Infection Prevention & Control (IPC) Policy

1. Introduction

Marylebone Diagnostic Centre (MDC) is committed to preventing and controlling infections for the safety of patients, staff, visitors and partners.

This IPC Policy outlines the systems, processes, and responsibilities that ensure a safe clinical environment and minimise infection risks across all services, including diagnostics, blood testing, laboratory procedures, IV therapy, intimate examinations and fertility-related sampling.

The policy aligns with:

• Care Quality Commission (CQC) Fundamental Standards
• UK Health Security Agency (UKHSA) infection control guidance
• NICE Infection Prevention & Control Standards
• Health and Social Care Act 2008 – Code of Practice
• HTM 01-05 and national decontamination guidance
• COSHH Regulations

2. Purpose

The aim of this IPC Policy is to:

• Prevent the transmission of infection in all clinical areas
• Ensure safe handling of samples, equipment, and clinical waste
• Protect vulnerable patients, including immunocompromised individuals
• Provide clear responsibilities for staff
• Support compliance with regulatory standards

3. Responsibilities

3.1 IPC Lead

MDC designates an Infection Prevention & Control Lead, responsible for:

• Oversight of IPC systems
• Staff training and competency
• Investigation of IPC incidents
• Reviewing IPC audits, risk assessments and action plans
• Reporting to the Clinical Governance Committee

3.2 All Clinical & Non-Clinical Staff

All staff must:

• Follow IPC protocols, PPE guidance and hand hygiene
• Maintain a clean and safe environment
• Report incidents or concerns without delay
• Undertake mandatory IPC training annually
• Adhere to safe sample handling and decontamination processes

4. Hand Hygiene

Effective hand hygiene is the single most important method of infection control.

All staff must:

• Wash or sanitise hands before and after patient contact
• Use hand hygiene before aseptic tasks
• Follow the WHO Five Moments for Hand Hygiene
• Remove jewellery and maintain short, clean nails

Hand sanitiser is available throughout clinical areas.

5. Personal Protective Equipment (PPE)

Appropriate PPE must be used to prevent contamination and protect staff.

PPE includes:

• Gloves
• Masks or respirators where clinically required
• Eye protection for splash risk procedures

PPE selection is based on risk assessment, procedure type and exposure likelihood.

6. Environmental Cleaning & Clinical Areas

MDC maintains a rigorous cleaning programme that includes:

• Daily cleaning of all clinical rooms
• Between-patient surface disinfection
• Use of approved medical-grade cleaning agents
• Regular deep-cleaning schedules
• Immediate cleaning of blood or body-fluid spills

All cleaning is documented and audited.

7. Equipment Decontamination

Reusable equipment must be cleaned between patients and disinfected according to manufacturer guidelines.

This includes:

• Phlebotomy chairs
• Blood pressure cuffs
• Diagnostic equipment
• Microscopes and laboratory surfaces
• Ultrasound and scanning equipment
• Semen analysis containers and counters

Single-use items must never be reused.

8. Sample Handling & Transport

All biological samples, including blood, semen, urine and swabs, must be handled safely.

Procedures include:

• Standard PPE when collecting samples
• Labelling samples correctly
• Storing specimens at appropriate temperatures
• Following UN3373 standards for transport
• Using rigid, leak-proof containers
• Immediate reporting of spillages

9. Waste Management

MDC follows HTM 07-01 and healthcare waste standards.

• Clinical waste is segregated at the point of care
• Sharps are disposed of in approved containers
• Hazardous waste is stored securely and collected by licensed contractors
• Waste management logs are maintained for audit

Sharps injuries must be reported immediately and handled under the Needlestick Injury Protocol.

10. Infection Risk Assessments

Risk assessments are carried out for:

• Clinical rooms
• Sample handling areas
• Laboratory sections
• Waiting areas
• IV therapy bays
• High-risk procedures

Findings are reviewed and updated regularly by the IPC Lead.

11. Management of Infectious Patients

Patients presenting with symptoms of infectious illness are:

• Assessed promptly
• Moved to a safe area where necessary
• Supported with appropriate infection control measures
• Rebooked if the risk of transmission is significant

Staff must follow isolation precautions as required.

12. Staff Health & Exposure Management

Staff must not attend work if experiencing symptoms of infectious disease.

MDC ensures:

• Immediate reporting of occupational exposures
• Access to medical advice
• Documentation of incidents
• Appropriate follow-up and risk assessment

13. Training & Competency

All staff receive:

• Annual IPC training
• Instruction on correct PPE use
• Regular updates on changing guidance
• Competency assessment for clinical tasks

Training records are maintained for audit.

14. Audit & Monitoring

IPC performance is monitored through:

• Monthly environmental audits
• Hand hygiene audits
• PPE compliance checks
• Incident and near-miss reviews
• Equipment cleaning logs
• Regular reporting to the Clinical Governance Committee

15. Policy Review

This policy is reviewed annually or sooner if:

• Guidance is updated
• New clinical services are introduced
• An IPC incident identifies a learning need

Approved by:
Clinical Governance Committee – Marylebone Diagnostic Centre