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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Infection Prevention and Control (IPC) and Cleanliness Policy

1. Purpose and Scope

This policy outlines the infection prevention and control measures at {{org_field_name}} to ensure the safety of service users, staff, and visitors. It aligns with the Code of Practice on the prevention and control of infections under the Health and Social Care Act 2008 and follows guidance from the UK Health Security Agency (UKHSA). In addition, the policy is designed to meet the requirements of Regulation 12: Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, ensuring that effective infection prevention and control measures are in place in line with CQC Fundamental Standards.

This policy applies to:

• All staff members, including care workers, managers, and administrative staff.
• Service users and their families, to promote safe care practices in the home environment.
• Visitors and external professionals involved in Supported Living services.

2. Infection Control Management and Monitoring Systems

To ensure effective infection prevention and control (IPC), {{org_field_name}} has established a structured governance framework that includes leadership responsibilities, infection prevention systems, and monitoring mechanisms.

2.1 Governance and Leadership

Governance and leadership in infection control are essential to maintaining a safe and hygienic care environment for service users, staff, and visitors. Key roles and responsibilities include:

Registered Manager ({{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}) Responsibilities:

• Ensuring compliance with the Health and Social Care Act 2008 and CQC infection control regulations (including Regulation 12 on safe care and treatment).
• Leading the development and implementation of infection prevention measures and related policies.
• Ensuring staff receive regular infection control training and updates.
• Overseeing incident reporting, investigations, and corrective actions in the event of infection outbreaks.
• Ensuring adequate PPE stock levels and proper PPE use across all care operations.
• Coordinating with UKHSA (local Health Protection Teams), NHS infection control teams, and local authorities when required.

Designated Infection Control Lead (ICL) – {{org_field_infection_control_lead_name}} ({{org_field_infection_control_lead_role}}) – Responsibilities:

• Conducting regular inspections to ensure infection control protocols are followed by staff.
• Providing ongoing training and competency checks for staff on IPC practices.
• Monitoring and reporting infection trends, outbreaks, and the findings of risk assessments.
• Advising on infection risk mitigation strategies for individual service users.
• Working with healthcare professionals to ensure infection control best practices are maintained.

The Registered Manager and the ICL will collaborate to ensure continuous improvement in infection prevention and control measures.

2.2 Infection Prevention Systems

A comprehensive infection prevention system is in place to minimize the risk of infection transmission in Supported Living settings. This includes upfront risk assessments, daily hygiene practices, and an incident reporting system.

Risk Assessment Process

Before delivering care, we conduct infection control risk assessments for each service user and environment. This process includes assessing:

1. Underlying Health Conditions: Certain health conditions increase the likelihood of infections. We consider:
   • Weakened immune systems (e.g. individuals on chemotherapy or immunosuppressive drugs, or those with HIV/AIDS).
   • Chronic illnesses such as diabetes, respiratory conditions (e.g. COPD, asthma), and heart disease.
   • Post-surgical recovery status or the presence of open wounds, pressure sores, or intravenous lines.
   • Conditions requiring frequent medical interventions (such as dialysis or catheterisation).
2. Environmental Risks: The service user’s living environment can pose infection risks. We consider:
   • Shared living spaces (e.g. supported living accommodations where multiple individuals reside).
   • Poor ventilation in the home, which could increase airborne infection risks.
   • Hygiene or sanitation concerns (lack of handwashing facilities, poor waste disposal).
   • The presence of pets that may carry bacteria or parasites.
   • Household cleanliness and maintenance issues (e.g. unsafe food handling practices or infestations like rodents or mould).
3. Contact Risks: The service user’s interactions with others can introduce infection risks. We consider:
   • Frequent visitors to the home (family, friends, caregivers, external professionals).
   • Regular exposure to healthcare settings (such as hospital visits, outpatient treatments, clinics).
   • Close contact with individuals who may have contagious illnesses.
   • Household members who work in high-risk environments (e.g. hospitals, care homes, schools).
4. Risk Level Classification: Each service user is categorized by infection risk level:
   • Low Risk: Minimal exposure to infection risks, with good personal hygiene and no significant underlying conditions.
   • Moderate Risk: Some risk factors present (e.g. mild chronic conditions or regular external visits).
   • High Risk: Significant vulnerability (e.g. compromised immune system, frequent healthcare exposure, or poor living conditions).
5. Documentation and Review: Infection risk assessments are documented in the service user’s care plan and kept up to date.
   • Risk levels are reviewed at least quarterly, or whenever a service user’s health status or environment changes significantly.
   • If an infection or outbreak is identified, an immediate reassessment of the service user’s risk and environment will take place.

Daily Infection Prevention Practices

All staff must adhere to Standard Infection Control Precautions (SICPs) at all times, including the following practices:

• Hand Hygiene: Staff must wash their hands with soap and water for at least 20 seconds before and after any care activity. Use of alcohol-based hand sanitiser is required when soap and water are not available (noting that hand sanitiser may be ineffective against some organisms such as norovirus).
• Personal Protective Equipment (PPE): Care workers must wear appropriate PPE (gloves, aprons, masks, etc.) as needed for the task. PPE should be disposed of safely in line with waste management policies to prevent cross-contamination.
• Environmental Cleanliness: High-contact surfaces (door handles, equipment, mobility aids, etc.) should be disinfected regularly. Care equipment must be cleaned after each use, and laundry should be handled and washed in a manner that prevents cross-contamination.

Infection Reporting and Outbreak Management

A robust reporting system is in place to track infections, suspected outbreaks, and incidents:

• Care workers must report any symptoms of infection observed in service users (e.g. fever, respiratory issues, gastrointestinal symptoms, or wounds with signs of infection) to the Registered Manager or Care Coordinator. Reports can be made via the care software system, by phone at {{org_field_phone_no}}, or by email at {{org_field_registered_manager_email}}.
• A central infection control log is maintained to record all reported infections and monitor trends.

If an outbreak occurs (for example, multiple cases of influenza, norovirus, COVID-19, or similar within a short period), emergency protocols will be activated, including:

• Immediate risk assessment and implementation of containment measures to limit spread.
• Notification to the local UKHSA Health Protection Team
• Implementation of isolation procedures for affected service users, if required (e.g. advising them to stay in their rooms or separate from others).
• Enhanced cleaning and disinfection of the environment and equipment.
• Communication with all staff, service users, and their families about the outbreak and measures taken (maintaining confidentiality as appropriate).

2.3 Monitoring and Audits

To maintain high infection control standards, we implement regular monitoring and auditing processes:

Monthly Infection Control Audits

• The Infection Control Lead conducts monthly audits to assess compliance with IPC protocols.
• Audits include spot-checks on hand hygiene practices, correct use of PPE, and environmental cleanliness in service user homes.
• Audit findings are documented, and any gaps identified result in action plans (with defined responsibilities and timelines for improvement).

Staff Compliance Checks

• Random competency assessments are performed to ensure staff are following infection prevention guidelines (for example, unannounced observations of handwashing technique or PPE usage).
• Observation audits are used to verify proper hand hygiene and PPE donning/doffing during care activities.
• Staff are encouraged to provide feedback or raise any infection control concerns. Regular briefings address any knowledge gaps or issues identified.

Annual Infection Control Training

• All staff receive mandatory infection prevention and control training during their induction and annual refresher training thereafter.
• Training includes handling of infectious diseases, outbreak management procedures, and updates on emerging infections.
• Scenario-based training is used to reinforce correct PPE usage, safe waste disposal, and decontamination procedures.
• Staff are kept updated on new infection control guidance or best practices issued by UKHSA or the NHS, ensuring our practices remain current.

3. Infection Risk Assessment and Management

Infection risk assessment and management are critical components of our infection control strategy at {{org_field_name}}. By identifying potential infection risks and implementing effective mitigation strategies, we ensure the safety of our service users and staff in supported living environments.

3.1 Identifying and Assessing Infection Risks

Each service user undergoes an individualised infection risk assessment as part of their initial care planning and ongoing reviews (see Risk Assessment Process in section 2.2). The assessment identifies the service user’s risk factors (health conditions, environmental and contact risks) and classifies their overall risk level (Low, Moderate, or High). This process allows staff to understand who may be more susceptible to infections or more likely to transmit infections, so that appropriate precautions can be taken.

(Refer to section 2.2 for detailed factors considered during infection risk assessments and risk level classifications.) All risk assessments are documented and kept up to date, with regular reviews and immediate updates if a service user’s situation changes or an infection incident occurs.

3.2 Mitigation Strategies

Once risks are identified, we implement tailored infection control measures to reduce the risk of infection transmission. This includes both standard precautions for all service users and enhanced precautions for those at higher risk:

Standard Infection Control Precautions (SICPs) for All Service Users

Standard precautions are the minimum infection prevention practices that all staff must follow for every service user, regardless of known infection status. These include:

• Hand hygiene: Thorough hand washing or sanitising before and after all care tasks (as detailed in section 2.2).
• Use of PPE: Wearing disposable gloves, aprons, masks, and other PPE as needed for personal care or cleaning tasks, and changing PPE between different tasks or service users.
• Safe waste disposal: Proper disposal of waste including used PPE, dressings, and sanitary products in designated clinical waste containers.
• Environmental cleaning: Regularly cleaning and disinfecting frequently-touched surfaces and ensuring good ventilation in the service user’s home.

Enhanced Precautions for High-Risk Service Users

For service users classified as High Risk (see risk assessment criteria), additional measures are taken to further protect them and others:

• Barrier nursing techniques: Care workers may be required to wear full PPE (e.g. gowns, masks, gloves, eye protection) for certain high-risk procedures or when caring for service users with highly infectious conditions.
• Dedicated care equipment: Wherever possible, items like thermometers, blood pressure cuffs, and other care devices are not shared between high-risk service users. If equipment must be shared, it is thoroughly disinfected before each use.
• Strict wound care protocols: Aseptic techniques are used for any dressing changes or wound care to prevent introducing infections. Sterile supplies are used and disposed of appropriately.
• Catheter and stoma care monitoring: Extra attention is given to hygiene during catheter, stoma, or other invasive device care, with early detection and reporting of any signs of infection.
• Promoting vaccinations: High-risk service users (and the staff caring for them) are encouraged to receive appropriate vaccinations (e.g. seasonal flu, pneumonia, COVID-19) to reduce preventable disease exposure.

Hand Hygiene Protocols for Care Workers

Proper hand hygiene is one of the most effective ways to prevent infections. All staff must:

• Wash their hands with soap and water for at least 20 seconds before and after any direct contact with a service user or their immediate environment.
• Use alcohol-based hand sanitiser when handwashing facilities are not readily available or in between tasks, provided hands are not visibly soiled.

Staff should also follow the World Health Organization’s “Five Moments for Hand Hygiene”, which are critical points during care when hand hygiene should be performed:

1. Before touching a service user.
2. Before a clean/aseptic procedure.
3. After exposure to body fluids or blood.
4. After touching a service user.
5. After touching surfaces or objects in the service user’s surroundings.

By adhering to these five moments, staff significantly reduce the risk of transmitting infections between themselves, service users, and the environment.

Environmental Cleaning and Disinfection

Regular cleaning and disinfection of the service user’s environment are a priority to prevent the spread of infections:

• Daily cleaning: High-touch surfaces such as doorknobs, handrails, light switches, mobile devices, and bathroom fixtures are cleaned and disinfected daily.
• Medical equipment: Any shared equipment (e.g. hoists, blood pressure monitors, thermometers) is disinfected after each use and between different service users.
• Laundry: Bedding, towels, and clothing are laundered regularly at appropriate temperatures. Soiled linens are handled with gloves and kept separate to prevent bacterial growth and cross-contamination.

Additional Measures During Outbreaks

If an infection outbreak occurs within our service (e.g. several service users or staff become ill with the same infectious disease in a short period), additional containment strategies will be implemented:

• Isolation: Affected service users may be asked to self-isolate in their rooms or homes if safe to do so, to reduce contact with others.
• Enhanced PPE for staff: Staff caring for infected individuals will use a higher level of PPE (for example, using FFP3 masks for respiratory outbreaks) and will ideally not care for non-affected service users during the outbreak period.
• Symptom monitoring: All staff and service users will be monitored daily for symptoms during an outbreak. Temperature checks or symptom questionnaires may be used to quickly identify new cases.
• Immediate reporting to authorities: The Registered Manager (or ICL) will promptly notify the relevant health authorities – specifically the local UKHSA Health Protection Team – in line with legal reporting obligations and guidance. We will follow any additional instructions or guidance provided by these authorities to manage the outbreak.

(See also section 7.2 on Outbreak Notification)

4. Compliance with the Health and Social Care Act 2008 Code of Practice

The Code of Practice on the Prevention and Control of Infections under the Health and Social Care Act 2008 sets out the legal framework and standards for infection control in health and social care settings. {{org_field_name}} is committed to full compliance with this Code to ensure the safety of service users, staff, and visitors. Compliance with this policy also demonstrates adherence to CQC’s Fundamental Standards, particularly Regulation 12: Safe care and treatment, which includes requirements to assess risks and prevent and control the spread of infections in care settings.

Compliance is achieved through clear governance, thorough risk assessment, staff training, and infection control protocols that align with CQC standards and current UKHSA guidance. The following measures are in place to meet these standards:

Maintaining a robust infection prevention and control governance framework

• A structured infection control governance system is in place to ensure effective leadership and accountability for IPC.
• The Registered Manager has overall responsibility for ensuring that infection prevention and control policies meet CQC requirements and the Code of Practice standards.
• A Designated Infection Control Lead (ICL) oversees day-to-day infection control activities, monitors compliance, and supports staff in best practices (see section 2.1 for roles).
• Policies and procedures are regularly reviewed and updated based on the latest guidance from UKHSA, the Department of Health and Social Care, and NHS infection control teams.
• An infection control committee or working group may be convened (as needed) to evaluate risks, review incidents, and recommend improvements in infection prevention practices.
• Infection control performance (audit results, incident reports, etc.) is reported to senior management and, if applicable, to board-level governance to ensure accountability and drive continuous improvement.

Ensuring effective risk assessments and monitoring systems are in place

• Risk assessments are conducted for each service user (and their environment) to identify infection risks, as described in sections 2 and 3. These assessments guide the precautions and care plans for each individual.
• Environmental risk assessments are also carried out in service users’ homes to identify potential infection hazards (cleanliness, ventilation, etc.).
• Staff and management regularly monitor infection control practices during service delivery, ensuring that hygiene protocols and safety measures are being followed.
• A systematic infection reporting and tracking system is in place. All infection incidents are logged, and trends are monitored so we can respond swiftly to any increase or outbreak.
• Performance monitoring tools, such as infection control audit checklists, staff competency reviews, and quality improvement plans, are used to evaluate the effectiveness of our infection prevention measures on an ongoing basis.

Providing ongoing infection control training for all staff

• A well-trained workforce is essential for maintaining high IPC standards. All new employees receive mandatory infection control training during their induction.
• Annual refresher training is provided to ensure all staff stay up to date with the latest infection control best practices, guidance, and any changes in legislation.
• Additional specialized training is offered for managing high-risk scenarios (for example, handling outbreaks, managing respiratory infections like COVID-19 or tuberculosis, and preventing bloodstream infections).
• Practical, hands-on training is included, covering topics such as correct PPE donning and doffing techniques, proper hand hygiene methods, cleaning and decontamination procedures, and safe waste disposal.
• Staff receive regular updates (via emails, newsletters, or e-learning modules) whenever new IPC guidance is released or if improvements are identified through audits and incident reviews.

Implementing evidence-based protocols for managing infections and outbreaks

• All infection control procedures and protocols at {{org_field_name}} follow national guidelines and evidence-based best practices (e.g. NHS England’s IPC manual, UKHSA guidance for adult social care). This ensures our practices are consistent with those expected in healthcare and community care settings.
• Standard Infection Control Precautions (SICPs) are in place at all times (see section 3.2), and Transmission-Based Precautions (TBPs) are implemented for service users with known or suspected infectious diseases to provide additional protection (e.g. using isolation, dedicated equipment, and enhanced PPE).
• We have a robust Outbreak Management Plan that details how the organisation will respond to an infection outbreak. This plan includes steps for immediate isolation or cohorting, enhanced cleaning schedules, notifying authorities promptly, and activating emergency staffing or resource provisions if needed.
• Clear protocols for the use of Personal Protective Equipment (PPE) ensure staff have access to, and correctly use, appropriate protective gear. This includes gloves, surgical masks or respirators, disposable aprons or gowns, and eye protection as required by the situation (see section 6 for PPE details).
• We follow principles of antimicrobial stewardship in partnership with healthcare professionals. This means antibiotics and other antimicrobial medicines are used appropriately and only when necessary, to help prevent the development of antimicrobial resistance (AMR).
• Regular evaluation and audit of our infection control measures (through the audits and checks described in section 2.3) help us assess the effectiveness of protocols and make improvements where necessary. Lessons learned from any incidents or audits are used to update policies and train staff, ensuring continuous improvement in our IPC practices.

5. Staff Vaccination Protocols

Vaccinations play a crucial role in infection prevention and control within Supported Living settings. {{org_field_name}} is committed to ensuring that all staff have access to recommended vaccinations to protect themselves, service users, and the wider community. By maintaining up-to-date immunisations among staff, we reduce the risk of outbreaks and ensure the safe delivery of care services.

Importance of Vaccinations in Infection Control

• Protects vulnerable service users from preventable infectious diseases that could cause serious illness.
• Reduces staff absenteeism due to illness, thereby ensuring continuity of care for service users.
• Helps prevent the spread of infectious diseases within the service, particularly seasonal illnesses like flu and emerging illnesses like COVID-19, as well as bloodborne infections.
• Aligns with UKHSA and NHS infection control guidelines, which encourage vaccination of health and social care staff as an important preventive measure.

Vaccination Requirements for Staff

All care staff are strongly encouraged to be vaccinated against high-risk infections in line with national guidance and best practice. The following staff vaccinations are recommended:

• Annual Influenza (Flu) Vaccination: Staff should receive the seasonal flu vaccine each year to reduce the risk of influenza outbreaks among service users. This is especially important for those working with older or immunocompromised individuals. We actively promote annual flu vaccination campaigns to ensure high uptake.
• COVID-19 Vaccinations and Boosters: Staff are encouraged to complete the full course of COVID-19 vaccinations and stay up to date with any recommended booster doses. Keeping staff vaccinated against COVID-19 helps prevent the virus from spreading within our care settings and protects high-risk service users. We monitor UKHSA guidance for new variants or booster recommendations and will update staff accordingly.
• Hepatitis B Vaccination: Staff who perform tasks with potential exposure to blood or bodily fluids (e.g. wound care, catheter care, handling needles or sharps) should receive the Hepatitis B vaccine. This vaccine protects staff from hepatitis B infection (a serious bloodborne virus) and, in turn, protects service users. Staff members who decline the Hep B vaccine will be advised on alternative safety measures, such as increased use of PPE and additional training on managing exposure risks.
• MMR (Measles, Mumps, Rubella): It is recommended that staff have received the MMR vaccine (usually given in childhood). Staff who have not been vaccinated or are unsure of their immunity should consider getting the MMR vaccine to prevent these highly infectious diseases.
• Tdap (Tetanus, Diphtheria, Pertussis): Staff are encouraged to stay current with their tetanus, diphtheria, and pertussis immunisations (often given as a combined booster). This ensures protection against these bacterial infections, particularly important for staff who may care for service users with open wounds or who are around infants (pertussis/whooping cough).
• Shingles Vaccine: The shingles (varicella-zoster) vaccine may be advised for staff, especially those over a certain age or working with older adults. Shingles can be contagious (causing chickenpox in those who haven’t had it) and can lead to complications in vulnerable individuals, so vaccinating staff can help protect the people we support.

(If staff are unsure about their vaccination status or eligibility, they are encouraged to consult with their GP or occupational health provider. {{org_field_name}} will facilitate access to these vaccinations through NHS services or local programs whenever possible.)

Maintaining Staff Vaccination Records

• A secure staff vaccination record system is maintained to monitor each staff member’s vaccination status and ensure records are kept up to date.
• Staff are asked to provide proof of relevant vaccinations as part of their pre-employment health check and ongoing occupational health reviews.
• Vaccination records are kept confidential and stored in compliance with GDPR and data protection regulations.
• The management team reviews staff vaccination records at least annually. Reminders are issued to staff ahead of each flu season or when booster shots (e.g. COVID-19 boosters) are due, to encourage timely vaccination.

Alternative Infection Control Measures for Non-Vaccinated Staff

If a staff member is not vaccinated or is unable to receive certain vaccines (due to medical contraindications or personal choice), we implement alternative precautions to mitigate infection risks:

• Increased use of PPE when appropriate – for example, unvaccinated staff may be required to wear face masks in high-risk situations or during outbreaks of vaccine-preventable diseases.
• More frequent hand hygiene and use of sanitiser, above and beyond standard protocols, especially after contact with vulnerable service users.
• Avoiding, where possible, close contact with highly vulnerable service users during outbreaks (for instance, reassigning duties so that vaccinated staff care for certain service users when there is an active flu outbreak).
• Undergoing additional infection control training and supervision to ensure strict adherence to all other IPC measures, thereby compensating for the lack of vaccination.

These measures help protect both the unvaccinated staff member and the people they support. Management will work with any staff who are not immunised to ensure safety is not compromised.

Staff Awareness and Support

We foster a workplace culture that values vaccinations and informed choice by:

• Organising annual vaccination awareness campaigns to educate staff on the benefits of immunisation and address any misconceptions. These may include informational sessions, posters, and sharing up-to-date guidance from NHS and UKHSA.
• Providing information on where and how to get vaccinated, including access to free NHS vaccination programs for health and social care workers (for example, free flu jabs offered each winter). Logistics and time will be arranged to help staff attend vaccination appointments as needed.
• Offering confidential support and guidance for staff who have concerns or questions about vaccines. Staff with medical contraindications or anxiety about vaccinations will receive tailored advice, and reasonable accommodations will be made to ensure they can continue to work safely (such as the alternative measures noted above).

6. Provision and Use of Personal Protective Equipment (PPE)

Personal Protective Equipment (PPE) is an essential component of infection prevention and control in Supported Living. Proper access to PPE, correct usage, and safe disposal help protect both care staff and service users from the transmission of infections. {{org_field_name}} ensures that all staff have continuous access to required PPE and are trained in its correct use, in line with UKHSA guidelines and CQC requirements.

PPE Provided for Care Staff

All care staff are supplied with appropriate PPE based on the level of risk and type of care they provide. The following PPE items are made available and must be used as indicated:

• Disposable gloves: Worn for all personal care tasks, during any contact with bodily fluids (e.g. bathing, wound care, toilet assistance), and when cleaning or disinfecting surfaces. Gloves are single-use and must be changed between tasks and between different service users.
• Face masks: Two main types of masks are provided:
  • Type IIR surgical masks for general care duties and routine IPC measures (e.g. when providing personal care if there is a risk of droplets, or when a service user has a cough).
  • FFP2/FFP3 respirator masks (only in exceptional situations, unlikely) for aerosol-generating procedures (AGPs) or when caring for service users with known or suspected airborne infections such as COVID-19 or tuberculosis. Fit testing is done for staff who may need to use FFP3 masks to ensure an adequate seal.
• Protective aprons/gowns:
  • Single-use plastic aprons are worn for tasks that involve direct contact with a service user or their immediate environment (for example, helping with personal hygiene or meal preparation) and for any cleaning tasks where splashes are possible.
  • Fluid-resistant long-sleeved gowns (unlikely to be used) are available for high-risk procedures or during outbreaks of infectious diseases, especially if there is a risk of extensive spraying of fluids or contact with highly infectious agents.
• Eye protection (goggles or face shields): Worn for any aerosol-generating procedures or situations where there is a risk of splashes or droplets to the face (for example, when suctioning, or if a service user is coughing heavily, or during wound irrigation). Eye protection may be single-use or reusable; reusable goggles/face shields are disinfected after each use.

All PPE provided meets the relevant safety standards and sizing is available to ensure proper fit for all staff.

PPE Distribution and Storage

We have established procedures to ensure continuous access to PPE for all staff:

• Central PPE storage and distribution points are set up (e.g. at the office or care hub) where staff can collect PPE supplies as needed.
• In service users’ homes where regular care is provided, PPE supplies (such as gloves, aprons, and masks) are stored in easily accessible locations. This ensures that staff can quickly don PPE when required during visits.
• Care Coordinators or designated staff monitor PPE stock levels frequently and replenish supplies proactively. We aim to prevent shortages by re-stocking before supplies run low.
• In the event of national PPE shortages or sudden increased demand (such as during a pandemic or local outbreak), we will identify alternative suppliers and implement PPE conservation strategies in line with guidance. During such times, PPE usage will be prioritised based on risk assessments (ensuring that those caring for the most vulnerable or at highest risk tasks have priority access).

PPE Usage Protocols

Strict protocols are in place for how staff should use PPE to maximize its effectiveness:

• Donning and doffing: Staff must perform hand hygiene before putting on PPE and immediately after removing PPE. We train staff in the correct sequence of donning (putting on) PPE and doffing (removing) PPE to avoid self-contamination (for example, gloves and apron removed first, then eye protection, then mask, with hand hygiene at each step as needed).
• Task-appropriate use: The correct PPE must be worn for each care task according to our guidelines. (For instance, gloves and apron for personal care, adding a mask if the service user has a respiratory infection, and eye protection if splashing is likely.) Staff are instructed never to substitute one type of PPE for another and never to perform a high-risk task without the recommended protective equipment.
• Changing PPE: Disposable gloves and aprons are single-task use – they must be changed between different care activities and between attending to different service users to prevent cross-contamination. Similarly, masks should be changed if they become damp, soiled, or after caring for a service user in isolation before moving to others.
• Face masks: When wearing a face mask, staff should avoid touching the mask itself while it is being worn. Masks should cover the nose and mouth completely and fit snugly. They are not to be pulled down or worn under the chin at any time. Surgical masks are single-session items (or sooner if contaminated) and must be disposed of after use; respirator masks (FFP3) are also generally single-use unless specific reuse protocols are in place (per national guidance).
• Reusable items: If any PPE item is designated reusable (for example, some eye protection or washable gowns), staff must clean and disinfect it according to the manufacturer’s instructions or our policy before the next use. Typically, eye goggles are disinfected or autoclaved if reusable; however, most of our eye protection is single-use to simplify compliance.
• Avoiding PPE misuse: Staff should not reuse disposable PPE items. Also, PPE should not be worn outside of care contexts (e.g., wearing gloves when not needed can spread germs, so we emphasize appropriate use only).

PPE Disposal Procedures

Proper disposal of used PPE is critical to preventing the spread of infection and environmental contamination:

• All used PPE (gloves, masks, aprons, etc.) that is contaminated with body fluids or has been used in the care of a possibly infectious service user is disposed of as clinical waste. Staff are trained to use designated clinical waste bags (usually yellow or orange bags) for used PPE.
• Bins for clinical waste are available in the service user’s home (we provide foot-operated lidded bins or bags). Staff tie off and secure waste bags after each visit or care session and dispose of them according to local protocols (either via the service user’s clinical waste collection service or by bringing back to our site for proper disposal).
• No reuse of disposable PPE: Single-use PPE is never reused. Even in situations of shortage, we follow national guidance on any extended use carefully, and only if explicitly allowed (for example, extended use of masks in a pandemic context, but never without proper risk assessment).
• Used PPE should be removed carefully and immediately placed in a waste bag upon removal. The waste bag is then sealed and disposed of in the designated clinical waste container. Staff then perform hand hygiene as the final step after disposing of all PPE.

PPE Monitoring and Compliance

To ensure PPE is used effectively and consistently, {{org_field_name}} will:

• Conduct regular spot checks and audits of PPE use during care visits. Supervisors or the Infection Control Lead may observe staff (with consent) to ensure PPE is being worn and changed correctly.
• Provide ongoing refresher training on PPE, including correct donning and doffing techniques. This may involve periodic hands-on sessions or instructional videos, especially if new types of PPE are introduced or if audit results show any issues.
• Encourage staff to give feedback on PPE availability or any challenges they encounter (for example, difficulties with fit, skin irritation from masks, etc.). This feedback helps us address problems quickly, such as supplying different sizes or types of PPE if needed.
• Monitor and document PPE stock levels and usage rates to ensure we always have sufficient supply and to help predict future needs. We aim to reduce wastage by educating staff on not opening new PPE items until needed and storing them correctly (dry, intact packaging, etc.).

7. Reporting and Incident Management

A robust reporting and incident management system is essential for ensuring that infection control measures are effective and that any infection-related incidents are promptly addressed. {{org_field_name}} has established a structured approach to reporting, investigating, and managing infection-related events, in order to prevent further spread and improve our overall infection prevention practices.

Reporting Infection-Related Incidents

All staff members are required to report any suspected or confirmed infection-related incidents or concerns. This includes:

• Service users exhibiting signs of infection: e.g. fever, coughing, vomiting, diarrhoea, unexplained rashes, or any wound with redness, swelling or discharge suggesting infection.
• Staff members experiencing infectious illness symptoms: If a staff member has symptoms such as fever, new cough, gastrointestinal illness, or a rash that could be contagious, they must inform management, as this could pose a risk to service users.
• PPE or protocol failures: Any situation where recommended PPE was not available or not used properly and a potential exposure occurred (for example, a glove tearing during wound care, or a missed hand hygiene opportunity after an incident).
• Environmental hazards: Discovery of environmental issues that might contribute to infection spread in a service user’s home, such as significant mould growth, pest infestations (e.g. rodents or insects), or sewage/drainage problems.

Staff should report these issues as soon as possible through the designated incident reporting system (e.g. an electronic incident report or paper form). Reports can be made verbally in urgent situations, but must be followed up in writing. Specifically, staff can report via:

• Email: Send details to the Registered Manager at {{org_field_registered_manager_email}}.
• Phone: Call {{org_field_registered_manager_phone}} to report immediately by telephone (especially for urgent matters or out-of-hours incidents).

All staff are trained on how to recognize potential infection risks and the importance of timely reporting. We foster an open culture where staff can report incidents or near-misses without blame, focusing on learning and improvement.

(Staff will receive training on recognizing, documenting, and escalating infection risks appropriately as part of their induction and ongoing education.)

Outbreak Notification to UKHSA

If multiple infection cases occur among service users or staff within a short timeframe, it may indicate an outbreak (for example, two or more people linked to our service with the same illness, such as COVID-19 or norovirus). In such cases:

• The Infection Control Lead will assess the situation to determine if it meets the criteria for an outbreak as defined by UKHSA guidance (UKHSA’s definitions for outbreaks in community settings).
• If an outbreak is suspected or confirmed, the Registered Manager is responsible for notifying the local UKHSA Health Protection Team (HPT) immediately. This notification is done via the designated reporting route: {{org_field_outbreaks_support_local_health_protection_team_website}} (the online reporting link for our local health protection team), or by telephone if instructed. We will also inform any other relevant health authorities as required.
• We will cooperate fully with UKHSA/HPT guidance. This may include providing case information, following specific infection control instructions (like testing of staff or service users, quarantine measures), and updating them on the outbreak’s status.
• Outbreak status updates will be communicated to all staff, and where appropriate to service users and their families/representatives, to keep them informed of the situation and measures being taken. We will maintain confidentiality and data protection – individuals will not be named publicly – but those who need to know for safety will be informed (for example, informing a service user’s family if that user must isolate due to an outbreak).

Investigation and Follow-Up Measures

After an infection incident or outbreak, we conduct an internal investigation to understand the cause and whether any improvements in practice are needed:

• Incident review: The Infection Control Lead, together with the Registered Manager, will review the circumstances of the incident or outbreak. This includes checking if staff followed all infection prevention protocols (hand hygiene, PPE use, cleaning, etc.) and if risk assessments were adequate.
• Identify lapses: We document any failures or lapses in infection control that may have contributed. For example, was there a delay in recognizing symptoms? Were there any communication breakdowns or reporting delays? Did all equipment function properly?
• Root Cause Analysis (RCA): If the incident is serious or part of a pattern, a formal RCA may be conducted to dig deeper into underlying causes (e.g. systemic issues like staffing levels, training gaps, or policy gaps that could have played a role).
• Implement corrective actions: Based on findings, we promptly take corrective actions. These can include providing additional staff training or refresher sessions, updating or clarifying policies and procedures, improving communication channels, or enhancing cleaning regimens. For instance, if an outbreak spread because staff weren’t fully adhering to mask protocols, we would re-train and possibly increase supervision around mask use. If an equipment failure was a factor, we would service or replace the equipment and review maintenance schedules.

Service users and staff who were directly affected by an infection incident will be offered appropriate support. This may involve arranging medical evaluations or treatment (through their GP or emergency care as needed), providing counseling or information, and ensuring they feel safe and cared for in the aftermath. If necessary, we assist with referrals to healthcare professionals (for example, if a service user needs follow-up wound care due to an infection, or if a staff member needs occupational health advice before returning to work).

Documentation and Learning from Incidents

All infection-related incidents and outbreak management activities are thoroughly documented and reviewed so that our organisation can learn and improve:

• A central Incident Log is maintained to track the frequency, types, and outcomes of infections and incidents. This log helps identify trends (for example, recurring UTIs in a particular setting or frequent flu cases in a season) which can prompt preventive actions.
• We conduct regular (e.g. monthly) infection control meetings or reviews to evaluate the effectiveness of our responses to incidents. Part of this includes reviewing audit results and any incidents from the past period to see if further action is required.
• Lessons learned from any incident or outbreak are shared with the staff team. For example, if an investigation finds that a particular practice could be improved, we will discuss this in team meetings or send out a learning briefing. We also incorporate these lessons into training sessions and updates to prevent repeat occurrences.
• Positive outcomes and successful management strategies are also noted (for instance, if swift isolation prevented an outbreak from spreading, this is reinforced as a best practice for future scenarios).

By maintaining a cycle of reporting, responding, investigating, and learning, {{org_field_name}} continually improves its infection prevention and control efforts, which in turn ensures high-quality, safe care for our service users.

8. Policy Review and Updates

This policy will be reviewed annually, or sooner if national guidelines, regulatory requirements, or best practices change. Updates will be made to ensure ongoing compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations, including any new guidance related to infection prevention (for example, any new CQC guidance, UKHSA updates, or changes in law). All staff will be informed of and trained on any significant changes to the policy.

Sources

Care Quality Commission – Regulation 12: Safe care and treatment (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014) – https://www.cqc.org.uk/guidance-regulation/providers/regulations-service-providers-and-managers/health-social-care-act/regulation-12

UK Health Security Agency (UKHSA) – https://www.gov.uk/government/organisations/uk-health-security-agency

UKHSA  – https://www.gov.uk/government/organisations/public-health-england

NHS England – National Infection Prevention and Control Manual (NIPCM) – https://www.england.nhs.uk/national-infection-prevention-and-control-manual-nipcm-for-england/

Health and Social Care Act 2008: Code of Practice on the prevention and control of infections (Department of Health & Social Care, updated 2022) – https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance

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