R52 Response Accepted AI-assessed

IPC policy adherence audits

Recommendation

Health Boards should ensure that adherence to infection prevention and control polices, for example C. difficile and Loose Stools Policies, is audited at least annually.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
According to Healthcare Improvement Scotland (2022-05-01), Healthcare Improvement Scotland's (HIS) IPC Standards (2022), Standard 4 (Assurance and Monitoring), requires systematic auditing of infection prevention and control (IPC) policy adherence. According to Healthcare Improvement Scotland (2022-05-01), the National Infection Prevention and Control Manual (NIPCM) provides audit tools for download, and national compliance is monitored through HIS inspections. According to the available evidence, the Scottish Government accepted this recommendation in 2015.
How was this assessed?
Assessed by gemini-2.5-flash on 19 Mar 2026
Checked data held on this site (government responses, progress updates, independent evidence)
External sources searched: www.gov.uk, www.gov.scot, www.legislation.gov.uk, hansard.parliament.uk
This recommendation requires implementation across many organisations. The assessment reflects central policy response, not adoption in individual organisations.
Jurisdiction
Scotland
Response
Accepted
Accepted Scottish Government
18 Jun 2015

Section 3.3 of the Scottish Government's response states that quality improvement uses a range of methods, such as audit, to deliver change and improve outcomes. Section 2.1 details that a robust HAI scrutiny regime is in place, with the Healthcare Environment Inspectorate (HEI) carrying out regular, often unannounced, inspections to check adherence to national standards and guidance. NHS boards are also responsible for monitoring and reporting hand hygiene compliance and ensuring suitable quality assurance processes are in place, with performance against revised HAI standards forming part of HEI inspections from June 2015.

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Published Evidence

Published assessments of implementation progress from inspectorates, select committees, official progress reports, and other sources. Check the source type badge to see whether each assessment is independent or government self-reported.

Confirmed Completed
01 May 2022
Healthcare Improvement Scotland Other

HIS IPC Standards (2022) Standard 4 (Assurance and Monitoring) requires systematic auditing of IPC policy adherence. NIPCM provides audit tools for download. National compliance monitoring through HIS inspections.

View detailed findings

Standard 4 specifically addresses auditing of IPC practices. Audit tools are available through the NIPCM website for use by all health boards.

HIS IPC Standards - Standard 4: Assurance and Mon… View Source
Source
Report The Vale of Leven Hospital Inquiry Report 24 Nov 2014
Responsible Bodies
NHS Health Boards (Scotland) Primary
Recommendation age 11.3 yrs
Last formal update 3932 days ago