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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Wound Care and Management Policy

1. Purpose

The purpose of this policy is to ensure the effective and safe prevention, assessment, treatment, and management of wounds within {{org_field_name}}. Our approach aligns with evidence-based best practices, NHS guidelines, and Care Quality Commission (CQC) standards to promote wound healing, prevent complications, and enhance the quality of life for service users.

By implementing structured wound care protocols, staff training, and robust monitoring systems, we ensure that all wounds are managed efficiently, reducing the risk of infections and hospital admissions.

2. Scope

This policy applies to:

• All service users requiring wound care, whether due to chronic conditions, pressure ulcers, post-surgical care, or trauma.
• All employees, including care workers, nurses, and healthcare assistants responsible for wound management.
• Healthcare professionals, including district nurses, general practitioners (GPs), and specialist wound care teams.
• Family members and caregivers involved in supporting service users at home.

It covers:

• Wound classification and assessment.
• Wound prevention strategies.
• Infection control measures.
• Wound dressing selection and application.
• Documentation and record-keeping.
• Staff training and competency assessments.
• Monitoring, reporting, and escalation procedures.

2.1 Scope of Service and Limits of the Policy

This policy applies only to wound care activities that {{org_field_name}} is registered, commissioned, insured, trained, and competent to provide. The existence of this policy does not mean that all wound care will be delivered directly by {{org_field_name}} staff.

Where wound care falls outside the provider’s service model, clinical competence, delegation arrangements, or registration status, staff must not undertake the task and must escalate to the appropriate healthcare professional or commissioner. This includes situations where the wound is newly identified, clinically unstable, complex, rapidly deteriorating, or requires specialist assessment or treatment.

3. Legal and Regulatory Framework

This policy is informed by and should be read alongside the following legislation, regulations and guidance applicable in England:

• Health and Social Care Act 2008
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular:
  • Regulation 9 – Person-centred care
  • Regulation 11 – Need for consent
  • Regulation 12 – Safe care and treatment
  • Regulation 13 – Safeguarding service users from abuse and improper treatment
  • Regulation 17 – Good governance
  • Regulation 18 – Staffing
  • Regulation 20 – Duty of candour
• Care Quality Commission (Registration) Regulations 2009, including requirements relating to statutory notifications, especially Regulation 18: Notification of other incidents
• Mental Capacity Act 2005 and associated best-interests principles where a service user may lack capacity to consent to wound care interventions
• Care Act 2014, including safeguarding duties and local authority safeguarding procedures
• Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance
• Data Protection Act 2018 and UK GDPR
• Relevant NICE guidance and quality standards, including pressure ulcer prevention and management guidance

{{org_field_name}} will ensure that wound care is delivered in a way that is safe, person-centred, lawful, evidence-based, properly recorded, clinically overseen where required, and carried out only by staff who are trained, competent and authorised to undertake the relevant task.

3.1 Consent, Mental Capacity and Involvement of the Service User

Before any wound assessment, dressing application, photography, monitoring, or treatment is undertaken, valid consent must be obtained from the service user or from a person lawfully able to act on their behalf. Information about the proposed intervention, expected benefits, risks, possible discomfort, alternatives, and escalation arrangements must be explained in a way the person can understand.

Where a service user appears to have difficulty making a decision about wound care, staff must act in accordance with the Mental Capacity Act 2005. Capacity must be presumed unless established otherwise, and any assessment of capacity must be decision-specific and recorded. If the person lacks capacity for the relevant decision, any action taken must be in their best interests, be the least restrictive option, and be clearly documented, including who was involved in the decision-making process.

A service user has the right to refuse wound care or to withdraw consent. In those circumstances, staff must record the refusal, explain risks sensitively, escalate to the appropriate clinician or line manager where necessary, and review the care plan promptly.

Where required, information must be provided in line with the person’s communication needs, including accessible formats, interpretation support, or involvement of relatives, advocates, attorneys, or deputies where lawful and appropriate.

4. Wound Classification and Assessment

Initial Assessment:

• Initial wound assessment must be undertaken only by an appropriately trained and competent practitioner acting within their professional role, level of competence, and the provider’s scope of service. Where the provider is delivering wound care under delegation, supervision, or a clinical care plan issued by a registered healthcare professional, staff must work strictly within that plan and must not practise beyond their competence.
• Includes detailed documentation of wound type, location, size, depth, exudate level, signs of infection, and pain assessment.
• Categorisation based on wound type:
  • Acute wounds (surgical, trauma-related, burns).
  • Chronic wounds (pressure ulcers, diabetic ulcers, leg ulcers).
  • Infected wounds (requiring escalation and possible antibiotic therapy).

Ongoing Monitoring:

• Regular wound reassessment to track healing progress.
• Use of a validated and locally approved risk assessment approach for skin integrity and pressure ulcer risk, with reassessment whenever the service user’s condition, mobility, continence, nutrition, hydration, or skin status changes. No single tool is to replace clinical judgement.
• Referral to specialist wound care teams for complex or non-healing wounds.

Clinical Oversight, Delegation and Escalation:

{{org_field_name}} will only undertake wound care where:

• the task is included within the service user’s agreed package of care and the provider’s registered/commissioned activity;
• there is a current care plan, treatment plan, delegation record, or written clinical instruction where required;
• the member of staff has been assessed as competent for that specific task; and
• escalation arrangements to the GP, district nurse, tissue viability service, podiatry, emergency services, or other relevant clinician are clear.

Any new wound, any deteriorating wound, suspected infection, suspected pressure ulcer, wound pain that is worsening, unexplained bleeding, necrosis, malodour, rapid increase in exudate, or signs of systemic illness must be escalated promptly in accordance with the service user’s care plan and emergency procedures.

5. Wound Prevention Strategies

• Pressure Ulcer Prevention:
  • Routine skin assessments for high-risk individuals.
  • Use of pressure-relieving equipment, repositioning techniques, and hydration management.
• Diabetic Foot Ulcer Prevention:
  • Regular foot checks for diabetic service users.
  • Education on foot hygiene and proper footwear.
• Surgical Site Infection Prevention:
  • Adherence to aseptic techniques when managing post-operative wounds.
  • Monitoring for early signs of infection and timely escalation.

Prevention strategies must be individualised and reflected in the care plan. Staff must involve the service user, and where appropriate their family or representative, in understanding skin integrity risks, repositioning support, nutrition and hydration measures, equipment use, footwear advice, and when to seek urgent clinical review. Prevention measures must be reviewed whenever the person’s mobility, continence, circulation, cognition, nutrition, hydration, or general health changes.

6. Infection Control Measures

• Hand Hygiene Protocols:
  • Mandatory handwashing before and after wound care procedures.
  • Use of disposable gloves and aprons to prevent cross-contamination.
• Aseptic Wound Dressing Techniques:
  • Single-use sterile dressings and equipment.
  • Proper disposal of used dressings following clinical waste disposal protocols.
• Wound Swabbing and Microbiological Testing:
  • Wound swabbing must not be undertaken routinely. It should only be undertaken where clinically indicated, in accordance with the service user’s treatment plan, local NHS/community guidance, or instruction from an appropriate clinician. Staff must recognise and promptly escalate signs of local or systemic infection, including increasing pain, redness, heat, swelling, malodour, purulent exudate, delayed healing, pyrexia, or sudden deterioration in the service user’s condition.
• Antibiotic Stewardship:
  • Ensuring antibiotics are prescribed based on clinical necessity to reduce antimicrobial resistance.

Infection prevention and control in wound care must comply with the organisation’s infection prevention policy and the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. This includes hand hygiene, appropriate use of PPE, safe management of equipment, environmental cleanliness, segregation and disposal of waste, and reduction of avoidable risks associated with healthcare-related infection.

7. Wound Dressing Selection and Application

Dressing selection must be based on an individual clinical assessment, the service user’s care plan, current wound presentation, pain level, exudate level, surrounding skin condition, and any documented instructions from the relevant clinician. {{org_field_name}} staff must not initiate, alter, or discontinue wound dressings outside their competence, authority, or delegated role.

Where wound care is delivered by care staff under delegation or an established treatment plan, staff must:

• follow the documented dressing type, frequency, technique, and escalation instructions exactly;
• check the wound and surrounding skin at each intervention for signs of deterioration, pain, leakage, bleeding, odour, or infection;
• stop and seek clinical advice where the dressing plan appears unsuitable, no longer effective, or inconsistent with the wound presentation; and
• clearly document the dressing applied, date and time, condition of the wound, pain level, and any concerns escalated.

Any change to dressing regimen must be authorised and recorded by the appropriate clinician unless the staff member is professionally competent and authorised to make that decision within their role.

8. Documentation and Record-Keeping

Comprehensive Wound Care Records

A wound record must be completed at each assessment and dressing intervention, as appropriate to the staff member’s role. Records must include the date and time, wound location, wound type, size where measured, tissue appearance, exudate, odour, pain score or pain description, condition of surrounding skin, dressing used, response to treatment, consent obtained, capacity or best-interests considerations where relevant, and details of any concerns or escalation.

Electronic and Paper-Based Records

• Secure storage of all wound care documentation in compliance with GDPR and Data Protection Act 2018.

Communication with Multidisciplinary Teams (MDT)

Information relevant to wound care must be shared promptly and lawfully with district nurses, GPs, tissue viability services, podiatry, pharmacists, out-of-hours services, hospitals, and other relevant professionals to maintain continuity and safety of care. Escalations, advice received, action taken, and follow-up arrangements must be clearly recorded.

Photographs and Body Maps

Where wound photography or body maps are used, this must be done in accordance with organisational policy, data protection requirements, and the service user’s consent or other lawful basis. The purpose of the image, date taken, storage method, access controls, and any sharing with clinicians must be recorded.

9. Staff Training and Competency Assessments

{{org_field_name}} will ensure that staff involved in wound care are trained, supervised and assessed as competent for the specific tasks they are expected to perform. Training and competency requirements must be role-specific and must reflect whether staff are:

• identifying and reporting skin concerns only;
• supporting prevention measures only;
• undertaking delegated wound care tasks under a care plan; or
• carrying out clinically assessed wound interventions within a professional scope of practice.

Not all care staff will undertake direct wound care. No member of staff may assess, dress, photograph, monitor, or escalate wounds beyond their competence, delegated authority, and job role.

Competency assessment must include, where relevant:

• infection prevention and control;
• consent and mental capacity;
• recognition of deterioration and red flags;
• safe dressing technique;
• record keeping;
• escalation procedures; and
• understanding when a task must be referred to a registered healthcare professional.

Competency must be reviewed at induction where relevant, after training, following any incident or concern, when practice changes, and at regular intervals determined by the provider’s governance arrangements. Records of training, supervision, observation, and signed competency assessment must be retained.

10. Monitoring, Reporting, and Escalation Procedures

Wound Care Review Meetings

Regular MDT meetings to review complex wound cases.

Incident Reporting for Wound Deterioration

Immediate reporting of non-healing wounds, infection signs, or adverse reactions.

Duty of Candour

Where a wound-related incident results in, or appears to result in, a notifiable safety incident, {{org_field_name}} will act in an open and transparent way with the service user and/or the relevant person in accordance with Regulation 20. This includes informing the person in a timely manner, providing an honest explanation of what is known, giving an apology where appropriate, offering reasonable support, keeping a written record of all communication, and reviewing the incident to reduce the risk of recurrence.

CQC Statutory Notifications

The Registered Manager, or delegated senior person, must consider after any serious wound-related incident whether a statutory notification to the Care Quality Commission is required under the Care Quality Commission (Registration) Regulations 2009. Notifications must be made without delay where the circumstances meet the relevant regulatory threshold, and the decision-making process, advice taken, and action completed must be recorded.

Escalation Pathways

Escalation pathways must specify who to contact, expected response times, interim risk controls, and when emergency services are required. The pathway must include GP, district nursing, tissue viability, podiatry, 111/out-of-hours, community urgent response, and 999 where clinically indicated.

11. Compliance Monitoring and Continuous Improvement

{{org_field_name}} will maintain effective governance systems to assess, monitor and improve the quality and safety of wound care. This will include:

• regular audits of wound assessments, care plans, consent documentation, dressing records, escalation, and outcomes;
• review of incidents, safeguarding concerns, complaints, and near misses relating to wound care;
• oversight of staff training, supervision, and competency records;
• review of infection prevention compliance and waste management practice;
• spot checks, observations, and record audits by managers or clinically competent supervisors where appropriate;
• analysis of themes, trends and repeat concerns; and
• evidence that learning is shared and acted upon.

Audit findings, action plans, responsible persons, timescales, and completion dates must be recorded and reviewed through the provider’s governance processes. Where gaps are identified, the provider must take prompt remedial action and monitor whether improvement has been sustained.

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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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