General Note 

NHS Fife acknowledges and agrees with the importance of regular and timely review of policy statements and aims to review policies within the timescales set out. New policies will be subject to a review date of no more than 1 year from the date of first issue. 

Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years. 

If a policy is past its review date, then the content will remain extant until such time as the policy review is complete and the new version published, or if national policy or legislative changes are made 

1. FUNCTION 

The purpose of this overarching policy is to ensure that responsibility for prevention and control of Healthcare Associated Infection (HAI) is embedded at all levels of the organisation and to clarify the responsibilities as laid down in national directives for prevention and control of infection, from the Chief Executive and Board through to individual practitioners. 

It describes the processes to prevent healthcare associated infections that will be implemented within NHS Fife to ensure the application of the highest standards in accordance with the requirements of NHS Healthcare Improvement Scotland (HIS) Infection Prevention and Control (IPC) Standards (2022) and Healthcare Associated Infection and Antimicrobial Resistance (AMR) Policy Requirements DL (2019) 23 or any relevant updates to these documents. 

It is supported by the mandated NHSScotland National Infection Prevention and Control Manual (NIPCM) and the NHS Fife Infection Prevention and Control Manual (FIPCM). 

2. LOCATION 

This policy applies to all staff within all the component parts of NHS Fife and Fife Health & Social Care Partnership (HSCP) whether working in healthcare premises, domiciliary settings or other locations where healthcare services are being delivered. It also applies to private and independent contractors working on NHS Fife premises, including GPs in community hospitals, locum and agency staff, and volunteers. It is offered as best practice guidance for independent contractors on their own premises including care home providers. 

3. RESPONSIBILITY 

3.1. NHS Fife Board  

Responsibilities of the Board are laid down in HIS IPC Standards (2022) (as amended).

3.1.1 The Board must: 

Ensure the organisation demonstrates leadership and commitment to infection prevention and control to promote a culture of continuous quality improvement. 

Ensure executive leaders and their teams have a working knowledge, appropriate to their role in the organisation, of the infection prevention and control policies and procedures as well as the national and local priorities that impact on care within the organisation.

1. Executive leaders and their teams have a working knowledge, appropriate to their role in the organisation, of the infection prevention and control policies and procedures as well as the national and local priorities that impact on care within their organisation.
2. There is an executive board member assigned to lead on infection prevention and control for the organisation.
3. There are local arrangements to ensure HAI issues are addressed by NHS board management.
4. There is an infection prevention and control team with the necessary expertise and leadership skills to support the organisation.
5. The organisation agrees and monitors key performance indicators for infection prevention and control, and executive leadership receives, reports and acts on these.
6. There is an infection prevention and control accountability framework, approved by executive leadership, which specifies the responsibilities, reporting structure and clinical governance of infection prevention and control risks at all levels in the organisation.
7. The organisation can demonstrate to patients, their representatives and staff:
   a. HAI risk assessments are undertaken to ensure continuity of safe patient care during periods of service planning and reorganisation,and
   b. effectiveness and improvement in maintaining a safe care environment.
8. The organisation can demonstrate effective management of outbreaks, including:
   
   a. preparedness
   b. assessment of patient care and safety
   c. reporting, and
   d.remedial action plans 
   
   
9. The organisation has strategic, operational and quality assurance systems, with clinical governance oversight to demonstrate compliance with infection prevention and control policies.
10. The organisation demonstrates a culture of learning from positive reporting, and adverse events, including outbreaks and incidents, and seeks confirmation of system change to reduce risk, prevent recurrence and promote resilience.
11. The organisation uses data from a variety of internal and external sources to meet its objectives and to support learning and continuous improvement in infection prevention and control practice. 

3.1.2. These responsibilities are discharged through the establishment of the following posts and structures: 

• Director of Public Health 

• Public Health Consultant in Communicable Disease and Environmental Health 

• Executive Lead for Infection Control 

• Executive Lead for Decontamination 

• Infection Prevention and Control Committee Structure 

3.2. Board Chief Executive  

Has overall responsibility for the provision of infection control within NHS Fife. 

The responsibilities of the Chief Executive with respect to infection control are laid down in DL (2024) 11, (replacing HDL (2005) 8) including the following: 

1. Is aware of their legal responsibilities to identify, assess and control risks of infection in the workplace
2. Appoints an Executive Lead to be the Healthcare Associated Infection (HAI) Executive Lead
3. Appoints either a Clinical Lead and/or Infection Control Manager to have responsibility for the IPC service with sufficient resource to provide IPC support and advice and is able to demonstrate clear lines of governance throughout the organisation 
4. Ensures that prevention and control of infection is a core part of their organisation’s clinical governance and patient safety programmes. 

3.3. Healthcare Associated Infection (HAI) Executive Lead  

The HAI Executive Lead holds delegated accountability for the IPC service function within their portfolio answering directly to the Chief Executive in line with the Board’s internal scheme of delegation.

HAI Executive Leads are responsible for:

1. Annual workforce planning to establish an IPCT appropriate to the size and complexity of the Board, in line with the requirements of the Health and Care (Staffing) (Scotland) Act 2019 
2. Responsible for the management of any IPC associated risks which have been escalated to ensure appropriate mitigation steps are taken
3. Ensure the IPC service can provide the function required and have an appropriate work programme which supports provision and continuous improvement 
4. Responsible for chairing the Infection Prevention and Control Committee (IPCC)
5. Oversee and ensure relevant and required IPC/ healthcare associated infection (HCAI) reports are published and/or sent to the appropriate National Board/Scottish Government.

3.4. Infection Control Manager (ICM) 

In line with DL (2024) 11, the Infection Control Manager (ICM) is accountable to the HAI Executive and plays a crucial leadership role in infection prevention and control across NHS Fife and associated Health and Social Care Partnerships (HSCP). This role builds upon previous definitions established in HDL (2001)10 and HDL (2005)8, incorporating updated responsibilities to ensure strategic oversight, compliance, and continuous improvement in infection control management. 

Key Responsibilities 

The ICM should: 

1. Provide leadership and management of the IPC Team across NHS Fife and HSCP. 
2. Ensure a coordinated IPC service with clearly defined strategies supporting low levels of Healthcare-Associated Infections (HAI). 
3. Develop and deliver a measurable an Annual Infection Control Work Programme based on national HCAI policy and guidance, tailored to local needs. 
4. Ensure wherever possible compliance with relevant national standards, regulations, and guidance, providing support to staff and informing senior management of concerns. 
5. Lead IPC attendance at Clinical Governance and Risk Management structures, ensuring robust systems for safe, effective, person-centred care. 
6. Assess the impact of plans/policies on infection prevention and recommend changes. 
7. Oversee the production of statutory reports, the Annual NHS Fife Infection Control Report and bimonthly HAIRT reports, ensuring alignment with strategic objectives. 
8. Manage dissemination of IPC-related information, including decontamination processes, in collaboration with the Director of Property and Asset Management. 
9. Provide strategic oversight for workforce planning and development within the IPC Team. 
10. Drive continuous quality improvement by implementing robust policies and SOPs for infection prevention and control, including decontamination. 
11. Ensure the provision of IPC advice to colleagues involved in estates, facilities, engineering and other areas of the healthcare-built environment to review and advise on infection risks to patients from environmental issues such as water, air, ventilation, decontamination, new builds and upgrades, etc.
12. Support a culture of IPC clinical research. 
13. Oversee the IPC service budget, ensuring financial accountability for infection prevention and control activities. 
14. The ICM is a full-time appointment and a member of the Infection Prevention and Control Committee (IPCC). 

The HAI Executive Lead will provide link between the ICM and the NHS Fife Board, the NHS Fife Clinical Governance Committee and the NHS Fife Executive Directors’ Group (EDG).

3.5.  Infection Control Doctors (ICD) 

The role and function of the Infection Control Doctors (ICD) is to provide strategic leadership in conjunction with the ICM and Lead IPCN for infection prevention and control to NHS Fife. 

The ICDs: 

1. Should have allocated specific sessions for infection control across NHS Fife. 
2. Will usually be a Consultant in Medical Microbiology. 
3. Will be accountable to the Medical Director, and report to the HAI Executive Lead. 
4. Should be trained in all aspects of infection control. 

The ICDs must: 

1. Provide strategic leadership in conjunction with the ICM and Lead IPCN for infection prevention and control to NHS Fife. 
2. Provide specialist expert advice on the control of infection for the IPCC and NHS Fife. 
3. Adopt national evidence-based guidance to ensure that patients are treated according to best practice. 
4. Ensure adequate infection control advice is available to all NHS Fife staff at all times. 
5. Work in partnership with the Infection Prevention and Control Team (IPCT) to deliver a comprehensive and effective IPC service. 
6. Attend Board IPCT and IPCC meetings to ensure IPC concerns are addressed at a strategic level. 
7. Lead or advise on the investigation and management of outbreaks, clusters, and incidents of healthcare-associated infections. 
8. Provide expert microbiological advice on alert organisms/conditions, review surveillance data, support prudent antimicrobial prescribing, and contribute to IPC policy development and implementation of standards. 
9. Collaborate with estates, facilities, engineering, and other healthcare-built environment teams to assess infection risks related to water, air, ventilation, decontamination, new builds, and upgrades. 
10. Provide expert microbiological advice on water safety issues as part of the Board Water Safety Group. 

3.6. Infection Prevention & Control Team (IPCT) 

The IPCT provides expert reactive and proactive advice and information to all staff within all the component parts of NHS Fife, HSCP and to private and independent contractors working on NHS Fife premises, including GPs in community hospitals, locum and agency staff, and volunteers.

The IPCT should: 

• Each member of the IPC Team is responsible for continuously updating their knowledge to effectively support all aspects of their role. 

• Provide expert reactive and proactive information and advice to all staff, patients and relatives about the management of healthcare associated infections and infection control and prevention issues. 

• Work in collaboration with all NHS Fife staff at all levels, clinical and non-clinical. 

• Provide expert advice and management of infection outbreaks and incidents including the rapid detection of outbreaks. 

• Review and respond appropriately to adverse incident reports relating to infection control. 

• Audit the status, in collaboration with others, of the built environment and the effectiveness of the facilities management services, including cleaning, to promote a safe and clean environment for patient care. 

• In liaison with other relevant staff prepare, review and update evidence-based SOPs and guidelines in line with relevant national guidance and monitor compliance. 

• Identify and support quality improvement initiatives related to IPC policies. 

• Contribute to the Annual Infection Control Plan in consultation with the ICM and the IPCC. 

• Develop priorities for targeted surveillance at local level, in line with national and local requirements. 

• Collate and provide real time surveillance data which allows local teams to recognise immediate and emerging threats and take appropriate action to minimise harm and protect patient/service user and staff safety. 

• Produce the Healthcare associated Infection Reporting Template (HAIRT) report to provide assurance on IPC activities. 

• Working collaboratively with NES, locally assess training needs, develop IPC resources and provide a comprehensive infection control education programme tailored to the needs of the NHS Fife workforce. 

• Support the development of information to patients and the public to ensure they are aware of how they can assist with the prevention of HAI. 

• Actively contribute to, support and promote the work of the Board Antimicrobial Management Team (AMT). 

• Provide clinical IPC subject matter expertise advice on the built environment, all new builds, refurbishments and reconfigurations and on the application of the HAI SCRIBE risk management tool. 

• Advise on aspects of decontamination, including all levels of equipment decontamination and cleaning. 

• Provide clinical IPC subject matter expertise, support and work collaboratively with key stakeholders such as AMT, Occupational Health, East Region Health Protection Team, ARHAI Scotland, NHS Assure, NHS Healthcare Improvement Scotland (HIS) and other relevant agencies where applicable.

3.7. Infection Prevention and Control Committee (IPCC) 

The Terms of Reference (TOR) for the IPCC set the parameters of their responsibilities: 

• Set and monitor local and national priorities related to infection control. 

• Coordinate and monitor infection control activity across the whole health community served by the IPCT. 

• Evaluate the impact of infection on service delivery. 

• Approve the development and monitor implementation of an annual programme of work associated with infection control. 

• Ensure compliance with national standards through development and implementation of robust monitoring systems across the health community served by the IPCT. 

• Support the delivery of governance and health and safety activities related to infection control. 

• Direct the development of the infection control policy, SOPs, guidelines and standards. 

• Receive and review risk management reports related to infection control. 

• Receive and review reports and minutes from infection control projects and subgroups of the IPCC. 

3.8. Directors, General Managers and Line Managers are responsible for ensuring they have a comprehensive understanding of their own remit within this policy and associated procedures and guidance laid down in the Infection Prevention and Control Manual.

Directors, General Managers and Line Managers must: 

• Lead by example, particularly in relation to good hand hygiene and adherence to uniform policy. 

• Actively manage staff and contractors to ensure that they are familiar with the SOPs contained within the Manual, and that these are adhered to. 

• Ensure adequate resources are available to meet infection control standards and requirements including completion and monitoring of audits. 

• Ensure staff involved in or affected by a sharps injury are provided with adequate support. 

• Facilitate their staff to complete training. 

• Ensure that all staff personal development plans (PDPs) contain appropriate infection control training and that staff undertake this training. 

• Ensure staff report infection outbreaks or incidents in accordance with the relevant infection control guidelines. 

• Ensure equipment decontamination is performed in line with local, national and manufacturers’ guidance. This includes the provision of adequate training, equipment and environmental standards for staff to safely decontaminate equipment. 

• Review the patient journey for emergency and planned patients in order to reduce the risk of transmission of infection by minimising the movement of potentially infected patients. 

• Actively manage staff who do not adhere to infection control guidelines, referring to NHS Scotland Policies and procedures where appropriate. Policies | NHS Scotland. 

• Ensure there is capacity for Infection Prevention and Control cover 24/7. 

3.8.1. The role of the Charge Nurses/Ward Leaders/Team Leader in infection control is further defined within HDL (2005)7 and includes the following: - 

1. Must have undertaken the ‘Cleanliness Champions’ educational programme or SIPCEP equivalent. 
2. Should ensure that all nurses have Personal Development Plans (PDP) that contain specific objectives for continuing professional development in HAI. 
3. Are expected to set sensible limits on visiting, ensuring that visitors don’t sit on beds, minimising the risk to patients. 
4. Are responsible for ensuring that any local or national infection control guidance is implemented within their areas. 
5. Should have the authority to require local domestic services to act timely on any problems identified. 
6. Charge nurses should be involved in auditing compliance with infection control policies and cleaning schedules within their areas. 

3.9. All members of staff 

Staff have a responsibility to demonstrate an acceptable level of competence in the workplace relating to control of HAI. 

They must:  

1. Ensure they have received appropriate infection prevention and control training in the last twelve months and fully adhere to Hand Hygiene Standards as per the NIPCM.
2. Never knowingly place a patient, member of staff or visitor at risk from an infection. 
3. Work to the infection control and related standards set out in the NHS Fife’s infection control policy and the mandated NIPCM. 
4. Adopt national evidence-based guidance in order to ensure patients are treated according to best practice. 
5. Challenge poor infection prevention and control practice and seek support from the IPCT as required. 
6. Communicate proactively and reactively with the IPCT ensuring clear lines of communication. 
7. Obtain advice from the IPCT or Occupational Health if they are concerned over their own risks. 

4. OPERATIONAL SYSTEM 

The aim of this policy statement is to ensure that NHS Fife provides a management process and framework under which all infection control activities will operate. 

This policy is underpinned by the National Infection Prevention and Control Manual, which details standard operating procedures and guidance for all aspects of infection prevention and control and is an integral part of this policy statement. All staff must be made aware of this document. It is also supported by the Prevention and Control of Infection Annual Work Programme, and the NHS Fife Prevention and Control of Infection Annual Report. 

4.1. The following functional arrangements for infection control are defined within the Health Improvement Scotland (HIS) IPC Standards (2022) (as amended) namely: 

1. The Prevention and Control of Infection Annual Work Programme 
2. The Prevention and Control of Infection Annual Report 
3. The National Infection Prevention and Control Manual 

The full operational system for these issues is set out in Appendix 9. 

4.2.1 The National Infection Prevention and Control Manual covers: 

• Chapter 1 – Standard Infection Control Precautions (SICPs) 

• Chapter 2 – Transmission Based Precautions (TBPs) 

• Chapter 3 - Healthcare Infection Incidents, Outbreaks and Data Exceedance 

• Chapter 4 – Infection Control in the Built Environment and Decontamination 

• Addendum for Infection prevention and Control within Neonatal Settings (NNU) 

• A-Z Pathogens 

• Care Home Infection Prevention and Control Manual (CH IPCM) 

• Appendixes 

• Resources (including Literature Reviews) 

The NIPCM is mandatory for NHSScotland. In all other care settings, to support with health and social care integration, the content of this manual is considered best practice. The Care Home Infection Prevention and Control Manual is a practice guide for use in care homes and should be adopted for all IPC practices and procedures within care home settings. 

4.2.2. The NHS Fife Infection Prevention and Control Manual covers:

1. Staff Health 
2. Standard Infection Control Precautions and Transmission Based Precautions 
3. Outbreak Management
4. Infection Control Guidelines on Ice for Patients 
5. Pets in Hospital 
6. Food Preparation, Storage and Handling 
7. Specimen Handling 
8. Care at the Point of Death - Last Offices
9. Epidemiology: Important Organisms and Diseases 
10. Principles of Decontamination 
11. Macerator Contingencies 
12. COVID-19 

Manual sections are reviewed on a rolling programme (and more frequently if national guidance changes) and the programme of reviews for the forthcoming year will be documented in the Prevention and Control of Infection Annual Work Programme and reported via the IPCC. 

5. RISK MANAGEMENT  

5.1. The risk to staff, patients and visitors will be managed by the application of the procedures laid down in the National Infection Prevention and Control Manual 

5.2. Risks will be documented in the Infection Prevention and Control Risk Register and reviewed bimonthly by the IPCC. 

5.3. Governance arrangements are laid down in the NHS Fife Prevention and Control of Infection Implementation Framework 2022-24 and risks will be escalated in line with the pathways laid down in that document. 

6. APPENDICES

Appendix 1 - Responsibilities of the Health Board

Appendix 2 - Responsibilities of the Board Chief Executive 

Appendix 3 - Responsibilities of the Executive Lead for HAI: Infection Control 

Appendix 4 - Responsibilities of the ICM 

Appendix 5 - Responsibilities of an ICD 

Appendix 6 - Responsibilities of the IPCT 

Appendix 7 - Responsibilities of the IPCC 

Appendix 8 - Responsibilities of Directors, General Managers and Line Managers 

Appendix 9 - Documents underpinning and supporting the Infection Control Policy 

7. RELATED DOCUMENTS 

National Infection Prevention and Control Manual 

NHS Fife Infection Prevention and Control Manual 

NHS Fife Prevention and Control of Infection Implementation Framework 2019-2021