SCOPE OF THIS CHAPTER
This chapter identifies key issues and balances that need to be considered when working with children and young people who have disabilities and/or medical and physical dependency needs.
This chapter was added to the manual in December 2017.
- Purpose and Scope
- References, Legislation and Policies
- Definition of Intimate Care
- Definition of Personal Care
- Principles of Intimate Care and Personal Care
- Policy Statements
- The Protection of Children
- Guidelines for Good Practice
- Treating Children and Young People with Dignity and Respect
- Infection Prevention and Control
- Forward Planning with Parents/Carers and Children
- Working with Other Agencies
- Resources and Training
- Children and Young People's Records
- Emergency Procedures
- Health and Safety at Work Regulations
- Dealing with Complaints
1. Purpose and Scope
The purpose of this document is to set out a clear framework within which all children and young people with disabilites receive intimate and personal care they require in order to participate fully in services and activities. As well as providing a clear policy statement to services that support children and young people with disabilities, the document provides guidance for people who provide intimate and personal care.
This policy particularly applies to children and young people who want to participate in universal services and require personal and intimate assistance due to their specific requirements.
An increasing number of children and young people with disabilities and medical needs are being included in mainstream, private, voluntary and independent sector settings. A significant number of these require assistance with intimate care tasks, especially toileting. Other children may also experience difficulties with toileting for a variety of reasons. All of the children/young people we work with have the right to be safe, to be treated with courtesy, dignity, and respect.
This document is a response to requests for clear principles and guidance on the issue of supporting intimate and personal care needs with specific reference to toileting.
The word 'setting' refers to all early years and childcare providers from the maintained, private, voluntary and independent sector including leisure centres. Settings need to follow their own registration and inspection requirements in addition to this guidance.
In the rest of this document where the term child/children is used, it refers to children and young adults with disabilities. The term parent/carer is used to refer to parents and legal guardians or carers. Staff includes all adults working in a setting, although those required to undertake intimate care will have that task specified in their job description, and are referred to in the rest of the document as “designated” for that task.
3. References, Legislation and Policies
- The Children Act 1989;
- The Childcare Act 2006;
- The Disability Discrimination Act 1995;
- UN Convention on the Rights of the Child (1989);
- Health and Safety at Work etc. Act 1974;
- Equality Act 2010;
- Local safeguarding policy;
- Local medicines management policy;
- Support Staff Pay and Grading Review 2005.
4. Definition of Intimate Care
There is a clear difference between personal and intimate assistance. 'Intimate Care' can be defined as care tasks of an intimate nature, associated with bodily functions, bodily products and personal hygiene, which demand direct or indirect contact with, or exposure of, the sexual parts of the body. Help may also be required with changing colostomy or ileostomy bags, managing catheters, stomas or other appliances. The Intimate care tasks specifically identified as relevant include:
- Dressing and undressing (underwear);
- Helping someone use the toilet;
- Changing continence pads (faeces/Urine);
- Bathing / showering;
- Washing intimate parts of the body;
- Changing sanitary wear;
- Inserting suppositories;
- Giving enemas;
- Inserting and monitoring pessaries.
In some cases, it may be necessary to administer rectal medication on an emergency basis for example where a child's life is in danger. Effective forward planning and communication with the child and their parents or carers will go some way to mitigating the risks in this eventuality.
5. Definition of Personal Care
Personal Care generally carries more positive perceptions than intimate care. Although it may often involve touching another person, the nature of this touching is more socially acceptable, as it is less intimate and usually has the function of helping with personal presentation and hence is regarded as social functioning. These tasks do not invade conventional personal, private or social space to the same extent as intimate care and are certainly more valued as they can lead to positive social outcomes for people.
Those personal care tasks specifically identified as relevant here include:
- Skin care/applying external medication;
- Administering oral medication;
- Hair care;
- Dressing and undressing (clothing);
- Washing non-intimate body parts;
- Prompting to go to the toilet.
Personal care encompasses those areas of physical and medical care that most people carry out for themselves but which some are unable to do because of disability or medical need. Children and young people may require help with eating, drinking, washing, dressing and toileting.
6. Principles of Intimate Care and Personal Care
The following are the fundamental principles of intimate and personal care upon which our policy guidelines are based:
- Every child has the right to be safe;
- Every child has the right to personal privacy;
- Every child has the right to be valued as an individual;
- Every child has the right to be treated with dignity and respect.
7. Policy Statements
All children who require intimate and/or personal care are treated respectfully at all times; the child's welfare and dignity is of paramount importance (included in the Support Staff Pay and Grading Review 2005).
Staff who provide intimate care are trained to do so (including Child Protection and Health and Safety training in moving and handling) and are fully aware of best practice. For staff that have difficulty fulfilling this main duty on the Job Description, support should be available to access appropriate training.
Staff will be supported to adapt their practice in relation to the needs of individual children taking into account developmental changes such as the onset of puberty and menstruation.
There is careful communication with each child who needs support in line with their preferred means of communication (verbal, symbolic, etc.) to discuss the child's needs and preferences. The child is aware of each procedure that is carried out and the reasons for it.
As a basic principle children will be supported to achieve the highest level of autonomy that is possible given their age and abilities. Staff will encourage each child to do as much for themselves as they can. This may mean, for example, giving the child responsibility for washing themselves.
Individual intimate care plans will be drawn up for particular children as appropriate to suit the circumstances of the child. These plans include a full risk assessment to address the personal safety and health of the child and the carer e.g. moving and handling, infection control etc.
Each child's right to privacy will be respected. Careful consideration will be given to each child's situation to determine how many carers might need to be present when a child needs help with intimate care. Where possible one child will be cared for by one adult unless there is a sound reason for having two adults present. If this is the case, the reasons should be clearly documented.
Wherever possible, the same child will not be cared for by the same adult on a regular basis; there will be a minimal rota of carers known to the child who will take turns in providing care. This will ensure, as far as possible, that over-familiar relationships are discouraged from developing, while at the same time guarding against the care being carried out by a succession of completely different carers.
Parents/carers will be involved with their child's intimate care arrangements on a regular basis; a clear account of the agreed arrangements will be recorded on the child's care plan. The needs and wishes of children and parents will be carefully considered alongside any possible constraints; e.g. staffing and equal opportunities legislation.
Each child/young person will have an assigned senior member of staff to act as an Advocate to whom they will be able to communicate any issues or concerns that they may have about the quality of care they receive.
8. The Protection of Children
Safeguarding Procedures and Inter-Agency Child Protection procedures will be accessible to staff and adhered to.
All staff involved in the provision of intimate and/or personal care will have all relevant checks completed before allowing them to be left alone with children (e.g. DBS checks) and will be subject to robust internal procedures such as reference checking and monitoring and regular updating of DBS checks.
Where appropriate, all children will be taught personal safety skills carefully matched to their level of development and understanding.
If a member of staff has any concerns about physical changes in a child's presentation, e.g. marks, bruises, soreness etc. s/he will immediately report concerns to the appropriate manager/designated person for child protection.
If a child becomes distressed or unhappy about being cared for by a particular member of staff, the matter will be looked into and outcomes recorded. Parents/carers will be contacted at the earliest opportunity as part of this process in order to reach a resolution.
If a child makes an allegation against a member of staff, all necessary procedures will be followed.
9. Guidelines for Good Practice
This guidance is not prescriptive but is based on the good practice and practical experience of those dealing with such children and young people. All children have the right to be safe and to be treated with dignity and respect. These guidelines are designed to safeguard children and staff. They apply to every member of staff involved with the intimate care of children.
9.1 Treating Children and Young People with Dignity and Respect
Young children and children with special educational needs can be especially vulnerable. Staff involved with their intimate care need to be particularly sensitive to their individual needs. Staff also need to be aware that in exceptional circumstances some adults may use intimate care as an opportunity to abuse children. It is important to bear in mind that some forms of assistance can be open to misinterpretation. Adhering to the following guidelines of good practice should safeguard children and staff.
- Involve the child in the intimate care
Try to encourage a child's independence as far as possible in his or her intimate care. Where a situation renders a child fully dependent, talk about what is going to be done and give choices where possible. Check your practice by asking the child or parent about any preferences while carrying out the intimate care.
- Treat every child with dignity and respect and ensure privacy appropriate to the child's age and situation.
Staff can administer intimate care alone however settings need to be aware of the potential safeguarding issues for the child and member of staff. Care should be taken to ensure adequate supervision primarily to safeguard the child but also to protect the staff member from potential risk.
- Be aware of your own limitations
Only carry out activities you understand and feel competent with. If in doubt, ASK. Some procedures must only be carried out by members of staff who have been formally trained and assessed.
- Promote positive self-esteem and body image
Confident, self-assured children who feel their body belongs to them are less vulnerable to Sexual Abuse. The approach you take to intimate care can convey lots of messages to a child about their body worth. Your attitude to a child's intimate care is important. Keeping in mind the child's age, routine care can be both efficient and relaxed.
- If you have any concerns you must report them.
If you observe any unusual markings, discolouration or swelling, report it immediately to the designated practitioner for child protection.
If a child is accidentally hurt during the intimate care or misunderstands or misinterprets something, reassure the child, ensure their safety and report the incident immediately to the designated Practitioner. Report and record any unusual emotional or behavioural response by the child. A written record of concerns must be made available to parents and kept in the child's personal file.
- Helping through communication
There is careful communication with each child who needs help with intimate care in line with their preferred means of communication (verbal, symbolic, etc.) to discuss the child's needs and preferences. The child is aware of each procedure that is carried out and the reasons for it.
- Support to achieve the highest level of autonomy
As a basic principle children will be supported to achieve the highest level of autonomy that is possible given their age and abilities. Staff will encourage each child to do as much for themselves as they can. This may mean, for example, giving the child responsibility for washing themselves. Individual intimate care plans will be drawn up for particular children as appropriate to suit the circumstances of the child. These plans include a full risk assessment to address issues such as moving and handling, personal safety of the child and the carer and health.
9.2 Infection Prevention and Control
Infection Prevention and Control is concerned with the prevention of avoidable risks of infection and the control and management of all unavoidable risks of infection to those administering and receiving intimate and personal care. We will manage infection risks related to the setting, equipment, staff working practices and clinical practices arising from the intimate and personal care of children.
9.3 Forward Planning with Parents/Carers and Children
Establishing effective working relationships with parents/carers is a key task for all settings and is particularly necessary for children/young people with special care needs or disabilities. Parents/carers should be encouraged and empowered to work with professionals to ensure their child/young person's needs are properly identified, understood and met. Although they should be made welcome, and given every opportunity to explain their child/young person's particular needs, they should not be made to feel responsible for their child/young person's care in each setting, or for making teaching staff disability aware. They should be closely involved in the preparation of Individual Education Plans (IEPs) and Health Care Plans. Staff have a duty to remove barriers to learning and participation for pupils and students of all abilities and needs. Plans for the provision of Intimate/personal care must be clearly recorded to ensure clarity of expectations, roles and responsibilities. Records should also reflect arrangements for ongoing and emergency communication between home and setting, monitoring and review. It is also important that the procedure for dealing with concerns arising from personal care processes is clearly stated and understood by parents/carers and all those involved.
9.4 Working with Other Agencies
Children and young people with special care needs or disabilities will be known to a range of other agencies. It is important that positive links are made with all those involved in the care or welfare of individual children/young people. This will enable the setting based plans to take account of the knowledge, skills and expertise of other professionals and will ensure the child/young person's well-being and development remains the focus of concern. Arrangements for ongoing liaison and support to setting staff where necessary should also be formally agreed and recorded. It is good practice for settings to identify a named member of staff to co-ordinate links with other agencies, and this person could be the SENCO or another senior member of staff. Achieving continence is one of hundreds of developmental milestones for all children usually reached within the context of learning in the home before the child/young person transfers to learning in a setting. In some cases this one developmental area can assume significance beyond all others. Parents and carers are sometimes made to feel guilty that this aspect of learning has not been achieved, whereas other delayed learning is not so stigmatising. Settings have a responsibility to teach toilet training and other personal care skills, as an essential PHSE basis in order to be able to access the rest of the curriculum.
9.5 Resources and Training
Each child's right to privacy must be respected. Careful consideration will be given to each child's situation to determine how many carers might need to be present when a child needs help with intimate care. Where possible a child will be cared for by one adult unless there is a sound reason for having two adults present. If this is the case, the reasons should be clearly documented and explained to the child or young person.
Where possible the child's key-person is responsible for undertaking the care of an individual child. When this is not possible a staff member who is known to the child will take on that responsibility. The staff member who is involved will always ask the child for permission to assist them.Space for privacy
If it is not possible to provide a purpose built changing area, then it is appropriate to provide a changing mat. It may be possible to change some children whilst they are standing. When changing a larger child it is desirable to use a pull down changing table that has been correctly secured to the wall to take heavier weights.
Ensuring that privacy and dignity are maintained during the time taken to change a child or when they are sitting on the toilet or potty is crucial. If necessary, a small screen can be used to support this basic human right. The time spent changing a child should be a positive experience for the child.Suitable hygiene resources
- Staff should wear disposable gloves and aprons while changing a nappy, pad or soiled clothing;
- Soiled nappies or pads should be double wrapped disposed of in the domestic waste. This process is recommended for up to three children, more than three children nappies or pads should be placed in a hygienic disposal unit;
- Agreed regular emptying of bins;
- Changing area to be cleaned after use;
- Hot water and liquid soap to wash hands as soon as the task is completed;
- Hot hand dryer or paper towels available for drying hands.
Written guidelines should specify:
- Who will the nappy/pad/clothes;
- Where nappy/pad/clothing changes will take place;
- What resources will be used (Cleansing agents used or cream to be applied);
- How the nappy/pad will be disposed of;
- What infection control measures are in place;
- What the staff member will do if the child is unduly distressed by the experience or if the staff member notices marks or injuries.
Training may be appropriate around positive handling, Safeguarding and Health and Safety issues around intimate care.
9.6 Children and Young People's Records
- What is recorded and where
Action Plan should be put in place in discussion with the parents, staff and child and monitored and review regularly. This should be kept on the child's confidential file;
Access to the files should be decided as part of the Action Plan;
This should be part of the whole setting confidentiality policy.
9.7 Emergency Procedures
- Contact and telephone numbers;
- Procedures for evacuation during I&PC assistance.
9.8 Health and Safety at Work Regulations
- Lifting and handling children and young people;
- Positive handling;
- Safe disposal of waste;
- Safe practices in First Aid.
9.9 Dealing with Complaints
People have the right to express their dissatisfaction if they feel that they are not receiving the levels of support they need and deserve. The service must respond positively to feedback and complaints and treat them as an opportunity to improve the services we provide to children and young people.
Further local information may be added here as required.