Care home infection control
45 items
2 sources
Failure to safely follow infection prevention and control (IPC) practices in care homes, risking outbreaks and resident health.
Cross-Source Insight
Care home infection control has been flagged across 2 independent accountability sources:
24 inquiry recs
21 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (24)
F240 — Hygiene
Recommendation: All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
SHI-11 — Training for IPC professionals engineers and clinicians
Recommendation: I would recommend that IPC professionals should receive some basic training on the recommendations made by the NHS's own guidance for engineering systems, insofar as they are made in the interests of patient safety and care, before they are recruited …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: NHS Scotland Assure is developing a framework of training and lessons learned that will be accessible …
Accepted
In progress
R12 — CDI infection control advice
Recommendation: Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary infection control precautions.
Gov response: Section 4.2 of the Scottish Government's response highlights initiatives to improve patient and family communication. The Person-centred Health and Care Collaborative's "Must Do with Me" elements include ensuring patients receive the information they need, which …
Accepted
R16 — CDI outbreak reporting
Recommendation: Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) to the Infection Control Team.
Gov response: Section 2.1 of the Scottish Government's response highlights a robust HAI scrutiny regime across NHS Scotland, which drives improvements in infection control and prevention practices. The National Infection Prevention and Control Manual, introduced in January …
Accepted
R17 — Ward admission responsibility
Recommendation: Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility for admission of patients to the ward or bay.
Gov response: Section 2.1 of the Scottish Government's response details the Standard Infection Control Precautions (SICP) which are basic infection prevention and control measures. One of the ten SICPs is "Patient placement in wards and bays," directly …
Accepted
R2 — HAI implementation strategy
Recommendation: Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is monitored.
Gov response: Section 2.1 of the Scottish Government's response highlights that Revised Healthcare Associated Infection (HAI) Standards were published in February 2015, which NHS boards will adopt from May 2015, with performance against them forming part of …
Accepted
R20 — Stool records for CDI patients
Recommendation: Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's stools is kept.
Gov response: Section 4.2 of the Scottish Government's response outlines the professional standards for record-keeping for nurses. The revised NMC code requires nurses and midwives to complete all records accurately and without any falsification, and to identify …
Accepted
R3 — IPC policy review
Recommendation: Health Boards should ensure that infection prevention and control policies are reviewed promptly in response to any new policies or guidance issued by or on behalf of the Scottish Government.
Gov response: Section 2.1 and 3.2 of the Scottish Government's response indicate that NHS boards are required to adhere to revised Healthcare Associated Infection (HAI) Standards and the National Infection Prevention and Control Manual, with performance against …
Accepted
R42 — Mandatory IPC training
Recommendation: Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention control training that includes CDI on appointment.
Gov response: Section 4.3 of the Scottish Government's response states that the HAI Taskforce delivery plan promoted a strategy to ensure all healthcare workers receive appropriate education and training related to HAI. The Cleanliness Champions Programme, which …
Accepted
R43 — IPC staff regular training
Recommendation: Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control of which a record should be kept.
Gov response: Section 4.3 of the Scottish Government's response notes that the HAI Taskforce delivery plan included an education framework for specialists working in infection prevention and control. For nurses, accredited education programmes for specialist and advanced …
Accepted
R50 — 24/7 IPC cover
Recommendation: Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.
Gov response: Section 4.1 of the Scottish Government's response discusses general workforce planning, including the use of nursing and midwifery workload and workforce planning tools to determine the number of nurses or midwives needed. However, the provided …
Accepted
R52 — 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.
Gov response: 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 …
Accepted
R53 — Surveillance systems fit for purpose
Recommendation: Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time.
Gov response: Section 2.1 of the Scottish Government's response details that national and local surveillance data are collected across a range of areas to support and monitor HAI policy, including data for HAI outbreaks. Section 4.2 further …
Accepted
R59 — Priority attendance at IPC meetings
Recommendation: Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority.
Gov response: Section 2.1 of the Scottish Government's response states that reducing HAI is a priority, leading to a wide range of measures driven by the national HAI Taskforce. This Taskforce has been restructured to provide efficient, …
Accepted
R60 — Cleanliness Champions implementation
Recommendation: Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as Cleanliness Champions Programme, are implemented without undue delay.
Gov response: Section 4.3 of the Scottish Government's response confirms that the Cleanliness Champions Programme was introduced in September 2003, with over 18,000 NHS Scotland staff having completed it. The program aims to prepare staff to promote …
Accepted
R61 — Unannounced inspections with lay representation
Recommendation: Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay representation.
Gov response: Section 2.1 of the Scottish Government's response highlights the role of the Healthcare Environment Inspectorate (HEI), established in April 2009, which conducts at least 30 unannounced inspections annually in acute and other healthcare settings. To …
Accepted
R62 — Senior manager clinical visits
Recommendation: Health Boards should ensure that senior managers accompanied by IPC staff visit clinical areas at least weekly to verify that proper attention is being paid to IPC.
Gov response: Section 3.1 of the Scottish Government's response details the 10 Patient Safety Essentials, which include leadership walk-rounds. These walk-rounds involve leaders, including executive and non-executive directors, and frontline staff discussing and reducing barriers to reliably …
Accepted
R63 — Effective CDI patient isolation
Recommendation: Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior management.
Gov response: Section 3.1 of the Scottish Government's response addresses patient isolation through the requirement for all planned new-build hospitals to provide 100% single-room accommodation, and refurbished builds at least 50%. This measure significantly reduces the risk …
Accepted
R64 — Cohorting only exceptional
Recommendation: Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in exceptional circumstances.
Gov response: Section 3.1 of the Scottish Government's response outlines a policy to increase single-room accommodation in hospitals. All planned new-build hospitals are now required to provide 100% single-room accommodation, and refurbished hospital builds must ensure at …
Accepted
R65 — Isolation for infectious diarrhoea
Recommendation: Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.
Gov response: Section 2.1 of the Scottish Government's response details the Standard Infection Control Precautions (SICPs), which are basic measures to reduce the risk of germ transmission. Among the 10 SICPs is "Patient placement in wards and …
Accepted
R66 — Healthcare environment maintenance
Recommendation: Health Boards should ensure that the healthcare environment does not compromise effective IPC, and that poor maintenance practices are not tolerated.
Gov response: Section 3.1 of the Scottish Government's response highlights the revised NHSScotland National Cleaning Services Specification and its monitoring framework, which enables NHS boards to assess and improve the physical healthcare environment. Significant investment has been …
Accepted
R67 — Link Nurse training
Recommendation: Health Boards should ensure that, where a local Link Nurse system is in place as part of the IPS system, the Link Nurses have specific training for that role.
Gov response: Section 4.3 of the Scottish Government's response describes the HAI Taskforce's support for education, which includes a strategy to ensure all healthcare workers receive appropriate education and training related to HAI. It also promotes an …
Accepted
R73 — OCT report detail sufficiency
Recommendation: Health Boards should ensure that OCT3 reports provide sufficient details of the key factors in the spread of infection to allow a proper audit to be carried out.
Gov response: Section 4.2 notes the report's recommendation that Outbreak Control Team (OCT3) reports should provide sufficient detail on key factors in infection spread to allow proper auditing (recommendation 73). While the "Our current position" section details …
Accepted
R9 — IPC clinical governance meetings
Recommendation: Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.
Gov response: Section 2.2 and 3.2 of the Scottish Government's response confirm that the infection control manager is an integral member of the organisation's infection prevention control, clinical governance, and risk management committees. Section 3.2 further states …
Accepted
PFD Reports (21)
Barbara Wingate
Concerns: Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
Pending
Walter Horton
Concerns: Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing infection risk.
Overdue
Patricia Lines
Concerns: Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due to lack of disinfection and reliance on 20-year-old evidence.
Responded
Sylvia Nash
Concerns: Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion over responsibilities and incorrect procedures.
Responded
Terence Hines
Concerns: Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.
Responded
Karen Starling and Anne Martinez
Concerns: Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety guidance is inadequate, lacking specific protocols for identifying and controlling mycobacteria in hospital settings.
Responded
Joyce Dennis
Concerns: Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor documentation and communication within the care home created significant risks.
Overdue
Alvin Black
Concerns: Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer to miss a critical post-surgery VTE risk assessment, indicating a broader protocol adherence issue.
Overdue
Anthony Slack
Concerns: The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.
Responded
Joan Sanderson
Concerns: The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.
Overdue
Irene Collins
Concerns: Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.
Overdue
Andrew Clegg
Concerns: Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify legionella risks in water systems.
Overdue
Joan Blaber
Concerns: Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting unsafe practices.
Responded
John Edwards
Concerns: The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.
Overdue
Ronald Farrington
Concerns: The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.
Overdue
Alwyn Head
Concerns: Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Responded
Margaret Clarke
Concerns: There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common in private and public leisure facilities.
Responded
Martin Dean
Concerns: Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection to vulnerable patients.
Overdue
Barbara Cooke
Concerns: Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.
Overdue
Wilhelmina Isobel Newton
Concerns: The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.
Response: Cumbria County Council has developed a new policy and guidance for staff on how to respond to potential head injuries in elderly residents, especially those on medication affecting blood clotting. …
Pending
Lilian Behrendt
Concerns: The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile recording devices, lack of staff accountability, and unclear DNACPR status.
Responded