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Infection prevention and control inspections in NHS trusts

Categories:
  • Organisations we regulate

Inspection prevention and control (IPC) is an essential part of safety in hospitals. We recognise that it is even more important during the coronavirus (COVID-19) pandemic.

We monitor a range of IPC indicators every week for acute, mental health and community health trusts. We will use national and local intelligence to plan inspections of trusts across England from February 2021 onwards.

In addition to our monitoring, in some trusts we may undertake an IPC focused inspection. These inspections are risk-based. They look at how trust leadership, strategy, culture, governance, risk and performance management, information management, engagement and learning processes translate into robust IPC practice at clinical level and in public areas of the hospital.

This assessment will include an onsite inspection and at least one Microsoft Teams call to the trust. You can open the questions to see the type of detail they will be interested in.

Leadership

W1: Is there the leadership capacity and capability to deliver high quality, sustainable care?

These questions relate to key line of enquiry W1.2.

IPC inspection questions
  • Does the trust have sufficient leadership capacity for IPC? (i.e. management time and competency?) at executive team level and at IPC team level?
  • Are leaders addressing the most significant IPC challenges? Do they have an impact at service level?
  • Have leaders self-assessed the trust’s governance of IPC against the criterion in the IPC code of practice?

Vision and strategy

W2: Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver?

These questions relate to key lines of enquiry W2.1, 2.2, 2.4, 2.5 and 2.6.

IPC inspection questions
  • Does the trust have a clear vision and strategy for continuously improving its IPC practices? Do these take into account future service developments?
  • How has the trust implemented the HSIB report on COVID Transmission in Hospitals recommendations?
  • How does the trust ensure that the IPC priorities are understood by staff and integrated into its wider strategy and service plans?
  • Is there a strategy in place for antimicrobial stewardship within the Trust?
  • Do other trust plans take account of IPC priorities, for example do the trust’s asset and facilities management plans support IPC improvements?
  • How does the IPC strategy/action plan align with joint working with partners in the wider health and social care economy to manage COVID 19 and other risks?
  • Is progress against the IPC action plan monitored and reviewed? Is this reported?

Culture

W3 Is there a culture of high-quality, sustainable care?

These questions relate to key lines of enquiry W3.1, 3.2, 3.5, 3.6, 3.7, 3.8 and 3.9.

IPC inspection questions
  • Are staff supported in raising concerns about IPC?
  • How robust and open is the trust’s safety culture to support good IPC practices?
  • Is the culture centred on the IPC needs of patients and visitors?
  • Are there special arrangements to promote staff physical and mental wellbeing during the pandemic?
  • Has the trust adequately risk assessed and taken measures to protect clinically vulnerable groups of staff and those at higher risk because of their protected characteristics (different ethnic groups, physical and learning disabilities, autism, mental illness)?
  • Do staff work cooperatively and constructive across teams on IPC issues?

Governance

W4: Are there clear responsibilities, roles and systems of accountability to support good governance and management?

These questions relate to key lines of enquiry W4.1, 4.2, and 4.3.

IPC inspection questions
  • Are there effective structures, processes and accountability to support standards of IPC including managing cleanliness and a suitable environment?
  • Do all levels of IPC governance and management interact with each other appropriately and effectively?
  • Do staff understand their roles regarding IPC? Has the organisation developed an effective and inclusive approach to ensuring guidance and policies are up to date, understood and practical for staff?

Management of risks, issues and performance

W5: Are there clear and effective processes for managing risks, issues and performance?

These questions relate to key lines of enquiry W5.1, 5.3, 5.4 and 5.6.

IPC inspection questions
  • Is there a comprehensive and robust assurance system for IPC which enables performance issues and risks to be addressed? How regularly is this reviewed?
  • Does the trust audit IPC processes and ensure that the learning improves IPC quality?
  • What processes does the trust have to identify and treat people who have or are at risk of developing an infection so that they don’t infect other people?
  • Does the trust have an effective system to manage and eliminate nosocomial transmission?
  • Is there oversight of risk in all of the buildings including corporate and public areas? For example, the education centre?
  • How does the trust identify patients at increased risk of COVID (for example communities of different ethnic groups, people who might need reasonable adjustments and people with pre-existing conditions) and mitigate risk, tailoring treatment to the individual? (this is a legal requirement)
  • How does the trust use equipment to control the risk of nosocomial infection? For example, ventilation, technology, PPE, uniforms.
  • Has finance ever been a constraint when planning effective IPC or obtaining IPC consumables? What happened?

Information management

W6: Is appropriate and accurate information being effectively processed, challenged and acted on?

These questions relate to key lines of enquiry W6.4, 6.5 and 6.6.

IPC inspection questions
  • Does the trust use valid, timely, reliable and relevant measures for IPC? Does it take timely action on nosocomial and other infections? Are there clear and robust IPC measures?
  • How does the trust ensure that IPC data quality is reliable?
  • How are information technology systems used to share, monitor and report on IPC information to improve the quality of care?
  • How is information shared about IPC history when referring, admitting, transferring, discharging and moving service users within and between health and adult social care facilities?
  • Are IPC Plans in place for patients who need them? Are records clear, accurate and up to date?

Engagement

W7: Are the people who use services, the public, staff and external partners engaged and involved to support high-quality sustainable services?

These questions relate to key lines of enquiry W7.2, 7.3 and 7.5.

IPC inspection questions
  • Does the trust use staff and public views to improve IPC practices?
  • What does it do to encourage feedback from underrepresented communities or groups, for example for example different ethnic groups?
  • Does the trust communicate it’s IPC performance, for example information about outbreaks, to staff and the public? How?
  • How does the trust communicate IPC changes to staff and the public? Does it do this in a variety of formats?

Learning, continuous improvement and innovation

W8: Are there robust systems and processes for learning, continuous improvement and innovation?

These questions relate to key lines of enquiry W8.1 and 8.3.

IPC inspection questions
  • How does the trust promote a continuous improvement culture around IPC?
  • Does the trust innovate regarding IPC practices?
  • Is there an active search for best practice on IPC? What has the trust learnt from top performing trusts?
  • How does the trust learn from internal/external review to improve IPC?
Last updated:
24 February 2021