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Self-Care, Wellbeing and Personal Care Support Policy

1. Purpose

This policy sets out our approach to supporting service users in self-care, wellbeing, and personal treatment in a way that promotes dignity, independence, and person-centred care. Our home care service recognises that self-care is fundamental to physical health, emotional wellbeing, and quality of life. We are committed to ensuring that all service users receive appropriate support, encouragement, and assistance in maintaining their personal care, hygiene, and overall wellbeing while respecting their rights and preferences.

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; the Social Services and Well-being (Wales) Act 2014; the Mental Capacity Act 2005 and its Code of Practice; the Equality Act 2010; applicable Welsh safeguarding legislation, codes and procedures; and current Welsh Government and Care Inspectorate Wales statutory guidance for domiciliary support services.

Care and support will be provided with sufficient care, competence and skill, in accordance with the service’s statement of purpose and the individual’s personal plan. Support will protect, promote and maintain the individual’s safety and wellbeing, uphold their rights, promote autonomy and independence, and assist them to achieve their agreed personal outcomes.

Our organisation ensures that service users are empowered to manage their own self-care as much as possible, with support tailored to their needs and abilities. Staff are trained to provide compassionate, professional assistance while preserving personal dignity, respecting privacy, and promoting autonomy.

In this policy, “personal plan” means the plan prepared in accordance with regulation 15 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017. “Representative” means a person who has legal authority, or the individual’s consent, to act on the individual’s behalf. “Delegated healthcare activity” means a healthcare activity delegated by a registered healthcare professional to a care worker following an individual assessment, with clear instructions, training, competence assessment, monitoring and arrangements for review.

2. Scope

This policy applies to:

• All employees, agency workers, workers engaged under a contract for services, volunteers and managers involved in delivering or overseeing domiciliary support.
• Individuals receiving support with self-care, personal hygiene, intimate personal care, grooming, wellbeing or related activities.
• Representatives and family members, where they are lawfully involved and where such involvement is consistent with the individual’s wishes, rights and wellbeing.
• Registered healthcare professionals and other external professionals where the service co-ordinates, supports or contributes to an individual’s treatment or care.
• Adults and children within the categories of individuals described in the service’s statement of purpose.

It covers:

• Personal hygiene and grooming assistance.
• Support with self-care routines for individuals with reduced mobility or health conditions.
• Wellbeing promotion, including emotional, social, and mental health support.
• Personal treatments, including access to external professionals for hairdressing, podiatry, and beauty treatments.
• Safeguarding considerations and risk management in personal care.

This policy does not authorise care workers to diagnose a condition, prescribe treatment, perform a regulated clinical procedure, provide complementary therapy, or undertake any activity outside their role, training, assessed competence and written authorisation. Clinical or delegated healthcare activities must be managed under the organisation’s delegated healthcare activity procedure and the individual’s personal plan.

3. Assessment, Personal Planning and Review

Before staff provide assistance with self-care, personal hygiene, intimate personal care or a related wellbeing activity, the individual’s needs, wishes, communication requirements, abilities, risks and personal outcomes must be assessed and recorded in their personal plan. The plan must identify what the individual can do independently, what support or prompting is required, what staff must do, what staff must not do, and when professional advice must be obtained.

The personal plan must record, where relevant:

• the individual’s preferred routines, products, clothing, grooming practices and level of assistance;
• privacy, dignity, cultural, religious, gender and identity-related preferences;
• the individual’s preferred language and communication method;
• mobility, falls, moving and handling and environmental risks;
• skin integrity, pressure-area, continence, oral-health, nutritional and hydration needs;
• allergies, sensitivities, prescribed creams and topical medicines;
• equipment, adaptations and assistive technology required;
• the individual’s consent and any relevant mental-capacity or best-interests arrangements;
• any delegated healthcare activity, including who delegated it, the written instructions, required competence and escalation arrangements;
• known signs of deterioration and the action staff must take;
• the steps required to promote independence and support positive risk-taking.

The personal plan must be co-produced with the individual and, where appropriate, their representative, placing authority, commissioner and relevant professionals. It must be reviewed whenever needs, risks, wishes or circumstances change and at least every three months in accordance with regulation 16.

4. Supporting Self-Care and Personal Hygiene

4.1 Encouraging Independence and Choice

Our service adopts a person-centred approach to self-care, ensuring that service users:

• Are empowered to maintain their own personal care wherever possible.
• Have a current personal plan that records their assessed care and support needs, personal outcomes, abilities, preferences, routines, communication requirements, cultural and religious needs, relevant risks, agreed risk-management measures and the support required to maintain or increase independence.
• Are encouraged to make decisions about their appearance, grooming, and hygiene in line with their lifestyle and personal identity.
• Receive consistent, respectful, and professional support from trained staff.

• Are supported to do as much as they can safely do for themselves, with staff using prompting, encouragement, preparation of equipment or partial assistance before providing full assistance.
• Are offered genuine choices and sufficient time to make decisions without being rushed, pressured or treated as incapable.
• Receive information in a language, format and communication method they can understand.
• Are supported to access independent advocacy where this would help them to express their views, make decisions or challenge arrangements.
• Have any reasonable adjustments required because of disability, sensory impairment, cognitive impairment, communication needs or another protected characteristic recorded and implemented.

Where service users need assistance with personal hygiene, staff will ensure that:

• Support is provided sensitively, discreetly, and in a manner that promotes dignity.
• Privacy is maintained at all times, ensuring doors are closed and curtains are drawn when assisting with personal care.
• Service users are given control and choice over products used (e.g., preferred soap, shampoo, deodorant).
• Cultural, religious, and gender preferences are respected when assisting with washing, dressing, and grooming.

4.2 Consent, Mental Capacity and Decision-Making

Staff must obtain the individual’s consent before providing personal care, intimate care, applying a personal care product, assisting with grooming, sharing information or supporting an external treatment. Consent must be voluntary, informed, specific to the activity and capable of being withdrawn at any time.

Staff must not assume that consent has been given because an activity is included in the personal plan, because the individual has previously accepted the activity, or because a family member requests it. Staff must explain the proposed support immediately before it is provided, observe verbal and non-verbal responses, and stop if the individual withdraws consent or shows distress, resistance or discomfort.

Where there is reason to doubt an individual’s capacity to make a specific decision, staff must follow the Mental Capacity Act 2005 and the organisation’s Mental Capacity Act policy. Capacity must be considered in relation to the particular decision and at the time the decision is required. Staff must support the individual to make the decision before concluding that they are unable to do so.

Where an individual aged 16 or over lacks capacity for a specific decision, any action must be lawfully authorised, necessary and in the individual’s best interests, and must be the least restrictive available option. The decision, consultation, rationale and outcome must be recorded. A representative or family member may not consent on behalf of an adult unless they have the appropriate legal authority.

For children, consent, parental responsibility, the child’s wishes and feelings, competence and safeguarding requirements must be considered in accordance with applicable law, the child’s age and understanding, and the organisation’s children’s care procedures.

4.3 Bathing, dressing and grooming

Where an individual requires assistance with bathing, showering, washing, toileting, dressing or grooming, staff must provide support only in accordance with the individual’s personal plan, moving and handling assessment, risk assessments, consent and expressed preferences.

• Encourage safe and independent bathing, using adapted equipment where required (e.g., shower chairs, grab rails).
• Support individuals in selecting their clothing while considering comfort, weather conditions, and personal preference.
• Provide agreed grooming assistance, such as brushing or styling hair, supporting shaving and providing routine non-clinical skin care, where this is recorded in the personal plan and staff have been trained and assessed as competent.
• Follow the individual’s skin-integrity and pressure-area care plan precisely. Staff must use only the equipment, repositioning arrangements, prescribed products and monitoring procedures recorded in the personal plan or specified by a relevant healthcare professional. Staff must not diagnose, grade or treat a pressure ulcer unless this forms part of their professional role or is a formally delegated healthcare activity for which they are trained and competent.
• Any new redness, non-blanching discoloration, heat, swelling, pain, blistering, broken skin, wound deterioration, discharge, odour or other concern must be recorded and escalated immediately in accordance with the individual’s plan and the organisation’s escalation and safeguarding procedures.

• Check that the room is warm, safe and private and that required equipment and personal care products are available before commencing.
• Check water temperature using the method specified in the personal plan and organisational procedures, and confirm that the water is comfortable for the individual.
• Never leave an individual unattended where the assessment identifies a risk of falls, scalding, seizure, loss of consciousness or other foreseeable harm.
• Use only equipment that has been assessed as suitable, is in safe working order and is used in accordance with the manufacturer’s instructions and the individual’s moving and handling plan.
• Explain each stage of care and expose only the part of the body being washed or treated.
• Respect the individual’s preference concerning the gender of the care worker wherever reasonably practicable and record any agreed arrangements in the personal plan.
• Observe the individual’s skin, mouth, mobility, presentation and general wellbeing without undertaking a clinical examination, and report concerns in accordance with the escalation procedure.
• Record the care provided, the individual’s participation, any refusal, any significant observation and any action taken.

4.4 Nail and Foot Care

Care workers must not cut or treat an individual’s toenails unless this activity is expressly included within the organisation’s scope of service, has been individually risk assessed, is permitted by organisational procedure, and the worker has received appropriate training and has been assessed as competent.

Care workers must not cut fingernails or toenails where the individual has diabetes, impaired circulation, neuropathy, reduced sensation, anticoagulant treatment, infection, inflammation, broken skin, an ingrown nail, a fungal condition or any other factor that increases the risk of injury, unless a registered healthcare professional has provided written instructions and the activity is lawfully delegated.

Routine filing may be undertaken only where it is assessed as safe, the individual consents, the activity is recorded in the personal plan, the equipment is clean and for the individual’s sole use, and no contraindication is present.

Any pain, swelling, heat, redness, discharge, wound, colour change, odour, loss of sensation or other foot-health concern must be recorded and reported promptly. Staff must not diagnose or treat the condition and must support referral to an appropriate healthcare professional.

4.5 Intimate Personal Care

Intimate personal care includes assistance with washing intimate areas, toileting, continence care, changing continence products, menstrual care, catheter or stoma-related support, dressing and undressing, and any activity during which the individual is partly or fully undressed.

Intimate personal care must be:

• individually assessed and recorded in the personal plan;
• provided with valid consent;
• undertaken by staff who are trained, competent and authorised;
• provided in a private and dignified manner;
• delivered using the least intrusive level of support;
• consistent with the individual’s wishes, identity, culture, religion and gender preferences;
• recorded accurately after each visit.

Staff must not:

• make unnecessary comments about the individual’s body, appearance or personal hygiene;
• leave doors or curtains open;
• use personal phones or recording devices;
• allow an unauthorised person to enter;
• continue when consent has been withdrawn, except where an immediate and lawful intervention is necessary to prevent serious harm;
• use force, intimidation, threats, ridicule or coercion;
• perform an intimate examination or clinical procedure outside their role.

Where two care workers are required, this must be based on an individual assessment rather than routine organisational practice. The reason and respective responsibilities of each worker must be recorded in the personal plan.

4.6 Continence and Toileting Support

Individuals must be supported to maintain independence and choice in their toileting and continence routines. Support must protect privacy and dignity and must follow the individual’s assessment and personal plan.

Staff must:

• respond promptly to requests for assistance;
• use the continence products and equipment specified for the individual;
• support regular toileting where this is part of the personal plan;
• provide appropriate hygiene and skin care;
• dispose of waste safely;
• report pain, constipation, diarrhoea, bleeding, changes in urine, changes in continence, urinary symptoms, skin damage or repeated leakage;
• record significant changes and actions taken.

Staff must not introduce a continence product, restrict access to a toilet or alter the individual’s toileting routine solely for staff convenience.

4.7 Oral Care

The provider assessment and personal plan must identify whether the individual requires prompting, preparation, supervision or physical assistance with oral care.

Staff must:

• support the individual to clean natural teeth, dentures, gums and mouth in accordance with their personal plan;
• use the individual’s own labelled oral-care equipment;
• clean and store dentures safely;
• observe for pain, swelling, bleeding, ulcers, broken teeth, loose dentures, difficulty swallowing, persistent dry mouth or other concerns;
• record and report identified concerns;
• support access to dental advice or treatment where required.

Staff must not use another person’s toothbrush, denture equipment or oral-care products.

5. Promoting Wellbeing and Emotional Health

5.1 Mental and Emotional Wellbeing

Wellbeing is about more than physical care; it includes emotional, social, and mental health support. Our service supports wellbeing by:

• Encouraging social interaction, helping service users engage in conversations, hobbies, and activities they enjoy.
• Observe for changes in mood, behaviour, sleep, appetite, communication, social engagement, cognition or emotional presentation. Staff must record and report concerns promptly to the manager or designated person and follow the individual’s personal plan and escalation arrangements. Care workers must not diagnose a mental health condition or independently make a clinical referral unless authorised to do so; the service will support timely contact with the GP, community mental health service, emergency service or other appropriate professional.

• Take all expressions of hopelessness, suicidal thoughts, self-harm or intent to harm another person seriously and follow the organisation’s immediate-risk and emergency procedures.
• Recognise that distress may be expressed through changes in behaviour, particularly where the individual has dementia, cognitive impairment or communication difficulties.
• Avoid describing distress as “challenging behaviour” without exploring unmet need, pain, fear, communication difficulties, environmental factors or other possible causes.
• Record the individual’s preferred emotional-support strategies and known triggers in the personal plan.

• Supporting access to counselling services, befriending services, or community social groups.
• Promoting good sleep hygiene and relaxation techniques to support rest and recovery.
• Ensuring that service users have access to spiritual and religious support if they wish.

5.2 Nutrition and Hydration Support

Where nutrition or hydration support is part of the agreed service, the individual’s personal plan must record their preferences, cultural and religious requirements, allergies, intolerances, dietary requirements, level of assistance, required equipment, known risks and any professional instructions.

Staff must:

• encourage and support adequate food and fluid intake without coercion;
• offer choice and respect the individual’s preferred routines;
• prepare food and drink safely and in accordance with food-hygiene requirements;
• follow any prescribed texture-modified diet, thickened-fluid instruction or swallowing plan exactly;
• use the equipment and positioning specified by the relevant professional;
• record food or fluid intake where monitoring is required;
• report reduced intake, dehydration indicators, weight loss, coughing or choking, recurrent chest infections, swallowing difficulty, vomiting, diarrhoea or other concerns promptly.

Staff must not alter the texture of food or fluids, introduce thickener, change a prescribed diet or make assumptions about swallowing safety without current instructions from an appropriately qualified healthcare professional.

6. Supporting Personal Treatments and External Services

6.1 External Personal Care, Healthcare and Wellbeing Services

Individuals may choose to access services such as hairdressing, barbering, podiatry, chiropody, beauty treatment or complementary therapy. The individual remains entitled to make their own decisions, subject to their capacity and any lawful risk-management arrangements.

Where the organisation recommends, commissions, arranges or pays an external provider, the manager must take proportionate steps to confirm, as applicable:

• the provider’s identity and contact details;
• professional registration where the activity requires registration;
• relevant qualifications and competence;
• current public liability and professional indemnity insurance;
• safeguarding suitability where the person will have contact with children or adults at risk;
• infection prevention and control arrangements;
• the provider’s arrangements for consent, record keeping, complaints and incident reporting;
• that the activity is compatible with the individual’s needs, personal plan and known risks.

Where the individual or their representative independently arranges a service, staff must not represent that the organisation has approved or endorsed the provider. Staff should raise any immediate safety or safeguarding concern and record the action taken.

Before supporting an external treatment, staff must confirm the individual’s consent, check relevant risks and ensure that the proposed activity does not conflict with known allergies, skin conditions, diabetes, medication, wounds, infection-control requirements or professional advice.

Any fee payable by the individual must be explained and agreed in advance. Care workers must not receive commission, gifts or other personal benefit from an external service provider.

6.2 Boundaries of Staff Practice

Care workers must only undertake activities that:

• are within the organisation’s statement of purpose and scope of service;
• are required by the individual’s personal plan;
• are supported by a current risk assessment;
• fall within the worker’s job description;
• are covered by organisational policy and insurance;
• the worker has been trained and assessed as competent to undertake;
• are consented to by the individual or otherwise lawfully authorised.

Care workers must not:

• diagnose a condition or recommend clinical treatment;
• prescribe, select or change a medicine, medicated cream or treatment;
• use another person’s prescribed preparation;
• undertake wound care, catheter care, stoma care, specialist skin treatment, invasive procedures or other healthcare activities unless formally delegated and authorised;
• perform massage, complementary therapy, beauty therapy or cosmetic treatment as part of their care role unless specifically employed, qualified, insured and authorised to provide that service;
• cut corns, calluses or ingrown nails;
• use blades or sharp instruments for foot treatment;
• make decisions about the individual’s appearance without their consent;
• continue an activity that causes pain, bleeding, injury, distress or an adverse reaction.

Where a worker is uncertain whether an activity is permitted, the activity must not be undertaken until the manager has obtained appropriate professional advice and confirmed the decision in writing.

6.3 Delegated Healthcare Activities

A delegated healthcare activity may be undertaken only where a registered healthcare professional has assessed the individual and determined that delegation is appropriate.

Before the activity begins, the service must have:

• written instructions specific to the individual;
• confirmation of the delegating professional and their contact details;
• a clear description of the activity and its limits;
• identified risks, contraindications and signs requiring escalation;
• arrangements for training, observation and competence assessment;
• confirmation that the care worker accepts the delegation and understands their responsibilities;
• arrangements for supervision, review and withdrawal of delegation;
• a recording system for each occasion on which the activity is undertaken.

A care worker must not accept or continue a delegated healthcare activity if they do not feel competent, if the instructions are unclear, if the individual’s condition has changed, if required equipment is unavailable, or if the activity falls outside the organisation’s scope or insurance arrangements.

Delegation does not transfer the care worker’s responsibility to work within their competence, nor does it remove the delegating professional’s responsibility for the decision to delegate and provide appropriate instructions and oversight.

7. Safeguarding Considerations and Risk Management

7.1 Identifying and Preventing Abuse or Neglect

Personal care routines must be handled in a way that is safe, respectful, and protective of the individual. Staff must be vigilant in identifying:

• Indicators of possible self-neglect, including a significant deterioration in personal hygiene, untreated health needs, unsafe living conditions, malnutrition, dehydration, hoarding, repeated refusal of essential care, inability to maintain a safe environment or a pattern of behaviour that places the individual or others at serious risk.
• Signs of abuse, such as unexplained injuries, fearfulness, or distress when receiving care.
• Concerns regarding external personal treatment providers, ensuring that all professionals involved in service user care are vetted and compliant with safeguarding policies.

A person’s unconventional lifestyle, appearance or informed refusal of personal care must not automatically be treated as neglect. Staff must distinguish between an individual making an informed choice and a situation in which there may be impaired capacity, coercion, abuse, severe self-neglect or serious risk. Concerns must be assessed proportionately and in accordance with the Mental Capacity Act 2005, the Social Services and Well-being (Wales) Act 2014, the Wales Safeguarding Procedures and local safeguarding arrangements.

If concerns arise, staff must:

• Report a safeguarding concern immediately in accordance with the organisation’s safeguarding policy and the Wales Safeguarding Procedures. Where there is an immediate risk of serious harm, staff must take emergency action, including contacting emergency services where necessary, before notifying the manager or safeguarding lead.

• Preserve evidence and do not clean, alter or dispose of relevant items unless this is necessary to prevent immediate harm.
• Record facts, observations, the individual’s own words and actions taken; do not investigate or ask leading questions.
• Make appropriate referrals to the local authority and other agencies in accordance with the safeguarding policy.
• Consider whether CIW notification, police notification, professional-body referral or a Disclosure and Barring Service referral may be required.
• Inform and support the individual in a manner appropriate to their communication needs and consider access to independent advocacy.

• Record all concerns, observations, and incidents in the service user’s care records.
• Follow the Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13).

7.2 Infection Prevention and Control

Staff must follow the organisation’s Infection Prevention and Control Policy, current public-health guidance, standard infection-control precautions and any additional precautions recorded in the individual’s personal plan.

Staff must:

• perform hand hygiene at the appropriate times and use an appropriate hand-hygiene method;
• wear gloves and aprons where indicated by the activity and risk assessment;
• change gloves and aprons between different care activities and between individuals;
• never use gloves as a substitute for hand hygiene;
• use eye or face protection where there is a foreseeable risk of splashing;
• cover cuts and abrasions with a waterproof dressing;
• ensure reusable equipment is cleaned and decontaminated after use in accordance with organisational procedure and the manufacturer’s instructions;
• use the individual’s own labelled personal-care equipment wherever practicable;
• handle laundry, continence products, sharps and clinical waste safely;
• report exposure incidents, spillages, sharps injuries, outbreaks and suspected infection promptly;
• follow any additional precautions required because of a known or suspected infectious illness.

Razors, toothbrushes, nail equipment, towels, washcloths, combs, hairbrushes, denture equipment and similar personal items must not be shared.

Staff must not attend work where an infectious illness or exclusion requirement makes this unsafe and must follow the organisation’s sickness-reporting procedure.

7.3 Refusal of Care or Support

An individual with capacity has the right to refuse personal care or support, even where staff or others consider the decision unwise. Staff must not use threats, deception, coercion, restraint or repeated pressure to obtain compliance.

When care is refused, staff must:

• remain calm and respectful;
• check whether the individual understands what is being offered;
• consider pain, fear, embarrassment, communication difficulties, preferred timing, preferred worker, cultural factors and environmental causes;
• offer reasonable alternatives or a later opportunity;
• identify whether there is an immediate risk;
• record the refusal, the explanation given, alternatives offered, the individual’s response and action taken;
• report repeated refusals, deterioration or significant risk to the manager.

Where there is doubt about capacity, staff must follow the Mental Capacity Act procedure. A refusal must not be overridden merely because personal care is included in the personal plan.

7.4 Restrictive Practices

Personal care must not be provided using control, restraint or a restriction of liberty unless the intervention is lawful, necessary to prevent harm, proportionate to the risk and carried out in accordance with the organisation’s Control, Restraint and Restrictive Practices Policy.

Routine practices that may amount to restriction, including preventing access to clothing, toiletries, food, drinks, mobility aids, communication aids or the toilet, must not be used for staff convenience.

Any use of control or restraint must be recorded within 24 hours and reported and reviewed in accordance with regulation 29 and organisational procedure.

7.5 Recording and Escalation

Staff must make an accurate, contemporaneous and factual record of the support provided. Records must include, where relevant:

• the care or support offered and provided;
• the individual’s participation, choices and consent;
• any care declined or not completed and the reason;
• skin, oral-health, continence, nutrition, hydration, mobility, emotional or behavioural concerns;
• pain, injury, bleeding, adverse reactions or signs of infection;
• equipment defects or missing supplies;
• advice sought, persons contacted and instructions received;
• safeguarding concerns, incidents and actions taken;
• any change from the personal plan and the reason.

Staff must use objective language and must not include humiliating, judgemental or disrespectful descriptions.

Urgent concerns must be escalated immediately and must not be left solely as an entry in daily records. The personal plan, risk assessment and provider assessment must be reviewed when a significant change is identified.

7.6 Incidents, Errors and Duty of Candour

Any error, omission, injury, avoidable delay, breach of privacy, inappropriate treatment or other incident arising during personal care must be reported immediately and managed under the organisation’s incident-reporting and duty-of-candour procedures.

The service will act openly and transparently with the individual and, where appropriate, their representative. This includes explaining what occurred, taking immediate action to reduce harm, offering an apology where appropriate, investigating the incident, sharing the outcome where lawful, and taking action to prevent recurrence.

The manager must consider whether the incident requires notification to CIW, the local authority, the police, a commissioner, a professional body, the Health and Safety Executive or another relevant body.

8. Staff Training, Competence and Responsibilities

The service provider must ensure that staff are suitably qualified, trained, skilled, competent and experienced to provide the care and support allocated to them.

Before working without direct supervision, staff must complete role-appropriate induction and competence assessment covering, where relevant:

• dignity, privacy, equality, diversity and human rights;
• person-centred practice and personal outcomes;
• consent and the Mental Capacity Act 2005;
• safeguarding adults and children;
• intimate personal care;
• infection prevention and control;
• moving and handling;
• skin integrity and pressure-damage awareness;
• continence care;
• oral care;
• nutrition, hydration and dysphagia awareness;
• communication and sensory impairment;
• dementia and cognitive impairment;
• mental health and emotional wellbeing;
• record keeping, confidentiality and data protection;
• incident reporting, duty of candour and escalation;
• delegated healthcare activities relevant to the worker’s role;
• the Welsh language Active Offer.

Training alone does not establish competence. Where staff undertake practical activities, competence must be assessed through an appropriate combination of knowledge assessment, observation, supervised practice and review. Competence records must identify the activity assessed, assessor, date, outcome, limitations and review date.

Staff must not undertake an activity where they have not been trained and assessed as competent, where their competence has expired or is in doubt, or where the individual’s condition or instructions have changed.

Managers must provide staff with supervision at least quarterly and an annual appraisal, together with additional supervision following an incident, concern, change in role or identified practice issue.

Agency and temporary staff must receive information about the individual’s personal plan, relevant risks, emergency arrangements and organisational policies before providing care.

8.1 Professional Boundaries

Staff must maintain professional boundaries and must not:

• impose their own standards of appearance, hygiene, dress, religion or lifestyle;
• shame, ridicule or criticise an individual;
• photograph or record the individual using a personal device;
• post information about the individual on social media;
• borrow, use or take the individual’s property or personal-care products;
• accept money, commission or personal benefit from a treatment provider;
• purchase or recommend products for personal financial gain;
• enter into an inappropriate personal, financial or sexual relationship;
• provide private paid treatments to an individual outside the service’s authorised arrangements.

8.2 Welsh Language and Communication

The service will identify and record each individual’s language and communication needs as part of the provider assessment and personal plan.

The service will make an Active Offer of Welsh-language care and communication rather than relying solely on individuals to request it. Where the individual wishes to receive care in Welsh, the service will take reasonable steps to match them with Welsh-speaking staff, provide information in Welsh and use appropriate interpretation or communication support where required.

Staff must record and follow the individual’s preferred:

• spoken language;
• written language;
• name and form of address;
• communication method;
• communication aids;
• support required to understand information and express choices.

Communication aids must be available, maintained and used by staff who understand how to use them. The service must consider the communication needs of people with sensory loss, dementia, learning disability, autism, acquired brain injury, speech impairment or limited literacy.

8.3 Equality, Identity and Reasonable Adjustments

Staff must provide support without unlawful discrimination and must have regard to the individual’s protected characteristics under the Equality Act 2010.

Personal care arrangements must respect, where relevant:

• age;
• disability;
• gender reassignment;
• marriage and civil partnership;
• pregnancy and maternity;
• race, nationality and ethnic origin;
• religion or belief;
• sex;
• sexual orientation.

Staff must respect the individual’s name, pronouns, gender identity, relationships, cultural practices, religious observances, modesty requirements, hair and skin-care practices and preferred clothing.

Reasonable adjustments must be identified, recorded, implemented and reviewed. Any inability to make a requested adjustment must be considered by the manager, discussed with the individual and recorded with reasons and any alternative arrangements.

8.4 Lone Working and Staff Safety

Staff must follow the organisation’s lone-working arrangements while recognising that staff safety measures must not unnecessarily compromise the individual’s privacy, dignity or autonomy.

Staff must report:

• unsafe access or environmental hazards;
• aggressive or threatening behaviour;
• unsafe equipment;
• uncontrolled animals;
• smoking, substance-use or fire risks affecting care delivery;
• harassment or discriminatory behaviour;
• any circumstance in which care cannot be delivered safely.

The manager must review the individual’s risk assessment and personal plan and work with the individual, representative, commissioner or relevant professional to identify proportionate measures. Care must not be withdrawn abruptly except where immediate action is necessary to prevent serious harm.

9. Legislation and Guidance

• Regulation and Inspection of Social Care (Wales) Act 2016.
• Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.
• Welsh Government statutory guidance for service providers and responsible individuals on meeting the service standard regulations, Version 3, March 2024.
• Social Services and Well-being (Wales) Act 2014.
• Current safeguarding codes issued under the Social Services and Well-being (Wales) Act 2014.
• Wales Safeguarding Procedures.
• Mental Capacity Act 2005 and Code of Practice.
• Human Rights Act 1998.
• Equality Act 2010.
• Data Protection Act 2018 and UK General Data Protection Regulation.
• Health and Safety at Work etc. Act 1974.
• Management of Health and Safety at Work Regulations 1999.
• Control of Substances Hazardous to Health Regulations 2002.
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013.
• Manual Handling Operations Regulations 1992.
• Social Care Wales Codes of Professional Practice and relevant practice guidance.
• More than just words: Welsh language plan for health and social care.
• Current Public Health Wales infection prevention and control guidance.

10. Governance, Monitoring and Policy Review

The Registered Manager is responsible for implementing this policy and ensuring that staff understand and follow it. The Responsible Individual must maintain oversight of the service’s compliance with the Regulations and the effectiveness of arrangements for safeguarding, quality and improvement.

Compliance with this policy will be monitored through:

• reviews of personal plans and risk assessments;
• observation of staff practice;
• supervision and competence assessments;
• review of daily records;
• infection-prevention audits;
• safeguarding and incident reviews;
• complaints, compliments and feedback;
• feedback from individuals and representatives;
• external professional feedback;
• analysis of missed, late or shortened visits where personal care was affected;
• quality-of-care reviews and improvement plans.

Audit findings must be recorded, assigned to a responsible person, given a completion date and followed through to completion. Learning must be shared with staff and used to revise personal plans, risk assessments, training and organisational procedures.

This policy will be reviewed at least annually and sooner where:

feedback indicates that the policy is not meeting individuals’ needs.

legislation, regulations or statutory guidance change;

CIW or another relevant body issues new guidance;

the statement of purpose changes;

an inspection, complaint, safeguarding matter, incident or audit identifies a weakness;

new treatments, equipment or delegated activities are introduced;

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