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Infection Toolkit

This toolkit provides a structured approach for recording, managing and learning from infection‑related events in health and social care settings. It supports surveillance, outbreak management, statutory notifications, timely clinical review and adherence to national infection prevention and control (IPC) standards.

Legislative Requirements

• Care Act 2014 — infection prevention is integral to promoting wellbeing. Providers must identify and manage infection risks to prevent deterioration, safeguard people and reduce avoidable care needs.
• Mental Capacity Act 2005 — applies to infection‑related decisions (testing, isolation, treatment). Always assume capacity, support decision‑making, and record best‑interest decisions where capacity is lacking.
• Health and Social Care Act 2008: Code of Practice on IPC — statutory IPC expectations for registered providers in England: risk assessment, surveillance, policies, outbreak systems and staff competence.
• Data Protection Act 2018 / UK GDPR — infection information is special category (health) data. Establish lawful bases (Article 6: public interest / legal obligation; Article 9: public health / healthcare) and apply minimisation, access controls, transparency and retention rules.

Regulatory Guidance

CQC (England)

• Regulation 12 requires providers to prevent and control the spread of infection. CQC will examine IPC systems, policies, training, outbreak handling and how learning is used to improve safety.
• Non‑compliance can lead to enforcement, registration actions or prosecution where avoidable harm occurs.

Care Inspectorate (Scotland)

• Scotland requires application of the National Infection Prevention and Control Manual (NIPCM). The manual is the evidence‑based standard for NHS and recommended for social care to reduce variation and improve safety.

Care Inspectorate Wales (CIW)

• CIW expects structured infection surveillance, early detection, containment actions and clear reporting and escalation to safeguard people and maintain service continuity.

Statutory Guidance

• Accountability — organisations must maintain systems for surveillance, outbreak reporting and learning. Notifiable diseases must be reported promptly (report on suspicion, within statutory timeframes).
• Duty of Candour — where infection causes moderate/severe harm, be open with the person and families, provide a full account and apologise as required.
• Safeguarding — if infection links to neglect, poor hygiene or unsafe practices, escalate via safeguarding channels and partner agencies.
• Recording — maintain contemporaneous records to enable prevention, detection, containment and audit of infection events and outcomes.

Health care Guidance

• Department of Health & Social Care — published IPC resources for adult social care (updated March 2024) that explain risk reduction, chain of infection and operational expectations for managers.
• Scottish Government / NIPCM — provides national, standardised IPC practice and reporting guidance for Scotland; care homes and services are expected to apply the manual.
• Wales — Welsh guidance adopts evidence‑based IPC with zero‑tolerance for preventable HCAIs and mandates prompt outbreak control.
• NICE / SIGN — NICE quality standards (QS61, QS113), NG125 and NICE IPC pathway emphasise routine surveillance, standard definitions and using data for improvement. SIGN aligns clinical practice and documentation expectations in Scotland.

Evidence Based Practice

• Use standard case definitions for HCAIs, notifiable diseases and outbreaks to ensure consistency and comparability.
• Record infections promptly and contemporaneously with: identifiers, onset date, likely source, organism (if known), location and actions taken.
• Report suspected notifiable infections without waiting for laboratory confirmation to enable rapid public health action.
• Use surveillance data for post‑infection reviews, trend detection, outbreak recognition and targeted quality improvement.

Clinical governance and Safety (NHS)

• Systems must be clinically safe: accurate capture, clear escalation, avoidance of blind spots and resilience against data loss.
• Identify infection‑related hazards (missed recording, misclassification, delayed outbreak detection) and log them in a Clinical Hazard Log with mitigations and owners.
• Ensure infection signals feed risk registers, governance committees and board assurance to demonstrate oversight and improvement.

PSIRF

• Infections are patient safety risks. Use PSIRF principles to decide proportionate learning responses (rapid reviews, thematic analysis or in‑depth investigations) based on harm, recurrence risk and learning potential.
• Document PSIRF decisions within the organisation’s Patient Safety Incident Response Plan (PSIRP) and use thematic reviews for trends in HCAIs or IPC breakdowns.

Using the Toolkit — Practical Steps

1. Log the Event — capture reporter, person affected, setting/ward, date/time of onset and discovery, presenting features and initial clinical status.
2. Initial Risk Assessment — assess immediate infection risk to others, need for isolation/cohorting, PPE requirements and urgent clinical escalation.
3. Notify — inform internal IPC lead, clinical lead and, where required, UKHSA/local health protection team and regulator within statutory timescales (report on suspicion for notifiable diseases).
4. Contain & Manage — implement isolation/cohorting, enhanced cleaning, testing, antimicrobial management and staff cohorting as per local IPC policy and national guidance.
5. Evidence Preservation — retain test results, observation charts, medication records, staff rostering and movement logs to support outbreak investigation.
6. Seven‑day Clinical Review — include a 7‑day review step for residents/patients to reassess clinical condition and outcomes following initial infection event.
7. Investigate & Analyse — determine likely source, transmission routes and contributory factors; involve microbiology, IPC and environmental services as required.
8. Actions & Owners — assign remediation (cleaning, training, process change), owners, deadlines and evidence of completion; verify effectiveness.
9. Communicate & Learn — follow duty of candour where harm occurred, brief staff and share learning through governance and quality improvement channels.
10. Close & Monitor — confirm outbreak closure criteria, continue surveillance for recurrence and feed aggregated data to leadership for prevention planning.

Templates & Data Fields (recommended)

• Event reference, status, priority and reporter details
• Person identifiers (anonymise where appropriate), location, date/time of onset and discovery
• Clinical features, severity, tests performed, organism identified (if known)
• Isolation/cohorting status, PPE use, environmental actions and staff exposures
• Notifiable disease flag, UKHSA / local health protection notification timestamps and case references
• Evidence log: lab reports, observation charts, medication records, staff movement/rostering logs
• Investigation type, investigators, findings and root/system analysis
• Action plan: description, owner, due date, completion evidence and verification
• Seven‑day review outcome, outcome measures (recovery, admission, mortality) and follow‑up
• Governance fields: committee escalation, surge plans invoked, board reporting
• Data protection fields: sensitivity flag, lawful basis (Article 6/9), retention and access controls

Monitoring, Audit and Reporting

• Maintain an infection surveillance register to track cases, clusters, outbreaks, action ageing and outcomes.
• Dashboards: infection counts by type, location, time to isolation, time to notify, outbreak duration, staff exposures and actions completed.
• Audit timeliness of notifications, quality of records, adherence to IPC measures and completeness of seven‑day reviews.
• Provide regular reports for IPC committees, quality boards and commissioners demonstrating trend analysis and improvement activity.

Value Proposition

• Delivers a single, auditable workflow to capture infection events, statutory notifications and outbreak control actions consistently and lawfully.
• Supports timely clinical review (including a 7‑day step), rapid containment, and integration with IPC teams and public health authorities.
• Enables leadership assurance through dashboards that aggregate risk, action completion and trends to reduce HCAIs and protect people and staff.
• Feeds learning into quality improvement to prevent recurrence and demonstrate regulatory compliance.

References

• Care Act 2014
• Health and Social Care Act 2008: Code of Practice on Infection Prevention and Control
• Mental Capacity Act 2005
• CQC Regulations (2014)
• Care Inspectorate Health and Social Care Standards
• Care Inspectorate Wales (CIW)
• Department of Health & Social Care (DHSC) IPC resources (2024)
• Scottish Government: National Infection Prevention and Control Manual (NIPCM)
• NICE Quality Standards QS61, QS113; NG125; NICE IPC pathway
• Scottish intercollegiate guidelines (SIGN)

Disclaimer

Radar Healthcare provides configuration templates and implementation guidance to support effective use of the platform. Any data protection or regulatory examples are for general guidance only and do not constitute legal, clinical or compliance advice. Radar Healthcare acts as a data processor under customer instruction. The customer, as data controller, remains responsible for assessing and managing data protection risks, determining lawful processing, and ensuring compliance with applicable regulations.