Care home infection control
Failure to safely follow infection prevention and control (IPC) practices in care homes, risking outbreaks and resident health.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
100match
#2 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
Discharging patients from hospital into social care without first testing them for COVID-19 was an appalling error. Shockingly, Government policy up to and including 15 April was to not test all patients discharged from hospital for COVID-19. In the period up to 15 April, up to a maximum of five symptomatic residents would be tested in a care...
Matched on
terms: care, home, infection
HSSIB recommendation
100match
Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response
On 13 May 2020, Public Health England withdrew the primary guidance for Covid-19 homecare provision and instead provided a link to the newer guidance on how to work safely in domiciliary care in England. This newer guidance included the personal protective equipment provisions needed when visiting people in the ‘clinically extremely vulnerable’ group, which were previously absent in...
Matched on
terms: care, control, home, infection
Inquiry recommendation
98match
R66 - Healthcare environment maintenance
Health Boards should ensure that the healthcare environment does not compromise effective infection prevention and control, and that poor maintenance practices, such as the acceptance of non-intact surfaces that could compromise effective infection prevention and control practice, are not tolerated.
Matched on
terms: care, control, infection
Committee recommendation
95match
#28 - NHS staff inconsistently adhere to basic infection prevention and control procedures.
We asked about issues with infection prevention and whether some of the basics were not being upheld as much as they should. DHSC said that we should not underestimate how much of the battle against AMR “is really basic things”, including cleaning, handwashing and hospital design. It told us that the experience of COVID-19 led to mixed progress,...
Matched on
terms: control, infection
Inquiry recommendation
90match
R12 - CDI infection control advice
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, particularly hand washing and laundry. Should it be necessary to request relatives to take soiled laundry home, the laundry should be bagged appropriately and clear instructions about washing should be given. Leaflets containing...
Matched on
terms: control, home, infection
PFD report
89match
Andrew Clegg
Architects designing care homes and healthcare premises rarely account for water safety in design, particularly concerning legionella prevention through pipework layout. Additionally, CQC inspectors lack training to identify legionella infection risks during their water safety inspections.
Matched on
terms: care, home, infection
Committee recommendation
86match
#22 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
Testing for NHS workers (with symptoms) only began from 27 March, with eligibility extended to social care workers (with symptoms) from 15 April, after the pandemic had passed its first peak. In the period up to 15th April up to a maximum of five symptomatic residents in each care home would be tested, and from the 28th April...
Matched on
terms: care, home
PFD report
85match
Martin Dean
The coroner noted visitors to the Critical Care Ward were not consistently washing their hands, identifying a lack of measures to ensure this essential infection control precaution was followed.
Matched on
terms: care, control, infection
Committee recommendation
85match
#51 - Third Report - Coronavirus: lessons learned to date
The Government should review the provision of infection prevention and control measures, including infection prevention and control nurses, to social care and ensure that social care providers, particularly care homes, are able to conduct regular pandemic preparedness drills. The Government must ensure that care homes have isolation facilities and social care providers are able to provide safe visiting...
Matched on
terms: care, control, home, infection
Committee recommendation
85match
#51 - Sixth Report - Coronavirus: lessons learned to date
The Government should review the provision of infection prevention and control measures, including infection prevention and control nurses, to social care and ensure that social care providers, particularly care homes, are able to conduct regular pandemic preparedness drills. The Government must ensure that care homes have isolation facilities and social care providers are able to provide safe visiting...
Matched on
terms: care, control, home, infection
CQC enforcement action
85match
Warning Notice: Barts Health NHS Trust
The Care Quality Commission issued three formal warning notices to Barts Health NHS Trust following unannounced inspections at Whipps Cross University Hospital in May and June. The warnings required urgent improvements to protect patients and addressed the hospital's non-compliance with national regulations in areas including cleanliness and infection control, equipment safety, and staff support.
Matched on
terms: care, control, infection
Inquiry recommendation
84match
R42 - Mandatory IPC training
Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention and control training that includes CDI on appointment and regularly thereafter. Staff records should be audited to ensure that such training has taken place.
Matched on
terms: care, control, infection
Committee recommendation
82match
#27 - Hospital-acquired C. difficile and MRSA infections reach multi-year highs across NHS.
An essential part of reducing the threat of AMR in humans is the day-to- day work of the NHS in preventing and controlling infections, such as good hygiene practices, aseptic technique and high standards of cleanliness, which can limit the need to use antimicrobials in the first place.67 A lot of AMR is spread through transmission in hospital....
Matched on
terms: control, infection
CQC action
81match
The York Hospital
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance.
Matched on
terms: care, control, infection
CQC action
81match
Northampton General Hospital
The trust must ensure the reduction of the risk of, and preventing, detecting and controlling the spread of, infections, including those that are healthcare associated;12(2)(h)
Matched on
terms: care, control, infection
CQC action
81match
Ellesmere Port Hospital
The trust must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance.
Matched on
terms: care, control, infection
Committee recommendation
81match
#2 - Second Report - Long-term funding of adult social care
The Government provided vital additional funding to the adult social care sector during the pandemic, and we appreciate that the additional covid-19 funding cannot continue indefinitely. However, the Government’s own guidance that care workers should self-isolate if they test positive for covid-19 indicates that the risk to the sector is not over. We do not accept that controlling...
Matched on
terms: care, control, infection
LGO / SPSO decision
78match
21-011-000 - East Anglia Care Homes Limited
Summary: Mr X complains his brother’s care home failed to tell him there was COVID-19 in the home, from which his brother died, and the care provider inappropriately contacted him about outstanding fees shortly after his death. The care home should have told Mr X his brother was at the end of his life. The Care Provider should...
Matched on
terms: care, home
LGO / SPSO decision
78match
21-011-064 - Hallmark Care Homes (Banstead) Limited
Summary: Mrs X complained about events leading up to her husband, Mr X, contracting COVID-19 and being admitted to hospital. These matters have already been investigated by the Care Provider and the Council has also carried out a safeguarding investigation. Both identified fault and the Care Provider has taken suitable actions to help prevent a reoccurrence. The findings...
Matched on
terms: care, home
LGO / SPSO decision
78match
21-004-573a - Cedars Place Care Home (21 004 573a)
Summary: Mrs B and Mrs C complained about the way the Trust cared for their late father, Mr D, when he was in hospital in December 2021 and contracted COVID-19. They also complained about the way the Council and Trust dealt with Mr D’s discharge to a care home, and about Mr D’s care at the Home. We...
Matched on
terms: care, home
Committee recommendation
78match
#11 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
We remained concerned that the Department had continued its policy of discharging people untested into care homes even once it was clear there was an emerging problem.26 The number of first-time outbreaks in individual care homes peaked at 1,009 in early April. Between 9 March and 17 May, around 5,900 care homes, equivalent to 38% of care homes...
Matched on
terms: care, home
PFD report
77match
Thomas Nicholls
The coroner identified a lack of care staff training regarding the mobility, handling, and care of residents on PEG feed regimes. There was also a failure to report an incident of projectile vomiting during PEG feeding to the care home manager.
Matched on
terms: care, home
PFD report
77match
Ronald Farrington
The coroner noted Nuffield Care Centre's failure to follow tissue viability nurse advice, maintain accurate records, and refer a patient to a GP for infection. Concerns also arose regarding insufficient tissue viability nurse staffing, inadequate CQC evidence collection, and lack of family involvement in reviews.
Matched on
terms: care, infection
PFD report
77match
John Edwards
The care home placement was inappropriate for the resident's complex needs, with inadequate falls and pressure sore prevention policies. Staff did not recognise deterioration, seek timely medical assistance, or properly manage medication and care records.
Matched on
terms: care, home
PFD report
77match
Joyce Dennis
The care home lacked continuous oversight, sufficient notes, and a process for recording family concerns. Staff training was inadequate regarding subtle signs of illness and sepsis in the elderly, leading to a failure to recognise and escalate health deterioration.
Matched on
terms: care, home
Committee recommendation
77match
#7 - Third Report - Social care: funding and workforce
The Government must ensure that standards for weekly testing for care home staff are maintained including rapid turnaround times and that regular data is published on the number of tests delivered to social care staff and residents. In addition, the Government should consider extending routine testing beyond care homes to other care settings, particularly domiciliary care and consider...
Matched on
terms: care, home
LGO / SPSO decision
77match
21-000-741 - Barchester Healthcare Homes Limited
Summary: Mrs J complained about the care her mother received while she was resident at Meadowbeck Care Home operated by the Care Provider. Among other matters, Mrs J complained she had only very limited opportunity to visit her mother before she died of COVID-19 in May 2020. We uphold the complaint finding Mrs J was caused injustice through...
Matched on
terms: care, home
Inquiry recommendation
77match
R60 - Cleanliness Champions implementation
Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as the Cleanliness Champions Programme, are implemented without undue delay. Staff should be given protected time by managers to complete such programmes.
Matched on
terms: control, infection
Committee recommendation
77match
#21 - Thirteenth Report: Whole of Government Response to COVID-19
Local authorities play a significant role in all parts of the UK government’s response to COVID-19. They have key obligations such as to deliver social care, other parts of the emergency response and support for individuals and businesses. Central government funding to local authorities has included £3.2 billion provided in two tranches of £1.6 billion and a £600...
Matched on
terms: care, control, home, infection
Committee recommendation
77match
#46 - Third Report - Coronavirus: lessons learned to date
Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and providing domiciliary care worked under strenuous conditions, at risk to themselves, to provide care to people. (Paragraph 291)...
Matched on
terms: care, control, home, infection
Committee recommendation
76match
#45 - Third Report - Coronavirus: lessons learned to date
The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the spread of infection in care homes. The seeding of infections also happened as a result of staff entering...
Matched on
terms: care, home, infection
Committee recommendation
76match
#45 - Sixth Report - Coronavirus: lessons learned to date
The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the spread of infection in care homes. The seeding of infections also happened as a result of staff entering...
Matched on
terms: care, home, infection
LGO / SPSO decision
76match
202104888 - Greater Glasgow and Clyde NHS Board - Acute Services Division
C complained about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died. C complained to the board about their parent contracting...
Matched on
terms: care, control, home, infection
Committee recommendation
74match
#9 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
On 17 March the NHS told trusts to discharge urgently all medically fit hospital patients with COVID-19 to maximise inpatient and critical care capacity. On 2 April, the Department told care homes that they needed to make their full capacity available and could admit patients with COVID-19 by isolating suspected or confirmed cases. Some Local Authorities were pressurising...
Matched on
terms: care, home
LGO / SPSO decision
74match
20-009-170a - The Old Hall - Spilsby Care Home (20 009 170a)
Summary: Mrs A complains about the care of her mother, Mrs B at a care home. She has also complained about a council’s safeguarding enquiries. We found fault in relation to the Home’s lack of mask wearing. We did not find fault with the other issues in this complaint.
Matched on
terms: care, home
PFD report
73match
Eliza Simpson
The care home had no system for reassessing residents when Deprivation of Liberty Safeguarding orders expired, which could lead to a lack of legal authority and insufficient observation. The absence of CCTV also hampered the subsequent police investigation.
Matched on
terms: care, home
PFD report
73match
Alvin Black
The report identifies concerns about the poor state of cleanliness at the prison's Health Care Centre, potentially increasing the risk of infection for prisoners; it also notes a missed opportunity to consider anti-coagulation therapy, with the system not picking up on this error.
Matched on
terms: care, infection
Committee recommendation
73match
#13 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
We heard how frequently social care had taken second place to the NHS’s needs, particularly in accessing test kits and results, and securing reliable PPE supply for care homes, which had been neither timely nor coordinated.33 When questioned, the Department denied that social care had been forgotten, citing the work it had done in the sector and that...
Matched on
terms: care, home
LGO / SPSO decision
73match
21-018-582 - Ashall Care Ltd
Summary: Mrs X complained about the short-term respite care her father, Mr Z, received at Farthings Residential Care Home which is owned by Ashall Care Ltd. The care provider has already found it failed to properly check Mr Z’s room when he moved in and did not explain how to keep his valuables safe. It has explained what...
Matched on
terms: care, home
Committee recommendation
73match
#16 - Thirteenth Report: Whole of Government Response to COVID-19
The Cabinet Office acknowledged that it was taken by surprise by the need for a massive quantity of protective equipment, and by the difficulty of sourcing it from reliable UK-based suppliers.36 It said that a particular challenge was supplying PPE to care homes, hospices and community care organisations. While NHS systems are designed to deal with supplying the...
Matched on
terms: care, home
CQC action
73match
St Benedict's Hospice
The service should ensure all staff follow trust policy with regard to infection prevention and control.
Matched on
terms: control, infection
CQC action
73match
West Berkshire Community Hospital
Makesureinfectionandpreventioncontrolpracticesareembeddedintheservice,especiallyinregardoftransporting humanwasteanddirtylinen.
Matched on
terms: control, infection
LGO / SPSO decision
73match
21-014-934 - Ebury Court Residential Home Limited
Summary: Mr X complained about the care his late mother, Mrs Z, received during the last few weeks of her life at Ebury Court Residential Home during the COVID-19 pandemic. There was no fault in the updates the Care Home provided the family, its care of Mrs Z, or how it interacted with health professionals. It is not...
Matched on
terms: care, home
Inquiry recommendation
72match
R59 - Priority attendance at IPC meetings
Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority. Non-attendance should only be justified by illness or leave or if there is a risk of compromise to other clinical duties in which event deputies should attend where practicable.
Matched on
terms: control, infection
Inquiry recommendation
72match
R52 - IPC policy adherence audits
Health Boards should ensure that adherence to infection prevention and control policies, for example the C. difficile and Loose Stool Policies, is audited at least annually, and that serious non-adherence is reported to the Board.
Matched on
terms: control, infection
Inquiry recommendation
72match
R50 - 24/7 IPC cover
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.
Matched on
terms: control, infection
Inquiry recommendation
72match
R43 - IPC staff regular training
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.
Matched on
terms: control, infection
Inquiry recommendation
72match
R9 - IPC clinical governance meetings
Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.
Matched on
terms: control, infection
Inquiry recommendation
72match
R3 - IPC policy review
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, and in any event at specific review dates no more than two years apart.
Matched on
terms: control, infection
CQC enforcement action
72match
Warning Notice: Medway NHS Foundation Trust
The Care Quality Commission has formally warned Medway NHS Foundation Trust that it needs to improve the care it provides to patients in the emergency department at Medway Maritime Hospital, Gillingham. CQC issued warning notices to the trust after an unannounced inspection in December found it was not meeting national standards relating to care and welfare of people,...
Matched on
terms: care, control, infection