Hygiene Code Revised January 2008

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The Health and

Social Care Act 2008

Code of Practice on the

prevention and control of infections

and related guidance


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DH INFORMATION READER BOX

Policy EstatesHR/Workforce Commissioning

Management IM&T

Planning Finance

Clinical SocialCare/PartnershipWorking

Document purpose Policy

Gateway reference 14808

Title TheHealthandSocialCareAct2008Codeof Practiceonthepreventionand

controlof infectionsandrelatedguidance

Author Departmentof Health

Publication date December2010

Target audience PCTCEs,NHSTrustCEs,SHACEs,CareTrustCEs,FoundationTrustCEs,

MedicalDirectors,Directorsof PH,Directorsof Nursing,LocalAuthority

CEs,Directorsof AdultSSs,PCTChairs,NHSTrustBoardChairs,Allied

HealthProfessionals,GPs,Primarycareorganisations,dentists,independent

ambulances,independenthealthcareandadultsocialcareorganisations,

directorsof infectionpreventionandcontrol,infectionpreventionandcontrol

leads,CareQualityCommission

Circulation list

Description Tohelpprovidersof healthcare,includingprimar ydentalcare,primarymedical

care,adultsocialcare,andindependentsectorambulanceproviders,plan

andimplementhowtheypreventandcontrolinfections.Itincludescriteriafor

CQCtotakeintoaccountwhenassessingcompliancewiththeregistration

requirementoncleanlinessandinfectioncontrol.

Cross reference N/A

Superseded docs TheHealthandSocialCareAct2008Codeof Practiceforhealthandadult

socialcareonthepreventionandcontrolof infectionsandrelatedguidance.

Action required RegisteredprovidersmusthaveregardtotheCodewhendecidinghowthey

willcomplywithregistrationrequirementforcleanlinessandinfectioncontrol.Timing Primary dental care and independent sector ambulance providers must

be registered by April 2011, and primary medical care providers by April

2012. The Code already applies to other registered providers.

Contact details SallyWellsteed

HealthcareAssociatedInfectionandAntimicrobialResistance

Room528,WellingtonHouse

133-155WaterlooRoad

LondonSE18UG

[email protected]

For recipients use

Crowncopyright2010

FirstpublishedDecember2010

PublishedtoDHwebsite,inelectronicPDFformatonly.

http://www.dh.gov.uk/publications
mailto:[email protected]://www.dh.gov.uk/publicationshttp://www.dh.gov.uk/publicationsmailto:[email protected]


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The Health and

Social Care Act 2008

Code of Practice on theprevention and control of infections

and related guidance

iii


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Contents

Executive summary 5Part 1: Introduction 7WhatandwhoistheCodeofPracticefor? 7 Thetermsusedinthisdocument 8 Background 9 Whatischanging? 9 Whenwillthishappen? 9 HowwilltheCodebeused? 10 Howwillcompliancebejudged? 10 Whathappensifaregisteredproviderdoesnotmeettherequirements intheCode? 11 Commissioningofservices 11 Keycomponentstosupportcompliance 12 Part 2: The Code of Practice 13Part 3: Guidance for compliance 14Part 4: Guidance tables 38Appendix A:Examplesofinterpretationforadultsocialcare 46 Appendix B:Examplesofinterpretationforprimarydentalcare 56 Appendix C:Examplesofinterpretationforindependentsector

ambulanceproviders 64 Appendix D:Examplesofinterpretationforprimarymedicalcare 70 Appendix E:Definitions 78 Appendix F:Regulations(extract) 86 Bibliography 87

iv


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Executive summary

Goodinfectionpreventionandcontrolareessentialtoensurethatpeoplewho

usehealthandsocialcareservicesreceivesafeandeffectivecare.Effective

preventionandcontrolofinfectionmustbepartofeverydaypracticeandbe

appliedconsistentlybyeveryone.

Goodmanagementandorganisationalprocessesarecrucialtomakesurethat

highstandardsofinfectionpreventionandcontrolaredevelopedandmaintained.

ThisdocumentsetsouttheCodeofPracticeonthepreventionandcontrol

ofinfections,underTheHealthandSocialCareAct2008.Itwillapplyto

registeredprovidersofallhealthcareandadultsocialcareinEngland.The

CodeofPractice(Part2)setsoutthe10criteriaagainstwhichtheCare

QualityCommission(CQC)willjudgearegisteredprovideronhowitcomplies

withthecleanlinessandinfectioncontrolrequirement,whichissetoutin

regulations.1Notallcriteriawillapplytoeveryregulatedactivitybuttoensure

thatconsistentlyhighlevelsofinfectionpreventionandcontrolaredeveloped

andmaintained,itisessentialthatallprovidersofhealthandsocialcarereadandconsiderthewholedocumentandnotjustselectiveparts.

Parts3and4ofthisdocumentwillhelpregisteredprovidersinterpretthecriteria

anddeveloptheirownriskassessments.Theappendicesprovideexamples

ofhowaproportionateapproachcouldbeappliedtothecriteriainallsectors

anditisimportanttoreadtheexamplesgivenintheappendices,alongsidethe

guidanceundereachcriterioninPart3ofthisdocument.Thebibliographylists

arangeofsupportingnationalguidance.

ThisdocumentbuildsonthepreviousCodeofPractice: The Health andSocial Care Act 2008 Code of Practice for health and adult social care on the

prevention and control of infections and related guidance,whichappliedtoNHS

bodiesandprovidersofindependenthealthcareandadultsocialcareinEngland.

TheregistrationrequirementswillextendfurtherfromApril2011toinclude

primarydentalcareandindependentsectorambulanceproviders,including

airorwaterambulances,andfromApril2012primarymedicalcareproviders.

WehaverevisedthepreviousCodeofPracticedocumentinordertomakeit

applicabletoallthesesettings.

1 TheHealthandSocialCareAct2008(RegulatedActivities)Regulations2010.Availableat:

www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated

+Activities%29+Regulations+2010&year=&number=&type=uksi

5
http://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksihttp://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksihttp://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksi


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TheHealthandSocialCareAct2008CodeofPracticeonthepreventionandcontrolofinfections

ThelawstatesthattheCodemustbetakenintoaccountbytheCQCwhenit

makesdecisionsaboutregistrationagainstthecleanlinessandinfectioncontrol

requirement.Theregulationsalsosaythatprovidersmusthaveregardtothe

Codewhendecidinghowtheywillcomplywithregistrationrequirements.So,by

followingtheCode,registeredproviderswillbeabletoshowthattheymeetthe

requirementsetoutintheregulations.However,theCodeisnotmandatoryso

registeredprovidersdonotbylawhavetocomplywiththeCode.Aregistered

providermaybeabletodemonstratethatitmeetstheregulationsinadifferent

way(equivalentorbetter)fromthatdescribedinthisdocument.TheCodeaims

toexemplifywhatprovidersneedtodoinordertocomplywiththeregulations.

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Part 1: Introduction

Goodinfectionpreventionandcontrolareessentialtoensurethatpeoplewho

usehealthandsocialcareservicesreceivesafeandeffectivecare.Effective

preventionandcontrolofinfectionmustbepartofeverydaypracticeandbe

appliedconsistentlybyeveryone.

Goodmanagementandorganisationalprocessesarecrucialtomakesurethat

highstandardsofinfectionpreventionandcontrolaresetupandmaintained.

AstheregulatorofhealthandadultsocialcareinEngland,theCareQuality

Commission(CQC)willprovideassurancethatthecarepeoplereceive,meets

essentiallevelsofqualityandsafety.Thesearesetoutinregulations.2This

documentoutlineswhatregisteredprovidersinEngland,shoulddotoensure

compliancewiththeregistrationrequirementforcleanlinessandinfectioncontrol

andsetsoutthe10compliancecriteriaagainstwhichregisteredproviderswill

bejudged.

TheCQChavepublishedguidanceaboutcompliance,includingtheirjudgementframework3andwillusethesedocumentsinconjunctionwiththisCodeof

Practiceandrelatedguidancewhenjudgingcompliance.

What and who is the Code of Practice for?

ThemainpurposesoftheCodeofPracticeonthepreventionandcontrolof

infections(TheCode)areto:

maketheregistrationrequirementforcleanlinessandinfectioncontrolcleartoallregisteredproviderssothattheyunderstandwhattheyneedtodo

tocomply;

provideguidancefortheCQCsstafftomakejudgementaboutcompliancewiththerequirementforcleanlinessandinfectioncontrol;

provideinformationforpeoplewhousetheservicesofaregisteredprovider;

2 www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated

+Activities%29+Regulations+2010&year=&number=&type=uksi

3 SeeGuidance about compliance: Essential standards of quality and safetyat:www.cqc.org.

uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfand

Guidance about compliance Judgement frameworkat:www.cqc.org.uk/_db/_documents/

Judgement_framework_March_2010_FINAL.pdf

7
http://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksihttp://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksihttp://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Judgement_framework_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Judgement_framework_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Judgement_framework_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Judgement_framework_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfhttp://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksi


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provideinformationforcommissionersofservicesonwhattheyshouldexpectoftheirproviders;and

provideinformationforthegeneralpublic.

ReaderswillnotethatonlyparagraphsinPart3ofthisdocumenthavebeen

numbered,astheseparticularsectionsarelikelytobespecificallyreferencedby

theCQCinensuringcompliancewiththeregulations.

The terms used in this document

Thereareawiderangeoftermsrelatingtoservices,organisationalstructures

anddifferentwaystodescribethesameorsimilarthingsacrosshealthand

socialcare.Inthisdocumentwehavetriedtoharmonisesomeofthoseterms

andusedescriptionsthataremeaningfulacrossallsectors.

Forexample,wehaveusedthetermserviceusertodescribepatients,donors,

residentsandclients.BecauseNationalHealthService(NHS)Trusts(asan

entity),primarycare,independenthealthcare,independentsectorambulance

providers,andadultsocialcareprovidersareallrequiredtoregisterwiththe

CQCasprovidersofhealthoradultsocialcare,theyarereferredtointhis

documentasregisteredproviders.Thetermcareworkerisusedtorefertoanyemployeewhosenormaldutiesinvolveprovidingdirectcaretoservice

users,forexamplemedicalstaff,nurses,healthcareassistants,careassistants

andvolunteers.Thetermindependentsectorambulanceprovidersincludes

triage,medicalorclinicaladviceprovidedremotely,face-to-facetreatmentand

transportservices.Transportservicesarethoseprovidedbymeansofvehicles,

whicharedesignedfortheprimarypurposeofcarryingapersonwhorequires

treatment.Thetermvehicleincludesroad,airorwaterambulances.

However,therearesomecircumstanceswhereusingaterm,whichhasa

specificmeaningineitherhealthcare,includingprimarycareand,independentsectorambulanceprovidersoradultsocialcarehasbeenthebestwayto

describewhatneedstobedonetocomplywiththeregulationsbyhavingregard

totheCodeandtherelatedguidance.

Theterminfectionisusedthroughoutthisdocument,ratherthanthemore

explicittermhealthcareassociatedinfection,exceptforcircumstanceswhere

thespecifictermisappropriate.TheCoderecognisesthatsomeinfectionsthat

ariseinthecommunitysuchasinfluenzaareresponsibleformuchmorbidity

inresidentialunitsandmaynotberelatedtothedeliveryofhealthcare.

Nevertheless,theymaybepreventablebygoodpractice,suchasimmunisation,whichisdealtwithintheCodeandtherelatedguidance.AppendixEprovides

furtherdefinitions.

8


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Part1:Introduction

Background

ThisdocumentbuildsonthepreviousCodeofPractice The Health and SocialCare Act 2008 Code of Practice for health and adult social care on the prevention

and control of infections and related guidance.ThepreviousCodeofPractice

appliedtoNHSbodiesandprovidersofindependenthealthcareandadultsocial

careinEngland,andwasusedbytheCQCtojudgewhetherthoseproviders

compliedwiththeregistrationrequirementforcleanlinessandinfectioncontrol.

Althoughtherelatedguidancehasbeenupdated,therevisedguidancedoesnot

introduceanynewrequirements.

What is changing?

Thewaythathealthandadultsocialcareisregulatedhasbeenchanging

sinceApril2009becauseoftheintroductionoftheHealthandSocialCare

Act2008(H&SCA2008).4ThisActestablishedtheCQCandsetsoutthe

overallframeworkfortheregulationofhealthandadultsocialcareactivities.

RegulationsmadeunderthisActdescribethehealthandadultsocialcare

activities,thatmayonlybecarriedoutbyprovidersthatareregisteredwith

theCQC,andsetouttheregistrationrequirementsthattheseproviders

mustmeettobecomeandstayregistered.FurtherdetailsonhowtheCQCwillassesscompliancewiththeregistrationrequirementsareavailableat:

www.cqc.org.uk/guidanceforprofessionals/registration/newregistrationsystem/

howthenewregistrationsystemwork/complyingwithnewregulations.cfm

TheH&SCA2008andregulationsarelawandmustbecompliedwith.TheCQC

hasenforcementpowersthatitmayuseifregisteredprovidersdonotcomply

withthelaw.

When will this happen?

NHSbodiesprovidingregulatedactivities,includingprisonhealthcareservices,

havebeenrequiredtocomplywiththefullsetofregistrationrequirementssince

1April2010withindependenthealthcareandadultsocialcareprovidersof

regulatedactivitiesrequiredtocomplywiththemfrom1October2010.Primary

dentalcareandindependentsectorambulanceprovidersmustberegisteredby

April2011,andprimarymedicalcareprovidersbyApril2012.

4 TheHealthandSocialCareAct2008isavailableat:www.legislation.gov.uk/search?title=heal

th+and+social+care+act&yearRadio=range&start-year=2008&end-year=2009&number=&serie

s=&type=primary

9
http://www.cqc.org.uk/guidanceforprofessionals/registration/newregistrationsystem/howthenewregistrationsystemwork/complyingwithnewregulations.cfmhttp://www.cqc.org.uk/guidanceforprofessionals/registration/newregistrationsystem/howthenewregistrationsystemwork/complyingwithnewregulations.cfmhttp://www.legislation.gov.uk/search?title=health+and+social+care+act&yearRadio=range&start-year=2008&end-year=2009&number=&series=&type=primaryhttp://www.legislation.gov.uk/search?title=health+and+social+care+act&yearRadio=range&start-year=2008&end-year=2009&number=&series=&type=primaryhttp://www.legislation.gov.uk/search?title=health+and+social+care+act&yearRadio=range&start-year=2008&end-year=2009&number=&series=&type=primaryhttp://www.legislation.gov.uk/search?title=health+and+social+care+act&yearRadio=range&start-year=2008&end-year=2009&number=&series=&type=primaryhttp://www.cqc.org.uk/guidanceforprofessionals/registration/newregistrationsystem/howthenewregistrationsystemwork/complyingwithnewregulations.cfm


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TheregulatedactivitiesandregistrationrequirementsaresetoutintheHealth

andSocialCareAct2008(RegulatedActivities)Regulations2010.Thisis

availableat:

www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%

28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksi

How will the Code be used?

Section21oftheH&SCA2008enablestheSecretaryof StateforHealthto

issueaCodeofPracticeabouthealthcareassociatedinfections.TheCode

containsstatutoryguidanceaboutcompliance5withtheregistrationrequirement

forcleanlinessandinfectioncontrol(regulation12oftheHealthandSocialCare

Act2008(RegulatedActivities)Regulations2010).

ThelawstatesthattheCodemustbetakenintoaccountbytheCQCwhenit

makesdecisionsaboutregistrationagainstthecleanlinessandinfectioncontrol

requirement.Theregulationsalsosaythatprovidersmusthaveregardtothe

Codewhendecidinghowtheywillcomplywithregistrationrequirements.So,

byfollowingtheCode,registeredproviderswillbeabletoshowthattheymeet

theregulationoncleanlinessandinfectioncontrol.However,theydonotbylaw

havetocomplywiththeCode.Aregisteredprovidermaybeabletodemonstratethatitmeetstheregistrationrequirementregulationoncleanlinessandinfection

controlinadifferentway(equivalentorbetter)fromthatdescribedinthisdocument.

Tobecomeandstayregistered,providersmustmeetthefullrangeof

registrationrequirements.TheCQChaspublishedguidanceabouthowto

complywithalltherequirementsotherthantheoneoncleanlinessandinfection

control.ThisguidanceisinGuidance about compliance: Essential standards of

quality and safety,whichcanbefoundat:

www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_

March_2010_FINAL.pdf

TheCodedoesnotreplacetherequirementtocomplywithanyotherlegislation

thatappliestohealthandadultsocialcareservices,forexample,theHealth

andSafetyatWorketc.Act1974andtheControlofSubstancesHazardousto

HealthRegulations2002.

How will compliance be judged?

TheCQCisresponsibleforjudgingcompliancewiththeregistration

requirementssetoutinregulations.Whendoingthisforthecleanlinessand

5 TheCQChaspublishedguidanceaboutcompliancewiththeremainingregistration

requirements.Furtherdetailsareavailableatwww.cqcguidanceaboutcompliance.org.uk/

10
http://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksihttp://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksihttp://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfhttp://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfhttp://www.cqcguidanceaboutcompliance.org.uk/http://www.cqcguidanceaboutcompliance.org.uk/http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_March_2010_FINAL.pdfhttp://www.legislation.gov.uk/search?title=The+Health+and+Social+Care+Act+2008+%28Regulated+Activities%29+Regulations+2010&year=&number=&type=uksi


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Part1:Introduction

infectioncontrolrequirement,itwilltakeaccountoftheCodeandhow

registeredprovidersaredoingwhattheCodesays.Itwilldothisinawaythat

isproportionatetotheriskofinfection.

Allregisteredproviderswillneedtohaveadequatesystemsforinfection

preventionandcontrol,asstatedintheCode(seePart2),iftheyareto

complywiththelaw,butbecauseofthewiderangeofservicesprovidedby

allregisteredproviders,theCodewillbeappliedinaproportionateway.For

example,inanacutehospitalsettingthereisagreaterrisktopatientsof

infectionandthereforetheregisteredproviderwillneedtocomplywithmost

aspectsofthecompliancecriteria.However,inaserviceprovidedinsomeones

ownhomeoracarehomewherepeoplearesupportedtobeindependentinadomesticsetting,theregisteredproviderwillnotneedtohavethesamefacilities

andapproachasanacutehospital.

What happens if a registered provider does not meet the

requirements in the Code?

TheCQCmayuseitsenforcementpowersortakeotheractionwhereitdecides

thataregisteredproviderisnotmeetingitslegalobligationsassetoutinthe

regulations.Itwillreachthisdecisionbylookingatwhetheraregisteredprovider

isdoingwhatissetoutintheCode.Ifaregisteredproviderisnotfollowing

theCode,thentheCQCwillwanttoconsiderwhetherthatisbecauseitisnot

appropriatetothetypeofservicebeingprovided.If itisappropriate,theCQC

willwanttoconsiderwhetheraregisteredproviderisstillprotectingpeoplefrom

theriskofinfectioninanother,equallyeffectiveway.

FurtherinformationabouthowtheCQCwillassessregisteredproviders

andwhatactionitcantakeifaregisteredproviderdoesnotcomplywiththe

regulationcanbefoundonitswebsite

(www.cqc.org.uk/guidanceforprofessionals/registration/newregistrationsystem/

howthenewregistrationsystemwork/complyingwithnewregulations.cfm)orby

contactingitscustomerservicesteamon03000616161.

Commissioning of services

TheCQCisresponsibleformonitoringcompliancewiththerequirementsof

theHealthandSocialCareAct2008(RegulatedActivities)Regulations2010.

Commissioningorganisationsmaywishtoassurethemselvesthattheservices

thattheycommissionaremeetingexpectedrequirementsandthismayinvolve

contractmonitoringoftheservice.Indoingso,commissionersmustmakeitcleartotheproviderthatthisdoesnotreplaceorduplicatetheregulatoryrole

oftheCQC.

11
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Key components to support compliance

Thisdocumentprovidesarangeofinformationincludingappendices,tables,definitionsandanextensivebibliographytosupportprovidersincomplyingwith

theregulations.

Part2(TheCode)detailsthecriteriaagainstwhichtheregisteredproviderwill

bejudgedonhowitcomplieswiththeregistrationrequirementforcleanliness

andinfectioncontrol.Part3(Guidanceforcompliance)providesguidanceon

howtointerpretthecompliancecriteriaanddevelopriskassessments.Part4

(Guidancetables)detailstherelevantcriteriathatmightapplytoeachregulated

activity,offerspotentialsourcesofprofessionalinfectionpreventionandcontrol

adviceand,listswhichpoliciesmayberequiredtodemonstratecompliance

withcriterion9.

Theappendicesprovideexamplesofhowaproportionateapproachcouldbe

appliedtothecriteriainadultsocialcare,primarydentalcare,independent

sectorambulanceproviders,andprimarymedicalcareservices.However,itis

importanttoreadtheexamplesgivenintheappendices,alongsidetheguidance

undereachcriterioninPart3ofthisdocumentandnotjustselectiveparts.

Thebibliographylistsarangeofsupportingnationalguidance.Although

mostoftheseguidancedocumentswerewrittenfortheNHSandpriortotheestablishmentoftheCQCanditsregistrationrequirements,therewillbe

elementsthatarerelevanttootherregisteredproviders.Howtheyareusedisa

matterforlocaldetermination.

UsersmayfindthewebsiteoftheNationalResourceforInfectionControl

(www.nric.org.uk)ausefulsiteforaccessingthesedocumentsandother

relevantmaterial.

12
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Part 2: The Code of Practice

ThetablebelowistheCodeofPracticeforallprovidersofhealthcare

andadultsocialcareonthepreventionandcontrolofinfectionsunderThe

HealthandSocialCareAct2008.Thissetsoutthe10criteriaagainstwhich

aregisteredproviderwillbejudgedonhowitcomplieswiththeregistration

requirementforcleanlinessandinfectioncontrol.Notallcriteriawillapplyto

everyregulatedactivity.Parts3and4ofthisdocumentwillhelpregistered

providersinterpretthecriteriaanddeveloptheirownriskassessments.

Compliance

criterion

What the registered provider will need to demonstrate

1 Systemstomanageandmonitorthepreventionandcontrolof

infection.Thesesystemsuseriskassessments andconsider

howsusceptibleserviceusersareandanyrisksthattheir

environmentandotherusersmayposetothem.

2 Provideandmaintainacleanandappropriateenvironmentin

managedpremisesthatfacilitatesthepreventionandcontrolofinfections.

3 Providesuitableaccurateinformationoninfectionstoservice

usersandtheirvisitors.

4 Providesuitableaccurateinformationoninfectionstoany

personconcernedwithprovidingfurthersuppor tornursing/

medicalcareinatimelyfashion.

5 Ensurethatpeoplewhohaveordevelopaninfectionare

identified promptlyandreceivetheappropriatetreatment

andcaretoreducetheriskof passingontheinfectionto

otherpeople.

6 Ensurethatallstaffandthoseemployedtoprovidecarein

allsettingsarefullyinvolvedintheprocessofpreventingand

controllinginfection.

7 Provideorsecureadequateisolationfacilities.

8 Secureadequateaccesstolaboratorysuppor tasappropriate.

9 Haveandadheretopolicies,designedfortheindividuals

careandproviderorganisations,thatwillhelptopreventand

controlinfections.

10 Ensure,sofarasisreasonablypracticable,thatcareworkers

arefreeofandareprotectedfromexposuretoinfectionsthat

canbecaughtatworkandthatallstaff aresuitablyeducated

inthepreventionandcontrolofinfectionassociatedwiththe

provisionofhealthandsocialcare. 13


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Part 3: Guidance forcomplianceInordertoachievecompliancewiththeregistrationrequirementsrelatingto

infectionpreventionandcontrol,registeredproviderswouldnormallybeexpected

todemonstratethattheyhaveinplacethepoliciesandprocedurestomeet

eachrelevantcriterionlistedinPart2andhavetakenaccountofthefollowing

guidanceforcompliance.Thisguidanceisnotmandatorybutisconsideredto

representthebasicstepsthatarerequiredtoensurethatthecriteriacanbemet.

Theremaybeadditionaloralternativestrategiesthataregisteredprovider

isabletojustifyasequivalent,ormoreeffective,inachievingcompliancein

theircircumstances.Registeredprovidersarefreetodecidetousealternative

approachesbutshouldbepreparedtojustifytotheCQChowthechosen

approachisequallyeffectiveorbetterinensuringthatthecriteriaaremet.

Providersofregulatedactivitiesneedtorecognisethateffectivemanagementof

infectionpreventionandcontrolisanimportantserviceusersafetyissue.

ThetablesinPart4maybeusedasaguidetohelptodecideontheapplication

oftheindividualcompliancecriteriaandavailableinfectionpreventionandcontroladvice.Theprincipleofpropor tionalityextendsthroughoutthisguidance

and,whereitisdecidedapolicyshouldexist,thepolicyslevelofdetailand

complexitywilldependonlocalneedbasedonriskassessment.

Guidance for compliance with criterion 1

Systemstomanageandmonitorthepreventionandcontrolofinfection.These

systemsuseriskassessments andconsiderhowsusceptibleserviceusers

areandanyrisksthattheirenvironmentandotherusersmayposetothem.

1.1 Appropriatemanagementandmonitoringarrangementsshouldensurethat:

aregisteredproviderhasanagreementwithintheorganisationthatoutlinesitscollectiveresponsibilityforkeepingtoaminimumtherisks

ofinfectionandthegeneralmeansbywhichitwillpreventandcontrol

suchrisks;

anindividualisdesignatedastheleadforinfectionpreventionandcontrolandbeaccountabledirectlytotheregisteredprovider;

themechanismsareinplacebywhichtheregisteredproviderintendstoensurethatsufficientresourcesareavailabletosecurethe

effectivepreventionandcontrolofinfection.Theseshouldincludethe

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Part3:Guidanceforcompliance

implementationofaninfectionpreventionandcontrolprogramme,

infectionpreventionandcontrolinfrastructureandtheabilitytodetect

andreportinfections;

relevantstaff,contractorsandotherpersons,whosenormaldutiesaredirectlyorindirectlyconcernedwithprovidingcare,receivesuitableand

sufficientinformationon,andtrainingandsupervisionin,themeasures

requiredtopreventandcontroltherisksofinfection;

aprogrammeofauditisinplacetoensurethatkeypoliciesandpracticesarebeingimplementedappropriately;

apolicyoninformationsharingwhenreferring,admitting,transferring,dischargingandmovingserviceuserswithinandbetweenhealthandadultsocialcarefacilitiesisavailable;and

adecontaminationleadisdesignated,whereappropriate.

(Refer also to Outcome 6, Regulation 24 Cooperating with other providers

contained in CQC Guidance about compliance)

Risk assessment

1.2 Aregisteredprovidershouldensurethatithas:

madeasuitableandsufficientassessmentoftheriskstothepersonreceivingcarewithrespecttopreventionandcontrolofinfection;

identifiedthestepsthatneedtobetakentoreduceorcontrolthoserisks;

recordeditsfindingsinrelationtothefirsttwopoints;

implementedthestepsidentified;and

putappropriatemethodsinplacetomonitortherisksofinfectiontodeterminewhetherfurtherstepsareneededtoreduceorcontrolinfection.

Directors of Infection Prevention and Control (in NHS provider organisations)

1.3 TheroleoftheDIPC6inNHSproviderorganisationsisto:

beaccountabledirectlytothechiefexecutiveandtotheboard(butnotnecessarilyamemberoftheboard);

beresponsiblefortheorganisationsinfectionpreventionandcontrolteam(IPT)orinfectioncontrolteam(ICT) 7;

6 ThisrolewasfirstdescribedinWinning ways: working together to reduce healthcare

associated infection in EnglandandhasbeendescribedinpreviouseditionsoftheCode.

7 HereafterbothIPTandICTarereferredtoasICTinthisdocument.

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overseelocalpreventionandcontrolofinfectionpoliciesandtheirimplementation;

beafullmemberoftheICTandregularlyattenditsinfectionpreventionandcontrolmeetings;

reportdirectlytotheNHSboardand,innon-NHScaresettings,theregisteredprovider;

havetheauthoritytochallengeinappropriatepracticeandinappropriateantibioticprescribingdecisions;

assesstheimpactofallexistingandnewpoliciesoninfectionsandmakerecommendationsforchange;

beanintegralmemberoftheorganisationsclinicalgovernanceandpatientsafetyteamsandstructures;and

produceanannualreportandreleaseitpubliclyasoutlinedin Winningways: working together to reduce healthcare associated infection in

England.Suggestionsastowhatcouldbeincludedinthereportare

providedinthetemplateat:

www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/

Dearcolleagueletters/DH_4083982

Infection Prevention and Control Lead (for example adult social care, primary

dental and medical care and independent sector ambulance providers)

1.4 TheroleoftheInfectionPreventionandControl(IPC)Leadinadultsocial

care,primarydentalcare,primarymedicalcareandindependentsector

ambulanceproviderswilldependontheorganisationalstructuresandon

thelevelandcomplexityofthecareprovided.(Thisisadescriptionofhow

theroleoftheDIPCinhealthcaremightbeappliedinthesesettings.)Their

roleisto:

beresponsiblefortheorganisationsinfectionpreventionandcontrolmanagementandstructure;

overseelocalpreventionandcontrolofinfectionpoliciesandtheirimplementation;

reportdirectlytotheregisteredprovider;

havetheauthoritytochallengeinappropriatepractice;

assesstheimpactofallexistingandnewpoliciesoninfectionsand

makerecommendationsforchange;

beanintegralmemberoftheorganisationsgovernanceandserviceusersafetyteamsandstructureswheretheyexist;and

16
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_4083982http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_4083982http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_4083982


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produceanannualstatementwithregardtocompliancewithgoodpracticeoninfectionpreventionandcontrolandmakeitavailable

onrequest.

Assurance framework

1.5 Activitiestodemonstratethatinfectionpreventionandcontrolarean

integralpartofqualityassuranceshouldinclude:

In NHS provider organisations

regularpresentationsfromtheDIPCand/ortheICTtotheNHSboardorregisteredprovider.Theseshouldincludeatrendanalysisforinfections

andcompliancewithauditprogrammes;

quarterlyreportingtotheNHSboardorregisteredproviderbyclinicaldirectorsandmatrons(includingnurseswhodonotholdthespecifictitle

ofmatronbutwhooperateatasimilarlevelofseniorityandwhohave

controloversimilaraspectsofthepatientorthepatientsenvironment).

Whatisreportedonwillvaryaccordingtothelocalarrangements.

Forexampleitmayinclude:

monthlycleanlinessscores(unlessthisisdoneviatheestates

andfacilitiesteam);

monthlyPatientEnvironmentActionTeamscores(wherethisisagreedpractice);and

contractperformancemeasureswhereprovisionisoutsourced,

whichwillincludecleanliness measuresandissuesof non-

complianceandsubsequentrectificationperformance;

areviewofstatisticsonincidenceofalertorganisms(forexample,butnotlimitedto,meticillin-resistantStaphylococcus aureus(MRSA)and

Clostridium difficile)andconditions,outbreaksandseriousuntoward

incidents;

evidenceof appropriateactiontakentodealwithoccurrencesof infectionincluding,whereapplicable,rootcauseanalysis;and

anauditprogrammetoensurethatpolicieshavebeenimplemented;

In adult social care, primary dental care and primary medical care etc.

evidenceof appropriateactiontakentodealwithoccurrencesofinfection;

anauditprogrammetoensurethatappropriatepolicieshavebeendevelopedandimplemented;and

evidencethattheannualstatementfromtheIPCLeadhasbeenreviewedand,whereindicated,actedupon.

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1.6 Inaccordancewithhealthandsafetyrequirements,wheresuitableand

sufficientassessmentofrisksrequiresactiontobetaken,evidencemust

beavailableoncompliancewiththeregulationsor,whereappropriate,

justificationofasuitablebetteralternative.Thisappliestoallhealthcare

andadultsocialcare.

Infection prevention and control programme

1.7 Theinfectionpreventionandcontrolprogrammeshould:

setobjectivesthatmeettheneedsoftheorganisationandensurethesafetyofserviceusers;

identifyprioritiesforaction; provideevidencethatrelevantpolicieshavebeenimplementedto

reduceinfections;and

if appropriate,reportprogressagainsttheobjectivesoftheprogrammeintheDIPCsannualreportortheIPCLeadsannualstatement.

Infection prevention and control infrastructure

1.8 Aninfectionpreventionandcontrolinfrastructureshouldencompass:

inacutehealthcaresettings,forexample,anICTconsistingofanappropriatemixofbothnursingandconsultantmedicalexpertise(withspecialisttrainingininfectionpreventionandcontrol)andappropriate

administrativeandanalyticalsupport,includingadequateinformation

technologytheDIPCisakeymemberoftheICT;

inothersettings,therewillbeaninfectioncontrolnurse(ICN)oranotherdesignatedpersonwhoisresponsibleforinfectionpreventionandcontrol

mattersandhasaccesstospecialistexpertiseasnecessary;and

24-houraccesstoanominatedqualifiedinfectioncontroldoctor(ICD)

orconsultantinhealthprotection/communicablediseasecontrol.

Theregisteredprovidershouldknowhowtoaccessthisadvice.

Movement of service users

1.9 Thereshouldbeevidenceofjointworkingbetweenstaffinvolvedinthe

provisionofadvicerelatingtothepreventionandcontrolofinfection;those

managingbedallocation;carestaff anddomesticstaff inplanningservice

userreferrals,admissions,transfers,dischargesandmovementsbetween

departments;andwithinandbetweenhealthandadultsocialcarefacilities.

Wherenecessary,ambulanceproviders,hospitalsandprimarycaretrusts(PCTs)mayneedtobeinvolvedinsuchplanning.

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1.10Aregisteredprovidermustensurethatitprovidessuitableandsufficient

informationonaserviceusersinfectionstatuswheneveritarrangesfor

thatpersontobemovedfromthecareofoneorganisationtoanother,

orfromaserviceusershome,sothatanyriskstotheserviceuserand

othersfrominfectionmaybeminimised.Ifappropriate,providersofa

serviceuserstransportshouldbeinformedofanyinfection.




Provideandmaintainacleanandappropriateenvironmentinmanaged

premisesthatfacilitatesthepreventionandcontrolofinfections.

(Refer also to Outcome 10, Regulation 15 Safety and suitability of premises


2.1 Withaviewtominimisingtheriskofinfection,aregisteredprovidershould

normallyensurethat:

itdesignatesleadsforenvironmentalcleaninganddecontaminationof

equipmentusedfordiagnosisandtreatment(asingleindividualmaybedesignatedforbothareas);

inhealthcare,thedesignatedleadforcleaninginvolvesdirectorsofnursing,matronsandtheICTorpersonsofsimilarstandinginall

aspectsofcleaningservices,fromcontractnegotiationandservice

planningtodeliveryatwardandclinicallevel.Inothersettings,the

designatedleadforcleaningwillneedtoaccessappropriateadviceon

allaspectsofcleaningservices;

inhealthcare,matronsorpersonsofasimilarstandinghavepersonalresponsibilityandaccountabilityfordeliveringasafeandcleancareenvironment;

thenurseorotherpersoninchargeofanypatientorresidentareahasdirectresponsibilityforensuringthatcleanlinessstandardsare

maintainedthroughoutthatshift;

allpartsofthepremisesfromwhichitprovidescarearesuitableforthepurpose,keptcleanandmaintainedingoodphysicalrepairandcondition;

thecleaningarrangementsdetailthestandardsofcleanlinessrequiredineachpartofitspremisesandthatascheduleofcleaningfrequency

isavailableonrequest;

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thereisadequateprovisionofsuitablehandwashingfacilitiesandantimicrobialhandrubswhereappropriate;

thereareeffectivearrangementsfortheappropriatecleaningofequipmentthatisusedatthepointofcare,forexamplehoists,bedsand

commodestheseshouldbeincorporatedwithinappropriatecleaning,

disinfectionanddecontaminationpolicies;and

thesupplyandprovisionoflinenandlaundryareappropriateforthelevelandtypeofcare.

2.2 Theenvironmentmeansthetotalityofaserviceuserssurroundingswhen

incarepremisesortransportedinavehicle.Thisincludesthefabricofthebuilding,relatedfixturesandfittings,andservicessuchasairandwater

supplies.Wherecareisdeliveredintheserviceusershome,thesuitability

oftheenvironmentforthatlevelofcareshouldbeconsidered.

Policies on the environment

2.3 Premisesandfacilitiesshouldbeprovidedinaccordancewithbestpractice

guidance.Thedevelopmentoflocalpoliciesshouldtakeaccountof

infectionpreventionandcontroladvicegivenbyrelevantexpertoradvisory

bodiesorbytheICT,andthisshouldincludeprovisionforliaisonbetween

themembersofanyICTandthepersonswithoverallresponsibilityforthemanagementoftheserviceusersenvironment.Policiesshouldaddress

butnotberestrictedto:

cleaningservices;

buildingandrefurbishment,includingair-handlingsystems;

wastemanagement;

laundryarrangementsforusedandinfectedlinen;

plannedpreventativemaintenance;

pestcontrol;

managementofdrinkableandnon-drinkablewatersupplies;

minimisingtheriskofLegionellabyadheringtonationalguidance;and

foodservices,includingfoodhygieneandfoodbroughtintothecaresettingbyserviceusers,staffandvisitors.



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Cleaning services

2.4 Thearrangementsforcleaningshouldinclude:

cleardefinitionofspecificrolesandresponsibilitiesforcleaning;

clear,agreedandavailablecleaningroutines;

sufficientresourcesdedicatedtokeepingtheenvironmentcleanandfitforpurpose;

consultationwithICTsorequivalentlocalexpertiseoncleaningprotocolswheninternalorexternalcontractsarebeingprepared;and

detailsofhowstaffcanrequestadditionalcleaning,bothurgentlyandroutinely.

Decontamination

2.5 Thedecontaminationleadshouldhaveresponsibilityforensuringthat

policiesexistandthattheytakeaccountofbestpracticeandnational

guidance.Theymaywishtoconsiderguidanceunderthefollowingheadings:

Decontaminationoftheenvironmentincludingcleaninganddisinfectionofthefabric,fixturesandfittingsofabuilding(walls,floors,

ceilingsandbathroomfacilities)orvehicle.

Decontaminationofequipmentincludingcleaninganddisinfectionofitemsthatcomeintocontactwiththepatientorserviceuser,butarenot

invasivedevices(egbeds,commodes,mattresses,hoistsandslings,

examinationcouches).

Decontaminationofreusablemedicaldevicesincludingcleaning,disinfectionandsterilisationofinvasivemedicaldevices.

Reusablemedicaldevicesshouldbereprocessedatoneofthefollowing

threelevels:

sterile(atpointofuse);

sterilised(i.e.havingbeenthroughthesterilisationprocess);

clean(i.e.freeofvisiblecontamination).

2.6 Thedecontaminationpolicyshoulddemonstratethat:

itcomplieswithguidanceestablishingessentialqualityrequirementsandaplanisinplaceforprogressiontobestpractice;

decontaminationofreusablemedicaldevicestakesplaceinappropriatefacilitiesdesignedtominimisetherisksthatarepresent;

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appropriateproceduresarefollowedfortheacquisition,maintenanceandvalidationofdecontaminationequipment;

staffaretrainedincleaninganddecontaminationprocessesandholdappropriatecompetencesfortheirrole;and

arecord-keepingregimeisinplacetoensurethatdecontaminationprocessesarefitforpurposeandusetherequiredqualitysystems.

(Refer also to Outcome 11, Regulation 16 Safety, availability and suitability of

equipment contained in CQC Guidance about compliance)


Providesuitableaccurateinformationoninfectionstoserviceusersand

theirvisitors.

3.1 Areasrelevanttotheprovisionofsuchinformationinclude:

generalprinciplesonthepreventionandcontrolofinfectionandkeyaspectsoftheregisteredproviderspolicyoninfectionpreventionand

control,whichtakesintoaccountthecommunicationneedsofthe

serviceuser;

therolesandresponsibilitiesofparticularindividualssuchascarers,relativesandadvocatesinthepreventionandcontrolofinfection,to

supportthemwhenvisitingserviceusers;

supportingserviceusersawarenessandinvolvementinthesafeprovisionofcare;

theimportanceofcompliancebyvisitorswithhandhygiene;

theimportanceofcompliancewiththeregisteredproviderspolicyonvisiting;

reportingfailuresofhygieneandcleanliness;

explanationsofincident/outbreakmanagement.

3.2 Informationshouldbedevelopedwithlocalserviceuserrepresentative

organisations,whichcouldincludeLocalInvolvementNetworks(LINks)and

PatientAdviceandLiaisonServices(PALS).

(Refer also to Outcome 1, Regulation 17 Respecting and involving service users


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Guidance for compliance with criterion 4 Providesuitableaccurateinformationoninfectionstoanypersonconcer ned

withprovidingfurthersuppor tornursing/medicalcareinatimelyfashion.

4.1 Aregisteredprovidershouldensurethat:

accurateinformationiscommunicatedinanappropriatemanner;

thisinformationfacilitatestheprovisionofoptimumcare,minimisingtheriskof inappropriatemanagementandfurthertransmissionofinfection;

and

wherepossible,informationaccompaniestheserviceuser.

4.2 Provisionofrelevantinformationacrossorganisationalboundariesis

coveredbytheregulationrequirementCo-operatingwithotherproviders.

Dueattentionshouldbepaidtoserviceuserconfidentialityasoutlinedin

nationalguidanceandtrainingmaterial.8




Ensurethatpeoplewhohaveordevelopaninfectionareidentified promptly

andreceivetheappropriatetreatmentandcaretoreducetheriskofpassing

ontheinfectiontootherpeople.

5.1 Registeredproviders,excludingpersonalcareproviders,shouldensure

thatadviceisreceivedfromsuitablyinformedpractitionersandthat,if

advised,registeredprovidersshouldinformtheirlocalhealthprotectionunit

ofanyoutbreaksorseriousincidentsrelatingtoinfection.

5.2 Arrangementstopreventandcontrolinfectionshoulddemonstratethat

responsibilityforinfectionpreventionandcontroliseffectivelydevolvedto

allgroupsintheorganisationinvolvedindeliveringcare.

8 Furtheradviceontheprinciplesforappropriateinformation-sharingcanbefoundin

Confidentiality: NHS Code of Practice; The Care Record Guarantee; and The Social Care

Record Guarantee. Trainingmaterialsoninformationgovernancecanbefoundin

NHS Information Governance Training Tool.

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Guidance for compliance with criterion 6 Ensurethatallstaffandthoseemployedtoprovidecareinallsettingsare

fullyinvolvedintheprocessofpreventingandcontrollinginfection.

6.1 Aregisteredprovidershould,sofarasisreasonablypracticable,ensure

thatitsstaff,contractorsandothersinvolvedintheprovisionofcare

co-operatewithit,andwitheachother,sofarasisnecessarytoenablethe

registeredprovidertomeetitsobligationsundertheCode.

6.2 Infectionpreventionandcontrolwouldneedtobeincludedinthejob

descriptionsandbeincludedintheinductionprogrammeandstaffupdates

ofallemployees(includingvolunteers).Contractorsworkinginserviceuserareaswouldneedtobeawareofanyissueswithregardtoinfection

preventionandcontrolandobtainpermissiontowork.Confidentialitymust

bemaintained.

6.3 Wherestaffundertakeprocedures,whichrequireskillssuchasaseptic

technique,staffmustbetrainedanddemonstrateproficiencybeforebeing

allowedtoundertaketheseproceduresindependently.

Guidance for compliance with criterion 7Provideorsecureadequateisolationfacilities.

7.1 Ahealthcareregisteredproviderdeliveringin-patientcareshouldensure

thatitisabletoprovide,orsecuretheprovisionof,adequateisolation

precautionsandfacilities,asappropriate,sufficienttopreventorminimise

thespreadofinfection.Thismayincludefacilitiesinadaycaresetting.

7.2 Policiesshouldbeinplacefortheallocationofpatientstoisolation

facilities,basedonalocalriskassessment.Theassessmentcouldinclude

considerationoftheneedforspecialventilatedisolationfacilities.Sufficient

staffshouldbeavailabletocarefortheserviceuserssafely.

7.3 Registeredprovidersofaccommodationshouldensurethattheyareable

toprovideorsecurefacilitiestophysicallyseparatetheserviceuserfrom

otherresidentsinanappropriatemannerinordertominimisethespread

ofinfection.

7.4 Carehomesarenotexpectedtohavededicatedisolationfacilitiesfor

serviceusersbutareexpectedtoimplementisolationprecautionswhena

serviceuserissuspectedorknowntohaveatransmissibleinfection.

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Secureadequateaccesstolaboratorysuppor tasappropriate.

8.1 Aregisteredprovidershouldensurethatlaboratoriesthatareusedto

provideamicrobiologyserviceinconnectionwitharrangementsfor

infectionpreventionandcontrolhaveinplaceappropriateprotocolsand

thattheyoperateaccordingtothestandardsrequiredbytherelevant

nationalaccreditationbodies.Inadultsocialcare,theserviceusers

GeneralPractitionerwillarrangesuchtestingwhennecessaryforthe

treatmentandmanagementofdisease.

8.2 Protocolsshouldinclude:

amicrobiologylaboratorypolicyforinvestigationandsurveillanceofhealthcareassociatedinfections;and

standardlaboratoryoperatingproceduresfortheexaminationofspecimens.


Haveandadheretopolicies,designedfortheindividualscareandproviderorganisations,thatwillhelptopreventandcontrolinfections.

9.1 Aregisteredprovidershould,inrelationtopreventing,reducingand

controllingtherisksofinfections,haveinplacetheappropriatepolicies

concerningthemattersmentionedinatoybelow.Allpoliciesshouldbe

clearlymarkedwithareviewdate.

9.2 AguideisgiveninTable3astowhichpoliciesmaybeappropriatetothe

regulatedactivities.Adecisionshouldbemadelocallyfollowingarisk

assessment.

9.3 Anyregisteredprovidershouldhavepoliciesinplacerelevanttothe

regulatedactivityitprovides.Eachpolicyshouldindicateownership(i.e.

whocommissionedandretainsmanagerialresponsibility),authorshipand

bywhomthepolicywillbeapplied.Implementationofpoliciesshouldbe

monitoredandthereshouldbeevidenceofarollingprogrammeofaudit

andadateforrevisionstated.

a. Standard infection prevention and control precautions

Policyshouldbebasedonevidence-basedguidelines,includingthose

onhandhygieneatthepointofcareandtheuseofpersonalprotective

equipment.

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Policyshouldbeeasilyaccessibleandbeunderstoodbyallgroupsofstaff,serviceusersandthepublic.

Compliancewiththepolicyshouldbeaudited.

b. Aseptic technique

Whereasepticproceduresareperformed:

clinicalproceduresshouldbecarriedoutinamannerthatmaintainsandpromotestheprinciplesofasepsis;

education,trainingandassessmentintheaseptictechniqueshouldbeprovidedtoallpersonsundertakingsuchprocedures;

thetechniqueshouldbestandardisedacrosstheorganisation;and

anauditshouldbeundertakentomonitorcompliancewiththetechnique.

c. Outbreaks of communicable infection

Thedegreeofdetailinthepolicyshouldreflectlocalcircumstances.Alowrisk,single-specialtyfacilityorproviderofprimarycarewillnot

requirethesamearrangementsasthoseprovidingthefullrangeof

medicalandsurgicalcare.

Professionaladviceoninfectionpreventionandcontrolforregulatedactivitiesmaybedrawnfromanumberofexpertsources.Table2

outlinesthemostlikelyarrangementsforthedifferentregulated

activities.

Policiesforoutbreaksofcommunicableinfectionshouldincludeinitialassessment,communication,managementandorganisation,plus

investigationandcontrol.

Thecontactdetailsofthoselikelytobeinvolvedinoutbreak managementshouldbereviewedatleastannually.

Allregisteredprovidersshouldreportsignificantoutbreaksofinfection

totheirlocalhealthprotectionunit,includingoutbreaksinserviceusers

whoaredetainedundertheMentalHealthAct1983,ifadvisedtodoso

bysuitablyinformedpractitioners.

d. Isolation of service users with an infection (see also criterion 7)

Theisolationpolicyshouldbeevidencebasedandreflectlocalriskassessment9.

9 HealthandSafetyExecutive(2006)Five steps to risk assessment.INDG163(rev2).

London:HSE.

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Indicationsforisolationshouldbeincludedinthepolicy,asshouldproceduresfortheinfectionpreventionandcontrolmanagementof

serviceusersinisolation.

Informationonisolationshouldbeeasilyaccessibleandunderstoodbyallgroupsofstaff,serviceusersandthepublic.

e. Safe handling and disposal of sharps

Relevantconsiderationsinclude:

riskmanagementandtraininginthemanagementofmucousmembraneexposureandsharpsinjuriesandincidents;

provisionofmedicaldevicesthatincorporatesharpsprotectionmechanismswherethereareclearindicationsthattheywillprovidesafe

systemsofworkingforstaff;

apolicythatiseasilyaccessibleandunderstoodbyallgroupsofstaff;

safeuse,securestorageanddisposalofsharps;and

auditingofpolicycompliance.

f. Prevention of occupational exposure to blood-borne viruses (BBVs),

including prevention of sharps injuries MeasurestoavoidexposuretoBBVs(hepatitisBandCandHIV)should

include:

immunisationagainsthepatitisB,assetoutin Immunisation againstinfectious disease,betterknownasTheGreenBook(publishedbythe

DepartmentofHealth);

thewearingofglovesandotherprotectiveclothing;

thesafehandlinganddisposalofsharps,includingtheprovisionofmedicaldevicesthatincorporatesharpsprotectionwherethereareclearindicationsthattheywillprovidesafesystemsofworkingforstaff;and

measurestoreducerisksduringsurgicalprocedures.

g. Management of occupational exposure to BBVs and post-exposure

prophylaxis

Managementshouldensure:

thatanymemberof staff whohasasignificantoccupationalexposuretobloodorbodyfluidsisawareoftheimmediateactionrequiredandis

referredappropriatelyforfurthermanagementandfollow-up;

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provisionofclearinformationforstaff aboutreportingpotentialoccupationalexposureinparticulartheneedforpromptaction

followingaknownorpotentialexposuretoHIVorhepatitisB;and

arrangementsforpost-exposureprophylaxisforhepatitisBandHIV.

(Refer also to Outcome 12, Regulation 21 Requirements relating to workers


h. Closure of rooms, wards, departments and premises to new admissions

Asystemshouldbeinplacefortheprovisionofadvicefromthelocalhealthprotectionunit/DIPC/ICTfortheregisteredprovider.

Thereshouldbeclearcriteriainrelationtoclosuresandre-opening.

Thepolicyshouldaddresstheneedforenvironmental decontaminationpriortore-opening.

i. Disinfection

Theuseofdisinfectantsisalocaldecision,andshouldbebasedon

currentacceptedgoodpractice.

j. Decontamination of reusable medical devices

Decontaminationinvolvesacombinationofprocessesandincludes

cleaning,disinfectionandsterilisation,accordingtotheintendeduseofthe

device.Thisaimstorenderareusableitemsafeforfurtheruseonservice

usersandforhandlingbystaff.

Effectivedecontaminationofreusablemedicaldevicesisanessentialpartof infectionriskcontrolandisofspecialimportancewhenthe

devicecomesintocontactwithserviceusersortheirbodyfluids.There

shouldbeasystemtoprotectserviceusersandstaff thatminimisesthe

riskoftransmission ofinfectionfrommedicaldevices.Thisrequiresthat

thedeviceorinstrumentsetcanbeclearlylinkedinatraceablefashiontotheindividualprocesscyclethatwasusedtodecontaminateit,such

thatthesuccess ofthatcycleinrenderingthedevicesafeforreusecan

beverified.

Reusablemedicaldevicesshouldbedecontaminatedinaccordancewithmanufacturersinstructionsandcurrentnationalorlocalbestpractice

guidance.ThismustensurethatthedevicecomplieswiththeEssential

RequirementsprovidedintheMedicalDevicesRegulations2002where

applicable.Thisrequiresthatthedeviceshouldbecleanand,where

appropriate,sterilised attheendofthedecontaminationprocessandmaintainedinaclinicallysatisfactor yconditionuptothepointofuse.

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Managementsystemsshouldensureadequatesuppliesofreusablemedicaldevices,particularlywherespecificdevicesareessentialtothe

continuityofcare.

Reusablemedicaldevicesemployedininvasiveprocedures,forexample,endoscopesandsurgicalinstrumentshavetobeeither

individuallyidentifiableoridentifiedtoasetofwhichtheyarea

consistentmember,throughouttheuseanddecontaminationcyclein

ordertoensuresubsequenttraceability.

Systemsshouldalsobeimplementedtoenabletheidentificationofserviceusersonwhomthemedicaldeviceshavebeenused.

Decontaminationofsingle-patientusedevices,i.e.thatequipmentdesignatedforuseonlybyonepatient,shouldbesubjecttolocalpolicy

andmanufacturersinstructions.



k. Single-use medical devices Policiesshouldbeinplaceforhandlingdevicesdesignedforsingleuseonly.

Single-usemedicaldevicesshouldbeusedonceanddisposedofsafely.

l. Antimicrobial prescribing Prescribingshouldgenerallybeharmonisedwiththatinthe British

National Formulary.However,localguidelinesmayberequiredincertain

circumstances.

Alllocalguidelinesshouldincludeinformationonaparticulardrugsregimenandduration.

Proceduresshouldbeinplacetoensureprudentprescribingand

antimicrobialstewardship.Thereshouldbeanongoingprogrammeofaudit,revisionandupdate.Inhealthcarethisisusuallymonitoredbythe

antimicrobialmanagementteamorlocalprescribingadvisors.

m. Reporting of infections to the Health Protection Agency or local authorityMandatory reporting of healthcare associated infections to the Health Protection Agency ThisincludesarequirementforNHSTrustChief Executivestoreport

allcasesofMRSAbacteraemiaandallcasesofClostridium difficile

infectioninpatientsagedtwoyearsorolderthatareidentifiedintheir

institution.Theindependentsectorhospitalsarealsoexpectedtoreport

casesinasimilarmanner.Therequirementsofthissystemwillvary

fromtimetotimeasdirectedbytheDepartmentofHealth.

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Health Protection (Notification) Regulations 2010

Theserequireattendingdoctors(registeredmedicalpractitioners)tonotifytheProperOfficerofthelocalauthorityofcasesof specified

infectiousdiseaseorofotherinfectiousdiseaseorcontamination,which

present,orcouldpresent,significantharmtohumanhealth,toallow

promptinvestigationandresponse.Theregulationsalsorequirediagnostic

laboratoriestestinghumansamplestonotifytheHealthProtectionAgency

oftheidentificationofspecifiedcausativeagentsofinfectiousdisease.

n. Control of outbreaks and infections associated with specific alert organisms Thisshouldtakeaccountoflocalepidemiologyandriskassessment.

Theseinfectionsmustinclude,asaminimum,MRSA,respiratoryinfection,diarrhoealoutbreaks,Clostridium difficileinfectionandtransmissible

spongiformencephalopathies.

MRSA

Thepolicyshouldmakeprovisionfor:

screeningofNHSpatientsonemergencyorrelevantelectiveadmissiontoaunitthatprovidessurgical,diagnosticorothermedicalcare.The

arrangementsforundertakingscreeningwillbesubjecttolocalagreement;

suppressionregimensforcolonisedpatientswhenappropriate;

isolationofinfectedorcolonisedpatients;

transferofinfectedorcolonisedpatientswithinorganisationsortoothercarefacilities;

antibiotic prophylaxisforsurgery;and

undertakingarootcauseanalysisonpatientswithaMRSAbacteraemia.

Clostridium difficile Thepolicyshouldmakeprovisionfor:

surveillanceofClostridium difficileinfection;

diagnosticcriteria;

isolationofinfectedserviceusersandcohortnursing;

environmentaldecontamination;

antibiotic prescribingpolicies;and

contraindicationofanti-motilityagents.

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Glycopeptide resistant enterococci (GRE)


identificationofhigh-riskgroups;

isolationandpreventionofcross-infection;and

prophylaxisforsurgicalandinvasiveprocedures.

Acinetobacter, extended-spectrum beta lactamase (ESBLs) and other

antibiotic-resistant bacteria


surveillanceofidentifiedpatientsatriskandofhigh-riskenvironments;and

proceduresformanaginginfectedpatientstopreventspreadofinfection.

Viral haemorrhagic fevers (VHF)


appropriatestafftobeawareofthespecialmeasurestobetakenfornursingVHFpatients,andtobeproperlytrainedintheapplicationoffull

isolationprocedures;

patientriskassessmentandcategorisation;

confirmedcasestobehandledunderfullisolationmeasuresinahighsecurityinfectiousdiseasesunitorequivalent;

handlingofpatientspecimensattheappropriatecontainmentlevel;

follow-upofallstaffincontactwiththepatientateverystageofcare;and

specialmeasuresforthehandlingofallwasteandlaundry.

Creutzfeldt-Jakob disease (CJD), variant CJD (vCJD) and other humanprion diseases

Thepolicyshouldmakeprovisionforthemanagementofpatientswith,or

atincreasedriskof,CJD/vCJDandotherhumanpriondiseases.

Relevant policies for other specific alert organisms

Thespecificalertorganismsthatfollowmayberelevanttoanyunit

admitting,ortreatingasout-patients.

Control of tuberculosis, including multidrug-resistant tuberculosis:

isolationofinfectiouspatients;

transferofinfectiouspatientswithincareorganisationsortoothercarefacilities;

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contacttracing;and

treatmentcompliance.Respiratory viruses:

alertsystemforsuspectedcases;

isolationcriteria;and

infectionpreventionandcontrolmeasures.

Diarrhoeal infections:

isolationcriteria; infectionpreventionandcontrolmeasures;and

cleaninganddisinfectionpolicy.

o. CJD/vCJD handling of instruments and devices Adviceonthehandlingofinstrumentsanddevicesinprocedureson

patientswithknownorsuspectedCJD/vCJD,oratincreasedriskofCJD/

vCJD,includingdisposal/quarantineprocedures,isprovidedinguidance

fromtheAdvisoryCommitteeonDangerousPathogens(ACDP)TSE

WorkingGroup.



p. Safe handling and disposal of waste Therisksfromwastedisposalshouldbeproperlycontrolled.Inpractice,in

relationtowaste,thisinvolves:

assessingrisk;

developingappropriatepolicies; puttingarrangementsinplacetomanagerisks;

monitoring,auditingandreviewingthewayinwhicharrangementswork;and

beingawareofstatutoryrequirementsand;legislativechangeandmanagingcompliance.

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Precautionsinconnectionwithhandlingwasteshouldinclude:

trainingandinformation(includingdefinitionandclassificationofwaste);

personalhygiene;

segregationandstorageofwaste;

theuseofappropriatepersonalprotectiveequipment;

immunisation;

appropriateproceduresforhandlingsuchwaste;

appropriatepackagingandlabelling; suitabletransporton-siteandoff-site;

clearproceduresfordealingwithaccidents,incidentsandspillages;and

appropriatetreatmentanddisposalofsuchwaste.

Systemsshouldbeinplacetoensurethattheriskstoserviceusers

fromexposuretoinfectionscausedbywastepresentintheenvironment

areproperlymanaged,andthatdutiesunderenvironmentallaware

discharged.Themostimportantoftheseare:

dutyofcareinthemanagementofwaste;

dutytocontrolpollutingemissionstotheair;

dutytocontroldischargestosewers;

obligationsofwastemanagers;

collectionofdataandobligationstocompleteandretaindocumentationincludingrecordkeeping;and

requirementtoprovidecontingencyplansandhaveemergencyproceduresinplace.



q. Packaging, handling and delivery of laboratory specimens Biologicalsamples,culturesandothermaterialsshouldbetransportedin

amannerthatensuresthattheydonotleakintransitandarecompliant

withcurrentlegislation.Staff whohandlesamplesmustbeawareofthe

needtocorrectlyidentify,labelandstoresamplespriortoforwardingtolaboratories.Inaddition,theymustbeawareoftheproceduresneeded

whenthecontainerorpackagingbecomessoiledwithbodyfluids.

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r. Care of deceased persons Appropriateproceduresshouldinclude:

riskassessmentofpotentialhazards;

theprovisionofappropriatefacilitiesandaccommodation;

safeworkingpractices;

arrangementsforvisitors;

information,instruction,trainingandsupervision;and

healthsurveillanceandimmunisation(whereappropriate).

s. Use and care of invasive devices Policyshouldbebasedonevidence-basedguidelinesandshouldbeeasily

accessiblebyallrelevantcareworkers.Compliancewithpolicyshouldbe

audited.Informationonpolicyshouldbeincludedininfectionprevention

andcontroltrainingprogrammesforallrelevantstaffgroups.



t. Purchase, cleaning, decontamination, maintenance and disposal ofequipment

Policiesforthepurchase,cleaning,decontamination,maintenanceand

disposalofallequipmentshouldtakeintoaccountinfectionprevention

andcontroladvicethatisgivenbyrelevantexpertsoradvisorybodiesor

bytheICT.

u. Surveillance and data collection Forallappropriatehealthcaresettings,thereshouldbeevidenceof

localsurveillanceanduseofcomparativedata,whereavailable,in

ordertomonitorinfectionratesandtoassesstherisksofinfection.Thisevidenceshouldincludedataonalertorganisms,andotherinfections

whereappropriate,alertconditionsandwoundinfectionperclinicalunit

orspecialty.Whenappropriateorwheretheyexist,recogniseddefinitions

shouldbeused.

ElectronicreportingtotheHealthProtectionAgencyofclinicallaboratory

isolatesisrecommendedwheretheappropriateinformationtechnologyis

inplace.

Thereshouldalsobetimelyfeedbacktoclinicalunits,witharecordof

achievementsandactionstakenasaresultofsurveillance.Post-discharge

surveillanceofsurgicalsiteinfectionshouldbeconsideredand,where

practicable,shouldbeimplemented.

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v. Dissemination of information

Thereshouldbealocalprotocolforthedisseminationofinformationabout

infectionsbetweencareorganisationsconcer ninganindividualservice

user.Thisistofacilitatesurveillanceandoptimalmanagementofinfections

inthewidercommunity.Guidanceondataprotectionlegislationalsoneeds

tobeobserved.



w. Isolation facilities Thereshouldbeapolicyconcer ningtheappropriateprovisionofisolation

facilities.Thisshouldaddress:

potentialsourcesofinfection;

theuseofprotectivemeasuresandequipment;and

themanagementofoutbreaks.

x. Uniform and dress code Uniformandworkwearpoliciesensurethatclothingwornbystaff

whencarryingouttheirdutiesiscleanandfitforpurpose.Particular

considerationshouldbegiventoitemsofattirethatmayinadvertentlycomeintocontactwiththepersonbeingcaredfor.Uniformanddresscode

policiesshouldspecificallysuppor tgoodhandhygiene.

y. Immunisation of service users Registeredprovidersshouldensurethatpoliciesandproceduresarein

placewithregardtotheimmunisationstatusofserviceuserssuchthat:

thereisarecordofallimmunisationsgiven;

theimmunisationstatusandeligibilityforimmunisationofserviceusersareregularlyreviewedinlinewith Immunisation against infectious

disease (TheGreenBook)andotherDepartmentofHealthguidance;

and

followingareviewoftherecordofimmunisations,allserviceusersareofferedfurtherimmunisationasneeded,accordingtothenational

schedule.

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Guidance for compliance with criterion 10 Ensure,sofarasisreasonablypracticable,thatcareworkersarefreeofand

areprotectedfromexposuretoinfectionsthatcanbecaughtatworkand

thatallstaff aresuitablyeducatedinthepreventionandcontrolofinfection

associatedwiththeprovisionofhealthandsocialcare.

10.1Registeredprovidersshouldensurethatpoliciesandproceduresarein

placeinrelationtothepreventionandcontrolofinfectionsuchthat:

allstaffcanaccessoccupationalhealthservicesoraccessappropriateoccupationalhealthadvice;

occupationalhealthpoliciesonthepreventionandmanagementofcommunicableinfectionsincareworkersareinplace;

decisionsonofferingimmunisationshouldbemadeonthebasisofalocalriskassessmentasdescribedinImmunisation against infectious

disease(TheGreenBook).Employersshouldmakevaccinesavailable

freeofchargetoemployeesif ariskassessmentindicatesthatitis

needed(COSHHRegulations2002);

thereisarecordofrelevantimmunisations;

theprinciplesandpracticeofpreventionandcontrolofinfectionareincludedininductionandtrainingprogrammesfornewstaff.The

principlesinclude:ensuringthatpoliciesareuptodate;feedbackfrom

auditresults;examplesofgoodpractice;andactionneededtocorrect

poorpractice;

thereisappropriateongoingeducationforexistingstaff(includingsupportstaff,volunteers,agency/locumstaffandstaffemployedby

contractors),whichshouldincorporatetheprinciplesandpracticeof

preventionandcontrolofinfection.

thereisarecordof trainingandupdatesforallstaff;and

theresponsibilitiesofeachmemberofstaff forthepreventionandcontrolofinfectionarereflectedintheirjobdescriptionandinany

personaldevelopmentplanorappraisal.

Occupational health services

10.2 Occupationalhealthservicesforstaffshouldinclude:

risk-basedscreeningforcommunicablediseasesandassessmentofimmunitytoinfectionafteraconditionalofferofemploymentand

ongoinghealthsurveillance;

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offerofrelevantimmunisations;and

havingarrangementsinplaceforregularlyreviewingtheimmunisationstatusof careworkersandprovidingvaccinationstostaffasnecessary

inlinewithImmunisation against infectious disease(TheGreenBook)

andotherDepartmentofHealthguidance.

10.3OccupationalhealthservicesinrespectofBBVsshouldinclude:

havingarrangementsforidentifyingandmanaginghealthcarestaffinfectedwithhepatitisBorCorHIVandadvisingaboutfitnessforwork

andmonitoringasnecessary,inlinewithDepartmentofHealthguidance;

liaisingwiththeUK Advisory Panel for Healthcare Workers Infected withBlood-borne Viruseswhenadviceisneededonproceduresthatmay

becarriedoutbyBBV-infectedcareworkers,orwhenadviceonpatient

tracing,notificationandofferofBBVtestingmaybeneeded;

ariskassessmentandappropriatereferralafteraccidentaloccupationalexposuretobloodandbodyfluids;and

managementofoccupationalexposuretoinfection,whichmayincludeprovisionforemergencyandout-of-hourstreatment,possiblyin

conjunctionwithaccidentandemergencyservicesandon-callinfectionpreventionandcontrolspecialists.Thisshouldincludeaspecificrisk

assessmentfollowinganexposureproneprocedure.

(Refer also to Outcome 12, Regulation 21 Requirements relating to workers


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Part 4: Guidance tables

Thesetablesaredesignedtohelpregisteredproviders,theDIPC(NHSprovider

organisations)andIPCLeads(adultsocialcare,primarydentalcareand

primarymedicalcare,andindependentsectorambulanceproviders)decide

howtheCodeandrelatedguidanceappliestotheregisteredactivitiesandtype

ofservicetheyprovide.Furtherguidanceontheactivitiesthatarecoveredby

registrationareavailableatwww.cqc.org.uk

Becauseofthewiderangeofservicesprovidedinhealthcareandadultsocial

care,registeredprovidersshouldcarryouttheirownriskassessmentstohelp

themdecidetheelementstobeincludedintheirpoliciesorwhetherornota

policyisrequiredatall.Theywillneedtobeabletojustifytheirdecisions.

Table1 TheapplicationoftheCodeofPracticetoregulatedactivities

Table2 Aguidetopotentialsources of professionalinfectionprevention

andcontroladvice

Table3 Policiesappropriatetoregulatedactivities

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http://www.cqc.org.uk/http://www.cqc.org.uk/


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Table 1 The application of the Code of Practice to regulated activities

Thistableprovidesaguideastowhichcriteriamayapplytoeachregulatedactivity.Thisisamatterfo

Regulated activities

Personalcare

Accommodationforpersonswho

requirenursingor

Accommodationforpersonswhorequiretreatment

Accommodationandnursingorpersonalcare

Treatmentof

disease,

Assessmentormedicaltreatment

Surgicalprocedures

Diagnosticand

screening

Managementofsupplyofbloodand

T

tpersonalcare forsubstance

misuseinthefurther

educationsectordisorderor

injuryforpersons

detained

underthe

procedures bloodderivedproductsetc

Mental HealthAct

1983

1 Systemstomanageandmonitorthepreventionandcontrolofinfection.Thesesystemsuseriskassessments andconsiderhowsusceptibleserviceusersareandanyrisksthattheirenvironmentandotherusers

mayposetothem

3 3 3 3 3 3 3 3 3

2 Provideandn maintainaclean

criterio andappropriate

environment

ance

inmanagedpremisesthatfacilitatesthe

3 3 3 3 3 3 3 3

Compli prevention

andcontrolofinfections

3 Providesuitableaccurateinformationoninfectionstoserviceusersandtheirvisitors

3 3 3 3 3 3 3 3 3

4 Providesuitableaccurateinformationoninfectionstoanypersonconcernedwithprovidingfurthersupportornursing/medicalcareinatimelyfashion

3 3 3 3 3 3 3 3 3

SeeTable3Appliestotransportandtriageservicesdeliveredatsite#DoesnotapplytoprimarydentalcareDoesnotapplytoprimarydental/medicalcare


40/109


Table 1 The application of the Code of Practice to regulated activities continued



Personalcare


requirenursingor


Accommodationandnursingorpersonalcare

Treatmentof

disease,


Surgicalprocedures

Diagnosticand

screening


T

tpersonalcare forsubstance

misuseinthefurther

educationsectordisorderor

injuryforpersons

detained

underthe

procedures bloodderivedproductsetc

Mental HealthAct

1983

5 Ensurethatpeoplewhohaveordevelopaninfectionareidentifiedpromptlyandreceivetheappropriatetreatmentand

3 3 3 3 3 3 3 3

caretoreducetheriskofpassingontheinfectiontootherpeople

6 Ensurethatall

staffandthose

Compliancecriterion

employedtoprovidecareinallsettingsarefullyinvolvedintheprocessofpreventingandcontrollinginfection

3 3 3 3 3 3 3 3 3

7 Provideorsecure adequateisolationfacilities

3 3 3 3 3

8 Secureadequateaccess tolaboratorysupportasappropriate#

3 3 3 3 3 3

9 Haveandadheretopolicies,designedfortheindividualscareandproviderorganisations,thatwillhelptopreventandcontrolinfections

3 3 3 3 3 3 3 3


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Table1TheapplicationoftheCodeofPracticetoregulatedactivitiescontinued



Personal Accommodation Accommodation Accommodation Treatment Assessment Surgical Diagnostic Management care forpersonswho forpersonswho andnursingor of ormedical procedures and of supplyof

requirenursingor requiretreatment personalcare disease, treatment screening bloodand tpersonalcare forsubstance inthefurther disorderor forpersons procedures bloodderived

misuse educationsector injury detained productsetc

underthe Mental

HealthAct1983

Compliancecriterion

10 Ensure,sofarasisreasonablypracticable,thatcareworkersarefreeofandareprotectedfromexposuretoinfectionsthatcanbecaughtatworkandthatallstaffaresuitablyeducatedinthepreventionandcontrol

3 3 3 3 3 3 3 3 3

ofinfectionassociatedwiththeprovisionofhealthandsocialcare



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Table2Aguidetopotentialsourcesofprofessionalinfectionpreventionandcontroladvice 10


Personalcare


requirenursingorpersonalcare


forsubstancemisuse

Accommodationandnursingorpersonalcareinthefurther

educationsector

Treatmentof

disease,disorderor

injury


forpersonsdetainedunderthe

MentalHealthAct

Surgicalprocedures

Diagnosticand

screeningprocedures


bloodderivedproductsetc

Transpservictriagemediadvi

providremot

1983

DirectorofInfectionPreventionandControl 3 3 3 3 orInfectionPreventionandControlLead

Infectioncontrolnurse/infectioncontrolpractitioner

3 3 3

Consultantmicrobiologist 3 3 3 3 3

Designatedsiteleadforinfection(maynotalways 3 3 3 3 3 3 3 3beahealthcare

group worker)

Accessto

al consultant in

ssion communicable

diseasecontrol/ 3 3 3 3 3 3 3 3

fe localHealth

Pro ProtectionUnit

Fullyconstitutedinfectioncontrolteamand 3 3 3 infectioncontrolcommittee

Primarycaretrustinfectioncontrolsuppor t

3 3 3

Primaryhealthcare teams 3 3 3 3

Occupationalhealthservices(consultwhenriskoftransmissionfromcareworkerstoserviceuserorviceversa)

3 3 3 3 3 3 3 3 3 3

10Wherenospecialistoccupationalhealthserviceadviceexists, Relevanttoacuteandindependentsectorambulanceproviders

advicemaybesoughtfromserviceusersgeneralpractitioner Appliestoprimarydental/medicalcare Da

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Table3Policiesappropriatetoregulatedactivities

Compliance with criterion 9


Personalcare




forsubstancemisuse


educationsector

Treatmentof

disease,disorderor

injury



MentalHealthAct

Surgicalprocedures

Diagnosticand

screeningprocedures



T

t

1983

Standardinfection

apreventionandcontrol 3 3 3 3 3 3 3 3 3precautions

b Aseptictechnique 3 3 3 3 3 3 3 3

Outbreaks of c communicable 3 3 3 3 3 3

infection#

Isolationofd serviceuserswith 3 3 3 3 3 3 3

Policies

aninfection#

eSafehandlinganddisposalofsharps

3 3 3 3 3 3 3 3 3

f

Preventionofoccupationalexposuretoblood-borneviruses,incpreventionofsharpsinjuries

3 3 3 3 3 3 3 3 3

g

Managementofoccupationalexposuretoblood-bornevirusesandpost-exposureprophylaxis

3 3 3 3 3 3 3 3 3

Closureof

hrooms,wards,departmentsand

premisestonew

3 3 3 3 3 3

admissions

i Disinfection 3 3 3 3 3 3 3 3

Decontamination

jofreusablemedicaldevices 3 3 3 3 3 3

kSingle-usemedicaldevices

3 3 3 3 3 3 3 3 3

Appliestotransportandtriageservicedeliveredatsite AppliestoinvasivediagnosticproceduresDecontaminationleadwillberesponsiblefortheseareas

Unlikelyordoesnotapplytoprimarydental/medicalcare#Doesnotapplytoprimarydentalcare


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Table3Policiesappropriatetoregulatedactivitiescontinued



Personalcare




forsubstancemisuse


educationsector

Treatmentof

disease,disorderor

injury



MentalHealthAct

Surgicalprocedures

Diagnosticand

screeningprocedures



T

t

1983

lAntimicrobialprescribing 3 3 3 3

Reportingofinfectionstothe

m HealthProtectionAgencyorlocal

3 3 3

authority#

Controlofoutbreaks

nandinfectionsassociatedwith 3 3 3 3 3 3specificalertorganisms#

CJD/vCJD

ohandlingofinstrumentsand 3 3 3 3

Policies

devices#

pSafehandlinganddisposalofwaste 3 3 3 3 3 3 3 3 3

q

Packaging,handlinganddeliveryoflaboratoryspecimens#

3 3 3 3 3 3 3 3

rCareofdeceasedpersons 3 3 3 3 3 3 3 3

sUseandcareofinvasivedevices# 3 3 3 3 3 3 3 3 3

Purchase,

t

cleaning,decontamination,

maintenance3 3 3 3 3 3 3 3

anddisposalofequipment

uSurveillanceanddatacollection # 3 3 3



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Table3Policiesappropriatetoregulatedactivitiescontinued



Personalcare




forsubstancemisuse


educationsector

Treatmentof

disease,disorderor

injury



MentalHealthAct

Surgicalprocedures

Diagnosticand

screeningprocedures



T

t

1983

Policies

vDisseminationofinformation 3 3 3 3 3 3

wIsolationfacilities 3 3 3 3 3 3 3 3

xUniformanddresscode 3 3 3 3 3 3 3 3 3

yImmunisationofserviceusers# 3 3 3 3 3 3




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The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections

Appendix A: Examplesof interpretation for adultsocial careIt is essential to read the following examples alongside the guidance under each

criterion in Part 3 and not just selective parts.

The examples demonstrate how a proportionate approach to the guidance could

apply in certain types of adult social care services. They are examples only andregistered providers and IPC Leads should carry out their own risk assessments

to help them decide which parts of the criteria apply to their particular service.

Registered providers and IPC Leads will make sure that they can provide

evidence to support any decision to follow these examples or any other

alternative approaches to the full guidance.


Systems to manage and monitor the prevention and control of infection. Thesesystems use risk assessments and consider how susceptible service users

are and any risks that their environment and other users may pose to them.

In a small service providing personal care or accommodation with personal care:

Someone with appropriate knowledge and skills will become the IPC Leadand take responsibility for infection prevention and control. This could be the

registered provider, registered manager or another member of staff.

Infection prevention and control programmes and infrastructures will not

need to be as complex as in a larger adult social care or health setting. As a

minimum the infection control programme should say what:

infection prevention and control measures are needed in the service;

policies, procedures and guidance are needed, and how they will be kept

up to date and monitored to make sure they are followed; and

initial and ongoing training staff will receive.

The infrastructure should include:

a record of the names and contact details of health practitioners who canprovid

Hygiene Code Revised January 2008

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Transcript of Hygiene Code Revised January 2008