Infection Prevention Solutions
AUDIT Audit of compliance with key policies and procedures is a requirement of the Code of Practice. An audit plan should be prepared annually by the IPC lead detailing a rolling programme of audit with clear timescales for completion and progress should be monitored through governance frameworks. The audit plan should be detailed in the Annual Programme. A summary of audit results may be included in the Annual Statement. Local commissioners may require audit results as an integral component of quality contracts. REVIEW Policies and procedures should be subject to regular review in compliance with the Code of Practice. All documentation should clearly state the review date. This Manual will be reviewed two yearly. Individual policies and guidelines will be updated as required, in response to new evidence, expert guidance or regulation. UNIFORM AND DRESS CODE The organisation supports the view that staff clothing should be such that it minimises risks of the transmission of infection. It is a requirement of the Code of Practice that all organisations have a written uniform and dress code policy. Compliance with this policy should form part of the annual audit programme. In particular clothing must facilitate good hand hygiene practice. Stoned rings and wrist jewellery should not be worn when washing hands or performing clinical tasks. Long sleeves, if worn, should be rolled to the elbow for hand washing and clinical tasks. SURVEILLANCE, DATA COLLECTION AND MANDATORY REPORTING Surveillance and data collection is a requirement of the Code of Practice and should reflect the environment of care. It is recommended that a local system for recording infections is implemented, including data on alert organisms, other infections where appropriate, alert conditions and outbreaks of infection. Mandatory reporting of infections to Public Health England (previously the Health Protection Agency) has been in place for almost a decade for some infections e.g. MRSA bacteraemia. In recent years, annual trajectories have been set by the Department of Health to reduce the number of cases of MRSA bacteraemia and toxin positive cases of C. difficile diarrhoea and, since 2017 for E. coli bacteraemia. Annual trajectories are set for all acute NHS Trusts and also for all Clinical Commissioning Groups (CCGs). Providers of hospice care may be involved in the post infection review of individual cases of these infections as part of the mandatory
Sample Issue Date: 01/10/2022 Review Date: 30/09/2024
Infection Prevention And Control Management Policy Infection Prevention Solutions ©2017 Page 4 of 9
