IPC policy adherence audits
Vale of Leven Inquiry · The Vale of Leven Hospital Inquiry Report · Issued 24 November 2014 · Addressed to: NHS Health Boards (Scotland)
Source — verbatim from the inquiry
●Inquiry 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.
Vale of Leven Inquiry, The Vale of Leven Hospital Inquiry Report · 24 Nov 2014 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The Scottish Government's response detailed national and local surveillance data collection, including mandatory CDI surveillance (started 2006 for patients aged 65+, extended April 2009 to all aged 15+). The LDP standard requires CDI rates of 0.32 or less per 1,000 total occupied bed days.
- Scotland achieved a CDI rate of 0.27 per 1,000 occupied bed days in the year ending December 2018, meeting the target with a decreasing year-on-year trend of 7.5% between 2014 and 2018.
- The requirement that adherence to IPC policies including CDI policies is audited at least annually is addressed through national surveillance systems operated by ARHAI Scotland (formerly Health Protection Scotland) and local audit requirements within the HAI Standards.
- The HCAI Strategy 2023-2025 maintains surveillance and reporting as core elements of Scotland's approach to HAI reduction (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
Response — verbatim from government
●Scottish Government
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.
Scottish Government · 18 Jun 2015 Written response →
Evidence trail — what's actually happened since
- 1 May 2022 · Healthcare Improvement Scotland 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 source → Confirmed Completed
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
How this page is built
Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.