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Registration Number: {{org_field_registration_no}}

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Clostridioides difficile (C. diff) Infection Prevention and Control Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} has a safe, effective and evidence-based approach to the prevention, identification, management and control of Clostridioides difficile (C. diff) infection within the care home.

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and the Welsh Government Statutory Guidance for service providers and responsible individuals on meeting service standard regulations, updated March 2024. It also takes account of Care Inspectorate Wales (CIW) requirements, Public Health Wales (PHW) infection prevention and control information, local Health Protection Team advice, and current good practice on antimicrobial stewardship and infection prevention.

{{org_field_name}} will ensure that infection prevention and control procedures are followed consistently, that staff understand their responsibilities, and that individuals, staff, visitors and others are protected from avoidable risk of infection.

2. Scope

This policy applies to all employees, agency staff, volunteers, visiting professionals, contractors and any other persons who may be involved in care delivery, cleaning, laundry, catering, maintenance or waste handling within {{org_field_name}}.

It covers:

• Prevention strategies to minimise the risk of C. diff transmission.
• Recognition of symptoms and risk factors.
• Prompt reporting and escalation of suspected or confirmed cases.
• Safe isolation and management of symptomatic individuals.
• Collection of stool samples where clinically indicated and requested by the GP or relevant healthcare professional.
• Hand hygiene, use of PPE, environmental cleaning, laundry and waste management.
• Antimicrobial stewardship and liaison with the GP, pharmacist, community nursing team, Health Board infection prevention team and Health Protection Team where required.
• Outbreak recognition, reporting and management.
• CIW notification requirements where an outbreak of infectious disease occurs.
• Record keeping, audit, staff training, duty of candour and continuous improvement.

3. Understanding Clostridioides difficile (C. diff)

Clostridioides difficile, commonly known as C. diff, is a bacterium that can live in the bowel. In some people it causes no symptoms, but it can cause illness when normal gut bacteria are disrupted, most commonly following antibiotic treatment. C. diff infection can cause diarrhoea, abdominal pain, loss of appetite, nausea, fever, dehydration and, in severe cases, colitis or other serious complications.

C. diff spores can survive for long periods on hands, fabrics, toilets, commodes, bed frames, equipment and other environmental surfaces. Transmission occurs mainly by the faecal-oral route, usually through contaminated hands, equipment or surfaces.

People at increased risk include individuals who:

• are aged 65 or over;
• live in, or have recently been admitted from, a hospital or care home setting;
• are taking, or have recently taken, antibiotics;
• are receiving chemotherapy or treatment that affects normal gut bacteria;
• are taking medicines that reduce stomach acid, such as proton pump inhibitors;
• have inflammatory bowel disease or have had bowel or stomach surgery;
• have a weakened immune system;
• have had a previous C. diff infection.

A person may carry C. diff without symptoms. Infection prevention precautions are particularly important where an individual has diarrhoea or suspected infectious diarrhoea.

4. Prevention Strategies

To minimise the risk of C. diff transmission, {{org_field_name}} will maintain safe systems for hygiene, infection prevention and control, cleaning, laundry, waste management and antimicrobial stewardship.

4.1 Hand hygiene

Staff must wash hands thoroughly with liquid soap and warm running water and dry them thoroughly:

• before and after providing care;
• after using the toilet or assisting an individual with toileting;
• after contact with faeces, body fluids, contaminated linen, waste, commodes or toilet areas;
• after removing gloves and aprons;
• before preparing, serving or assisting with food or drinks;
• when entering and leaving the room of an individual with suspected or confirmed C. diff.

Alcohol-based hand rub must not be relied upon for C. diff because it is not effective against C. diff spores. Alcohol hand rub may be used only where otherwise appropriate after hand washing, but it is not a substitute for soap and water when C. diff is suspected or confirmed.

4.2 Personal protective equipment

Staff must wear disposable gloves and disposable aprons when providing direct care to an individual with suspected or confirmed C. diff, when handling contaminated linen or waste, and when cleaning contaminated areas. PPE must be removed and disposed of safely before leaving the room or care area, followed immediately by hand washing with soap and water.

4.3 Antimicrobial stewardship

The Registered Manager, nursing staff where applicable, and senior care staff will liaise with the GP, pharmacist and relevant healthcare professionals to support safe antibiotic use. Antibiotics must only be used when clinically indicated and prescribed by an authorised prescriber. Where C. diff is suspected or confirmed, the GP or prescriber must be asked to review current antibiotics, laxatives, anti-diarrhoeal medicines and medicines that may increase risk, such as proton pump inhibitors, where clinically appropriate.

Staff must not give anti-diarrhoeal medication unless this has been specifically prescribed or approved by a qualified healthcare professional.

4.4 Environmental hygiene

Enhanced cleaning must be implemented when C. diff is suspected or confirmed. High-touch surfaces, toilets, commodes, bed rails, call bells, door handles, taps, mobility aids and shared equipment must be cleaned frequently using a chlorine-releasing or other approved sporicidal product suitable for C. diff, in accordance with manufacturer’s instructions, COSHH requirements and local IPC advice.

4.5 Equipment

Where possible, care equipment must be dedicated to the individual until symptoms have resolved and terminal cleaning has been completed. Where equipment must be shared, it must be cleaned and decontaminated after each use using an approved product effective against C. diff spores.

4.6 Continence and toileting

Individuals with suspected or confirmed C. diff must have prompt access to toilet facilities, continence care and hygiene support. A dedicated toilet or commode must be used wherever possible. Commodes must be cleaned and disinfected after each use.

4.7 Supplies

{{org_field_name}} will maintain adequate supplies of liquid soap, disposable paper towels, gloves, aprons, clinical waste bags, laundry bags, cleaning equipment and approved disinfectant products to support effective infection prevention and control.

5. Early Identification, Immediate Action and Reporting

Prompt identification of suspected C. diff is essential to reduce the risk of transmission.

Staff must report immediately to the nurse in charge, senior carer, Infection Prevention and Control Lead or Registered Manager if an individual has:

• three or more episodes of unexplained loose or watery stool within 24 hours;
• diarrhoea that is unusual for the individual;
• diarrhoea with abdominal pain, fever, nausea, loss of appetite, dehydration or signs of deterioration;
• diarrhoea following current or recent antibiotic treatment;
• diarrhoea following recent hospital admission or healthcare contact;
• a previous history of C. diff infection.

Where C. diff is suspected, staff must take the following immediate action:

1. Inform the senior person on duty, Infection Prevention and Control Lead and Registered Manager.
2. Support the individual to remain in their own room wherever possible and provide dedicated toilet facilities or a dedicated commode.
3. Implement contact precautions immediately, including gloves, aprons and hand washing with soap and water.
4. Contact the GP, community nurse, NHS 111 Wales where clinically appropriate, or other relevant healthcare professional for clinical assessment and advice.
5. Seek advice about obtaining a stool sample. Stool samples must only be collected where clinically indicated and must be labelled, stored and transported in line with local laboratory and Health Board procedures.
6. Record symptoms, stool frequency, hydration, temperature, abdominal pain, food and fluid intake, actions taken and professional advice received.
7. Inform the local Health Protection Team or Health Board Infection Prevention and Control Team where advised, where there are multiple cases, or where an outbreak is suspected.
8. Review the individual’s personal plan and risk assessment to reflect infection control precautions and care needs.
9. Inform the individual and, where appropriate and with due regard to consent and confidentiality, their representative or family about the precautions being taken.

C. diff must be considered in any unexplained diarrhoea, but staff must also consider other causes of diarrhoea, including laxatives, diet, norovirus, other infections, medicines and underlying health conditions. Clinical advice must be sought before assuming the cause.

6. Stool Samples and Testing

Where C. diff is suspected, the GP, nurse or relevant healthcare professional will advise whether a stool sample is required. Staff must follow local Health Board and laboratory instructions for collection, labelling, storage and transport of stool specimens.

Only staff who are competent and authorised to do so may collect stool samples. PPE must be worn when collecting or handling specimens. Hands must be washed with soap and water after removing PPE.

A stool sample must be accompanied by accurate information, including the individual’s symptoms, date and time of onset, antibiotic history, relevant medication history, recent hospital admission or healthcare contact, and any previous C. diff history.

A formed stool must not normally be sent for C. diff testing unless specifically requested by a healthcare professional or laboratory. Repeat testing must only be undertaken on the advice of a healthcare professional, laboratory, Health Board IPC team or Health Protection Team.

All stool sample requests, results and actions taken must be recorded in the individual’s care records and infection control log.

7. Managing Suspected or Confirmed C. diff Cases

The same infection prevention precautions must be applied to suspected and confirmed cases until C. diff is excluded or until clinical advice confirms that precautions can be stepped down.

7.1 Isolation and room-based care

The individual must be supported to remain in a single room with the door closed where safe and appropriate. The individual must have dedicated toilet facilities or a dedicated commode wherever possible. The individual must be treated with dignity and compassion, and isolation must not result in neglect, reduced care, loss of meaningful contact or failure to meet emotional, nutritional, hydration or personal care needs.

Isolation precautions should continue until the individual has been free from diarrhoea for at least 48 hours and has returned to their normal bowel pattern, unless the GP, Health Board IPC team or Health Protection Team advises otherwise.

7.2 Clinical monitoring

Staff must monitor and record:

• stool frequency and consistency;
• temperature;
• abdominal pain or distension;
• signs of dehydration;
• food and fluid intake;
• urine output where relevant;
• skin integrity and continence needs;
• signs of deterioration, confusion or sepsis.

Urgent medical advice must be sought if the individual becomes acutely unwell, develops signs of dehydration, severe abdominal pain, blood in stool, fever, reduced consciousness, sepsis indicators or any other significant deterioration.

7.3 Treatment

Treatment must be directed by the GP, prescriber or relevant healthcare professional. Staff must administer prescribed treatment in line with the Medication Policy and must ensure the individual is encouraged and supported to complete the prescribed course unless the prescriber advises otherwise.

7.4 Care planning

The individual’s personal plan, continence plan, nutrition and hydration plan, moving and handling plan, skin integrity plan and infection control risk assessment must be reviewed and updated as needed.

7.5 Dignity, rights and well-being

The individual must be supported to understand, as far as possible, the reason for precautions. Information must be provided in a way the individual can understand. Restrictions must be proportionate, regularly reviewed and must not be used as a substitute for safe staffing, cleaning or care planning.

8. Enhanced Cleaning and Terminal Cleaning

When C. diff is suspected or confirmed, enhanced cleaning must begin immediately.

The following areas must be cleaned at least daily and more often where visibly contaminated or advised by IPC professionals:

• toilet areas, commodes, flush handles, taps and sinks;
• bed rails, bed frames, pressure-relieving equipment and mattresses;
• call bells, light switches, door handles and handrails;
• chairs, tables and bedside furniture;
• mobility aids and care equipment;
• shared bathroom or shower areas after use.

Cleaning must be carried out using products effective against C. diff spores, such as chlorine-releasing or other approved sporicidal products, in line with manufacturer’s instructions and COSHH requirements.

Cleaning equipment used for the affected room or area must be disposable or dedicated to that area and cleaned or disposed of safely after use.

When the individual has been symptom-free for at least 48 hours, or when isolation ends following professional advice, terminal cleaning must be completed. Terminal cleaning must include the room, toilet or commode, frequently touched surfaces, reusable equipment, mattress, bed frame, furniture and any other potentially contaminated items. Curtains must be changed or cleaned in line with local procedures if contaminated or as part of terminal cleaning arrangements.

A record must be kept of enhanced cleaning and terminal cleaning, including date, time, areas cleaned, product used and staff member completing the task.

9. Laundry, Waste and Spillages

9.1 Laundry

Linen, towels and clothing from an individual with suspected or confirmed C. diff must be handled as potentially infected laundry. Staff must wear gloves and aprons when handling contaminated laundry. Items must not be shaken. Laundry must be placed directly into the appropriate laundry bag in the individual’s room or care area and processed in line with the home’s laundry procedure, local IPC guidance and washing instructions.

Where items are heavily soiled, soluble or alginate bags must be used where available and appropriate. Laundry must be washed at the highest temperature suitable for the fabric and in line with local infection control guidance.

9.2 Waste

Used PPE, continence products, wipes and other contaminated disposable items must be disposed of as clinical or infectious waste in line with the home’s waste management procedure and local waste contractor requirements. Waste bags must not be overfilled and must be sealed and stored safely.

9.3 Spillages

Faecal spillages must be dealt with immediately by trained staff wearing appropriate PPE. The area must be cleaned and disinfected using an approved product effective against C. diff spores. The area must be made safe before being used again. Spillages and actions taken must be recorded where they present an infection risk or require enhanced cleaning.

10. Visitors and Visiting Professionals

Visitors should not be unnecessarily restricted, but visiting arrangements may be reviewed during suspected or confirmed C. diff infection to protect individuals, visitors and staff. Decisions must be proportionate and based on risk assessment, the individual’s well-being, professional advice and any outbreak control measures in place.

Visitors must be advised to:

• wash their hands with soap and water when entering and leaving the room;
• avoid using alcohol hand gel as a substitute for hand washing when C. diff is suspected or confirmed;
• wear PPE if advised by staff;
• avoid visiting if they have diarrhoea, vomiting or symptoms of infection;
• avoid using the individual’s toilet or commode;
• speak to staff before visiting other individuals in the home.

Visiting healthcare professionals, contractors and other professionals must follow the home’s infection control procedures and any additional precautions in place.

The individual and their representative must be kept informed about any visiting precautions, unless doing so would be inappropriate or inconsistent with the individual’s well-being.

11. Staff Training and Competency

All staff must receive infection prevention and control training appropriate to their role. Training must be completed during induction and refreshed at least annually, or sooner where required due to changes in guidance, outbreaks, audit findings, poor practice, incidents or competency concerns.

Training must include:

• what C. diff is and how it spreads;
• risk factors, symptoms and early recognition;
• hand hygiene, including the requirement to use soap and water;
• correct use and disposal of PPE;
• isolation and contact precautions;
• safe handling of continence products, waste, laundry and spillages;
• enhanced cleaning and terminal cleaning;
• safe use of chlorine-releasing or sporicidal cleaning products, including COSHH requirements;
• stool sample procedures where relevant to the staff member’s role;
• escalation to the GP, Registered Manager, Infection Prevention and Control Lead, Health Board IPC team or Health Protection Team;
• outbreak recognition and reporting;
• record keeping, confidentiality and duty of candour.

Staff who carry out cleaning, laundry, waste handling or direct personal care must have competency checks appropriate to their duties. Competency concerns must be addressed through supervision, retraining and, where necessary, performance management.

Agency staff, volunteers and visiting workers must receive enough information before starting duties to ensure they follow the home’s infection control procedures.

12. Outbreak Management and Reporting

An outbreak must be suspected where there are two or more linked cases of diarrhoea, suspected C. diff or confirmed C. diff among individuals, staff or others connected with the care home, or where the Health Protection Team, Health Board IPC team or GP advises that an outbreak should be declared.

Where an outbreak is suspected or confirmed, {{org_field_name}} will:

1. Inform the Registered Manager, Responsible Individual and Infection Prevention and Control Lead immediately.
2. Seek advice from the local Health Protection Team and/or Health Board Infection Prevention and Control Team.
3. Notify CIW through CIW Online where there is an outbreak of infectious disease.
4. Inform the GP and relevant healthcare professionals involved in the individual’s care.
5. Inform commissioners, placing authorities or representatives where required and appropriate.
6. Implement enhanced infection prevention precautions, including isolation, cohorting where advised, enhanced cleaning and dedicated equipment.
7. Review staffing arrangements to reduce staff movement between affected and unaffected areas where practicable.
8. Consider temporary changes to communal activities, admissions, transfers or visiting only where proportionate and advised by the Health Protection Team, Health Board IPC team or Registered Manager following risk assessment.
9. Maintain an outbreak log, including affected individuals, symptoms, onset dates, test results, rooms affected, actions taken and professional advice received.
10. Communicate clearly with individuals, staff, visitors and representatives while maintaining confidentiality.
11. Complete a post-outbreak review to identify lessons learned and update risk assessments, training, cleaning schedules and policies where required.

The Responsible Individual must ensure significant outbreaks of infection are included in governance reporting and quality monitoring arrangements.

13. Compliance, Records and Monitoring

The Registered Manager, Responsible Individual and Infection Prevention and Control Lead are responsible for ensuring that this policy is implemented and monitored.

The following records must be maintained where relevant:

• individual care notes and personal plan updates;
• infection control risk assessments;
• stool charts and symptom monitoring records;
• hydration, nutrition and clinical observation records where needed;
• stool sample request, result and action records;
• professional advice and escalation records;
• cleaning schedules and terminal cleaning records;
• PPE, waste and laundry actions where relevant;
• outbreak logs;
• CIW notifications;
• Health Protection Team or Health Board IPC communications;
• staff training and competency records;
• infection control audit reports and action plans.

Audits must include hand hygiene practice, PPE use, cleaning standards, laundry arrangements, waste disposal, availability of supplies, staff knowledge and quality of records.

Findings from audits, incidents, outbreaks, complaints, safeguarding concerns or professional advice must be reviewed and used to improve practice. Actions must be recorded, allocated to a responsible person and followed up to completion.

Records must be accurate, up to date, securely stored and available for inspection by CIW or other authorised bodies where required.

14. Duty of Candour, Safeguarding and Escalation

{{org_field_name}} will act in an open, honest and transparent way when infection prevention and control concerns arise. Where something has gone wrong, or may have caused harm or avoidable risk, the individual and/or their representative will be informed in line with confidentiality, consent, mental capacity, safeguarding and duty of candour requirements.

A safeguarding referral must be considered where poor infection prevention practice, neglect, failure to provide care, failure to escalate symptoms, unsafe staffing, inadequate cleaning or other acts or omissions place an individual at risk of abuse, neglect or improper treatment.

Staff must raise concerns immediately if they believe infection prevention and control procedures are not being followed or individuals are being placed at risk. Staff may use the Whistleblowing Policy where required.

15. Related Policies

This policy should be read alongside:

• CHW11 – Safe Care and Treatment Policy
• CHW16 – Health and Safety at Work Policy
• CHW17 – Infection Prevention and Control Policy
• CHW22 – Handling and Disposal of Hazardous Substances Policy
• CHW36 – Initial Assessment and Care Planning Policy

16. Policy Review

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

• Welsh legislation, CIW requirements, Public Health Wales guidance, Health Board IPC guidance or local Health Protection Team advice changes;
• an outbreak, incident, complaint, safeguarding concern or audit identifies the need for improvement;
• there are changes to the care home’s statement of purpose, resident group, staffing arrangements, premises, cleaning systems or waste/laundry arrangements;
• CIW, commissioners, the Health Board IPC team or Health Protection Team recommend changes.

The Registered Manager is responsible for ensuring that staff are informed of any changes and that updated procedures are implemented in practice.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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