cddft policy hand hygiene policy.pdf · policy for the hand hygiene within county durham &...

Policy for the Hand Hygiene within County Durham & Darlington NHS Foundation Tru st

CDDFT Policy

Reference Number POL/ICC/0002 Title Policy for Hand Hygiene within County Durham & Darlington

NHS Foundation Trust Version number 6.3 Document Type Policy Original Policy Date August 2007 Date approved 22/05/2013 Effective date 31/05/2013 Approving body Quality and Healthcare Governance Committee Originating Directorate Nursing and Transformation Scope Trust wide Last review date April 2013 Next review date January 2015 Reviewing body Infection Control Committee Document Owner Director of Infection Prevention & Control Equality impact assessed Yes – January 2012 Date superseded N/A Status Approved Confidentiality Unrestricted Keywords Hand Hygiene

Approval Signature of Chairman of Approving Body

Name/Job Title of Chairman of Approving Body:

Mr Mike Wright Executive Director of Nursing Chair of Quality and Healthcare Governance Committee

Signed paper copy held at (location): Library Services DMH

POL/ICC/0002 Version 6.3 of 26

Policy for Hand Hygiene within County Durham & Darlington NHS Foundation Trust


Index Page

1 Introduction 3 2 Aim 3 3 Duties (Roles and Responsibilities) 3 4 Your 5 moments for Hand hygiene 4 5 Hand hygiene facilities and equipment 4 6 Bare below elbows 5 7 Jewellery 5 8 Nails 5 9 Cuts and Abrasions 5 10 Skin problems/irritation 5 11 Hand Hygiene procedure 6 12 Skin care 7 13 “Coughs and Sneezes spread diseases” 7 14 Advice and Guidance 7 15 Equality and Diversity 8 16 Hand Hygiene Training 8 17 Review and Monitoring 8 18 References 9 19 Associated documents 9 Appendices 1 Hand washing assessment document 10 2 Lewisham observational tool 11 3 Hand hygiene facilities audit 15 4 5 moments for hand hygiene 19 5 6 step hand hygiene technique 20 6 Equality Impact Assessment 21

Document Control Information

Version control table

Date of issue Version number Status August 2007 1.0 Superseded March 2009 2.0 Superseded May 2010 3.0 Superseded January 2011 4.0 Superseded July 2011 5.0 Superseded January 2012 6.0 Superseded February 2012 6.1 Superseded April 2012 6.2 Superseded April 2013 6.3 Approved

Table of revisions

Date Section Revision Author March 2009 Full To update current advice ICT May 2010 Full To update current advice ICT January 2011 Full To ensure policy reflects the needs of acute

and community services ICT

July 2011 Review & monitoring For NHSLA monitoring ICT January 2012 Full Annual review ICT February 2012 Training For NHSLA review ICT April 2012 Training Following NHSLA review ICT April 2013 Training Following NHSLA review ICT



1. Introduction

The most common way micro-organisms are transmitted and potentially cause infection in susceptible people is from the hands of healthcare staff. Transmission of micro-organisms by healthcare workers hands from one patient to another can result in adverse outcomes. Consequently, effective hand hygiene is considered the single most important practice in preventing the spread of micro-organisms and reducing cross-infection.

All staff are required to carry out hand hygiene as a standard (universal) infection control precaution.

The term hand hygiene refers to the practice of hand washing with liquid soap and water or hand decontamination using other solutions, e.g. alcohol hand rub.

Hand decontamination refers to the process of physical removal of blood, body fluids or transient organisms.

Hand hygiene must be performed adequately (i.e. good technique) and appropriately (i.e. when required) to effectively prevent infection spread.

The nature of the work being undertaken by staff, will usually determine the hand hygiene procedure and frequency required. These are normally determined as:

Social or hygienic hand hygiene; requiring either hand wash with liquid soap and water

or use of alcohol hand rub This policy primarily relates to this area of hand hygien practice Or

Surgical scrub; requiring the use of antibacterial solutions before invasive surgical procedures (more information regarding surgical scrub can be found in WHO guidelines (2009) available at http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

2. Aim

This policy sets out:

The importance of hand hygiene in improving patient/client safety by reducing transmission of infectious organisms and Health Care Associated Infections (HCAI’s) during delivery of care.

A formal statement of principles and recognised hand hygiene practice and techniques for all health care staff.

3. Duties

Trust Board The Board, via the Chief Executive, is ultimately responsible for ensuring that systems are in place that effectively manages the risks associated with Infection Control.

Day to day operational responsibility in relation to Infection Control will be that of the Director of Infection Prevention & Control (DIPC). The DIPC will provide assurance t o the board that effective systems are in place. The DIPC will be a member of the Infection Control Committee.

http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf



Infection Control Committee (ICC) The ICC is responsible for developing and approval all IC related policies within the organisation.

Infection Control Team (ICT) The ICT are responsible for ensuring all staff are aware of all IC policies (as appropriate to their role), providing and delivering a programme of education and training and advising staff on IC issues.

All employees, bank staff and volunteers All staff are responsible for:

ensuring that they follow this hand hygiene policy and all other Infection Control policies as approved by the ICC relevant to their role ensuring they attend Essential training ensuring that they have a hand hygiene practical assessment every two years

4 ‘Your 5 Moments for Hand Hygiene’

Knowing the key times when hand hygiene should be performed is essential in preventing infection spread. Sax et al (2007) acknowledge it is sometimes difficult for staff t o determine the ‘risk’ attached to activities (i.e. potential/actual hazards, potential/actual contamination, and vulnerability of patients) and when hand hygiene should be undertaken.

The W orld Health Organisation (WHO 2009) considered the research evidence available and identified crucial times in health care delivery when hand hygiene should be performed. These crucial times for hand hygiene are identifed as:

‘Your 5 Moments for Hand Hygiene’ (Appendix 4).

1. Before patient contact 2. Before an aseptic technique 3. After body fluid exposure risk 4. After patient contact 5. After contact with patient surroundings (e.g. surroundings may mean the patient’s

room, bed and surrounding bed-space or chair and surrounding space) 5 Hand hygiene facilities and equipment

Access to appropriate hand hygiene facilities (e.g. washbasin, water) and appropriate equipment (e.g. liquid soap, paper towels or alcohol hand rub) is essential to ensure adequate hand hygiene.

Elbow or lever taps (designed so taps can be turned on and off with the elbows) or automatic taps are preferable in clinical or communal areas to prevent re-contamination of hands following hand hygiene at a wash basin. Or alternatively use paper towel to turn off tap.

Hands should be washed and rinsed under running water (plugs must not be used to fill wash basins with standing water).

Hand hygiene solutions i.e. liquid soap, or alcohol hand rub should be easy to use, easy to clean, and available in single use containers. Container nozzles should be cleaned daily and any congealed product removed.



Disposable paper towels for hand drying should be of good quality and wall mounted in easy to use clean holders.

Ensure best practice advice relating to hand wash stations is followed to minimise the risk of contamination.

Do not dispose of body fluids at the wash hand basin. Do not wash any patient equipment in hand wash basins. Do not use hand wash basins for storing used equipment for decontamination. Use pre-filled single use bottles for alcohol based handrubs - do not top up.

6. ‘Bare below elbows’ (DOH 2010)

Any staff who have direct or close personal contact with patients/clients or their surroundings (i.e. the patient’s room/facilities, bed and surrounding bed-space or chair and surrounding space) or who food-handle must adopt ‘bare below elbows’ guidance. This practice exposes forearms so hands and wrists can be more readily decontaminated. Where for religious reasons, members of staff wish to cover their forearms when not engaged in patient care they should ensure that sleeves can be pushed up the arm and secured in place for hand washing and direct patient care activity. Disposable over-sleeves can be worn where gloves are used, but strict adherence t o washing hands and wrists must be observed before and after use. Over-sleeves must be discarded in exactly the same way as disposable gloves.

7 Jewellery

Any staff undertaking clinical work must remove all hand and wrist jewellery including wrist watches as these may harbour micro-organisms and make effective hand hygiene more difficult. A plain band is acceptable.

8 Nails

All staff who have direct or close personal contact with patient s or their surroundings should ensure:

Nails are short and clean Nail polish is removed Artificial fingernails/extensions are not worn Nail brushes are not used for social hand hygiene as these may cause skin damage or dispersal of skin scales

9 Cuts and abrasions

Staff must cover cuts and abrasions with waterproof dressings until fully healed. Catering staff are required to use blue waterproof dressings.

10 Skin problems/irritation

Staff with skin problems or skin irritation must inform their line manager. The line manager can refer the staff member to the Occupational Health Department for advice regarding their fitness for work, including hand hygiene measures if this is not clear or if it appears they have a specific reaction to a substance used in their work. During hand hygiene assessments, any member of staff with problematic skin will be advised to go to Occupational Health for further advice and management.



11 Hand hygiene procedure

Decontaminate hands using liquid soap and water or alcohol hand rub.

Use liquid soap and water:

If hands are visibly soiled or potentially contaminated with dirt or organic material Before preparing, serving or eating food After using the toilet Caring for or in contact with patients diagnosed with Clostridium difficile or any diarrhoeal or vomiting illness and their environment or surroundings If any contact with blood or body fluids Before starting any aseptic procedure Ideally after glove removal.

Hand washing with liquid soap and water Effective hand washing technique involves three stages: preparation, washing and rinsing.

Preparation “Bare below the elbows”. All wrist and hand jewellery should be removed. Use hand washing sink if possible with mixer taps.

Washing and rinsing. Wet all surfaces of the hands and wrists with tepid running water. Apply approximately 3ml (one squirt) of liquid soap to hands. Rub vigorously for a minimum of 10 – 15 seconds using the six step technique (Appendix 5). This physical action is essential to remove micro-organisms from the skin. Rinse thoroughly with running water to remove all traces of soap.

Drying Dry hands with good quality paper towels including underneath any ring worn. Dispose of paper towel by using foot operated domestic waste bin. It is important to dry hands thoroughly to prevent skin drying and cracking. Damaged skin is more difficult to clean and increases the risk of micro-organisms being harboured on the hands which may be transferred to others.

Use alcohol hand rub

If hands are not visibly soiled or contaminated with organic material If use is not precluded as outlined in the hand washing section above



Hand hygiene using alcohol hand rub

Effective hand hygiene procedure using alcohol hand rub will normally take minimum 15-30 seconds.

Hands should be free from dirt and organic material if using alcohol hand rub. Apply alcohol hand rub (Approximately 3 mls./1 squirt) to hands and wrists. Rub vigorously for a minimum of 15-30 seconds using the 6 step technique (Appendix 5) to ensure all surfaces of hands are covered with hand rub; pay particular attention to the tips of the fingers, thumbs and webbed areas between the fingers and underneath any ring worn.

Continue rubbing until the solution has evaporated and hands feel dry.

There is no evidence to advise the maximum number of times (applications) in succession alcohol hand rub can be used before hand washing is required (i.e. when hands have not been soiled). As a general rule, hand wash with liquid soap and water after several applications of alcohol hand rub and if hands feel sticky (with residue from using the alcohol hand rub).

12. Skin care

Emollients (hand cream) should be available to staff in all areas. They should be dispensed from wall-mounted containers or pump dispensers. Container nozzles should be cleaned daily and any congealed product removed.

Apply emollients regularly to keep skin moisturised and protected from drying. It is recommended staff apply emollient before going for a break and before going off duty (so the cream has some time on the skin).

13 Coughs and sneezes

Staff are advised to:

Cover nose and mouth with disposable tissues when sneezing, coughing, wiping or

blowing noses

Dispose of used tissues in clinical waste

Decontaminate hands by hand washing with liquid soap and water or using alcohol hand rub

14 Advice & guidance

Advice or guidance on infection control (IC) issues can be obtained by contacting the IC department (08:30-16:30 Monday to Friday) or via the microbiologist on call (out of hours). Advice is also available from the Trust’s intranet site:

http://intranet/Directorates/CorporateDirectorates/NursingDirector/infectionControl/ Pages/default.aspx

http://intranet/Directorates/CorporateDirectorates/NursingDirector/infectionControl/Pages/default.aspx





15. Equality and diversity statement

The Trust is committed to providing equality of opportunity, not only in its employment practices but also in all the services for which it is responsible. As such, an Equality Impact Assessment has been carried out on this policy to identify any potential discriminatory impact. (See Appendix 6).

16. Hand Hygiene Training

All employees’ bank staff and volunteers on appointment must attend Hand Hygiene training as part of their induction programme. Thereafter all staff are required to undertake a hand hygiene education update annually (by attendance or e-learning).

Attendance at Essential Training is recorded by P &OD and entered onto the Trust Training Management System, OLM. Monitoring of non-attendance will be in line with the Training Needs Analysis, Monitoring and Evaluation Policy and carried out by P &OD. Please refer to this policy for detailed information

17 Review and monitoring

Monitoring criterion Response Who will perform the monitoring

Matrons. Ward managers Infection control Link workers. Infection control team

What are you monitoring? Hand hygiene practice and hand hygiene facilities

When will the monitoring be performed?

Monthly observations of hand hygiene practice and compliance with policy.

Annual audit of facilities.

How are you going to monitor?

Monthly observations of practice and compliance with the policy monitored on KPI dashboard

Annual hand hygiene facilities audit

What will happen if any shortfalls are identified?

Any dips in compliance with practice are addressed immediately and local action plans implemented and followed up on re-audit

Where will the results of the monitoring be reported?

DIPC Report to the Board ICC and Q&HCG Committee

How will the resulting action plan be progressed and monitored?

Annual Board Report Monitoring via weekly clinical escalation meeting. Monthly Task & Finish Group, Matrons meetings. Infection Control Committee

How will learning take place? Reports and Action Plans sent out to W ard Managers, raising awareness through various forums, newsletters, intranet site etc.

In addition to the monitoring outlined in the table above, attendance at Essential Training is recorded by P&OD and entered onto the Trust Training Management System, OLM. Monitoring of non-attendance will be in line with the Training Needs Analysis, Monitoring and Evaluation Policy and carried out by P &OD. Please refer to this policy for detailed information.



18. References

Ayliffe, G. A., Babb, J. R., Quoraishi, A. H. (1978) A test for ‘hygienic’ hand disinfection, Journal of Clinical Pathology, Volume 31, Number 10, pp. 923-928

Department of Health (2005) Saving Lives: a delivery programme to reduce healthcare associated infection including MRSA, London, The Stationery Office

Department of Health (2007) Uniforms and Workwear: An evidence base for developing local policy, London, DH

Meengs et al 1994: Handwashing frequency in an emergency department. Annals of Emergency medicine 23 (6) 1307-12

National Patient Safety Agency (NPSA) (2008), ‘Help us to Prevent Infections Spreading’ cleanyourhands campaign Available at: http://www.npsa.nhs.uk/cleanyourhands http://www.npsa.nhs.uk/cleanyourhands/the-campaign/training-video/additional-resources/ (Accessed 03.03.09)

Pittet et al 2000: Effectiveness of hospital wide programme to improve compliance with hand hygiene. Lancet 356: 1307-12

Pratt, R. J., Pellowe, C., Loveday, H. P., Robinson, N., Smith, G. W. (2007), epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England, Journal of Hospital Infection, 2007, 655, S1-S64

Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J., Pittet, D. (2007), ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene, Journal of Hospital Infection, Volume 67, pp. 9-21

World Health Organisation (2006), ‘Your Five Moments for Hand Hygiene’ Available at: http://www.who.int/gpsc/5may/background/5moments/en/index.html

(Accessed 09 01 12).

19 Associated Documents

Procedure for developing policies and guidance Staff Induction Policy Training Needs Analysis Clinical Audit policy

http://www.npsa.nhs.uk/cleanyourhands

http://www.npsa.nhs.uk/cleanyourhands/the-campaign/training-video/additional-resources/

http://www.who.int/gpsc/5may/background/5moments/en/index.html

Policy for the Hand Hygiene within County Durham & Darlington NHS Foundation Trust

Hand hygiene: hand washing assessment APPENDIX 1

Date:

Department/Ward: (use column below if drop in)

Assessor:

Name Ward/Dept

observed: or x

6 step technique observed: or x

Bare below elbows (including appropriate removal of any hand/wrist jewellery)

Nails short, clean, natural

Cuts/ abrasions covered

1

Palm to palm

2

Backs of hands

3

Palm to palm, fingers interlaced

4

Backs of hands/ opposing palms, fingers interlocked

5

Thumbs

6

Rotational rubbing, fingers on palms



APPENDIX 2

CDDFT HAND HYGIENE OBSERVATION TOOL

Format Monitoring adherence with hand hygiene and providing staff with feedback on their performance is strongly recommended in recent literature. There are a range of tools available for assisting staff in calculating hand hygiene compliance and a number are currently under development. The tool is adapted from the National NPSA Clean Your Hands Campaign.

Ward managers are advised to identify staff on the ward who will undertake observations. This could be an infection control link practitioner. The identified person should attend a training session before using the tool (contact Infection Control Team on ext. 43024 at DMH and 32190 at UHND)

Sample tool: The Lewisham observational tool

The hand hygiene observation tool is designed to assist staff in observing hand hygiene behaviour and allows for meaningful feedback to staff.

It is based on a tool used in one of the largest studies undertaken internationally on hand hygiene which demonstrated that feedback was a key feature of improvement.

The basis of the tool is that it allows you to record over a 20-minute period whether healthcare workers who touch patients have adequately decontaminated their hands in a timely way.

The model used here has been adapted by Jeanes (2002) from that used by Pittet et al (2000) and used extensively in University Hospitals Lewisham (UCH), further adaptation took place to include staff groups at Mayday University Hospitals.

The tool is based on the principle that when touching patients (or their environment) healthcare staff have ‘hand hygiene opportunities’.

Hand hygiene opportunities

The following provides some examples to illustrate opportunities for cleaning hands:

Before touching a patient’s skin Before doing a sterile procedure After handling body substances After touching a patient

All of the above should be followed by hand washing or use of alcohol hand rub.

The observations tool compares hand hygiene opportunities (O) with actual observed hand hygiene (H). Compliance can then be expressed as a percentage.

Compliance can be defined as either washing hands with soap and water or rubbing with an alcohol rub in accordance with a hand hygiene opportunity, so

Compliance = observed hand hygiene (H) x 100 = compliance %

hand hygiene opportunity (O)


Instructions 1. The staff member undertaking observation should undertake a number of practice

observations to get familiar with the tool and to minimise the Hawthorne Effect. This also reduces staff on the wards’ awareness of the presence of the observer.

2. Observations can take place by just one person or with a partner.

3. Identify an area within your ward/department where you can comfortably observe staff.

Stay in this place for 20 minutes and observe your ’window’ of activity. Do not move from this place during the 20 minutes. If staff walk away without you seeing whether they perform hand hygiene, do not follow them. Do not mark anything down unless you see it.

4. Position yourself so that you do not cause an obstruction but c an still see what is

happening. It may feel strange and you might think that you are too noticeable. This is normal and the best thing is to just carry on.

5. Observe for 20-minute periods.

6. Using the observation sheet mark an ‘O’ for a hand hygiene opportunity and a ‘H’ for an

actual hand hygiene activity taking place. If hand hygiene does not take place leave it blank.

7. When you have completed 20 minutes observation, give feedback to the staff – a feedback

form is included in this pack. When you give verbal feedback try to stress positive findings first and if you give negative feedback give examples and suggestions for improvement.

8. Keep hold of the completed observations and hand to the Senior Nurse for your area.

9. While you are observing you may identify issues which are barriers to hand hygiene, eg.

no soap, obstructed sinks, no alcohol hand rub by the bed, alcohol hand rub not working, alcohol hand rub empty – include this in your feedback.

10. Senior Nurses should compile these results and ensure results are entered onto the KPI

dashboard.



CDDFT hand hygiene observation sheet

Date: Time: Location:

Observer:

Nurses/Stn

Doctors

HCAs

Others

20-minute period

Compliance = observed hand hygiene (H’s) x 100 = Compliance percentage

hand hygiene opportunities (O’s)


Hand Hygiene Observation Tool - Feedback Form

Date

Time

Ward/unit

Observers

Score: Observed hand hygiene (H) x 100

Hand hygiene opportunities (O)

Score by staff group (if requested)

Score compared to last observation

Score compared to divisional/unit/directorate average

Specific feedback

Feedback given to:

Further action required


INFECTION CONTROL AUDIT TOOL

Hand hygiene facilities

APPENDIX 3

Standard: Hands will be decontaminated correctly and in a timely manner using a cleansing agent, at the facilities available, to reduce the risk of cross infection.

Date ……………………………..………..… Ward ………….……………………………..

Auditor …………………………..….………

Yes

No

N/A

Comments

1

Liquid soap is available at all hand washing sinks

2

Liquid soap must be single use cartridge dispensers

3

Dispenser nozzles are visibly clean

4

Soft absorbent paper towels are available at all hand washing sinks

5

Wall mounted or pump dispenser hand cream is available for use.

6

Antibacterial solutions are only used for invasive procedures and surgical scrubs

7

The hand wash sinks are free from plugs, overflows, used equipment and inappropriate items.


Yes

No

N/A

Comments

8

Hand wash sinks are dedicated for that purpose.

9

There are sufficient numbers of hand wash sinks available, e.g. one sink per bay or side room.

10

Access to hand wash sinks is clear

11

Hand washing facilities are clean and intact (Check sinks, taps, splash backs)

12

There is appropriate temperature control to provide suitable hand wash water at all sinks.

13

Elbow operated or automated taps are available in hand wash sinks in clinical areas.

14

Disposal bins are available and well placed for disposal of paper towels

15

Information posters regarding hand hygiene are available at the entrance to wards and departments.

16

Alcohol hand rub is directly accessible at the point of care (e.g. one dispenser per bed) or hand held.

17

Alcohol hand rub is portable for clinical procedures

18

Staff are aware of uniform policy and do not wear wrist watches/stoned rings or other wrist jewellery when carrying out patient care.

19

Staff nails are short, clean and free from nail varnish.

20

Posters promoting hand decontamination are available and displayed in areas visible to staff before and after patient contact


Yes

No

N/A

Comments

21

Patients are offered hand hygiene facilities after using the toilet/commode/bedpan e.g. hand wipes.

22

Patients are offered hand hygiene facilities prior to meals.

Observational audit

23

Nursing staff use the correct procedure for decontaminating hands (observe practice)

24

Medical staff use the correct procedure for decontaminating hands (observe practice)

25

Allied Health Care Professionals (eg physiotherapist, occupational therapist etc) use the correct procedure for decontaminating hands (observe practice)

26

Ancillary staff (eg portering staff) use the correct procedure for decontaminating hands (observe practice)

27

Nursing staff can indicate when it is appropriate to use alcohol rub

28

Medical staff can indicate when it is appropriate to use alcohol rub

29

Allied Health Care Professionals can indicate when it is appropriate to use alcohol rub

30

Ancillary staff can indicate when it is appropriate to use alcohol rub

Hand hygiene is performed in the following circumstances (observe practices)

31a

Following patient contact


Yes

No

N/A

Comments

31b

After removal of gloves

31c

Prior to clinical procedures

31d

After a clinical procedure

31e

Prior to handling food

31f

After handling contaminated items

31g

After leaving an isolation room


Appendix 4


Appendix 5


Appendix 6

Equality Analysis / Impact Assessment

Full Assessment Form v2/2011

Division/Department: Nursing and Transformation/Infection Control Department

Title of policy, procedure, decision,

project, function or service:

Policy for hand hygiene within County Durham & Darlington NHS Foundation Trust

Lead person responsible: Senior Nurse Infection Control

People involved with completing

this:

Infection Control Team

Type of policy, procedure, decision, project, function or service:

Existing

New/proposed

Changed


Step 1 – Scoping your analysis

What is the aim of your policy, procedure, project, decision, function or service and how does it relate to equality?

The aim of this Policy is to set out the importance of hand hygiene in improving patient/client safety by reducing transmission of infectious organisms and Health Care Associated Infections (HCAI’s) during delivery of care and to set out a formal statement of principles and recognised hand hygiene practice and techniques for all health care staff.

Who is the policy, procedure, project, decision, function or service going to benefit and how?

Staff and patients.

What outcomes do you want to achieve?

To improve patient/client safety by reducing the transmission of infectious organisms and Health Care Associated Infections (HCAI’s) during delivery of care.

What barriers are there to achieving these outcomes?

None.

How will you put your policy, procedure, project, decision, function or service into practice?

Policy will be disseminated Trustwide and available on the Trust intranet. Infection Control Newsletter alerts people that there is a new policy.

Does this policy link, align or conflict with any other policy, procedure, project, decision, function or service?


No.

Step 2 – Collecting your information

What existing information / data do you have?

The Policy is based on National Guidance and is relevant to all groups.

Who have you consulted with?

Infection Control Team and Infection Control Committee

What are the gaps and how do you plan to collect what is missing?

None

Step 3 – What is the impact?

Using the information from Step 2 explain if there is an impact or potential for impact on staff or people in the community with characteristics protected under the Equality Act 2010?

Ethnicity or Race

No impact or potential for impact on any group


Sex/Gender


Age


Disability


Religion or Belief


Sexual Orientation


Marriage and Civil Partnership


Pregnancy and Maternity


Gender Reassignment



Other socially excluded groups or communities e.g. rural community, socially excluded, carers, areas of deprivation, low literacy skills


Step 4 – What are the differences?

Are any groups affected in a different way to others as a result of the policy, procedure, project, decision, function or service?

No.

Does your policy, procedure, project, decision, function or service discriminate against anyone with characteristics protected under the Equality Act?

Yes No

If yes, explain the justification for this. If it cannot be justified, how are you going to change it to remove or mitigate the affect?

N/A

Step 5 – Make a decision based on steps 2 - 4

If you are in a position to introduce the policy, procedure, project, decision, function or service, clearly show how this has been decided.


Following consultation with Infection Control Team and Infection Control Committee. Approved at Quality & Healthcare Governance Committee.

If you are in a position to introduce the policy, procedure, project, decision, function or service, but still have information to collect, changes to make or actions to complete to ensure all people affected have been covered please list:

N/A

How are you going to monitor this policy, procedure, project or service, how often and who will be responsible?

As detailed in Section 17 (page 8) of this policy. Step 6 Completion and Central Collation

Once completed this Equality Analysis form must be attached to any documentation to which it relates and must be forwarded to Jillian Wilkins, Equality and Diversity Lead. [email protected]

mailto:[email protected]