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Catheter Care Policy

1. Purpose

At {{org_field_name}}, we are committed to delivering safe, effective, and person-centred catheter care to individuals requiring urinary catheterisation. This policy ensures that catheter care is provided in a dignified, hygienic, and clinically safe manner, reducing the risk of infection and promoting comfort and independence.

This policy is aligned with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, CQC Fundamental Standards, the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance, NICE CG139 Healthcare-associated infections: prevention and control in primary and community care, NICE NG113 Urinary tract infection (catheter-associated): antimicrobial prescribing, NICE QS61 Infection prevention and control, NICE QS90 Urinary tract infections in adults, the Mental Capacity Act 2005, the Human Rights Act 1998, the Care Act 2014, UK GDPR and the Data Protection Act 2018.

This policy supports compliance with CQC expectations that people receive safe, effective, person-centred care; are protected from avoidable harm, infection and abuse; are treated with dignity and respect; are supported to make informed decisions; and receive care from staff who are suitably trained, competent and supervised. It also supports the CQC single assessment framework quality statements for safe systems, safe and effective staffing, involving people to manage risks, safeguarding, medicines optimisation where relevant, infection prevention and control, governance, learning and improvement.

2. Scope

This policy applies to all staff, including permanent, temporary, agency, and volunteer workers involved in catheter care within our Supported Living service.

This policy covers the support that staff may provide with catheter care in a supported living setting, including observation, hygiene support, positioning of drainage systems, emptying drainage bags, recording, reporting concerns, supporting hydration where this is part of the person’s care plan, and supporting the person to access healthcare professionals. Catheter insertion, catheter removal, catheter replacement, catheter irrigation/washout, bladder scanning, clinical diagnosis, prescribing, and treatment of suspected infection must only be undertaken by an appropriately registered healthcare professional or by a staff member where the task has been formally delegated by a competent healthcare professional, is within the provider’s regulated activity, is included in the person’s care plan and risk assessment, and the staff member has been trained, assessed as competent and authorised in writing.

In supported living, staff must work within the person’s tenancy, consent, care and support plan, commissioned service agreement and the provider’s CQC registration. Staff must not undertake a catheter-related task simply because it appears in this policy. The task must be individually assessed, authorised, risk assessed, documented and within the staff member’s competence. Where the person receives catheter care from district nurses, community nurses, GPs, continence services or other NHS professionals, staff must follow the agreed shared-care arrangements and must not alter clinical instructions without professional advice.

3. Related Policies

• SL12 – Safe Care and Treatment Policy
• SL16 – Infection Prevention and Control Policy
• SL07 – Person-Centred Care Policy
• SL08 – Dignity and Respect Policy
• SL34 – Confidentiality and Data Protection (GDPR) Policy
• SL21 – Medication Management and Administration Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• Consent and Mental Capacity Policy
• Delegated Healthcare Tasks / Clinical Tasks Policy
• Staff Training, Supervision and Competency Policy
• Incident, Accident and Near Miss Reporting Policy
• Duty of Candour Policy
• Complaints and Compliments Policy
• Waste Management Policy, including clinical waste where applicable
• PPE Policy
• Equality, Diversity and Human Rights Policy
• Information Sharing and Confidentiality Policy
• Care Planning and Risk Assessment Policy
• Continence Care Policy, if separate
• Moving and Handling Policy, where catheter tubing, bags or positioning may be affected during transfers

3.1 Legal and Regulatory Framework

This policy must be read alongside the following legal and regulatory requirements:

• Health and Social Care Act 2008: The Act establishes the Care Quality Commission and its regulatory role. CQC’s main objective is to protect and promote the health, safety and welfare of people who use health and social care services. The Act also enables requirements relating to regulated activities, including the prevention and control of healthcare-associated infections.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: This policy particularly supports compliance with Regulation 9 Person-centred care, Regulation 10 Dignity and respect, Regulation 11 Need for consent, Regulation 12 Safe care and treatment, Regulation 13 Safeguarding service users from abuse and improper treatment, Regulation 17 Good governance, Regulation 18 Staffing, Regulation 19 Fit and proper persons employed, and Regulation 20 Duty of Candour.
• Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance: The provider must have effective systems to prevent, detect, assess and control infection risks and must ensure staff follow safe infection prevention and control practice.
• CQC single assessment framework: Catheter care must evidence safe systems, person-centred risk management, effective infection prevention and control, learning from incidents, good governance, safe staffing and partnership working with external healthcare professionals.
• NICE guidance and quality standards: Staff must take account of NICE CG139, NICE NG113, NICE QS61 and NICE QS90 when supporting catheter care and when recognising or escalating possible catheter-associated urinary tract infection.
• Mental Capacity Act 2005: Where a person may lack capacity to consent to catheter care or related support, staff must follow the Mental Capacity Act 2005, including capacity assessment, best interests decision-making, least restrictive practice and involvement of relevant representatives.
• Care Act 2014: Catheter-related neglect, failure to obtain medical help, poor hygiene, unsafe practice or deliberate misuse of catheter care may amount to safeguarding concerns and must be reported in line with local safeguarding procedures.

4. Principles of Catheter Care

4.1 Person-Centred Approach

• Individuals must be fully informed about their catheter care and involved in decision-making wherever possible.
• Staff must respect privacy and dignity, ensuring catheter care is provided discreetly and sensitively.
• Support must be tailored to individual needs, promoting independence where possible, such as assisting individuals in self-care.
• The person’s catheter care plan must reflect their communication needs, preferred name, gender identity, cultural and religious needs, privacy preferences, trauma history where known, and the level of support they want with intimate care.
• Staff must promote independence and self-management wherever safe, including encouraging the person to empty or manage their own catheter bag if they wish to do so and have been assessed as able.
• Staff must explain each intervention before it takes place and must obtain consent before providing catheter-related support. Consent must be recorded where the support is intimate, refused, withdrawn or where there is any concern about capacity.
• Staff must respect the person’s right to refuse support unless there is an immediate risk of serious harm. Refusal must be recorded and escalated in line with the person’s care plan and risk assessment.

4.2 Consent and Mental Capacity

Staff must obtain the person’s consent before providing catheter care or support. Consent must be specific to the task being carried out, such as supporting hygiene, emptying a catheter bag, checking tubing, assisting with clothing, or sharing information with a healthcare professional.

Where the person appears unable to understand, retain, weigh up or communicate a decision about catheter care, staff must follow the Mental Capacity Act 2005 and the organisation’s Consent and Mental Capacity Policy. A capacity assessment must be decision-specific and time-specific.

If the person lacks capacity for a catheter-care decision, any decision or support provided must be in the person’s best interests, be the least restrictive option, involve relevant family members or representatives where appropriate, and be clearly recorded. Staff must not use restraint, coercion or restrictive practice during catheter care unless this is lawful, necessary, proportionate, care-planned and authorised in accordance with the Mental Capacity Act 2005 and safeguarding procedures.

If catheter care is refused and this creates a risk of infection, blockage, skin damage, pain, urinary retention or other harm, staff must record the refusal, encourage the person using accessible information, and escalate to the senior on duty, registered manager, GP, district nurse, community nurse or emergency services according to the level of risk.

4.3 Assessment and Catheter Selection

• Catheterisation must only be used where clinically necessary, following assessment by an appropriately registered healthcare professional, and after less invasive alternatives have been considered.
• The decision to insert, continue, change or remove a catheter is a clinical decision and must be made by an appropriately registered healthcare professional. Support workers must not make decisions about catheter selection, insertion, replacement or removal unless a specific task has been formally delegated and competency assessed.
• The type, size and route of catheter, such as urethral, suprapubic or intermittent catheterisation, must be determined by a healthcare professional and recorded in the catheter care plan.
• A catheter care plan must be developed in collaboration with healthcare professionals, the individual, and their family (where appropriate).
• The plan must detail:
  • The type and size of catheter
  • The reason for catheterisation
  • Expected duration of use
  • Signs and symptoms requiring medical intervention
  • Individual preferences and comfort measures
  • The healthcare professional responsible for catheter review
  • Date of insertion and planned review or change date
  • Whether the catheter is urethral, suprapubic, intermittent, long-term or short-term
  • Whether the drainage system is a leg bag, night bag, catheter valve or other system
  • Latex allergy or sensitivity and any product allergies
  • Infection history, blockage history and any previous catheter-related complications
  • Skin integrity risks, pressure damage risks and securement arrangements
  • The person’s usual urine output, colour and symptoms, where known
  • Clear instructions for fluid support, including any fluid restriction or contraindication
  • What staff are authorised to do and what must be escalated to healthcare professionals
  • Emergency escalation instructions, including when to call 111, GP, district nurse, community nurse or 999
  • Review frequency and who is responsible for review

4.4 Infection Prevention and Control

• Strict hand hygiene must be followed before and after catheter care.
• Staff must use the level of infection prevention and control practice appropriate to the task. Routine external catheter hygiene and emptying of drainage bags must be carried out using clean technique, hand hygiene and appropriate PPE. Aseptic non-touch technique must be used for invasive catheter-related procedures or manipulation of sterile connections where the task has been delegated by a healthcare professional and the staff member has been trained and assessed as competent.
• Catheters must be securely positioned to prevent unnecessary movement, which could lead to trauma or infection.
• Daily monitoring for signs of infection (e.g., cloudy urine, fever, pain, or swelling) must be conducted.
• Catheter-associated urinary tract infections (CAUTIs) must be documented, and individuals must be referred for medical review if required.
• Staff must follow the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance, the organisation’s Infection Prevention and Control Policy and current national IPC guidance for adult social care.
• Staff must decontaminate hands before and after catheter care, after removing gloves, after contact with urine or body fluids, and after contact with catheter equipment.
• Disposable gloves and aprons must be worn where there is a risk of contact with urine, body fluids, contaminated equipment or intimate care. PPE must be changed between tasks and disposed of safely.
• Catheter drainage systems must be kept as closed as possible. Staff must not disconnect catheter tubing or drainage systems unless this is part of the care plan and the staff member is specifically trained and authorised.
• Drainage taps must not touch the toilet, container, floor or any contaminated surface.
• Urine containers must be clean, used for one person only, emptied promptly and cleaned or disposed of according to the infection prevention and waste policy.
• Catheter equipment must be stored clean, dry, off the floor and according to manufacturer’s instructions.
• Any suspected catheter-associated infection, avoidable contamination, poor practice, lack of supplies, PPE failure or breach of infection control must be reported to a senior member of staff and recorded as an incident where appropriate.

4.5 Catheter Maintenance and Monitoring

• Daily Hygiene: Staff must support the person to maintain catheter and personal hygiene in line with their care plan, clinical advice and personal preferences. The catheter entry site and surrounding skin should normally be cleaned at least daily and after bowel movements or soiling, using warm water and mild soap where appropriate, unless a healthcare professional advises otherwise. Staff must avoid antiseptic solutions, creams, powders or perfumed products unless prescribed or clinically recommended. Skin must be observed for redness, swelling, discharge, bleeding, soreness, pressure damage or leakage and concerns must be recorded and escalated.
• Fluids and Hydration: Staff must support the person to maintain hydration in line with their care plan, health conditions, swallowing assessment and clinical advice. Staff must not encourage increased fluid intake where the person has a fluid restriction or where increased fluids may be unsafe, for example due to heart failure, renal disease or swallowing difficulties. Fluid intake and output must be monitored where this is required by the care plan or requested by a healthcare professional.
• Checking for Kinks and Blockages: The catheter tubing should be checked frequently to ensure it is free from kinks, twisting, or pressure from clothing or furniture.
• Positioning and Securing the Catheter:
  • The catheter should be secured to the individual’s thigh or abdomen (for suprapubic catheters) to prevent movement and trauma.
  • Ensure the drainage bag is below bladder level to prevent backflow but does not touch the floor.
• Emptying the Drainage Bag:
  • The drainage bag must be emptied according to the person’s care plan, manufacturer’s instructions and individual need, and always before it becomes overfull or causes pulling, discomfort, backflow risk or leakage.
  • As a general guide, the bag should be emptied when it is around two-thirds full, before transport or activities where pulling may occur, and before the person goes to bed where this forms part of the care plan.
  • Staff must perform hand hygiene, wear appropriate PPE, avoid touching the drainage tap against the toilet or container, empty urine safely, close the tap securely, clean the tap if required by local procedure, remove PPE and perform hand hygiene again.
  • Staff must maintain privacy and dignity throughout and must record output where the care plan requires fluid balance or urine monitoring.
• Changing Drainage Bags and Catheter Valves:
  • Drainage bags and catheter valves must be changed only in line with the person’s care plan, manufacturer’s instructions and clinical advice.
  • Leg bags are commonly changed every 5–7 days depending on the product and clinical instructions, or sooner if damaged, contaminated, leaking, odorous, visibly soiled or not functioning.
  • Single-use night drainage bags must be disposed of after use. Reusable night drainage systems, where used, must be managed strictly according to manufacturer’s instructions and infection prevention guidance.
  • Staff must not disconnect or change catheter bags unless this task is included in the care plan, the staff member has been trained and assessed as competent, and the provider has authorised the task.
  • Any difficulty changing a bag, contamination of the system, leakage, pain, bleeding, accidental disconnection or concern about infection must be escalated promptly.
• Monitoring Urine Output, Colour and Symptoms:
  • Staff must monitor and record urine output, colour, odour, sediment, leakage and comfort where this is required by the care plan or where concerns arise.
  • Staff must remember that cloudy, strong-smelling urine or sediment alone does not confirm infection, especially in a person with a long-term catheter.
  • Staff must look for symptoms and changes such as fever, rigors, new lower abdominal or back pain, flank pain, pelvic discomfort, new confusion or delirium, reduced urine output, blood in urine, catheter-site pain, burning, worsening spasms, feeling generally unwell, or signs of sepsis.
  • Staff must not use urine dipstick testing to diagnose UTI in adults with indwelling urinary catheters unless specifically directed by a healthcare professional, because dipstick testing is not reliable in this situation.
  • Suspected catheter-associated UTI must be escalated to the GP, district nurse, community nurse, NHS 111 or emergency services according to severity and the person’s care plan.
  • Staff must not request or expect antibiotics for cloudy or smelly urine alone where the person is otherwise well, unless advised by a clinician.
• Checking for Leaks and Discomfort:
  • Observe for leakage around the catheter site, which may indicate a blockage or displacement.
  • If the individual experiences pain, burning, or bladder spasms, report it immediately for medical review.
• Suspected Blockage or Reduced Drainage:
  • If urine output is reduced or stops, staff must check for simple non-invasive causes such as kinks in tubing, the drainage bag being above bladder level, a closed tap, tight clothing, pressure from furniture, or the person’s position.
  • Staff may reposition tubing or support the person to change position where safe and consented.
  • Staff must not flush, irrigate, manipulate, remove or replace the catheter unless this has been formally delegated by a healthcare professional and the staff member is trained, competent and authorised.
  • Staff must contact the district nurse, community nurse, GP, NHS 111 or other agreed healthcare professional urgently if there is no drainage, abdominal pain, bladder distension, leakage around the catheter, visible blood, fever, rigors, new confusion, severe discomfort, autonomic dysreflexia risk, or signs of sepsis.
  • Call 999 immediately if the person is seriously unwell, has signs of sepsis, severe pain, collapse, reduced consciousness, breathing difficulty, or any other life-threatening symptoms.
• Catheter Changes:
  • Catheter change frequency must be determined by the responsible healthcare professional and manufacturer’s instructions, based on the person’s catheter type, clinical need, blockage history, infection risk and comfort.
  • Support workers must not change urethral or suprapubic catheters unless the task has been formally delegated by a healthcare professional, is within the provider’s registration and insurance arrangements, is included in the care plan and risk assessment, and the worker has been trained, assessed as competent and authorised in writing.
  • If a catheter falls out, is accidentally pulled out, is damaged, cannot be reconnected safely, causes bleeding or severe pain, or the person is unable to pass urine, staff must seek urgent clinical advice immediately.

4.6 Urine Specimens, Testing and Antimicrobial Stewardship

Staff must not take urine samples, perform urine dipstick tests or request antibiotics unless this is included in the care plan, requested by a healthcare professional, or required under local clinical instructions.

For adults with indwelling urinary catheters, urine dipstick testing must not be used as the basis for diagnosing UTI because catheterised people often have bacteria in the urine without infection. Staff must report symptoms and clinical changes rather than relying on urine appearance or dipstick results.

Where a urine specimen is requested by a healthcare professional, staff must follow the agreed procedure for obtaining the sample from the correct sampling port using the correct equipment and infection prevention technique. Samples must not be taken from the drainage bag unless a healthcare professional specifically instructs this.

Staff must support antimicrobial stewardship by escalating suspected infection appropriately, giving accurate observations and history, and avoiding unnecessary requests for antibiotics where the person has no symptoms of infection.

4.7 Recognising and Managing Complications

Staff must be able to recognise catheter-related complications and must escalate concerns promptly. Complications may include:

• reduced or absent urine drainage
• catheter blockage or suspected blockage
• catheter bypassing or leakage around the catheter
• catheter dislodgement, accidental removal or pulling
• pain, burning, bladder spasms or new discomfort
• blood in urine or bleeding around the catheter site
• cloudy urine, sediment or offensive odour when accompanied by symptoms or deterioration
• fever, rigors, shivering, flank pain, pelvic pain, lower abdominal pain or back pain
• new confusion, delirium, drowsiness, agitation or sudden change in presentation
• redness, swelling, discharge, bleeding, pain or overgranulation at a suprapubic catheter site
• skin damage, pressure damage or soreness caused by straps, tubing or drainage bags
• signs of dehydration or fluid overload
• signs of sepsis, including very high or low temperature, fast breathing, fast heart rate, mottled or cold skin, reduced urine output, severe weakness, confusion, collapse or reduced consciousness.

Staff must follow the escalation plan in the person’s care plan. This may include contacting the senior on duty, registered manager, GP, district nurse, community nurse, NHS 111 or 999. Emergency services must be contacted immediately where the person appears seriously unwell or there are signs of sepsis, severe pain, collapse, reduced consciousness or other life-threatening symptoms.

Any catheter-related incident, avoidable harm, infection-control breach, delay in escalation, medication concern, safeguarding concern or hospital admission must be recorded and reported in line with the Incident Reporting, Safeguarding, Infection Prevention and Duty of Candour policies.

4.8 Catheter Removal and Trial Without Catheter (TWOC)

• Catheters should be reviewed regularly by the responsible healthcare professional and removed as soon as they are no longer clinically necessary. Catheter removal and Trial Without Catheter must only be undertaken under medical or nursing direction. Support workers must not remove a catheter unless the task has been formally delegated, risk assessed, care planned, competency assessed and authorised in writing.
• The Trial Without Catheter (TWOC) process must be followed under medical guidance, ensuring:
  • The individual is fully informed and supported.
  • Hydration levels are maintained to assess bladder function.
  • Urine output is monitored for 24-48 hours post-removal.
  • Any difficulties with urination are reported immediately for reassessment.

Following catheter removal or TWOC, staff must monitor and record the person’s comfort, urine output, ability to pass urine, fluid intake where required, pain, abdominal distension, agitation, confusion or deterioration. Any inability to pass urine, severe pain, abdominal swelling, distress, fever or deterioration must be escalated urgently.

4.9 Delegated Healthcare Tasks

Some catheter-related tasks may be delegated to support staff only where this is safe, lawful and appropriate. Delegation must be person-specific, task-specific and time-specific.

Before any catheter-related task is delegated, the registered manager must ensure that:

• the task is within the provider’s CQC registration, commissioned service and insurance arrangements
• the task has been requested or approved by an appropriately registered healthcare professional
• the person has consented, or a lawful best interests decision has been made where the person lacks capacity
• a risk assessment and care plan are in place
• staff have received task-specific training
• staff have been observed and assessed as competent by an appropriate professional or competent assessor
• competency is recorded and reviewed at agreed intervals
• staff know when not to proceed and when to escalate
• there is access to clinical advice if concerns arise.

Staff must decline and escalate any catheter-related task they have not been trained, assessed and authorised to perform.

4.10 Equipment, Storage and Waste

Catheter supplies, drainage bags, straps, stands, wipes, gloves, aprons and related equipment must be available in sufficient quantities and stored in a clean, dry place according to manufacturer’s instructions.

Staff must check that equipment is within expiry date, intact, visibly clean and suitable for the person before use. Damaged, contaminated, expired or incorrect equipment must not be used and must be reported.

Used catheter bags, PPE and urine-contaminated waste must be disposed of safely in line with the organisation’s Waste Management Policy, local authority arrangements and infection prevention guidance. Where clinical waste arrangements are required, the registered manager must ensure appropriate collection and disposal systems are in place.

5. Staff Training and Competency

Staff must only provide catheter-related support that is within their role, training, competence and written authorisation. The registered manager is responsible for ensuring that staff are suitably trained, supervised and competent before they provide catheter-related care or support.

Staff involved in catheter care must receive training appropriate to their role, which may include:

• infection prevention and control
• hand hygiene and PPE
• catheter hygiene and safe handling of drainage systems
• privacy, dignity and person-centred intimate care
• consent and Mental Capacity Act 2005 requirements
• safeguarding adults and recognising neglect or unsafe practice
• recognising catheter-related complications
• recognising deterioration and possible sepsis
• escalation procedures and emergency response
• record keeping and confidentiality
• duty of candour and incident reporting
• delegated healthcare task procedures, where applicable
• aseptic non-touch technique, where the staff member is authorised to undertake a task requiring ANTT
• learning disability and autism training appropriate to the person’s role, where required for staff working in regulated activities.

Competency must be assessed before staff undertake catheter-related tasks and reviewed at least annually, or sooner where there is a change in the person’s needs, equipment, procedure, guidance, staff role, incident, concern or performance issue.

Competency records must show the task assessed, assessor, date, outcome, review date and any restrictions on the staff member’s practice. Staff who are not competent, not confident or not authorised must not undertake the task and must escalate to a senior member of staff or healthcare professional.

Agency, temporary and new staff must not provide catheter-related support unless their competence and authorisation have been checked and recorded.

6. Record-Keeping and Documentation

Accurate, complete and contemporaneous records must be kept for all catheter-related care and support. Records must be factual, respectful, person-centred and completed as soon as possible after the care or event.

The person’s care records must include, where applicable:

• catheter type, size and route
• date of insertion and planned review or change date
• reason for catheterisation, where shared by the healthcare professional
• responsible healthcare professional or service
• individual catheter care plan and risk assessment
• consent or Mental Capacity Act/best interests records
• authorised staff tasks and any restrictions
• catheter bag, valve or drainage system details
• allergies, latex sensitivity and product sensitivities
• usual urine output and monitoring requirements
• hydration plan, including any fluid restriction
• skin integrity and pressure area risks
• daily care provided, where recording is required
• urine output/fluid balance where required
• signs of infection, blockage, leakage, pain, bleeding or deterioration
• action taken and escalation to healthcare professionals
• advice received from GP, district nurse, community nurse, NHS 111, emergency services or other professionals
• incidents, near misses, infection-control breaches and outcomes
• hospital attendance or admission related to catheter care
• catheter removal or TWOC monitoring, where applicable.

The registered manager or delegated senior must review catheter care records regularly to identify trends, repeated blockages, infections, delays in escalation, equipment problems, staff competency issues or safeguarding concerns. Learning from audits, incidents, complaints and professional feedback must be used to improve practice.

6.1 Notifications, Duty of Candour and Safeguarding

The registered manager must consider whether catheter-related incidents require notification to CQC, safeguarding referral, commissioner notification, family/representative communication, professional escalation or Duty of Candour action.

Duty of Candour must be followed where a notifiable safety incident occurs. The person, and where appropriate their representative, must receive a truthful explanation, apology, information about what happened, what action has been taken, and what will be done to reduce the risk of recurrence.

Safeguarding procedures must be followed where there is concern about neglect, acts of omission, poor hygiene, failure to seek medical help, unsafe or unauthorised catheter care, misuse of equipment, deliberate interference with a catheter, unexplained injury, coercion, lack of consent, or organisational failure leading to avoidable harm.

Examples of catheter-related incidents that may require management review include repeated infections, avoidable blockage, catheter dislodgement, hospital admission, sepsis, pressure damage from catheter equipment, unauthorised catheter manipulation, failure to escalate deterioration, or lack of essential supplies.

7. Confidentiality, Data Protection and Information Sharing

Catheter care records contain confidential health information and must be managed in accordance with UK GDPR, the Data Protection Act 2018, the organisation’s Confidentiality and Data Protection Policy and professional information-sharing principles.

Staff must only access catheter care information where they need it for their role. Information must be accurate, relevant, proportionate and stored securely.

Relevant catheter care information may be shared with healthcare professionals, emergency services, commissioners, safeguarding authorities or others where this is necessary for the person’s care, treatment, safety, safeguarding, legal obligation or vital interests. Wherever practicable, the person’s consent should be sought before information is shared, unless there is a lawful basis to share without consent.

7.1 Equality, Dignity and Human Rights

Catheter care is intimate care and must always be provided in a way that protects the person’s dignity, privacy, autonomy and human rights. Staff must make reasonable adjustments for people with disabilities, communication needs, sensory needs, learning disability, autism, mental health needs, trauma history or cultural and religious preferences.

The person must be offered choice wherever possible, including choice about who supports them, how care is provided, the timing of care, privacy arrangements and involvement of family or representatives where appropriate.

Staff must use respectful language and must never shame, blame, mock or expose a person because of catheter use, urine leakage, odour, continence needs or intimate care needs.

7.2 Quality Assurance and Audit

The registered manager must ensure there are systems to monitor the safety and quality of catheter care. Audits may include care plan accuracy, risk assessments, consent records, staff competency, infection prevention practice, PPE availability, catheter-related incidents, escalation records, healthcare professional advice, hospital admissions, complaints and learning actions.

Audit findings must be used to improve care, update risk assessments, refresh staff training, identify patterns and reduce avoidable harm. Where themes are identified, the registered manager must implement an action plan and monitor completion.

8. Policy Review

This policy will be reviewed at least annually, or sooner if required due to:

• changes in legislation, statutory guidance, CQC requirements or NICE guidance
• updates to infection prevention and control guidance
• changes in the provider’s regulated activity, service model or commissioned responsibilities
• catheter-related incidents, near misses, safeguarding concerns or complaints
• learning from audits, supervision, competency assessments or professional feedback
• changes in local NHS, continence, district nursing or community nursing procedures
• new equipment, manufacturer instructions or clinical practice changes.

The registered manager is responsible for ensuring this policy remains current, implemented and understood by staff.

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