Regulation 31

establish an infection prevention and control programme (called in this regulation the IPC programme) that satisfies the conditions mentioned in paragraph (2);

appoint an infection prevention and control committee to assist the licensee in establishing, implementing and regularly reviewing the IPC programme;

ensure that the infection prevention and control committee comprises the appropriate number of personnel with the appropriate qualifications, skills and competencies for the purpose of carrying out the licensee’s functions mentioned in sub‑paragraph (b); (d)keep proper and accurate records of —

the implementation of the IPC programme; and

every infection prevention and control activity carried out at the approved permanent premises;

ensure that only equipment, material or articles that are reprocessed through high‑level disinfection or sterilisation in accordance with the specifications by the manufacturer of the equipment, material or articles (as the case may be) and are not subsequently contaminated, are used in any endoscopic, operative or any other invasive procedure on a patient;

ensure that every equipment, material or article that is used in every endoscopic, operative or any other invasive procedure is —

reprocessed through high‑level disinfection or sterilisation in accordance with the specifications by the manufacturer of the equipment, material or article, as the case may be; and

kept and stored under the appropriate conditions to ensure that the equipment, material or article remains fit for use until it is used in the next endoscopic, operative or invasive procedure; and (g)ensure that every equipment that is used to reprocess or sterilise any other equipment, material or article is checked regularly and maintained properly in accordance with the specifications by the manufacturer of the equipment, so as to ensure its proper and effective operation.

standard operating procedures relating to the infection prevention and control of any infection at the licensee’s approved permanent premises;

policies and guidelines relating to the prevention, identification, control and management and elimination of any infection that is acquired in or brought into the licensee’s approved permanent premises, including the practice of good hand hygiene and in the use of personal protective equipment;

policies and the appropriate processes for the training and competency assessment of the licensee’s personnel to ensure that the personnel are familiar with and are able to comply with the matters mentioned in sub‑paragraphs (a) and (b);

surveillance plans to monitor every incident at the licensee’s approved permanent premises that involves an epidemiologically important organism or an infection that is acquired at the approved permanent premises;

plans to carry out regular audits on the personnel, patients and environment of the licensee’s approved permanent premises to ensure that the IPC programme is being implemented effectively.