infection prevention and control assurance

Version 2.0 December 2018

Infection Prevention and Control Assurance

Target Audience

Who Should Read This Policy

All BCPFT Staff

Infection Prevention and Control Assurance Policy

Version 2.0 December 2018 2

1.0 Introduction 4

2.0 Purpose 4

3.0 Objectives 5

4.0 Process 6

5.0 Procedures connected to this Policy 8

6.0 Links to Relevant Legislation 8

6.1 Links to Relevant National Standards 9

6.2 Links to other key policy/s 9

6.3 References 9

7.0 Roles and Responsibilities for this Policy 11

8.0 Training 17

9.0 Equality Impact Assessment 17

10.0 Data Protection and Freedom of Information 18

11.0 Monitoring this policy is working in practice 18

Appendices

1.0 Infection Prevention and Control Assurance and Accountability Arrangements 21

2.0 Ward/Departmental Infection Prevention and Control Competency Check List 22

3.0 Infection Prevention and Control Standard Operating Procedures index list 25

Ref. Contents Page



Explanation of terms used in this policy

Term used Explanation

Bacteraemia The presence of bacteria in the blood – a potentially life threatening infection

Clinical staff Clinical staff work directly with patients providing direct care within in-patient and community service areas (or having direct contact e.g. receptionists, housekeepers)

Competence (Competency) The ability of an individual to do a job properly. A competency is a set of defined behaviours that provide a structured guide enabling

the identification, evaluation and development of the behaviours in

individual employees

Health Care Associated

Infection (HCAI)

Infections that are acquired as a result of healthcare interventions

Outbreak An outbreak is the occurrence of more cases of disease than normally expected within a specific place or group of people over a

given period of time

Infection Prevention and Control Standard Operating

Procedures (IPC SOPs)

Are standard procedures to be followed in carrying out a given task, a clear set of instructions to be followed to optimise patient,

staff & visitor safety

Surveillance A system used to detect infections early, identify common source

outbreaks and identify any problem areas



1.0 Introduction

The prevention and control of healthcare associated infections (HCAI) remains high on the government agenda with a continued focus to reduce HCAI’s, improving and sustaining the quality of care provided by NHS Trusts. This is reinforced by Care Quality Commission (CQC) Outcome 8 (Regulation 12) Cleanliness and Infection Control which requires all providers to comply with the Health and Social Care Act 2008, Code of Practice for health and adult social care on the Prevention and Control of Infections and related guidance. This policy should be read in conjunction with the Infection Prevention & Control Annual Work Plan. This policy relates primarily to the Infection Prevention & Control functions of the Trust. This policy is supported by a suite of Infection Prevention & Control Standard Operating Procedures (IPC SOPs) which give specific information on prevention & control of infections to our workforce. This policy details the organisational structure and the operational systems and assurances which are in place to ensure that infection prevention & control activity is focused, coordinated, owned and communicated effectively within the Trust. The Trust is required to reduce the potential for infection. Therefore it is essential that staff seek advice from the Infection Prevention and Control Team:

prior to the purchase of new equipment

before new building work occurs

any commissioning of capital developments. Managers need to make contact with the Infection Prevention and Control Team at an early stage in order to ensure compliance with essential standards.

2.0 Purpose

The purpose of this document is to set out the system for the prevention and control of infection in the Black Country Partnership NHS Foundation Trust, which is a key priority within the Trusts strategic objective of patient safety. The Trust has a continued commitment to an approach whereby prevention & control of infection is viewed as integral to service delivery and development.

The implementation of this policy will ensure that:

There is support from the Executive Team for the Infection Prevention and Control (IP&C) Annual Programme.

The Director of Infection Prevention and Control (DIPC) and the Infection Prevention and Control Team have prime responsibility for the day-to-day management of the infection prevention and control service.

The infrastructure of the Infection Prevention & Control Team is made clear.

Trust wide targets are defined within the infection prevention and control annual work plan, with processes for monitoring progress against the agreed standards to prevent avoidable infections e.g.

- MRSA, MSSA and E. coli bacteraemias

- Reducing rates of Clostridium difficile

- Reducing the incidents of outbreaks of infections



- Preventing the emergence of resistance in infectious agents

Individual roles and responsibilities are identified with robust arrangements for the prevention and control of infection which are clearly understood within the Trust.

Infection prevention and control is embedded at all levels of the organisation ‘from the Board to the Ward’

Standard operating procedures and policies for effective infection prevention and control are in place (See Infection Control Standard Operating Procedures listed in Appendix 3 for detailed information).

Groups/Divisions involvement with the annual infection prevention and control programme reflects their commitment to preventing infections and completing actions plans defined by audit findings within the agreed timeframes.

Infection Prevention Champions have protected time for infection prevention & control activities including training and audit.

The process for the provision of training and education in the Trust is identified and supported by the Learning & Development Department.

The process for the ratification and review of Infection Prevention & Control policies and procedures is specified.

3.0 Objectives

Minimise the risk to patients from healthcare associated infection (HCAI) and prevent all avoidable HCAI’s and bacteraemia’s.

Maintain compliance with all the requirements of the Code of Practice for Health & Adult Social Care on the Prevention & Control of Infections & related guidance.

The continued delivery of education and training on the prevention and control of infection so that staff understand their personal responsibilities and take appropriate actions.

Continued commitment to working in partnership with other healthcare providers in the wider healthcare economy, to prevent infections as far as is reasonably practical.

The enhanced surveillance of infections across all in-patient areas in order to promptly recognise and respond to any problems.

To support proactive antimicrobial stewardship within the Trust.

Ensure appropriate information relating to infection risks is communicated to all relevant parties in a timely manner.

Ensure collaborative working within the Trust to ensure the maintenance of a clean and appropriate environment.

Ensure policies and procedures are in place to fulfil the requirements of the Health & Social Care Act.

To identify the roles and responsibilities of key personnel involved in the prevention and control of infection.

To identify the functions of the Infection Prevention and Control Committee and the Infection Prevention & Control Team.



4.0 Process In order to achieve these objectives the Trust has an annual workplan for the prevention & control of healthcare associated infections, along with a suite of Infection Prevention and Control Standard Operating Procedures (IPC SOPs), which will provide specific guidance for staff. These IPC SOP documents do not form part of this assurance policy but are listed in Appendix 3 and kept up to date by the infection Prevention and Control Team. Any changes are publicised via the Trust’s weekly communications e-bulletin and information is sent out by The Governance Assurance Unit to all managers in relation to new documents uploaded onto the Intranet. The IPC SOPs can be updated without the need for re-approving the policy itself. The lead officer who ensures that these documents are regularly updated is the Director of Infection Prevention and Control; and each procedure has a review date identified within it.

4.1 Ensure the Trust complies with the Code of Practice for health and adult social care on the prevention & control of infections & related guidance

The Trust is committed to ensuring compliance with the code of practice, under CQC Outcome 8 (Regulation 12).

The Trust monitors gaps in compliance through the CQC assurance framework, reporting exceptions to the Infection Prevention & Control committee, and implementing agreed corporate and divisional actions where necessary.

Divisions will continue to monitor compliance and address non-compliances through their governance processes.

4.2 Ensure the Training & Education of staff in relation to the prevention & Control of infection

The Trust is committed to ensure the workforce are educated and trained so that they have a clear understanding of the nature of infections and have the knowledge and attitudes to keep patients, staff and visitors safe from infection.

Infection prevention and hand hygiene training is part of statutory and mandatory training requirements for all staff.

Monitoring of training occurs through quarterly education key performance indicators and discussion at Divisional level, through Governance committees.

Practice is monitored through the infection prevention & control audit programme which are reported to the Infection Prevention & Control Committee quarterly, and annually to the Trust Board in addition to any exception reports.

Regular education & training sessions are also provided by the IPC Team to the nominated IPC Champions for them to cascade to the fellow workers.

The IPC Team continues to develop and update educational resources, such as standard procedures, e-learning packages and on-line resources for staff.

4.3 Work with Partners and External Agencies

The Trust is committed to working with partners to improve the patient pathway across the health care economy in order to reduce healthcare acquired infections. Key partners include:

Sandwell & West Birmingham Hospitals NHS Trust Royal Wolverhampton NHS Trust Dudley Group NHS Foundation Trust Dudley & Walsall Mental Health Partnership NHS Trust Public Health England Clinical Commissioning Groups



The Trust will continue to take part in national initiatives and innovations in order to improve patient safety in relation to the prevention of healthcare acquired infections.

4.4 Infection Prevention & Control Team Internal Processes & Systems

The IPC Team will continue to review internal department processes and systems to ensure they are effective in order to improve productivity, quality and make good use of available resources.

Continue to review and evaluate processes and systems of working

Undertake an annual service review to ensure the service meets the needs of the Trust when preparing the annual work plan.

Report any changes to the IPC Committee as part of the quarterly report delivery.

4.5 Surveillance Systems

The IPC Team is committed to the enhancement of existing surveillance systems, such as those for MRSA and Clostridium difficile. The IPC Team has introduced surveillance systems to meet the requirements set out in the Health & Social Care Act.

Routine surveillance of alert organisms and alert conditions is carried out each week and findings are reported in the IPC quarterly report - this assists the team to identify early and potential or actual outbreaks.

The IPCT advice clinical staff caring for patients on specific infections and in response to any microbiology results received.

4.6 Antimicrobial Stewardship

The Trust is committed to proactive antimicrobial stewardship. The IPC Team collaborates with the Pharmacy Department to ensure appropriate prescribing of antibiotics continues to be practiced. This is achieved through a combination of the IPC Team’s weekly surveillance which includes antibiotics prescribing information and regular ward visits undertaken by the Pharmacy & IPC teams.

The Trust has a comprehensive antibiotic prescribing policy approved by the Consultant Microbiologist.

Compliance monitoring occurs via completion of the Trusts Antibiotic Prescribing

Audit undertaken bi-annually in addition to the Pharmacy Teams weekly ward visits.

4.7 Patient and Public Involvement

The Trust is committed to the involvement of people who use our services in order to continuously improve the quality of care and the patient experience.

The IPC Team believes in patient and public involvement to aid the prevention of infection and improve the patients experience of healthcare acquired infections

The IPC Team have developed a series of patient information leaflets which are available on the intranet.

4.8 Infection Prevention Audit Programme

The Trust is committed to ensuring infection prevention standards and practice are monitored and to improving practice where poor compliance is observed.

Standards and practice are monitored via the annual infection prevention & control audit programme. Audits completed by clinical areas and teams are reported quarterly to the IPC Committee which aims to drive improvements in practice.

Any fall in standards are also monitored by the Matrons and the Divisional Governance Groups.



4.9 Policies and Procedures

The IPC Team ensures that policies and procedures are reviewed and updated within the specified review dates.

New policies are developed in consultation with key committees and staff members.

All IPC policies & procedures are approved by the IPC Committee members.

Trust policies are developed in accordance with the Code of Practice and CQC Outcome 8, through the CQC assurance framework.

Non-compliance and out-of-date policies and procedures will be reported as exceptions to the IPC Committee and the Governance Assurance Unit.

4.10 Infection Prevention & Annual Workplan

The Trust is committed to ensuring that Infection Prevention & Control is effectively planned and delivered.

The Annual Workplan is developed detailing priorities for the coming year and commences with each new financial year.

The annual workplan is approved, monitored, reviewed and updated quarterly following presentation to the Infection Prevention & Control Committee by the Lead Infection Prevention & Control Nurse.

Any priorities not addressed within the agreed time frames are reported as exceptions to the committee and the CCGs.

It should be noted that these priorities mirror the requirements of the Code of Practice which are also monitored by the CQC.

5.0 Procedures connected to this Policy

The Infection Prevention & Control Team has developed a comprehensive suite of Infection Prevention & Control Policies and Standard Operating Procedures (IPC SOPs), a list of these can be found in Appendix 3. 6.0 Links to Relevant Legislation Health and Social Care Act 2008 The Health and Social Care Act 2008 (revised 2015) sets out the code of practice for the prevention and control of infections. Good Infection prevention, cleanliness and prudent antimicrobial is essential to ensure that people who use health and social care services receive safe and effective care. Effective prevention of infection and cleanliness must be part of everyday practice and be applied consistently by everyone. Good management and organisational processes are crucial to make sure that high standards of infection prevention and cleanliness are set up and maintained. As the regulator of health and adult social care in England, the Care Quality Commission (CQC) will provide assurance that the care people receive, meets the fundamental standards of quality and safety. This Act outlines what registered providers in England, should do to ensure compliance with registration requirement 12 (2) (h) – providers must assess the risk of, and prevent, detect and control the spread of, infections, including those that are health care associated. It also sets out the10 compliance criteria against which registered providers will be judged.



6.1 Links to Relevant National Standards

CQC Fundamental Standards-

Regulation 12: Safe Care and Treatment - The intention of this regulation is to prevent service users from receiving unsafe care and treatment, in order to prevent any avoidable harm or risk of harm. To meet the requirement of this regulation, the provider must take appropriate steps to assure itself that the care and treatment it delivers is safe for all service users. This includes assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated.

Regulation 15: Premises and equipment - The intention of this regulation is to make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located, and that the equipment that is used to deliver care and treatment is clean, suitable for the intended purpose, maintained, stored securely and used properly. Providers retain legal responsibility under these regulations when they delegate responsibility through contracts or legal agreements to a third party, independent suppliers, professionals, supply chains or contractors.

6.2 Links to other key policy/s

Hand Hygiene Policy - The aim of hand hygiene is to prevent the spread of infection via the hands by removing transient organisms, or reducing them to a level where they no longer pose a threat to the next person or surfaces touched.

Infection Prevention & Control Policy - Pandemic Influenza Management Plan - This policy details the infection prevention and control measures that must be implemented and complied with in the event of an influenza pandemic affecting the Black Country Partnership NHS Foundation Trust’s.

Influenza (Seasonal) Vaccination Policy - This policy is intended to provide guidance for all healthcare workers within Black Country Partnership NHS Foundation Trust (BCPFT) regarding influenza: recognition; transmission; care of patients with symptoms; staff self-care and prevention of influenza (including vaccine administration to staff and in-patients). N.B. this policy is updated annually.

Management of Medical Devices Policy & associated SOPs - It is a requirement that all NHS Trusts have in place a comprehensive organisation wide policy on the deployment, monitoring and control of medical devices, as outlined in Managing Medical Devices: Guidance for Healthcare and Social Services Organisations 2014. This policy covers the provision for systems and process to ensure that whenever/ wherever a device is used it is:

- Suitable for its intended purpose - Properly understood by the professional and end user Maintained in

a safe and reliable condition

6.3 References

Clean, Safe care: Reducing Infections and Saving Lives( 2008).Department of Health, London



The Health & Social Care Act (2008) Revised 2015. Department of Health, London

Clinical Negligence Scheme for Trusts (CNST): Mental Health and Learning Disability Management Standards (2018)

Saving Lives: A delivery programme to reduce healthcare associated infection including MRSA (2005). Department of Health, London

Standards for Better Health (2004). Department of Health, London

Winning Ways. Working Together to Reduce Healthcare Associated Infection in England (2003). Department of Health, London

Getting Ahead of the Curve: A strategy for combating infectious diseases (2002). Department of Health, London



6.0 Roles and Responsibilities for this Policy

All staffs are responsible for establishing, maintaining and supporting a coordinated approach to infection prevention in all areas of their responsibility. All staffs have responsibility for complying with the Trust’s infection prevention & control policies and standard operating procedures and attending mandatory infection prevention and control training. All staff should aim to be proactive in identifying and addressing infection risks in their area of work and ensure they work towards reducing healthcare associated infections in order to improve patient safety and to meet local and national targets. Divisions, groups and clinical areas have a responsibility for ensuring staff engagement in the investigation of infectious incidents, outbreaks and for developing and implementing action plans in order to address areas of risk. Infection prevention & control must be a key component of business plans.

Title Role Responsibilities

Chief Executive/ Trust

Board Accountable

- Accepts collective responsibility for infection prevention and control within the Trust. This responsibility is delegated to the

Executive Lead for Infection Control – the Director of Nursing / Director of Infection Prevention & Control.

- Ensures there are effective arrangements in place to reduce the risk of healthcare associated infection and communicable diseases within the Trust.

- Meets all statutory requirements.

- Supports the measures to prevent and control the risks of healthcare associated infections.

- The Board will support the provision of adequate resources to secure effective prevention and control of healthcare associated infections.

- Ensures that Induction & Mandatory Training programmes include the basic principles of infection prevention, and that

programmes are adequately resourced (Groups/Divisions are accountable for ensuring all staff involved in the direct and indirect care of patients attend appropriate training sessions as requested).

- Receives infection prevention and control annual workplan and annual report outlining an effective audit programme that monitors compliance with key policies/standards.

- Receives exception reports as/when necessary detailing action taken where there are breaches in infection prevention or

control.

- Ensures appropriate management systems are established for infection prevention and control.

- Ensures that staffs have access to and adhere to clinical care protocols and infection prevention and control policies/standard operating procedures.




Director of Infection Prevention and Control

(DIPC)

Responsible

- Chairs the Infection Prevention & Control Committee & ensures the terms of reference are reviewed annually as agreed.

- Manages the Infection Prevention & Control Team within the organisation.

- Oversees local infection prevention and control guidelines and their implementation.

- Reports directly to the Chief Executive, the Board & Executive Committee/ Quality and Safety Committee every quarter and

with exception reports as necessary, having the authority to challenge inappropriate clinical hygiene practice as well as inappropriate antibiotic prescribing decisions.

- Ensures the board is made aware of any potential threats e.g. new resistant organisms, local outbreaks of infection etc.

- Assess the impact of all existing and new policies/procedures on healthcare associated infection and make recommendations for change.

- Oversees the production of the annual report on the state of healthcare associated infection within the organisation and release this publicly.

- Approves an annual work programme for the Infection Prevention & Control Team, which is discussed and agreed by the

Board. Quarterly reviews of this plan to be discussed at the Infection Prevention & Control Committee (& the board as deemed necessary).

- Advises the board regarding resources required to support improvements in infection prevention & control.

- Supports the Infection Prevention and Control team in the development and implementation of infection prevention and

control standards.

- Ensures new & existing national guidance is implemented promptly within the organisation and that the Infection

Prevention and Control annual work plan is amended as required incorporating new national guidance.

- The DIPC will be an integral member of the organisation’s Business and Performance Committee & Quality and Safety Committee.




Infection Prevention &

Control Committee

Approval and

Implementation

- Commissions and approves infection prevention and control policies/procedures and standards for the Trust (See

Appendix 1 for Infection prevention and control assurance & accountability arrangements Flow Chart).

- Ensures that infection prevention and control policies & procedures are implemented to ensure patients are protected from preventable infections.

- Ensures that infection prevention and control activities maintain a high profile within the organisation by meeting formally on a quarterly basis.

- Main forum where Service Managers/ Matrons representing each Group formulate and agree an annual programme of

activities including the commissioning of infection prevention and control policies/procedures.

- Include the following items as a minimum in their agenda: Infection prevention and control risks; reviewing of

Environmental Health Officers reports following kitchen inspections and the food service; water management (control of Legionella & Pseudomonas); waste management; hospital cleanliness and summaries of infection prevention and control

audit activities.

- Review summaries of their management when appraised of outbreaks of infection in order to learn from experience.

- Review projects undertaken throughout the year which impact on the prevention and control of infection for patients,

visitors and staff.

- Report as appropriate, any outbreaks or incidents involving microbiological hazard to the Chief Executive. All major

outbreaks must also be reported as Serious Untoward incidents to NHS England, Public Health England and Clinical Commissioning Groups.

- Assist in the planning and development of services and facilities on issues that are relevant to infection prevention &

control.

- Monitor and advise on specific areas of hygiene and infection prevention throughout the Trust.

- Report on the incidence and prevalence of alert organisms, novel and infectious diseases to the Chief Executive.

- Review outbreaks of infection and advise service managers on outbreak control and prevention measures for the future.

- Ensure that patients, visitors and staff, (including contractors) in the Trust are protected from infection wherever possible.

- Ensure that infection surveillance systems are in place to provide early warning system and to minimise the risk of infection.

- Ensure that an appropriate education and training programme is available for all Trust staff (including overseeing education necessary for ‘contracted out ‘services) in infection prevention and control practices.

- Ensure that information is available for patients, staff & visitors on the arrangements for preventing and controlling healthcare associated infections. Information will be available via the Infection Prevention & Control homepage on the

hospital intranet. In addition the annual report will be made available via the Trust Board meetings (open session).





Control Lead Nurse & Team

Lead and support

- Produces the Trusts Annual Infection Prevention & Control Programme and presents it to the Infection Prevention &

Control Committee for validation.

- Identifies and requests any resources required to deliver the annual infection & prevention control programme.

- Attends the Infection Prevention & Control Committee & produces quarterly and annual Infection Prevention & Control

reports summarising infection prevention and control activity in the trust during the reporting period.

- Plans the annual infection prevention and control audit programme and ensures detailed action plans are provided by the

Groups to rectify areas of non-compliance. Results from audit activity will be summarised within quarterly and annual

infection prevention and control reports to be discussed at the infection prevention & control committee.

- Collates surveillance data to monitor Healthcare Associated Infections and advises on action to minimise and reduce risks.

This includes reporting on the incidence and prevalence of alert organisms, outbreaks and incidents relating to infection prevention & control.

- Alerts the DIPC to any increase of infection or potential threats in a timely manner.

- Monitors and respond to outbreaks of infection by conveying the outbreak management team.

- Undertakes post infection reviews within 14 days of all MRSA, MSSA, E. coli bacteraemia’s and deaths (part 1a of death

certificate) associated with Clostridium Difficile and to share the learning from such reviews across the Trust and with the wider health care economy.

- Liaises with Acute NHS Trusts, Public Health England (Local Unit,) Clinical Commissioning Groups, Environmental Health Department and NHS England as required to notify specific infections.

- Produces and reviews infection prevention & control policies and standard operating procedures within the agreed

timeframes.

- Develops a programme of education, in conjunction with the learning and development team, for all trust staff in relation

to infection prevention and control procedures and management.

- Advises on infection prevention and control so that designers, architects, engineers, facilities & estate managers etc.,

working on new-builds, refurbishments or maintenance projects reduce risks of HCAIs at their inception.

- Advises on the contracting and monitoring process for clinical services e.g., Occupational Health, laundry, clinical waste disposal, domestic services, estates services and laboratory services.

- Advises on purchase & decontamination of medical devices and all infection control related products, e.g. sharps bins, wipes, gloves etc.

- Promotes effective communication with all relevant parties both within the Trust and the wider health care economy.

- Attends local, regional and national infection prevention and control events as requested to influence local and national

policy formation in relation to infection prevention & control.

- The DIPC, Lead Nurse - Infection Prevention & Control and the Infection Prevention & Control Nurse provide a service from 9.00am to 5.00pm Mon–Friday from the Trust Head Quarters, Delta House (Cover may be arranged outside of working hours by special arrangement).




Infection Prevention and Control Champions

Support

- Act as a local resource and point of contact for infection prevention and control issues. They have received specific training

to undertake this role from the Infection Prevention and Control Team.

- Champions, monitors and ensures best practice in infection prevention and control in their local workplace.

- Attends regular update meetings with the Infection Prevention and Control Team and feedback to their clinical team.

leaders/managers.

- Actively participates in all required infection prevention and control audit activities and reports findings to their manager.

- Completes action plans for areas of non-compliance and report any areas of non-compliance to their manager for action, if

the champion is unable to do so.

Microbiology Services &

Microbiology Consultants

Advice

- Provides Microbiology and antibiotic prescribing advice for medical staff through service level agreements with: Sandwell

and West Birmingham NHS Trust; Royal Wolverhampton NHS Trust; Dudley Group NHS Foundation Trust and Walsall

Healthcare Trust.

- Provides advice for Trust patient’s in-patient services within their geographical area (It should be noted that these

contracts are under review and services may change in the near future).

Lead Nurses/ Clinical Directors/ Service

Directors

Operational

- Have designated infection prevention and control responsibilities with identified outcome measures.

- Responsible for monitoring compliance with the infection prevention and control Policies, associated policies and standard

procedures. This responsibility also extends to the evaluation and purchase of equipment and supplies.

- Identifies any resources required to implement the infection prevention & control programmes within their Groups.

- Nominates representatives to attend the infection prevention & control committee. (These should be senior enough to be able to make decisions on behalf of the Group represented).

- Discuss any outbreaks, serious problems or hazards relating to infection prevention and control within the Group and

ensure action plans are completed and infection prevention & control is a standing agenda item at Group management boards.

- Ensures infection prevention & control responsibility & accountability is included in all job descriptions & KSFs.

- Ensures all clinical staffs have annual infection prevention and control competency review as part of the annual appraisal

process (Appendix 2).

Service Managers and Matrons

Operational

- Ensures that the cleanliness of hospital and healthcare premises are of the highest standards. The expectation for this should be included in the KSF for Matrons. They will liaise with and act on behalf of patients to ensure a cohesive

approach is taken which will include housekeeping, facilities management and infection prevention and control.

- Monitors compliance with the infection prevention & control policies/procedures and associated policies.

- Ensures Team Leaders release staff to attend infection prevention and control training programmes.

- Ensures infection prevention & control responsibility & accountability is included all job descriptions & KSFs.






Team Leaders/ Ward

Managers

Operational

Implementation

- Ensures that healthcare workers are free from and are protected from exposure to communicable infections during the

course of their work.

- Ensures infection prevention & control responsibility & accountability is included in all job descriptions & KSFs for staff in the team.

- Monitors compliance with the infection prevention & control policies/procedures and associated policies.

- Notifies the Infection Prevention & Control Team promptly when clients with known or suspected infection are admitted

and ensures an infection risk assessment & care plan is instigated.

- Ensures that all staffs are up to date with mandatory training for infection prevention and control (including new starters).

- Releases staff to attend induction and mandatory infection prevention and control training programmes, and inform the

infection prevention & control team of any additional specific training requirements relating to infection prevention & control.

- Releases and support infection prevention champions directly involved in the infection prevention and control programme

to attend meetings and undertake audits as required.

- Ensures all new starters are assessed on good hand decontamination techniques & complete the competency checklist

(Appendix 2).



All Employees Adherence

- Be aware of infection prevention and control policies & procedures and know how to access them.

- Know how and when to contact the Infection Prevention & Control Team.

- Promptly notify the Infection Prevention & Control Team of any infection risks.

- Attends induction and mandatory infection prevention and control training sessions as/when required.

- All clinical staff must complete the annual infection prevention and control competency review as part of the annual

appraisal process as directed by their manager (Appendix 2).

- Protects patients from infection by undertaking procedures correctly every time, for every patient, in every healthcare

setting - see Appendices 2 and list of IPC SOPs.



8.0 Training

What aspect(s)

of this policy will require

staff training?

Which staff groups require

this training?

Is this training covered in

the Trust’s Mandatory and Risk Management Training

Needs Analysis document?

If no, how will the training be

delivered?

Who will deliver the training?

How often will staff require training?

Who will ensure and monitor that staff have

this training?


Control (including Hand Hygiene &

Inoculation

Incidents)

All Trust staff Yes Learning and Development Team

On induction and annually thereafter

E-learning mandatory training

Workforce Development Group

Infection

Prevention &

Control Champions acting

as a local resource and

point of contact

for infection prevention and

control issues

Infection

Prevention &

Control Champions

No, champions will receive

specific training and

educational sessions in relation to their role and

responsibilities

Internally Infection

Prevention &

Control Team

Monthly/Quarterly

IPC Champions

meetings

Infection Prevention & Control

Team

Infection

Prevention &

Control Educational

sessions as per service needs

All clinical staff No Internally Infection

Prevention &

Control Team

As and when required

to meet service need

Service Managers/ Matrons

9.0 Equality Impact Assessment

Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]

mailto:[email protected]



10.0 Data Protection and Freedom of Information

Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data.

The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities; unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act.

All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.

11.0 Monitoring this policy is working in practice

What key elements

will be monitored? (measurable policy

objectives)

Where

described

in policy?

How will they be

monitored? (method + sample

size)

Who will undertake this monitoring?

How Frequently?

Group/Committee

that will receive and

review results

Group/Committee

to ensure actions

are completed

Evidence

this has

happened

Compliance with Hand Hygiene

Manual of IPCSOPs –

SOP 1

Inpatient Services Audit

Infection Prevention & Control Team

Monthly Infection Prevention & Control Committee

Infection Prevention & Control Committee

Detailed in Infection

Prevention & Control

Team’s Quarterly and

annual

reports and exception

reports

Community Services Audit


Quarterly

Compliance with Disposal of Sharps Waste


Inpatient Services audit


Monthly Infection Prevention & Control Committee





What key elements


objectives)

Where described

in policy?

How will they be


size)


How Frequently?

Group/Committee that will receive and

review results

Group/Committee to ensure actions

are completed

Evidence this has

happened

SOP1 Audit Programme for all other areas


Annually Prevention & Control

Team’s

Quarterly and annual

reports and exception

reports

Compliance with Environmental Cleanliness


SOP 1

Matrons audits (In-Patient Units only)

Service Matrons Monthly/ Quarterly





Team’s

annual report and exception

report

Compliance with the

Annual Infection

Prevention and Control Audit Programme

n/a All Inpatient Units

will be audited as per

the annual work plan & reported quarterly

to the IPC Committee


Control Team

Annually Infection Prevention &

Control Committee

Infection Prevention

& Control Committee

Detailed in

Infection


Team’s annual report

and exception

report

Other Clinical

Services will submit a Self-Assessment

Audit as per the

annual work plan & reported quarterly to

the IPC Committee

Self-Assessment

submitted to Infection Prevention & Control

Team

Annually Infection Prevention &

Control Committee


& Control Committee

Detailed in


Control

Team’s annual report

and exception report



What key elements


objectives)

Where described

in policy?

How will they be


size)


How Frequently?

Group/Committee that will receive and

review results

Group/Committee to ensure actions

are completed

Evidence this has

happened

In all cases of confirmed HCAI Infection the CCG is

notified within 24hrs (of

the next working day) by the Infection Prevention

& Control Team

n/a Feedback from Clinical

Commissioning

Group on receipt of quarterly report


Quarterly Clinical Commissioning Group



Prevention &

Control Team’s

annual report and exception

report



Appendix 1

Infection Prevention and Control Assurance and Accountability Arrangements

Trust Board / Chief Executive Officer

(Infection Control represented by DIPC)

Quality & Safety

Committee

Board of Directors

CEO, DIPC & Exec.Team

Infection Prevention & Control Committee Infection Control Team

Group Service Directors (via operational Safety &

Quality Group)

Team Leaders, Ward &/

Departmental Managers

All Trust

Employees

Dashed line indicates Quality Assurance compliance route Bold line indicates Operational Procedure Accountability & Compliance


Champions across the Groups


Ward/Departmental Infection Prevention and Control Competency Check List

NAME:

BAND: Personal No.:

DEPT:

DATE:

This checklist is to ensure an individual’s competence around infection prevention & control, hand hygiene and inoculation incidents. The following is not exhaustive, but outlines the main subject areas to be covered. Any specific infection prevention and control issues relating to the ward or department should be addressed as part of this induction. All clinical staff must have local infection prevention and control induction using this competency checklist within 4 weeks of commencement. This checklist must also be completed annually for all Qualified Nurses, Healthcare Support Workers, Medical Staff, Physiotherapy & Occupational Therapy staff. For all other clinical staff, this must be completed every 3 years. Upon completion a copy of this checklist should be retained in your Personal File by your manager, in your own Personal Development Profile.

Standard Requirements Assessor please print

Assessed as

competent Date

1. To be able to locate the infection prevention and control policies and have knowledge & awareness of the contents

Demonstrate to the assessor where the policies are located (Dept. folder & intranet)

Be able to discuss the type of information contained in the policy folder

Be aware of the Trust’s responsibilities in relation to the Health and Social Care Act 2008

2. To demonstrate knowledge of how to find additional IC information, patient leaflets, outbreak charts etc.

Demonstrate to the assessor how to access the Infection prevention and control home page on the Trust’s intranet

3. To be able to contact Infection prevention and control Demonstrate knowledge of when / how to contact the Infection prevention and control Nurse / Consultant Microbiologist and be aware of the procedures for ‘out of hours’

4. To know how & when to wash/decontaminate hands to minimise the risk of transmission of microorganisms

Be able to describe the principles of hand hygiene in the prevention of transmission of infection

Be able to demonstrate the ‘Ayliffe’ hand washing technique

5. To know when and how to use the correct Personal Protective Equipment (PPE) (gloves, aprons, masks & goggles)

Be able to demonstrate correct use of PPE

To be able to describe the principles of using PPE in the prevention of transmission of infection

6. To be able to segregate & dispose of sharps waste correctly in line with the Trusts policies

To demonstrate correct sharps & waste disposal in-line with the Trust’s Waste Management policy

7. To be able to segregate & dispose of household & clinical waste correctly in line with the Trusts policies

To be able to describe the principles of sharps segregation prior to disposal

To demonstrate waste disposal in-line with the Trust’s Waste Management policy

Appendix 2




Date assessed as competent

8. To know what to do following a needle stick / blood contamination or similar injury

To demonstrate knowledge of the immediate first aid required following a needle stick or similar injury to minimise the risk of acquiring an infection

To demonstrate knowledge of reporting systems following a needle stick or similar injury

9. To be able to segregate used/soiled/infected linen correctly & place ready for collection

To demonstrate knowledge of the correct linen disposal in-line with the Trust’s Laundry policy

10. To be able to decontaminate used equipment correctly between each patient use e.g. BP/TPR equipment, stethoscope, commode, hoist & other manual handling equipment etc.

To be able to recognise relevant symbols e.g. single use, sterile etc.

To describe the three levels of decontamination including being able to provide examples of equipment that needs to be decontaminated at those levels. (Cleaning, disinfection & sterilization)

Understand who is responsible for cleaning items used in patient care and how and when is this done.

Know how to identify single use items.

To describe their role in the maintenance of environmental cleanliness and impact on infection prevention and control

11. To be able to collect & label specimens correctly e.g. blood, urine, sputum, faeces, swabs etc. including safe transportation to the laboratory

To know the procedure for microbiological investigation such as specimen collection for screening and investigation, including safe storage & transportation of specimens

12. To be able to care for a patient with a known or suspected infection (see isolation policy)

Understand the principles of isolation; describe how to safely manage patients with specific alert organisms, for example MRSA, diarrhoea, and influenza.

13. To demonstrate competence in aseptic procedures (use of sterile equipment) to maintain asepsis

To demonstrate correctly a simple aseptic procedure (e.g. injection, small wound dressing) as described in the Royal Marsden manual of clinical nursing procedures

14 To be able to decontaminate following blood/body fluid contamination incident

To be able to demonstrate how to deal with blood / body fluid spillage as describe in the blood spillage policy

15. To be able to recognise and take appropriate action when an outbreak or cluster of infections is suspected

To demonstrate an understanding of what an outbreak is and be able to list immediate action to be taken

16. To be able to complete a risk assessment in relation to healthcare associated infections & know how to transfer a patient or receive a patient with a known or suspected infection to another ward / healthcare provider

To be able to correctly complete a patient Infection Risk Assessment and take appropriate action




Date assessed as competent

17. To understand what the standard precautions are and when they should be applied

To describe what the standard precautions are

18. To be able to understand the modes of transmission of influenza, norovirus and other organisms

To describe how a specific organism is spread from person to person

19. Cadaver bags – when & how to use them To demonstrate knowledge of how to find out when to use a cadaver (body) bag and how to obtain one

Comments:

Signature of line manager: Signature of employee:

N.B. A copy to be retained in the employees personal file



Appendix 3

Manual of Infection Prevention and Control Standard Operating Procedures (SOPs)

Contents

IPC

SOP

Topic

1 Standard Infection Prevention and Control Precautions (SICPs):

Patient Placement,

Hand Hygiene - please see separate policy

Respiratory Hygiene and Cough Etiquette

Personal Protective Equipment (PPE)

Management of Care Equipment

Cleaning and Maintenance of the Environment

Safe Management of Linen

Management of Blood and Body Fluid Spillages

Safe Disposal of Waste

2 Transmission Based Precautions– used in addition to standard precautions

Airborne Precautions

Contact Precautions

Droplet Precautions

3 Surveillance of Infection and Data Collection

Alert Organisms

Alert Conditions

Mandatory Reporting

Surveillance & Data Collection

4 Reporting Incidents of Infection to Public Health England and/or the Local Authority

5 Management and Recognition of Outbreaks of Communicable Infection/Disease

Outbreak Recognition

Outbreak Management

Closure of Wards/Departments due to Infection

Re-opening of Wards following an Outbreak

6 Isolation – Care of Patients in Isolation due to Infection or Disease

Care of Patients in Isolation due to Infection or Disease

Source Isolation - for Patients with a Known/Suspected Infection

Protective Isolation - for Immunocompromised/Neutropenic Patients

http://luna.smhsct.local/documents/policies-a-z/h/4153-hand-hygiene/file



IPC

SOP

Topic

7 Decontamination (Cleaning, Disinfection and Sterilisation)

Cleaning

Disinfection

Sterilisation

8 Sharps and Blood/Body Fluid Contamination Injury – Immediate Actions

Principles of Good Practice for the Prevention of Inoculation/splash Injuries

First Aid - Procedure for Immediate Management of an Occupational Inoculation / Bite or Splash Injury / Incident

9 A-Z of infections – A Quick Reference Guide

10 Aseptic Procedures

11 Cleaning Toys, Games & Play Equipment

12 Procurement, Cleaning, Replacement & Audit of Beds, Mattresses & Pressure Cushions

13 Closure of Bays or Wards due to an Infection Control Issue

14 Undertaking a Patient or Environment Infection Risk Assessment

15 Infection Prevention and Control in the Built Environment

Key Principles and Considerations

Sources of Infection

Common Problems to Avoid

Post Project Evaluation

Recommendations

16 Sharing Information with other Health and Social Care Providers

17 Preventing Infection in Indwelling Urinary Catheters

Key Principles for Preventing Infections Associated with the use of Urethral Catheters

Other Considerations

18 Post Infection Review (PIR)

19 Alert Organisms – MRSA (Meticillin Resistant Staphylococcus Aureus)

What is MRSA?

Routes of Transmission for Staphylococcus Aureus and MRSA

Clinical Isolates

Initial Screening to Identify MRSA Colonisation

Decolonisation/Suppression Regime

Caring for Patients with MRSA Colonisation/Infection

Outbreaks/Periods of Increased Incidence of MRSA



IPC

SOP

Topic

20 Alert Organisms – Clostridium Difficile

What is Clostridium Difficile?

Routes of Transmission for Clostridium Difficile

Key Recommendations

Caring for Patients with Clostridium Difficile / Potentially Infectious Diarrhoea

Reporting

Outbreaks/Periods of Increased Incidence of Clostridium Difficile

21 Alert Organisms – Glycopeptide Resistant Enterococci (GRE) and Vancomycin Resistant Enterococci (VRE)

What is GRE/VRE?

Routes of Transmission for GRE

Key Recommendations – Treatment and Management

Reporting

Outbreaks/Periods of Increased Incidence of GRE

22 Alert Organisms – Multi-Resistant Gram Negative Bacteria

23 Alert Organisms – Transmissible Spongioform Encephalopathy

24 Alert Organisms – Respiratory Viruses

25 Alert Organisms – Invasive Group A Streptococcus

26 Alert Organisms – Gastroenteritis

27 Alert Conditions – Blood Borne Viruses

28 Alert Conditions – Chickenpox and Shingles

29 Alert Conditions – Human Infestations

30 Alert Conditions – Tuberculosis

31 Alert Conditions – Typhoid (Enteric Fever) and Paratyphoid

Other IPC Policies:

Hand Hygiene policy

Pandemic Influenza policy

Seasonal Influenza vaccination policy

Infection prevention in vascular access infusion devices policy



Policy Details

* For more information on the consultation process, implementation plan, equality impact

assessment, or archiving arrangements, please contact Corporate Governance

Review and Amendment History

Version Date Details of Change

V2.0 Dec 2018 Full review & update made to Section 4.1; Appendix 3; All references checked and updated as necessary.

V1.0 Nov 2015 Alignment of policies following TCS and new policy format

Title of Policy Infection Prevention and Control Assurance Policy

Unique Identifier for this policy BCPFT-CO1-POL-05

State if policy is New or Revised Revised

Previous Policy Title where applicable N/A

Policy Category Clinical, HR, H&S, Infection Control etc.

Control of Infection

Executive Director whose portfolio this policy comes under

Executive Director of Nursing, AHPs and Governance

Policy Lead/Author Job titles only

Infection Prevention and Control Team

Committee/Group responsible for the approval of this policy

Infection Prevention and Control Committee

Month/year consultation process completed *

n/a

Month/year policy approved January 2019

Month/year policy ratified and issued February 2019

Next review date December 2021

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

Key Words for this policy Hand decontamination, Contamination, Infection, Environmental cleanliness

infection prevention and control assurance

Documents