Established practice
A weak IPC programme turns a cluster of SSIs into a CQC investigation
For independent hospitals without a dedicated IPC team, surgical site infection rates are both a patient safety failure and a regulatory liability. A cluster of preventable cases can cost tens of thousands in extended treatment alone, before any CQC action begins.
- steps
- 6
- steps
- to start
- 1 to 3 months
- to start
The short answer
Your infection prevention and control (IPC) programme is assessed against the Health and Social Care Act 2008 Code of Practice on infection prevention, NICE guidance such as NG125 on surgical site infection and, where you deliver NHS services, the National Infection Prevention and Control Manual for England (best practice in other settings). The usual gaps are an IPC lead without protected time, surgical site infection surveillance that stops at discharge, and audits that are done but not acted on. Close those three and you meet most of what inspectors and insurers ask.
6 steps
Do it yourself: step by step
0 of 6 done
Name an IPC lead with recognised training and written protected hours, plus access to a consultant microbiologist through a service agreement.
- Time
- 1 to 3 months
- Typical cost
- Lead time plus £5,000 to £15,000 a year for microbiology advice (Solvable estimate)
- Who does it
- Hospital director
Done when: Job plan shows protected hours and the microbiology agreement is signed.
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Annual IPC programme checklist
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Annual IPC programme checklist
[Hospital name] Year: [year] IPC lead: [name] Microbiologist: [name]
Leadership
- Named IPC lead with protected hours: [hours a week]
- Consultant microbiologist advice agreement in place, expires [date]
- Director with board responsibility for IPC: [name]
- IPC committee meets [frequency], terms of reference current
Policies (reviewed in last 2 years)
- Hand hygiene
- Standard and transmission-based precautions
- Surgical site infection prevention (skin preparation, hair removal, normothermia, antibiotic prophylaxis)
- Decontamination of reusable instruments and equipment
- Isolation and outbreak management
- Sharps and inoculation injuries
- Waste management
- Water safety and ventilation (with estates)
- Antimicrobial stewardship
Surveillance
- Surgical site infection surveillance to 30 days, up to one year for prosthetic implants
- Post-discharge follow-up method: [questionnaire, call, clinic review]
- Response rate to post-discharge follow-up: [%]
- Results by procedure reported monthly
- Participation in UKHSA surveillance: [yes or no, which procedures]
Audit programme (monthly)
- Hand hygiene by area
- Environmental cleanliness
- Antibiotic prophylaxis given within the agreed window before incision
- Peripheral and urinary catheter care
- Decontamination and sterile services
Training
- IPC mandatory training compliance: [%]
- Link nurses named for each area
- Consultants included in induction and training
Reporting
- Quarterly IPC report to the board
- Annual IPC statement published
- Notifiable infections reported as required
Gaps: [list] Owner: [name] Due: [date]
Avoid these
Common mistakes
- Surgical site infection surveillance that stops when the patient leaves the hospital.
- An IPC lead who also runs a ward with no protected time.
- Policies copied from a template with no local review or microbiologist sign-off.
- Audits completed but results never shared with the teams audited.
- Antibiotic prophylaxis timing not audited, so late doses go unnoticed.
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What I need from you
- Eight tap answers about your IPC programme
- Your number of beds and theatres
What you get
- How you compare with the Code of Practice and NICE NG125
- The three gaps to close first
- What to report to your board
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Paul Robinson
14 years in UK private healthcare
I solve this one for hospitals
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Questions
Frequently asked questions
Do independent hospitals have to follow NICE guidance?
NICE guidance is not law, but CQC expects you to follow current evidence-based guidance or explain why not.
What is the Code of Practice?
The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections. It sets the criteria CQC uses to judge IPC.
How long should we follow patients up for infection?
Thirty days after surgery, and up to one year where a prosthetic implant is inserted, in line with the UKHSA surgical site infection surveillance protocol.
Do we need our own microbiologist?
You need access to consultant microbiology advice. A service agreement with an NHS trust or private microbiology service is common.
What triggers an outbreak response?
Two or more linked cases of the same infection. Your outbreak policy should define who is told and what happens in the first 24 hours.
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