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Registration Number: {{org_field_registration_no}}

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Best Practice in Intimate Personal Care Policy

1. Purpose

The purpose of this policy is to set out the arrangements for the safe, dignified, respectful and person-centred provision of intimate personal care within {{org_field_name}}.

{{org_field_name}} will provide intimate personal care 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, the Social Services and Well-being (Wales) Act 2014, the Mental Capacity Act 2005 where applicable, and relevant statutory guidance issued by the Welsh Ministers.

In particular, intimate personal care will be provided in a manner that protects, promotes and maintains each individual’s safety and well-being; respects their privacy, dignity, confidentiality, autonomy and independence; takes account of their protected characteristics; and reflects their assessed needs, wishes, preferences and personal outcomes.

Arrangements for intimate personal care will be agreed with the individual, recorded in their personal plan and followed by staff providing care and support.

2. Scope

This policy applies to all persons working at {{org_field_name}} who provide, assist with, supervise or manage the provision of intimate personal care, including permanent, part-time, temporary and agency staff and persons engaged under a contract for services.

Only staff who have received appropriate induction, training and competency assessment relevant to the intimate personal care they are required to provide may undertake such care.

This policy covers:

• dignity, privacy, respect and confidentiality;
• consent, choice and decision-making;
• assessment and personal planning;
• safe delivery of intimate personal care;
• infection prevention and control;
• safeguarding from abuse, neglect and improper treatment;
• communication and language needs;
• staff training, supervision and competence;
• reporting and escalation of concerns; and
• recording and documentation.

All intimate personal care must be provided in accordance with the individual’s current personal plan, assessed needs, wishes and preferences.

3. Related Policies

This policy should be read alongside the following:

• CHW07 – Person-Centred Care Policy: Ensuring care is tailored to individual needs and preferences.
• CHW08 – Dignity and Respect Policy: Upholding dignity in all aspects of care provision.
• CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy: Protecting residents from harm and maintaining high care standards.
• CHW17 – Infection Prevention and Control Policy: Minimising infection risks during personal care procedures.
• CHW39 – Mental Capacity and Deprivation of Liberty Safeguards Policy: Ensuring decisions are made in the best interests of residents who lack capacity.

4. Policy Statement

{{org_field_name}} is committed to ensuring that intimate personal care is provided safely and with dignity, privacy, respect and sensitivity.

Individuals will be supported to exercise choice and control over their intimate personal care and to be as independent as reasonably possible. Staff will explain the care or support proposed in a manner the individual can understand and will seek the individual’s consent before providing intimate personal care where the individual has capacity to make that decision.

An individual who has capacity has the right to consent to or refuse intimate personal care, including particular aspects of that care. Staff must respect a refusal and must not use coercion, intimidation or unnecessary restriction to obtain compliance. Any refusal that creates a significant risk to the individual’s health, safety or well-being must be reported to the person in charge and managed through assessment, review of the personal plan and, where appropriate, involvement of relevant healthcare professionals.

Where there is reason to believe that an individual may lack capacity to make a particular decision about their intimate personal care, staff must act in accordance with the Mental Capacity Act 2005 and the associated Code of Practice. Capacity must be considered in relation to the specific decision at the relevant time. Where the individual lacks capacity, any act of care must be undertaken lawfully and in the individual’s best interests, using the least restrictive option available.

Intimate personal care must be provided in accordance with the individual’s current personal plan and with due regard to their assessed needs, wishes, feelings, preferences, communication needs, culture, religion or belief and relevant protected characteristics.

Safeguarding, infection prevention and control and safe working practices will underpin the provision of all intimate personal care.

5. Principles of Best Practice in Intimate Personal Care

Intimate personal care must be provided in accordance with the following principles:

• Dignity, privacy and respect: Care must be provided sensitively and respectfully. Doors, curtains or privacy screens must be used as appropriate, unnecessary exposure must be avoided and only those people whose presence is necessary for the safe provision of care should normally be present.
• Individual preferences: The individual’s preferences regarding intimate personal care must be discussed with them, agreed wherever possible and recorded in their personal plan. Staff must follow those arrangements unless there is a justified reason for not doing so, which must be recorded and escalated where appropriate.
• Consent and choice: Where the individual has capacity to make the relevant decision, staff must explain what they intend to do and seek consent before intimate personal care is provided. The individual’s right to refuse or withdraw consent must be respected.
• Mental capacity: Where an individual lacks capacity to make a specific decision concerning their intimate personal care, decisions and actions must be taken in accordance with the Mental Capacity Act 2005, including its statutory principles and best-interests requirements.
• Independence and autonomy: Individuals must be encouraged and supported to undertake as much of their own personal care as they are able and wish to undertake. Staff must not take over tasks unnecessarily.
• Communication: Staff must communicate clearly, sensitively and respectfully before and throughout intimate personal care and must take reasonable steps to meet the individual’s language and communication needs. Relevant communication aids or equipment must be available and used where required.
• Welsh language needs: Where Welsh is the individual’s language of need or choice, reasonable steps must be taken to support meaningful communication in Welsh in accordance with the service’s arrangements for meeting Welsh language needs.
• Equality and individual identity: Staff must have regard to the individual’s relevant protected characteristics and must respect their cultural, religious, philosophical and personal preferences when providing intimate personal care.
• Infection prevention and control: Staff must follow the service’s current infection prevention and control procedures, including appropriate hand hygiene and the correct selection, use and disposal of personal protective equipment.
• Safety and safeguarding: Care must be provided in a manner that protects the individual from abuse, neglect and improper treatment. Any concern arising during intimate personal care must be acted upon immediately in accordance with the service’s safeguarding procedures.
• Continuity of care: Staffing arrangements should provide reasonable continuity and familiarity while continuing to meet the individual’s needs, preferences, personal plan and safety requirements.

5.1 Intimate Personal Care and the Personal Plan

The arrangements for each individual’s intimate personal care must be based on appropriate assessment and recorded in the individual’s personal plan.

The personal plan must contain sufficient detail to enable staff to provide intimate personal care consistently, safely and in accordance with the individual’s wishes and assessed needs. Where relevant, this must include:

• the individual’s level of independence and the support they require;
• their preferred routines and usual personal care arrangements;
• their wishes and preferences concerning the way intimate personal care is provided;
• relevant cultural, religious, philosophical or personal considerations;
• communication and language needs;
• relevant consent and mental capacity considerations;
• continence care requirements;
• skin integrity risks and required interventions;
• moving and handling requirements;
• equipment required and any relevant safe working arrangements;
• the number of staff required to provide particular aspects of care safely where this has been assessed as necessary;
• identified risks and measures required to mitigate those risks; and
• any other information necessary to support the individual’s safety, dignity, independence and personal outcomes.

The individual must be involved in preparing and reviewing their personal plan. The placing authority, where applicable, and any representative must also be involved as required by the regulations, subject to the individual’s wishes, legal authority and well-being.

The personal plan must be reviewed whenever required because of a change in needs or circumstances and at least every three months. Following review, the plan must be revised where necessary.

Staff providing intimate personal care must have access to the relevant current information within the personal plan and must provide care in accordance with it.

6. Providing Intimate Personal Care Safely

Before providing intimate personal care, staff must check the individual’s current personal plan and any relevant risk assessments and must provide care in accordance with the arrangements recorded within them.

The following requirements apply:

• Personal plan: The individual’s personal plan must contain sufficient information to enable staff to understand and meet their intimate personal care needs safely. This must include, where applicable, the individual’s wishes and preferences, usual routines, communication needs, level of independence, assistance required, continence needs, skin care requirements, moving and handling arrangements, relevant risks and any specialist equipment to be used.
• Consent: Staff must explain the proposed care in a manner appropriate to the individual’s communication and understanding and seek consent where the individual has capacity to make the relevant decision. Where the person lacks capacity for the particular decision, staff must act in accordance with the Mental Capacity Act 2005 and any lawful arrangements recorded within the personal plan.
• Privacy: Intimate personal care must normally be provided in private. Doors, curtains and privacy screens must be used appropriately, and the individual’s body must remain covered as far as reasonably practicable while care is being provided.
• Number of staff: The number of staff assisting with intimate personal care must be based on the individual’s assessed needs, risks, independence, moving and handling assessment, relevant equipment instructions and personal plan. A second member of staff must be used where the assessment, personal plan, safe system of work or equipment instructions require this. Staff must not routinely use two people where this is unnecessary and inconsistent with the individual’s assessed needs or independence.
• Moving and handling: Where moving and handling is required, staff must follow the individual’s current moving and handling assessment and use only equipment for which they have received appropriate training and have been assessed as competent.
• Personal preferences: Staff must respect preferences recorded in the individual’s personal plan, including preferences relating to routines, communication, privacy, cultural or religious practices and, where reasonably practicable, the staff providing intimate care.
• Infection prevention and control: Staff must undertake hand hygiene and use personal protective equipment appropriate to the task and assessed infection risk in accordance with the service’s infection prevention and control policy.
• Skin integrity: Staff must observe the individual’s skin while providing care where this forms part of their role and must report and record any new redness, damage, bruising, pressure damage, wound, soreness or other unexplained change in accordance with the individual’s personal plan and the service’s reporting procedures.
• Continence: Where continence support is required, this must be provided sensitively and in a manner that protects the individual’s dignity and privacy. Recommendations arising from continence assessment, including any specialist aids or products, must be reflected in the personal plan and followed by staff.
• Changes or concerns: Any significant change in the individual’s needs, abilities, presentation or risks identified during intimate personal care must be recorded and reported promptly so that appropriate assessment, professional advice and review of the personal plan can take place.
• Emergency assistance: Where an immediate risk to the individual’s health or safety arises, staff must summon appropriate assistance and take proportionate action in accordance with their training, the individual’s personal plan and the service’s emergency procedures.

7. Staff Training, Competence and Supervision

{{org_field_name}} will ensure that staff providing intimate personal care have the knowledge, skills, competence and training necessary for the care and support they are required to provide.

Staff must receive an induction appropriate to their role before undertaking intimate personal care without appropriate support or supervision. Training and competency requirements will be determined according to the needs of individuals using the service and the duties undertaken by the member of staff.

Relevant training must include, as applicable to the member of staff’s role:

• dignity, privacy, confidentiality and person-centred care;
• safeguarding adults from abuse, neglect and improper treatment;
• consent and the Mental Capacity Act 2005;
• infection prevention and control;
• moving and handling and the safe use of any relevant equipment;
• continence care;
• skin integrity and pressure damage awareness;
• equality, diversity and relevant protected characteristics;
• communication and language needs;
• record-keeping and reporting; and
• any specialist training necessary to meet the assessed needs of individuals using the service.

Staff must not undertake a task requiring specialist knowledge or skill unless they have received appropriate training and have been assessed as competent to undertake that task.

Staff competence will be kept under review through observation of practice, supervision, appraisal and other competency assessment processes appropriate to the task.

Staff will receive one-to-one supervision with their line manager, equivalent officer or an appropriately senior member of staff no less than quarterly, and all staff will receive an annual appraisal. Additional supervision or competency assessment will be provided where concerns, incidents, changes in practice or changes in an individual’s needs indicate that this is required.

Training and development needs will be reviewed regularly, and a written record will be maintained of training, supervision, competency assessments and development undertaken or required.

8. Safeguarding and Reporting Concerns

Intimate personal care presents particular safeguarding considerations because of the individual’s privacy, vulnerability and the close physical contact involved. All staff must remain alert to signs or allegations of abuse, neglect, improper treatment, discrimination, unexplained injury, inappropriate restraint, sexual abuse or other safeguarding concerns.

Where a member of staff witnesses, receives an allegation of, suspects or identifies evidence of abuse, neglect or improper treatment, they must:

• take immediate and proportionate action to protect the individual and any other person who may be at risk;
• obtain urgent medical assistance or contact the emergency services where necessary;
• report the concern immediately in accordance with {{org_field_name}}’s Safeguarding Adults from Abuse and Improper Treatment Policy;
• preserve relevant evidence where appropriate;
• make a clear and accurate contemporaneous record of the concern, allegation or evidence and the action taken; and
• not undertake their own investigation or question the individual beyond what is necessary to establish their immediate safety unless specifically authorised to do so as part of an appropriate safeguarding process.

The Registered Manager or other person responsible for managing the concern must ensure that the service’s safeguarding procedures are followed and that appropriate referrals are made without delay to the relevant local authority safeguarding team and any other relevant agency in accordance with the Wales Safeguarding Procedures.

Where the circumstances require notification to Care Inspectorate Wales under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the required notification must be submitted within the applicable timescale. This includes any abuse or allegation of abuse relating to an individual that involves the service provider, a member of staff or a volunteer.

Where required, consideration must also be given to referral or notification to the police, Disclosure and Barring Service, Social Care Wales or another relevant professional regulator.

The individual’s immediate safety and well-being must take priority. The individual must be provided with information and support appropriate to their communication needs and level of understanding, including information about independent advocacy where appropriate.

Staff may also raise concerns through {{org_field_name}}’s Whistleblowing (Speaking Up) Policy. No member of staff must be subjected to victimisation for raising a genuine safeguarding concern in good faith.

All safeguarding referrals, actions and outcomes must be recorded and retained in accordance with the service’s safeguarding and record-keeping arrangements.

9. Record-Keeping and Documentation

Accurate, timely and confidential records must be maintained in relation to intimate personal care.

Staff must:

• record intimate personal care provided in the individual’s care records in accordance with the service’s recording procedures;
• record relevant information necessary to demonstrate that care has been delivered in accordance with the individual’s personal plan;
• record refusals of care where relevant, together with any significant risks, action taken and escalation;
• record and report significant changes in the individual’s needs, abilities, continence, skin integrity, behaviour, physical presentation or emotional well-being;
• record any accident, incident, injury, safeguarding concern or allegation in accordance with the relevant service procedure;
• ensure entries are factual, accurate, legible where handwritten, completed promptly and attributable to the person making the record; and
• maintain confidentiality and ensure information is only accessed, used and shared by persons who have lawful authority or a legitimate need to do so.

The individual’s personal plan must accurately describe how intimate personal care is to be provided, including relevant needs, risks, wishes, preferences, personal outcomes and required support.

Where an individual’s intimate personal care needs, risks, wishes or circumstances change, the information must be escalated to an appropriate person so that the provider assessment and personal plan can be reviewed and revised where necessary.

Personal plans must be formally reviewed as and when required and at least every three months in accordance with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

10. Planning and Organising Intimate Personal Care

Arrangements for intimate personal care must be organised around the assessed needs, personal outcomes, wishes and preferences of individuals rather than organisational convenience.

{{org_field_name}} will ensure that:

• sufficient suitably qualified, trained, skilled, competent and experienced staff are deployed to meet individuals’ assessed intimate personal care needs;
• care is provided at appropriate times and in accordance with each individual’s personal plan and preferences;
• staffing arrangements provide reasonable continuity of care;
• staff are given sufficient time to provide intimate personal care safely, sensitively and without unnecessary rushing;
• changes in an individual’s needs or circumstances are identified, reported and reflected in assessment, staffing arrangements and the personal plan as necessary; and
• urgent or unexpected personal care needs are responded to promptly and safely.

Feedback from individuals about their intimate personal care will be encouraged and considered through the service’s arrangements for monitoring, reviewing and improving the quality of care and support.

11. Responsibilities

The Service Provider is responsible for:

• ensuring the service is provided with sufficient care, competence and skill;
• ensuring appropriate policies and procedures are in place, are kept up to date and are implemented in practice;
• ensuring sufficient numbers of suitably qualified, trained, skilled, competent and experienced staff are deployed; and
• ensuring effective arrangements are in place for monitoring, reviewing and improving the quality and safety of care.

The Responsible Individual is responsible for:

• maintaining effective oversight of the management, quality, safety and compliance of the service in accordance with their statutory responsibilities;
• obtaining assurance that appropriate arrangements for intimate personal care are implemented;
• ensuring identified concerns or compliance failures are acted upon appropriately; and
• considering relevant information about care quality, safeguarding, complaints, incidents and staff practice through the service’s governance arrangements.

The Registered Manager is responsible for:

• implementing this policy in day-to-day practice;
• ensuring staff understand and follow the policy;
• ensuring staff providing intimate personal care are appropriately trained, supervised and competent;
• ensuring individuals’ personal plans contain appropriate information about intimate personal care;
• responding to concerns, incidents and safeguarding matters;
• ensuring required referrals and regulatory notifications are made; and
• monitoring practice and taking action where improvements are required.

Care staff are responsible for:

• providing intimate personal care in accordance with this policy and each individual’s current personal plan;
• maintaining dignity, privacy, confidentiality, choice and independence;
• obtaining consent where the individual has capacity to make the relevant decision and following lawful Mental Capacity Act arrangements where they do not;
• working within their training and competence;
• maintaining accurate records; and
• immediately reporting changes, risks, incidents, safeguarding concerns or unsafe practice.

Persons responsible for workforce training and records are responsible for:

• maintaining accurate records of relevant training, supervision, appraisal and competency assessment; and
• bringing expired, overdue or incomplete requirements to the attention of the Registered Manager.

Individuals and representatives:

Individuals will be encouraged and supported to express their wishes and preferences, participate in decisions about intimate personal care and provide feedback about the service. Representatives will be involved where the individual wishes this, where they have lawful authority, or where otherwise appropriate in accordance with applicable legislation.

12. Regulatory Compliance

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including requirements relating to:

• provision of the service with sufficient care, competence and skill;
• provision of care and support in accordance with the individual’s personal plan;
• protection and promotion of individuals’ safety and well-being;
• respect and sensitivity, including privacy, dignity, confidentiality, autonomy, independence and relevant protected characteristics;
• language and communication needs;
• safeguarding individuals from abuse, neglect and improper treatment;
• appropriate and lawful use of control, restraint and restrictions;
• sufficient numbers of suitably qualified, trained, skilled, competent and experienced staff;
• staff induction, training, supervision, appraisal and development;
• infection prevention and control;
• maintenance of appropriate records; and
• notifications to Care Inspectorate Wales where required.

The service provider, Responsible Individual and Registered Manager will ensure that practice under this policy is consistent with the service’s Statement of Purpose, individuals’ assessed needs and personal plans, and applicable Welsh statutory guidance.

Where the service chooses an approach that differs from Welsh Ministers’ statutory guidance, the service provider must be able to evidence that its approach nevertheless meets the applicable regulatory requirements.

13. Policy Review

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

An earlier review must be undertaken where there is:

• a change in relevant legislation, regulations or statutory guidance;
• a relevant change in Care Inspectorate Wales or Social Care Wales requirements or guidance;
• a change to the service’s Statement of Purpose that affects this policy;
• learning arising from a safeguarding concern, accident, incident, complaint, inspection or quality review;
• evidence that the policy is no longer effective or consistent with current practice; or
• a material change in the needs of individuals using the service.

The service provider will ensure that the policy remains appropriate to the needs of individuals, consistent with the Statement of Purpose and up to date.

Relevant amendments will be communicated to staff, and additional instruction, training or competency assessment will be provided where a change affects staff 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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