Every NHS trust and CQC-registered independent hospital is required to comply with the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections (the 'Hygiene Code'). The IPC risk assessment is the document that demonstrates compliance at ward or department level. It covers the standard precautions that apply to every patient interaction, the transmission-based precautions (contact, droplet, airborne) that apply when a specific organism is suspected or confirmed, the environmental controls, and the outbreak-management procedure. This template is written for an acute hospital ward but is portable to theatres, ED, radiology, mental health units and dialysis.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 reg 12 requires registered providers to assess the risk of, and prevent, detect and control the spread of infections. The associated Code of Practice (the Hygiene Code) sets the ten criteria CQC inspects against. The IPC assessment must reference the trust's IPC policy, the IPC team's BAU surveillance, and the named director of IPC (DIPC). For acute care the assessment also references epic3 (the national evidence-based guidelines for preventing healthcare-associated infections), NICE QS61 (infection prevention and control quality standard), and the relevant UKHSA outbreak guidance.
For specific organisms the assessment must cross-reference the organism-specific guidance — C. difficile, MRSA, CPE / CRE (UKHSA toolkit), norovirus (UKHSA outbreak guidance), TB (NICE NG33 / BTS guidance), and any current emerging-pathogen guidance.
Standard precautions apply to every patient regardless of known infection status. The assessment names: hand hygiene (WHO 5 Moments, alcohol-based hand rub with soap-and-water for C. diff / norovirus / spores); PPE (gloves, apron, surgical mask, eye protection — selected by risk, not by routine); safe injection practice and sharps management under the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013; decontamination of patient equipment (single-use vs single-patient-use vs reusable, with the trust's decontamination protocol referenced); waste segregation (clinical / offensive / domestic / sharps under HTM 07-01); and the management of body fluid spills.
This section is rarely the source of audit failure but is read first to establish the baseline.
When an organism is suspected or confirmed, transmission-based precautions are added on top of standard precautions. Contact precautions (gloves and apron, side room where possible — typically MRSA, C. diff, CPE, norovirus, multi-resistant organisms), droplet precautions (surgical mask within close range, side room — typically influenza, COVID-19, meningococcal, pertussis), and airborne precautions (FFP3 respirator with fit test, negative-pressure side room where available — typically TB, measles, varicella, MERS / SARS / pandemic respiratory viruses).
The assessment names the side-room provision on the ward, the negative-pressure room availability, the cohort-nursing arrangement where side rooms are exhausted, and the visiting restrictions. For ED specifically, the assessment names the triage screening for high-consequence infectious diseases (HCID) and the route to the trust's HCID isolation facility.
Two or more linked cases of the same organism on a ward triggers the outbreak procedure. The assessment names the outbreak control team (OCT) composition, the ward closure-to-admissions / restriction-to-discharge decision authority, the enhanced cleaning regime (typically chlorine-based at elevated concentration for C. diff / norovirus), the staff and patient cohorting plan, and the communications route to UKHSA / the local Health Protection Team.
For RIDDOR-reportable infections (specifically named diseases including TB, hepatitis, leptospirosis, anthrax and a number of others contracted at work) the assessment names the route to RIDDOR notification under SI 2013/1471.
The numbered sections a reviewer expects to see, in order.
Ward name, specialty, named IPC link nurse, named DIPC, date and review interval (minimum annual; sooner on policy or organism change).
Hand hygiene, PPE, sharps management, decontamination, waste, body-fluid spill response — each linked to the trust policy reference.
Specialty-specific risk profile (elderly care, haematology, ITU, ED) and the organisms most commonly encountered.
Side room allocation, cohort nursing, gloves / apron, dedicated equipment, enhanced cleaning, visitor management.
Surgical mask within close range, side room, patient mask during transfer, visitor screening.
FFP3 with annual fit test, negative-pressure side room or alternative, donning / doffing supervision, transfer protocol.
Ventilation (HTM 03-01), water safety (HSG274 / HTM 04-01), built environment (HBN 00-09), cleaning frequency (NHS National Standards of Healthcare Cleanliness).
OCT composition and triggers, ward-closure authority, enhanced cleaning regime, cohorting plan, UKHSA / HPT notification.
Mandatory MRSA / C. diff / E. coli / Klebsiella / Pseudomonas surveillance, RIDDOR-reportable infections, internal Datix / IR1.
Occupational health clearance, MMR / varicella / hepatitis B / annual flu and COVID, fit-test register for FFP3 users.
Why a risk assessment gets sent back — these are the patterns we see most often.
The legal framework this risk assessment operates inside. Links go to the official source.
DHSC Hygiene Code
The ten-criterion Hygiene Code that CQC inspects against.
SI 2014/2936
Safe care and treatment — the statutory hook for IPC.
SI 2013/645
Sharps safety duty for healthcare employers — implementing the EU Directive 2010/32.
DH HTM 03-01
Engineering standard for ventilation in theatres, isolation rooms and clinical areas.
HSE HSG274
Water-system safety; cross-referenced for HTM 04-01 compliance in healthcare buildings.
SI 2013/1471
Notification regime for occupational infections (Schedule 1).
The trust IPC policy is the overarching framework; the ward / department assessment is the local application — naming the specialty risks, the side-room provision, the named IPC link nurse and the local outbreak response. CQC inspects both: the policy on paper and the assessment in practice.
Statutory. CQC must take it into account when assessing compliance with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Code's ten criteria are the de facto inspection framework.
Most trusts adopt the UKHSA definition of two or more linked cases of the same organism within a defined time and place. The assessment names the trigger threshold for the specific organisms most commonly encountered on the ward — typically lower for high-consequence organisms (CPE, C. diff, norovirus) and pandemic respiratory viruses.
Yes — and the fit test is specific to the make and model of respirator. A staff member with a fit test for one model is not certified to wear a different model. The assessment names the fit-test provider, the make / models on the ward and the next-due date by named user.
It cross-references the trust's sharps policy under the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. The detailed sharps procedure (safer devices, no resheathing, immediate disposal at point of use, exposure-source testing and post-exposure prophylaxis pathway) typically sits in a separate policy and is summarised here with the policy reference.
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Final RAMS must be reviewed and approved by a competent person before use.