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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Catheter Care Policy

1. Purpose

This policy sets out the arrangements by which {{org_field_name}} will provide safe, lawful, person-centred and evidence-informed support to people who use urinary catheters in their own homes. It aims to protect each person’s dignity, privacy, choice, comfort, independence and health while reducing avoidable catheter-associated infection, trauma, blockage, leakage and unnecessary catheter use.

Catheter care will only be provided in accordance with the person’s assessed needs, current personal plan, catheter care instructions and risk assessment. Staff must work within their role, training, assessed competence and authority. They must not insert, replace, remove, irrigate, flush or otherwise undertake a clinical catheter procedure unless the activity is included within the service’s registered scope, has been appropriately authorised or delegated by a relevant healthcare professional, and the staff member has been individually assessed as competent to perform that specific task.

Where there is any conflict between this policy and a person-specific instruction issued by an authorised healthcare professional, staff must stop, seek clarification and follow the current clinically authorised instruction once confirmed and recorded.

2. Scope

This policy applies to:

• All managers, care coordinators, supervisors, support workers, healthcare assistants, agency workers and other staff who plan, arrange, supervise, record or provide catheter-related support.
• People supported by {{org_field_name}} who use an indwelling urethral catheter, suprapubic catheter, intermittent catheter or external urinary collection device.
• Routine non-invasive support, including observation, personal hygiene, positioning of drainage systems, emptying drainage bags, changing drainage bags where authorised, supporting hydration, monitoring for complications and escalating concerns.
• Catheter-related clinical procedures only where these are within the service’s registered scope and have been specifically authorised or delegated by an appropriate healthcare professional.

This policy does not by itself authorise a member of care staff to insert, reinsert, replace, remove, flush, irrigate or undertake a catheter washout. These procedures must not be carried out unless all required clinical instructions, delegation arrangements, training, competency assessments, equipment and emergency arrangements are in place.

3. Legal and Regulatory Requirements

Catheter care and support must be provided in accordance with the following legislation, standards and guidance, as amended:

• Public Services Reform (Scotland) Act 2010.
• Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, SSI 2011/210.
• Health and Social Care Standards: My support, my life.
• Adults with Incapacity (Scotland) Act 2000, where applicable.
• Adult Support and Protection (Scotland) Act 2007, where applicable.
• Human Rights Act 1998.
• Equality Act 2010.
• 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.
• Data Protection Act 2018 and UK General Data Protection Regulation.
• Scottish Social Services Council Codes of Practice for Social Service Workers and Employers, 2024.
• National Infection Prevention and Control Manual, including current Standard Infection Control Precautions and applicable urinary catheter quality-improvement resources.
• Relevant current NHS Scotland, local NHS board, continence, urology and community nursing guidance.
• Applicable manufacturer’s instructions for catheters, valves, drainage bags, fixation devices and other equipment.
• Relevant evidence-based clinical guidance, including current guidance on catheter-associated urinary tract infection.

Under regulation 3 of SSI 2011/210, the service must be provided in a manner that promotes quality and safety, respects the person’s independence and gives the person choice about how their care is provided. Regulation 4 requires the provider to make proper provision for the health, welfare and safety of people using the service. Regulation 5 requires a written personal plan, review when needs significantly change or when requested, and review at least once in every six-month period.

The applicable Health and Social Care Standards and SSSC Codes must be reflected in staff practice, supervision, competency assessment, recording and quality assurance. The 2024 SSSC Codes require workers to practise lawfully, safely and effectively, keep clear and up-to-date records, seek support where they are not prepared to undertake a task, and maintain their learning and skills. Employers must provide suitable learning, supervision, reporting systems and safe working arrangements.

4. Principles of catheter care

{{org_field_name}} will ensure that:

• A catheter is treated as a clinically indicated device and not as a routine response to incontinence, staffing pressures or convenience.
• The reason for the catheter and the arrangements for reviewing its continuing need are recorded.
• The person is supported to understand why the catheter is required, the available alternatives, expected benefits, foreseeable risks and who to contact for advice.
• The person’s privacy, dignity, identity, culture, communication requirements and preferred routines are respected.
• Care is the least restrictive necessary and promotes independence, self-care and informed risk-taking.
• The catheter and drainage system are handled as little as necessary.
• A closed drainage system is maintained unless there is a documented clinical reason to disconnect it.
• The person’s catheter care plan is reviewed whenever there is a change in catheter type, clinical instruction, health, capacity, risk, equipment or recurring complication.
• Antibiotics are not requested or administered solely because urine is cloudy, odorous or contains sediment in the absence of relevant clinical symptoms and professional assessment. NICE states that bacteriuria is common in catheterised people and that antibiotics are not routinely required for asymptomatic bacteriuria.

5. Responsibilities

5.1 Provider and Registered Manager

The provider and Registered Manager must:

• Ensure catheter-related support is consistent with the service’s conditions of registration, aims and objectives, insurance arrangements and staff job descriptions.
• Ensure that clinical catheter procedures are not introduced without governance arrangements, professional advice, written procedures, appropriate equipment and competency assessment.
• Maintain access to current legislation, infection prevention guidance, manufacturer’s instructions and local healthcare pathways.
• Ensure sufficient trained and competent staff are available to meet assessed needs safely.
• Establish written arrangements for delegation, supervision, competency reassessment, escalation and withdrawal of delegation.
• Ensure incidents, near misses, catheter-related infections, injuries and recurring problems are reviewed and used to improve practice.
• Make any required Care Inspectorate notification in accordance with current notification guidance.
• Ensure staff are supported to raise concerns and are not instructed to carry out a task beyond their competence or authority.

5.2 Care Coordinator or Supervisor

The Care Coordinator or Supervisor must:

• Confirm that the personal plan contains current catheter information and person-specific instructions before assigning catheter-related support.
• Allocate only staff who have completed relevant training and whose competence remains current.
• Verify any delegation restrictions, including whether competence is limited to a named person, catheter type, procedure or time period.
• Arrange prompt review following a significant change, incident, hospital admission, catheter replacement, repeated blockage, leakage, trauma or suspected infection.
• Monitor records for completeness, trends and delayed escalation.

5.3 Delegating healthcare professional

Where a healthcare task is delegated, the delegating healthcare professional remains responsible for deciding whether the task is suitable for delegation and for supplying adequate person-specific instructions. The service must obtain written confirmation of:

• The exact task delegated.
• The person to whom the task relates.
• The equipment and technique to be used.
• Contraindications and circumstances in which the task must not proceed.
• Expected findings and escalation thresholds.
• The level of supervision required.
• The frequency of competency review.
• The period for which delegation applies.

5.4 Care staff

Care staff must:

• Read the current personal plan and catheter instructions before providing support.
• Obtain consent and explain the care before starting.
• Follow infection prevention measures and the person-specific care plan.
• Check that equipment is intact, in date where applicable, and suitable for the person.
• Observe the person, catheter, tubing, drainage system, urine output and skin condition.
• Record the care provided and any relevant findings promptly and accurately.
• Stop and seek advice where instructions are unclear, the person’s condition has changed, equipment differs from the care plan, or the task exceeds the worker’s competence.
• Report errors, omissions, incidents, injuries, suspected infection, recurring blockage, leakage or other deterioration without delay.

5.5 Person receiving support and representative

The person must be fully involved in decisions about their catheter support as far as they wish and are able. A family member or representative may only be involved with the person’s consent or where they have lawful authority to act. Family involvement does not replace professional assessment or authorisation.

6. Consent, capacity and lawful decision-making

Staff must seek the person’s valid consent before providing catheter care. Consent must be voluntary, informed and specific to the support being offered. Consent may be expressed verbally, through behaviour or by another established communication method, but it must not be assumed merely because the person has previously accepted care.

Staff must respect a person’s refusal and must not use force, restraint, deception or coercion to provide catheter care. Where refusal creates a significant risk, staff must maintain the person’s immediate dignity and safety, report the refusal promptly and seek clinical and managerial advice.

Capacity is decision-specific and may fluctuate. A diagnosis of dementia, learning disability, mental illness or communication difficulty does not by itself mean that the person lacks capacity.

Where there is concern that the person lacks capacity to make the relevant decision, staff must follow the organisation’s Adults with Incapacity procedure. Any intervention must provide benefit, be the least restrictive available option, take account of the person’s present and past wishes and involve the relevant welfare attorney, guardian or other lawful representative where applicable.

Any certificate, authority or proxy decision relevant to catheter care must be identified within the personal plan. A relative or “next of kin” does not automatically have legal authority to consent on behalf of an adult.

7. Types of urinary catheter and collection device

• Indwelling urethral catheter: A catheter inserted through the urethra into the bladder and retained by an internal balloon. Insertion, removal and replacement must only be undertaken by a suitably authorised and competent person.
• Suprapubic catheter: A catheter inserted into the bladder through a surgically created tract in the lower abdomen. The tract may close rapidly if the catheter is displaced, particularly where it is newly formed; displacement therefore requires urgent clinical advice.
• Intermittent catheter: A catheter inserted temporarily to drain the bladder and removed immediately afterwards. Intermittent catheterisation must only be undertaken in accordance with an individual clinical plan and assessed competence.
• External urinary sheath or external urinary collection device: A non-invasive device fitted externally, usually to the penis, and connected to a drainage bag. The correct size, skin assessment, application method and frequency of change must be specified within the person’s care plan and manufacturer’s instructions.
• Catheter valve: A valve attached to an indwelling catheter to allow planned bladder filling and emptying. A valve must only be used where clinically assessed as suitable and in accordance with the person-specific plan.

Staff must use the terminology stated in the person’s clinical instructions. The phrase “condom catheter” should be avoided in formal records unless it appears within the manufacturer’s product name.

8. Safe and Dignified Catheter Care Procedures

8.1 Infection Prevention and Control

Hand Hygiene

Staff must perform hand hygiene immediately before and after catheter care, before putting on gloves and after removing gloves. The method used must follow the National Infection Prevention and Control Manual and the organisation’s hand-hygiene procedure. Soap and water must be used where hands are visibly dirty or where otherwise required by infection prevention guidance; alcohol-based hand rub may be used where appropriate on visibly clean hands.

Personal Protective Equipment (PPE)

Staff must undertake a point-of-care risk assessment and wear appropriate personal protective equipment. Single-use disposable gloves must be worn when contact with urine, the catheter, the drainage outlet, mucous membranes, non-intact skin or contaminated equipment is anticipated. A disposable apron must be worn where there is a risk of contamination of clothing. Gloves and aprons must be changed between people and between separate care activities where contamination may have occurred. Personal protective equipment does not replace hand hygiene.

Aseptic Technique

Catheter insertion and any invasive catheter procedure must be undertaken using the aseptic technique specified by the relevant healthcare professional, current infection prevention guidance and manufacturer’s instructions. Routine maintenance must use standard infection control precautions and a non-touch approach to key parts. Staff must not touch catheter connections, drainage outlets or other key parts unnecessarily.

Only a person who is trained, authorised and assessed as competent may insert a urinary catheter or undertake another invasive catheter procedure. Current Scottish catheter improvement material states that only competent individuals, or individuals working under appropriate close supervision, should catheterise people or undertake catheter care procedures.

Cleaning the Catheter Site

• Support the person with daily washing of the genital and urethral area using warm water and, where tolerated, mild unperfumed soap.
• Follow the person’s preferred personal-care routine where this is safe and does not conflict with clinical advice.
• Do not routinely use antiseptic solutions, powders, creams or perfumed products around the urethral opening unless specifically prescribed or clinically instructed.
• Clean away from the urethral opening where practicable and avoid pulling, twisting or placing tension on the catheter.
• Dry the area gently and check for redness, swelling, discharge, bleeding, pressure damage, pain, encrustation or catheter traction.
• Do not retract the foreskin forcibly. Where the foreskin has been retracted for hygiene, return it to its normal position afterwards to reduce the risk of paraphimosis.

Suprapubic site care

• Follow the current instructions supplied by the relevant healthcare professional, particularly where the tract is new, healing, infected or producing discharge.
• Once the site has healed, routine cleansing will normally involve warm water and gentle drying unless different clinical instructions are recorded.
• Observe for redness, heat, swelling, increasing pain, bleeding, purulent discharge, overgranulation, leakage, skin breakdown or change in catheter position.
• Do not apply dressings, barrier products, antiseptics or creams unless included in the personal plan or clinically authorised.
• Report signs of infection, worsening leakage, new bleeding or concern about displacement promptly.

Drainage Bag Management

• Keep the drainage bag below the level of the bladder during the day and night, including during transfers, while ensuring it does not pull on the catheter.
• Secure the catheter and drainage tubing using an appropriate fixation or support device in accordance with the personal plan.
• Position the tubing to allow unrestricted drainage and check that it is not kinked, compressed, twisted, trapped under the person or looped above bladder level.
• Keep the drainage outlet off the floor and away from contaminated surfaces.
• Empty the drainage bag when clinically required and before it becomes excessively full, using a clean disposable container allocated to that person or the method specified in the care plan.
• Perform hand hygiene and wear appropriate personal protective equipment before opening the outlet.
• Avoid touching the outlet. Do not allow the outlet to touch the container.
• Close the outlet securely and ensure it is clean and dry before returning it to position.
• Dispose of urine in accordance with the organisation’s waste and infection prevention procedure.
• Record urine output where this is required by the personal plan.

Scottish community catheter guidance states that the drainage bag should remain below bladder level, the outlet should not contact the floor or another surface, and the closed drainage system should not be broken except for a clinical reason such as changing a bag in accordance with the manufacturer’s recommendations.

Changing Catheters and Drainage Bags

• An indwelling catheter must be changed only at the interval specified by the relevant healthcare professional, the catheter prescription and the manufacturer’s instructions, or earlier where clinically indicated. Staff must not apply a generic four-to-twelve-week interval. The catheter type, size, balloon volume, material, date inserted, planned change date and authorised person responsible for changing it must be recorded.
• Drainage bags, night bags, valves and related equipment must be changed at the frequency stated in the person’s clinical plan and the manufacturer’s instructions, or earlier if damaged, leaking, contaminated, disconnected or otherwise unsafe. Routine disconnection must be avoided.
• Maintain a sterile closed drainage system. Do not disconnect the catheter from the drainage system unless clinically necessary and authorised. If the closed system is accidentally broken, contaminated or damaged, staff must follow the person-specific clinical instructions and seek advice where required.

6.2 Monitoring and Maintenance

Checking for Signs of Infection

Staff must observe for symptoms that may indicate catheter-associated urinary tract infection or another complication, including:

• New or worsening suprapubic, pelvic, loin or back pain.
• Fever, rigors or feeling acutely unwell.
• New confusion, delirium or marked deterioration, while recognising that these symptoms may have causes other than urinary infection.
• New haematuria.
• Purulent discharge or worsening inflammation around the catheter site.
• New urinary leakage associated with pain, reduced drainage or suspected blockage.
• Nausea, vomiting, hypotension, tachycardia or other signs of systemic illness.

Cloudy, concentrated or strong-smelling urine, sediment or a positive urine dipstick result must not be treated as proof of infection in isolation. Dipstick testing is not an effective diagnostic method for urinary tract infection in adults with indwelling catheters because catheterised urine commonly contains bacteria.

Staff must record observations and seek clinical advice in accordance with the person’s escalation plan. Staff must not independently diagnose urinary tract infection or request antibiotics solely on the basis of urine appearance or odour.

Report concerns promptly to the designated healthcare contact, such as the district nurse, community nurse, GP, NHS 24 or specialist continence or urology team, in accordance with the person’s escalation plan. Inform the on-call manager or Registered Manager where required by the organisation’s reporting procedure. Emergency services must be contacted where the person is seriously unwell or immediate life-threatening deterioration is suspected.

8.2.1 Urine samples

Staff must not obtain a urine specimen unless instructed by an appropriate healthcare professional and trained to do so.

A specimen must not be taken from the drainage bag. It must be obtained from the designated sampling port using the prescribed aseptic method or collected by an authorised healthcare professional.

The reason for the specimen, date, time, method, healthcare professional instruction and destination of the specimen must be recorded.

Where catheter-associated urinary tract infection is suspected, antibiotic treatment must not be delayed where urgent treatment is clinically required. NICE advises considering removal or change of a catheter that has been in place for more than seven days when treating catheter-associated infection, without delaying antibiotics; this decision must be made by the responsible healthcare professional.

8.2.2 Catheter patency and urine flow

Staff must:

• Check that the tubing and drainage system are correctly positioned and unobstructed.
• Observe the person for bladder discomfort, spasms, pain, leakage, abdominal distension, reduced drainage or no drainage.
• Consider whether reduced output may be related to low fluid intake, dehydration, kinking, constipation, catheter position, disconnection or blockage.
• Follow the person-specific escalation plan and seek clinical advice where urine flow remains reduced or absent after simple external checks.
• Never squeeze, milk, strip or manipulate the catheter tubing unless this has been specifically authorised within the clinical plan.
• Never insert an object into the catheter or drainage system.
• Never attempt to remove, reinsert or replace a catheter in response to a suspected blockage unless specifically authorised, delegated and competent to do so.

Hydration and Diet

Support the person to maintain an appropriate fluid intake in accordance with their preferences, assessed needs and current clinical advice. A fixed daily target must not be imposed where the person has heart failure, kidney disease, swallowing difficulties, fluid restriction or another condition affecting safe intake.

The personal plan must state whether fluid monitoring is required, any minimum or maximum target set by a healthcare professional, preferred drinks, assistance required and action to take where intake decreases.

Staff should support a balanced diet and bowel routine because constipation may contribute to bladder discomfort, leakage and poor catheter drainage. Dietary restrictions must only be applied where agreed with the person and supported by appropriate clinical advice.

Staff must not state that all people with catheters should avoid caffeine or alcohol. Any advice should be individualised, proportionate and recorded within the personal plan.

8.3 Blockage, leakage and other catheter complications

8.3.1 Suspected blockage or absent drainage

Staff must:

• Ask the person about pain, bladder discomfort, spasms, urgency or feeling unwell.
• Check for visible kinks, compression, disconnection, poor drainage-bag position or a closed valve.
• Check whether the bag is below bladder level and whether the tubing is trapped.
• Consider recent fluid intake and the person’s usual urine output.
• Observe for abdominal distension, leakage around the catheter, haematuria or signs of systemic illness.
• Contact the appropriate healthcare professional urgently where drainage does not resume, the person is in pain, the bladder appears distended, leakage is associated with suspected blockage, or the person is unwell.

Staff must not repeatedly reposition the person or encourage excessive fluid intake as a substitute for urgent clinical assessment.

8.3.2 Bypassing or leakage around the catheter

Leakage may be associated with blockage, bladder spasm, constipation, infection, catheter traction, incorrect catheter positioning or another clinical cause. Staff must not assume that a larger catheter is required. They must check the external system, provide skin care, record the occurrence and seek professional advice where leakage is new, persistent, painful or associated with reduced drainage.

8.3.3 Haematuria and trauma

Small amounts of blood may occasionally follow catheter movement or a recent procedure, but staff must report new, increasing or persistent haematuria. Urgent medical advice is required where there is heavy bleeding, blood clots, severe pain, reduced urine output, suspected trauma or deterioration.

8.3.4 Catheter displacement

• A displaced suprapubic catheter requires urgent clinical attention because the tract may close. Staff must immediately contact the service identified in the person’s emergency plan and must not attempt reinsertion unless specifically authorised and competent.
• Where a urethral catheter is expelled or pulled out, staff must not reinsert it unless this has been specifically authorised and delegated. Check for bleeding, pain and injury, preserve the person’s dignity and obtain urgent clinical advice.
• If any part of the catheter appears damaged or the retention balloon may have ruptured, retain the equipment where safe to do so for professional examination and incident review.

8.3.5 Bladder spasm

Report new or worsening bladder spasms, pain or recurrent leakage for clinical review. Staff must not alter medication, catheter size, balloon volume or drainage arrangements without authorisation.

8.3.6 Catheter irrigation, washout or maintenance solution

Catheter irrigation, flushing or washout is an invasive clinical procedure and must not be undertaken routinely to prevent blockage.

It may only be undertaken where:

• There is a current person-specific instruction or prescription from an authorised healthcare professional.
• The intended solution, volume, frequency, technique and clinical indication are clearly recorded.
• The service is authorised and insured to provide the procedure.
• The staff member has received task-specific training, has been individually assessed as competent and has current delegated authority.
• An aseptic non-touch technique can be maintained.
• The required equipment and immediate escalation arrangements are available.

The procedure is not limited solely to suprapubic catheters; however, the route and indication must always be determined by the responsible clinician. Staff must never select saline, water, maintenance solution or any other product themselves.

Staff must stop and seek urgent advice if resistance, pain, bleeding, leakage, inability to instil or withdraw fluid, or deterioration occurs.

8.4 Person-centred support, privacy and independence

Staff must:

• Knock, announce their presence and obtain permission before entering the person’s home or private space.
• Explain the proposed support in a way the person can understand and check consent before beginning.
• Offer the person choices about timing, position, clothing, gender preferences of staff where reasonably practicable, equipment and level of involvement.
• Expose only the area necessary and maintain warmth and privacy.
• Use the person’s preferred name, language and communication method.
• Encourage the person to undertake any aspect of catheter care they can safely manage.
• Avoid infantilising, stigmatising or task-focused language.
• Respect the person’s relationships, sexuality, body image, cultural practices and social activities.
• Discuss how the catheter may affect sleep, mobility, clothing, travel, work, exercise, intimacy and community participation where the person wishes.
• Ensure catheter bags, tubing and fixation devices are positioned discreetly and comfortably without compromising drainage or safety.

Personal plans should identify what matters to the person, their preferences, abilities, desired outcomes, risks and the exact support staff must provide. Care Inspectorate personal-planning guidance emphasises that plans must reflect assessed needs, wishes, choices, meaningful involvement and regular review.

9. Personal plan and catheter care plan

A catheter care plan must be prepared as part of the person’s personal plan. It must be available to staff before catheter-related support is provided and must include, where relevant:

• The clinical reason for the catheter.
• Catheter type, route, material, manufacturer and product.
• Catheter size and balloon volume, where relevant.
• Date inserted or last changed.
• Planned review and change date.
• Name and contact details of the responsible healthcare team.
• Whether the person uses a leg bag, night bag, valve or another drainage arrangement.
• Frequency and authorised method for changing equipment.
• Fixation and positioning requirements.
• Personal hygiene and skin-care instructions.
• Normal urine output and appearance for that person.
• Whether urine-output or fluid-balance monitoring is required.
• Fluid recommendations and any restrictions.
• The person’s usual bowel pattern and constipation plan where relevant.
• Known history of blockage, encrustation, bypassing, trauma, autonomic dysreflexia, infection or allergy.
• Signs requiring routine, urgent or emergency escalation.
• Daytime and out-of-hours contact details.
• Procedures staff are authorised to undertake and procedures they must not undertake.
• Details of any healthcare delegation.
• Communication, consent, capacity and representative arrangements.
• The person’s preferences, outcomes and desired level of independence.
• Equipment storage and waste-disposal arrangements.
• Contingency arrangements for missed visits, equipment failure, power failure where relevant, travel and emergencies.

The personal plan must be prepared in consultation with the person and any representative who is appropriately involved. It must be reviewed:

• At least every six months.
• Whenever requested by the person or their representative.
• Following a significant change in health, welfare or safety needs.
• Following catheter replacement, hospital discharge, recurring blockage, infection, trauma, repeated leakage or another significant incident.

These review requirements reflect regulation 5 of SSI 2011/210.

10. Delegated healthcare tasks

Delegation must be person-specific, task-specific and worker-specific. Completion of a general training course does not itself authorise a worker to perform an invasive catheter procedure.

Before accepting a delegated task, {{org_field_name}} must be satisfied that:

• The task is suitable for delegation.
• The delegation is compatible with the service’s registration, insurance and policies.
• Written person-specific instructions have been received.
• The worker has appropriate knowledge, practical skill and understanding.
• Competence has been directly observed and formally recorded.
• The worker understands when not to proceed and how to obtain immediate advice.
• Equipment, personal protective equipment, time and supervision are available.
• The person has consented to the proposed arrangement.

Staff have a duty to refuse or pause a task where they are not competent, the person’s condition has changed, instructions are missing or unclear, equipment is unavailable, or safe practice cannot be maintained.

Delegation must be reviewed whenever the person, procedure, equipment, healthcare instruction or worker changes, or following an incident, extended absence or concern about competence.

11. Training, supervision and competency

Staff must not provide catheter-related support until they have received training appropriate to their responsibilities and have been assessed as competent for the tasks they will undertake.

Training must cover, as applicable:

• Urinary anatomy and the purpose of catheterisation.
• Types of catheter and drainage equipment.
• The risks of unnecessary catheterisation.
• Consent, capacity, privacy, dignity and communication.
• Standard infection control precautions.
• Hand hygiene and personal protective equipment.
• Closed drainage-system maintenance.
• Personal hygiene, skin assessment and catheter fixation.
• Emptying and changing drainage equipment.
• Monitoring urine output and recognising deterioration.
• Catheter-associated urinary tract infection and antimicrobial stewardship.
• Blockage, leakage, bypassing, haematuria, trauma and displacement.
• Suprapubic catheter emergencies.
• Autonomic dysreflexia, where relevant to the people supported.
• Documentation, incident reporting and escalation.
• Limits of role and delegated healthcare tasks.

Competency must:

• Be assessed through direct observation by a suitably qualified and competent assessor.
• Be documented against defined criteria.
• Be specific to the worker and the task.
• Include knowledge, practical skill, judgement, infection prevention and escalation.
• Be reassessed at an interval determined by risk, local arrangements and professional instruction.
• Be reassessed sooner following an incident, change in procedure, equipment or guidance, extended absence, or concern about performance.

Annual training may form part of the organisation’s learning programme, but attendance at annual training must not replace individual competency assessment. Staff must receive ongoing supervision and be encouraged to identify learning needs and raise concerns.

The 2024 SSSC Codes require employers to provide appropriate induction, learning, development and supervision and require workers to seek support where they are not adequately prepared to carry out a task.

12. Records, reporting and confidentiality

Staff must make a clear, accurate, factual and contemporaneous record of catheter-related support. Records must include, where applicable:

• Date and time of care.
• Consent obtained or refusal.
• Personal hygiene and site care provided.
• Condition of the urethral or suprapubic site and surrounding skin.
• Catheter and tubing position.
• Drainage-bag or valve care.
• Urine output where monitoring is required.
• Relevant urine appearance, while avoiding unsupported diagnosis.
• Pain, discomfort, spasms, leakage, blockage, bleeding or other concerns.
• Equipment changes, including product and date.
• Advice sought, the person contacted, instructions received and action taken.
• The person’s response and outcome.
• Any variance from the personal plan and the reason.

Staff must not use vague entries such as “catheter care done”, “all well” or “urine normal” without sufficient supporting information.

Catheter insertion, change and removal records must include the procedure, indication, catheter type, size, balloon volume, batch or lot information where required, date, time, name and role of the person completing the procedure, difficulties encountered, urine drainage and the next planned review or change date.

Records must be stored securely and accessed only by authorised persons. Information may be shared with healthcare professionals and others only where there is a lawful basis and the disclosure is necessary and proportionate.

Where an incident or near miss occurs, staff must complete the organisation’s incident report in addition to the daily care record. The manager must consider:

• Immediate clinical action.
• Duty of candour requirements.
• Safeguarding or adult-protection action.
• Notification to the Care Inspectorate.
• Referral to the SSSC or another professional regulator.
• Equipment quarantine or reporting.
• Review of competence, personal plan and risk assessment.
• Learning to prevent recurrence.

13. Incident management and duty of candour

Catheter-related incidents include, but are not limited to:

• Unauthorised insertion, removal, flushing or washout.
• Incorrect catheter, balloon volume, drainage equipment or product.
• Failure to maintain a closed drainage system.
• Accidental catheter removal or displacement.
• Trauma, bleeding or significant pain.
• Delayed response to blockage, no drainage or suspected infection.
• Failure to follow a healthcare instruction.
• Missed catheter-related care.
• Use of unclean, damaged, expired or unsuitable equipment.
• Medication or solution error associated with catheter treatment.
• Breach of privacy, dignity or confidentiality.

The person must receive appropriate immediate care and a clear explanation of what has occurred. Managers must follow the organisation’s incident, adult protection, duty of candour and Care Inspectorate notification procedures as applicable.

Where practice has caused or may have caused harm or loss, the service and its workers must be open and honest and cooperate with investigation. This reflects the 2024 SSSC Codes.

14. Equipment, storage and waste

Catheters, bags, valves, fixation devices, sterile solutions and related equipment must:

• Be prescribed or clinically approved where required.
• Be used only for the person for whom they were supplied.
• Be stored in a clean, dry and secure location.
• Remain in original packaging until required.
• Be checked for package integrity, expiry date and suitability before use.
• Be used in accordance with the manufacturer’s instructions.
• Not be reused where labelled for single use.

Staff must report shortages in sufficient time to avoid interruption of care. Expired, damaged, opened or contaminated equipment must not be used.

Urine, disposable bags, gloves, aprons and other waste must be handled and disposed of in accordance with the person’s home arrangements, local waste requirements and the organisation’s infection prevention procedure. Sharps must be disposed of immediately into an approved sharps container where a sharps procedure forms part of authorised care.

15. Autonomic dysreflexia

Autonomic dysreflexia is a medical emergency that may occur in some people with spinal cord injury. A blocked, kinked or overfull catheter drainage system may act as a trigger.

The person-specific plan must identify whether the person is at risk and state their usual blood pressure, individual symptoms and emergency procedure.

Possible signs include:

• Sudden severe or pounding headache.
• Flushing or sweating above the level of injury.
• Pallor or goosebumps below the level of injury.
• Nasal congestion.
• Anxiety, blurred vision or feeling unwell.
• Sudden high blood pressure or change in pulse.

Staff must follow the person’s emergency plan immediately, check the visible catheter tubing and drainage system for simple external obstruction, and obtain urgent medical assistance. Staff must not delay escalation while repeatedly attempting to resolve catheter drainage.

16. Related Policies

• Infection Prevention and Control Policy
• Personal Care Policy
• Health and Safety Policy
• Incident Reporting and Management Policy

• Adults with Incapacity and Consent Policy.
• Adult Support and Protection Policy.
• Delegated Healthcare Tasks Policy.
• Duty of Candour Policy.
• Data Protection, Confidentiality and Records Management Policy.
• Staff Training, Supervision and Competency Policy.
• Deterioration and Emergency Escalation Policy.
• Waste Management Policy.
• Equality, Human Rights and Dignity Policy.
• Complaints and Feedback Policy.
• Whistleblowing Policy.
• Hydration and Nutrition Policy.
• Continence Care Policy.
• Medication Management Policy, where catheter maintenance solutions or prescribed products are involved.

17. Quality assurance and audit

The Registered Manager must ensure regular audit of catheter care. The frequency of audit must be proportionate to the number of people supported, complexity of procedures and identified risk.

Audit must consider:

• Whether each catheter remains clinically indicated.
• Whether the personal plan is current and person-centred.
• Whether catheter details and change dates are complete.
• Whether healthcare instructions and delegation records are available.
• Staff training and competency status.
• Hand hygiene and infection prevention practice.
• Maintenance of the closed drainage system.
• Site, skin and fixation care.
• Quality and completeness of daily records.
• Timeliness of escalation.
• Catheter-associated infection, blockage, leakage, trauma and unplanned hospital admission.
• Incidents, complaints, missed care and near misses.
• Feedback from people receiving support and their representatives.
• Evidence that learning has resulted in improvement.

Audit findings must lead to a recorded improvement action plan with named responsibilities, timescales and review of effectiveness.

Care Inspectorate personal-planning guidance describes quality assurance and self-evaluation as essential to determining whether personal plans are achieving the outcomes people want.

18. Policy Review

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

• A change in legislation, Care Inspectorate expectations, infection prevention guidance or clinical evidence.
• A change in the service’s registration, scope or delegated healthcare arrangements.
• New equipment or a change in manufacturer’s instructions.
• A catheter-related incident, complaint, outbreak, significant near miss or identified practice concern.
• Feedback from a person receiving support, representative, healthcare professional, staff member or regulator.

The Registered Manager must ensure that revised requirements are communicated to staff, affected personal plans are reviewed, and any necessary training or competency reassessment is completed before revised procedures are implemented.

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