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Supporting Guidance Standard 2.4

Health and Care Standards

Supporting Guidance
Standard 2.4:  Infection Prevention and Control (IPC) and Decontamination


What is the Standard about?

Services should be designed, developed and adapted to ensure all aspects of Infection Prevention and Control (IPC) can be effectively and efficiently managed.

Different healthcare environments will need to comply with guidelines and memoranda specific to their own areas and needs.  The health, safety and wellbeing of people who use the services must not be adversely affected by inadequate IPC facilities and arrangements.  Where care is provided in service users own homes, the principles of IPC will apply.


Who is it for?

All individuals and health services in all settings

In relation to the standard criteria (in bold) the following key questions need to be considered

There are appropriate organisational structures and management systems for infection prevention, control and decontamination in place.

  • Is there a Board level statement outlining its collective responsibility for minimising the risks of infection and the general means by which it prevents and controls such risks?
  • Have you implemented an appropriate assurance framework, IPC programme, antimicrobial stewardship programme and IPC infrastructure? (refer to the code of practice for the prevention of and control of Healthcare Associated Infections for further information)


Physical environments are maintained and cleaned to a standard that facilitates infection prevention and control and minimises the risk of infection.

  • Do you have policies for the environment? (see Code of practice)
  • Do you have designated lead managers for environmental cleaning and decontamination of equipment used for treatment?
  • Do your cleaning arrangements detail the standards of cleanliness required in each part of its premises? (see Code of Practice)
  • Is a schedule of cleaning frequencies readily available?
  • Are there effective arrangements for the appropriate decontamination of instruments and other equipment? ( See Code of Practice)
  • Is there adequate provision of suitable hand hygiene facilities?
  • Does the supply and provision of linen and laundry reflect Health Service Guidance (HSG) (95)18 Hospital Laundry Arrangements for Used and Infected Linen?


Suitable and accurate information on infections is available.

  • Is all data relating to HCAIs published accurately in an open and transparent manner? (see Code of Practice)
  • Do the general policies on IPC take into account the communicating to the needs of the service user? (see Code of Practice)
  • Do the roles and responsibilities of IPC staff include support for visiting service users?


Suitable, timely and accurate information on infections is provided to any person concerned with providing further support or nursing/medical care when a person is moved from one organisation to another or within the same organisation.

  • Is there provision of suitable and sufficient information on a service user’s infection status whenever it arranges for the service user to be moved from the care of one organisation to another? (see Code of Practice)
  • Is information communicated accurately in an appropriate and confidential manner?
  • Does the information facilitate the provision of optimum care, minimising the risk of inappropriate management and the transmission of infection?


Staff employed to provide care in all settings are fully engaged in the process of infection prevention and control.

  • Is IPC sufficiently covered in staff job descriptions? (see Code of Practice)
  • Are contractors working in service areas aware of all issues relevant to their role and have they obtained permission to work?
  • Are staff who undertake procedures sufficiently trained and able to demonstrate competency?
  • Are staff aware of their responsibilities with regards to vaccine preventable diseases and how they can protect themselves and service users?


Adequate isolation facilities are provided to support effective infection prevention and control.

  • Are isolation precautions and facilities sufficient to prevent or minimise the spread of infection?  (see Code of Practice)
  • Are policies in place for the allocation of service users to isolation facilities, based on a local risk assessment and with escalation process described clearly? Does the assessment include consideration of the need for special ventilated isolation facilities?
  • Are isolation facilities with special ventilation functioning in compliance with extant national guidelines and are staff suitably trained to be available to care for the service users safely whilst in isolation?


Policies on infection prevention and control are in place and made readily accessible to all staff.

  • In relation to preventing and controlling the risks of HCAIs do you have in place the appropriate core policies as outlined by the code of practice?
  • How do you ensure that policies are kept up to date?
  • Do you have an ongoing audit programme that audits adherence to the policies?
  • What arrangements are in place for feeding back the results of audits?


So far as is reasonably practicable staff are free of and are protected from exposure to infections that can be acquired or transmitted at work.

  • Do all staff can access occupational health services and/ or access appropriate occupational health advice as outlined by the code of practice?
  • Do you have occupational health policies on the prevention and management of communicable infections in staff in place
  • Do you have a record of relevant immunisations


Staff are suitably trained and educated in infection prevention and control associated with the provision of healthcare.

  • Are the principles and practice of IPC are included in induction and training programmes for all new staff?
  • Is there appropriate ongoing education for existing staff (including support staff, volunteers, agency/locum staff and staff employed by contractors), which incorporates the principles and practice of IPC?
  • Do you have a documented training and education delivery plan?
  • Is there a record of training and updates for all staff?
  • Are the responsibilities of each member of staff for IPC are reflected in their job description and in any personal development plan or appraisal?


Suitable and sustainable systems, policies and procedures are in place for medical device decontamination by competent staff in an appropriate environment.

  • How do you know that your decontamination and sterilisation procedures are effective?
  • How do you know that your sterilisation facilities and decontamination equipment are fit for purpose? 
  • What arrangements exist for ensuring that purchases of equipment or loans of equipment are undertaken in liaison with decontamination leads?
  • What systems are in place to ensure that automated equipment is used, maintained, tested and validated according to manufacturer instructions, regulatory requirements (e.g. European standards, requirements or guidance)?
  • What arrangements are in place to provide appropriate training including refresher requirements for those involved in using or reprocessing medical devices?


Patients and visitors are supported to achieve and maintain high standards of hygiene.

  • How do you provide patients, service users and carers with information and facilities to maintain high standards of hygiene in health service premises?


Proper arrangements exist for the segregation, handling, transporting and disposal of waste including human tissue and subsequent disposal appropriately and sensitively.

  • What arrangements are in place to support the safe handling, segregation, transport and disposal of waste?
  • What changes have been made as a result of monitoring the handling, segregation and disposal of waste in all healthcare settings?
  • What arrangements are in place to support the safe segregation, handling, transport and decontamination of laundry?
  • What arrangements are in place to monitor the quality and safety of linen and laundry services?
  • What arrangements are in place for the safe disposal of tissue and samples?
  • What arrangements are in place for the safe, sensitive handling and disposal of human and foetal tissue?
  • How do you provide for cultural requirements when handling human tissue and its subsequent disposal?


Legislation and Guidance


Health & Safety at Work Act

Health and Safety (Sharps Instruments in Healthcare Regulations) 2013

NICE Quality Standard – Infection Prevention and Control (QS61)

Health Protection – Infectious Diseases

Safe Management of Healthcare Waste (HTM 07 01)

Minimise transmission risk of CJD and vCJD in healthcare settings


For Dental Teams

Health Service Guidance (HSG) (95)18 Hospital Laundry Arrangements for Used and Infected Linen


Good Practice

National E learning Resource for Healthcare Associated Infections

Learning at Wales

1000 Lives Plus - How to Guide 2 - Reducing Healthcare Associated Infections: Appropriate and Timely Use of Invasive Devices (includes insertion and maintenance bundles)



1000 Lives Plus Programme

One of the aims of the programme is to reduce HCAIs.  The key outcome measure in the programme is the overall HCAI rate.  The interventions have 3 main approaches:

  • Preventing transmission through standard hygiene precautions, decontamination and isolation
  • Preventing infection through better stewardship of antimicrobials and rigorously applying effective techniques to prevent surgical site infection, ventilator associated pneumonia, central line infections and urinary catheter infection
  • Responding rapidly to early signs of infection.


Health & Safety Executive: PPE Brief Guide

Welsh Health Technical Memoranda (WHTMs) & Health Technical Memoranda (HTMs)

Public Health England

National Occupational Standards – Skills for Health – Infection Control

Outcome Competences for Practitioners in IPC