and effective care; or
• learning from residents, staff or healthcare professionals demonstrates that amendment is required.

The Responsible Individual must ensure that suitable arrangements are in place for this policy to be kept up to date.

Where the policy is revised, relevant staff must be informed of the changes and provided with additional instruction, training or competency assessment where required before the revised practice is implemented.

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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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