SL147-Wound Care and Management Policy

Registration Number: {{org_field_registration_no}}

Wound Care and Management Policy

1. Purpose

The purpose of this policy is to establish clear, safe, and effective guidelines for the prevention, assessment, treatment, and monitoring of wounds within {{org_field_name}}. It ensures that service users receive high-quality, person-centred care in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, specifically Regulation 12 on Safe Care and Treatment.

This policy aims to:

Ensure wounds are identified, assessed, and treated promptly.
Promote healing, prevent complications, and reduce pain.
Maintain dignity and respect while delivering wound care.
Involve service users, families, and healthcare professionals in wound management plans.

2. Scope

This policy applies to all staff involved in the care and support of service users at {{org_field_name}}. It covers all aspects of wound management, including:

Prevention of wounds, including pressure ulcers.
Assessment and classification of wounds.
Wound treatment and dressing changes.
Monitoring and documentation.
Infection control and safeguarding considerations.

The policy extends to external healthcare professionals, including district nurses and general practitioners (GPs), ensuring a collaborative approach to wound management.

3. Policy Statement

{{org_field_name}} is committed to providing high-quality, evidence-based wound care that prioritises the safety, dignity, and well-being of service users. Wound care will be delivered by district nurses or trained staff following individualised care plans, ensuring that service users receive timely interventions and appropriate referrals to healthcare professionals when needed.

The service adheres to CQC’s Safe Care and Treatment standards, ensuring that all wound care practices are based on clinical guidelines and best practices. We recognise that effective wound care not only promotes physical healing but also enhances emotional well-being and quality of life.

4. Wound Care Management Process

4.1 Wound Prevention

Prevention is a core focus of wound management at {{org_field_name}}. This includes regular skin assessments, promoting mobility, maintaining proper nutrition and hydration, and ensuring appropriate use of pressure-relieving equipment. These practices align with CQC’s Regulation 14 on Meeting Nutritional and Hydration Needs.

Staff conduct risk assessments for all service users, identifying those at higher risk of developing pressure ulcers, skin tears, or other wounds. This includes individuals with limited mobility, chronic conditions, or compromised nutritional status.

Regular repositioning, appropriate skin care products, and prompt attention to skin changes are key components of our prevention strategy.

4.2 Wound Identification and Assessment

When a wound is identified, staff must conduct an immediate assessment, documenting:

The wound’s location, size, depth, and appearance.
The presence of exudate, odour, or signs of infection.
The service user’s pain level and overall well-being.

Staff use recognised wound assessment tools, such as the Waterlow Score for pressure ulcer risk, ensuring a consistent and thorough approach. Photographic documentation, with consent, is used to support monitoring and clinical decision-making.

If a wound is complex or shows signs of infection, an immediate referral is made to a healthcare professional, such as a district nurse or GP. This aligns with Regulation 12 on Safe Care and Treatment, ensuring that service users are protected from avoidable harm.

4.3 Individualised Wound Care Plans

An individualised wound care plan is developed for each service user with a wound. This plan includes:

The type and frequency of wound dressings.
Pain management strategies.
Nutritional support to promote healing.
Mobility and positioning recommendations.
Monitoring schedules and escalation procedures.

Service users and their families are involved in developing and reviewing the care plan, ensuring a person-centred approach as required under Regulation 9. Plans are reviewed regularly, especially if the wound’s condition changes.

4.4 Wound Treatment and Dressing Changes

All wound care is provided by district nurses, following the service user’s individualised care plan. Staff are trained to:

Use aseptic or clean techniques, depending on the wound type and infection risk.
Apply dressings appropriate for the wound stage and healing requirements.
Manage pain and discomfort during dressing changes.
Maintain the service user’s dignity and privacy throughout the procedure.

Dressings are stored securely and monitored for expiry dates, ensuring that only appropriate products are used. Any concerns about wound deterioration are reported immediately to healthcare professionals.

4.5 Monitoring and Documentation

Accurate and timely documentation is critical for effective wound management. Staff record:

The wound’s condition after each dressing change.
Any signs of infection, such as increased redness, swelling, or discharge.
The service user’s pain levels and overall comfort.
Communication with healthcare professionals and updates to care plans.

Regular wound reviews are conducted in collaboration with district nurses, ensuring a multidisciplinary approach to care. Monitoring aligns with CQC’s Good Governance requirements under Regulation 17.

4.6 Infection Control

To prevent infection, staff adhere to strict infection prevention and control measures, including:

Hand hygiene before and after wound care.
Use of personal protective equipment (PPE), such as gloves and aprons.
Safe disposal of dressings and clinical waste.
Regular cleaning of care environments and equipment.

If an infection is suspected, staff immediately inform healthcare professionals and follow prescribed treatment plans. This aligns with Regulation 12 on Safe Care and Treatment.

4.7 Pain Management and Emotional Support

Wound care can be physically and emotionally challenging. {{org_field_name}} ensures that service users receive adequate pain relief, including prescribed analgesics and non-pharmacological methods such as repositioning and relaxation techniques.

Staff provide emotional support, ensuring that service users feel safe, respected, and involved in their care decisions. This approach aligns with CQC’s Regulation 10 on Dignity and Respect.

4.8 Safeguarding Considerations

Wounds that raise safeguarding concerns, such as unexplained injuries or signs of neglect, are reported immediately following {{org_field_name}}’s Safeguarding Adults from Abuse and Improper Treatment Policy. This ensures that service users are protected from harm and that concerns are escalated appropriately.

5. Collaboration with Healthcare Professionals

{{org_field_name}} works closely with healthcare professionals to ensure safe, effective wound management. This includes:

Prompt referrals for complex wounds or suspected infections.
Joint wound assessments and care planning.
Regular multidisciplinary reviews to evaluate healing progress.
Clear communication about treatment changes and service user needs.

Staff facilitate appointments and provide transport if necessary, ensuring that service users receive timely specialist care.

6. Training and Competency

All staff involved in wound care receive comprehensive training, including:

Wound assessment and classification.
Aseptic and clean dressing techniques.
Infection prevention and control.
Pain management and holistic care approaches.

Staff competency is assessed regularly, with refresher training provided to maintain high standards. This aligns with CQC’s Regulation 18 on Staffing and Competency.

7. Communication and Family Involvement

Effective communication is essential for successful wound management. {{org_field_name}} ensures that:

Service users and families are fully informed about wound care plans and progress.
Any changes in wound condition are communicated promptly.
Families are supported in understanding wound prevention and management.

Where service users lack capacity, decisions are made in their best interests, following the principles of the Mental Capacity Act 2005.

8. Incident Reporting and Learning

Any wound-related incidents, such as deteriorating wounds, infections, or dressing errors, are reported immediately through the service’s incident reporting system. Investigations are conducted to identify root causes and implement preventive actions.

Findings are shared with staff during team meetings, promoting continuous learning and improvement. This aligns with the Duty of Candour requirements under Regulation 20.

9. Related Policies

This policy works alongside the following policies:

Safe Care and Treatment Policy.
Infection Prevention and Control Policy.
Medication Management and Administration Policy.
Safeguarding Adults from Abuse and Improper Treatment Policy.
Person-Centred Care Policy.
Duty of Candour Policy.

10. Monitoring and Continuous Improvement

{{org_field_name}} continuously monitors wound care practices through:

Regular audits of wound care documentation.
Feedback from service users and families.
Learning from incidents and near misses.
Collaboration with healthcare professionals for service reviews.

Findings are discussed during quality assurance meetings and used to inform staff training and service improvements, ensuring alignment with CQC’s Good Governance standards.

11. Policy Review

This policy will be reviewed annually or earlier if there are changes in clinical guidelines, CQC regulations, or service needs. The Registered Manager is responsible for ensuring the policy remains current, effective, and reflective of best practices.

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.