infection, prevention & control - welcome to kent and ... · pdf fileinfection, prevention...

1

Infection, Prevention & Control

Annual Report 2014 - 2015

Compiled by: Donna Eldridge, Deputy Director of Nursing / Deputy DIPC

Rod Harford-Rothwell, Senior Infection Control Nurse

Prepared on Behalf of Pippa Barber, Director of Nursing & Governance Director of Infection Prevention and control (DIPC)

2

Contents Page Number

1. Forward

3

2. Executive Summary

5

3. Introduction

5

4. Structure, Accountability and Assurance

6

5. Reporting Mechanisms

7

6. The Health & Social Care Ace (2008) Code of Practice/Assurance Framework

7

7.

Policies 7

8. Clinical Audit and Effectiveness

8

9.

Antimicrobial Prescribing and Management 17

10.

Training and Education 17

11.

Link infection control nurse/Workers

18

12.

Needle stick / Sharps Injuries 18

13.

Outbreaks of Diarrhoea and Vomiting including Norovirus

19

14. MRSA Screening

20

15. Decontamination

20

16.

Commodes 21

17.

Flu Campaign 21

18.

Conclusion 21

Appendix A – Assurance Framework

22

3

1. FORWARD

I am pleased to present the annual infection prevention control report for 2014/15. The following report will provide an overview of Infection Prevention and Control (IPC) activities in Kent and Medway NHS & Social Care Partnership Trust and sets out the plans for the forthcoming year using the assurance framework. Infection Prevention and Control is one of the fundamental aspects of safe service delivery and everyone within the organisation, service users, carers and visitors to our services have a vital role to play in reducing the risk of spreading infection. As the Director of Infection Prevention and Control (DIPC), both I and the Infection Prevention control Team continue to be committed to ensuring that patient safety is at the forefront of everything we do. I commend this annual report to you and thank the Infection Control Team for their excellent leadership of this and all the Trust for their continued focus that they are giving to this important area Pippa Barber Executive Director of Nursing and Governance (DIPC)

4

2. EXECUTIVE SUMMARY

The Annual Report of the Director of Infection Prevention and Control provides information on the progress and achievements of the Infection Prevention Control Team throughout the period of 2014/15. The Corporate Nursing Team in 2014 developed a Physical Health Team which now incorporates infection prevention and control. The report continues to give assurance of the continual commitment to the prevention and control of infection within all services to achieve positive outcomes. This report summarises the infection control activities carried out in the Kent and Medway NHS & Social Care Partnership Trust during 2014 – 2015. The Trust continues to promote infection prevention and control as the heart of good management and clinical practice, and is committed to ensuring that appropriate resources are allocated for effective protection of patients, their relatives, staff and members of the public. In this regard, emphasis is given to the prevention of healthcare associated infection (HCAI) and the improvement of cleanliness in all our in-patient wards and community settings. This annual report has been written to provide information about our current progress on infection prevention and control and our future direction for the Trust. This information is primarily intended for our internal organisation, external partners, patients and their carers, but may also be of interest to members of the public in general.

5

3. INTRODUCTION

Kent and Medway NHS & Social Care Trust has a pro-active infection prevention and control team that is very clear on the actions necessary to deliver and maintain patient safety. Equally, it is recognised that infection prevention and control is the responsibility of every member of staff and must remain a high priority for all to ensure the best outcome for patients. The Trust has a zero tolerance to avoidable infections and a collective responsibility which places a duty on all staff to minimise the risk of infection at all times. The annual programme of work for 2014/2015 focused on ensuring ongoing compliance with the Health and Social Care Act 2008 This report provides assurance from the DIPC that the Trust has a robust, effective and proactive infection prevention and control programme in place that demonstrates compliance with the Health and Social Care Act 2008. The Trust is formally registered with the Care Quality Commission (CQC) and declared as

compliant with the Health and Social Care Act 2008. In December 2010, a revised code of practice was introduced for the prevention and control of health care associated infections (HCAI); The Health Act (2008), Code of Practice on the Prevention and Control of Infections and Related Guidance. The code of practice is also referred to as the Hygiene Code and is regulated by the Care Quality Commission. The Trust remains committed to ensuring that patient safety is at the forefront of everything we do and promotes infection prevention and control as the heart of good management and clinical practice. The Trust is committed to ensuring that appropriate resources are allocated for effective protection of patients, their relatives, staff and members of the public. Infection prevention and control continues to be essential in ensuring that people who use health and social care services receive safe, effective, well-led, responsive care. Effective prevention and control must, and is part of everyday practice and has to be applied consistently by everyone. Infection Prevention and control is everyone’s business . The key documents and legislation including that the Organisation adheres to are:

Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.

Care Quality Commission (Registration) Regulations 2009.

Care Quality Commission Essential Standards of Quality and Safety 2009.

Code of Practice for health and adult social care on the prevention and control of infections

and related guidance (2010) - Outcome 8 of Essential Standards of Quality and Safety 2009.

All relevant NHS / DH / NPSA Guidance.

All relevant expert guidance / evidence-based practice.

Evolving clinical practice, expanding services, emerging infections, antimicrobial resistance and an increase in vulnerable populations present new challenges for which a constant review of policies and procedures is essential.

6

4. STRUCTURE, ACCOUNTABILITY AND ASSURANCE

The structure for the Management of the Infection Prevention and Control Service is in compliance with Hygiene code 2008 The Chief Executive is accountable for the provision of a safe patient environment, Including the prevention and control of healthcare associated infection. The Director of Infection Prevention and Control (DIPC) The DIPC has lead responsibility for the prevention and control of healthcare associated infection (HCAI) and is accountable for this to the Chief Executive. The Trust wide Infection Control Group meets bi monthly and draws clinical members of staff from all Service lines. It is the key forum for the discussion; development and planning of all activities by which the Trust Board both receives and provides assurance those systems are in place for the prevention of HCAI. The Infection Control Team. This team comprises of the DIPC, Deputy DIPC. In 2014 the formulation of a physical health team commenced and this now incorporate IP&C The Senior Infection Control Nurse who report directly to the physical health lead nurse, carries out the day-to-day management of the Infection Control Service. Microbiology Services. The processing of clinical specimens is carried out via the microbiology departments within the 4 Acute hospitals within Kent through service level agreements. (SLA)

Donna Eldridge Deputy Director of

Nursing (Deputy DIPC)

Angela McNab Chief Executive

Pippa Barber Director of Nursing

& Governance (DIPC)

Alison Worsfold

Physical Health Lead Nurse

Rod Harford-Rothwell

Senior Infection Control Nurse

7

5. REPORTING MECHANISIMS

In 2014/15 the DIPC reports to the board on a bi-monthly basis. These reports are exception reports and risk incident summaries. Data surveillance for the previous month is also reported on. Data surveillance of all suspected or confirmed infections are emailed through to the infection control team from all services and this is monitored through the Trust wide Infection Prevention and Control group. The day to day infection control issues are dealt with in the first instance by the Senior Infection Control Nurse with support and advice from the Physical Health Lead Nurse and Deputy DIPC. The members of the Infection Control Team provide infection control expertise including results of surveillance, audit and alert organism reporting to a variety of groups across the organisation. The senior infection control nurse has continued to provide a named infection control link to senior staff within the services lines.

6. ASSURANCE FRAMEWORK

The Health and Social Care Act’s (2008) Code of Practice for health and adult social care on the prevention and control of infections and related guidance (also known as the Hygiene Code) was revised and came into force in April 2010.

The Kent and Medway NHS and Social Care Partnership Trust formulated an assurance framework which ensures that all relevant actions are being taken by our Trust to ensure compliance with the 10 criteria identified in the Hygiene Code. The Infection Prevention and Control Team (IP & C) produces the assurance framework which provides our Trust with a simple but comprehensive method for the effective and focused management of the principal risks to meeting our objectives. It also provides a structure for the evidence to support the statement on internal control. (Appendix A)

7. POLICIES

The following policies were updated during 2014-2015 and are available to staff on the staff intranet and in paper format kept on the wards / units:

Acintobacter ANTT – Aspetic Non-Touch Technique Blood Borne Virus Management – (New 2015) Books, Toys, Games & Magazines Cleaning Policy (New 2015) Clostridium difficile Management Policy Hand Hygiene Human Infestation Policy [formerly Scabies & Headlice Policy] (New 2015) Isolation Nursing Policy Mattress, Cushions, Duvet & Pillow Policy (Revised) MRSA Screening Taking Specimens Trust-wide Infection Prevention & Control Policy Tuberculosis Vancomycin Resistant Enterococci /.Glycopeptide Resistant Enterococci Varicella Zoster Virus (VZV) Viral Haemorrhagic Fever / Ebola Ward Closure Policy

8

During this time the IP&C Team revised all patient information leaflets to keep them current and up to date with best practice guidelines also The Infection Prevention and Control Aide Memoir leaflet was revised during 2014-2015.

The policies are reviewed and updated in line with current legislation and guidance.

8. CLINICAL AUDIT AND EFFECTIVENESS

There were 3 audits undertaken and described in this report:

1. Trust wide Infection Prevention and Control Audit (to include the unannounced visits) 2. Hand Hygiene Audit 3. Mattress Audit

TRUST WIDE INFECTION PREVENTION & CONTROL AUDIT (incorporating the unannounced visits)

Reducing nosocomial healthcare associated Infections is of major national and local concern for the health service in order to help reduce needless harm to service users and reduce the impact HCAI’s can have on the trust. The Kent and Medway NHS & Social Care Partnership Trust (KMPT) are required to produce an audit to develop and implement plans for reducing Healthcare Associated Infection (HCAI), including Methicillin Resistant Staphylococcus Aureus (MRSA), Clostridium difficile (C.diff) and other significant infections. Last year the data collection audit tool used was SNAP - software made available via a web link which could be accessed via the KMPT Staff Zone website. However due to the time element involved it was agreed at the Trust Wide Infection Prevention and Control Committee for the Senior Infection Control Nurses (SICN) to carry out this audit. This had a 2 fold effect:

1. To reduce the burden of audits on the ward teams 2. To increase inter-rata reliability by having an infection control practitioner undertaking and reporting

the data captured. The audit tool used was adapted from a previous version that had been updated and revised. The environmental elements (Kitchens areas) are audited by the Quality and Performance Teams by Kent & Medway Facilities on behalf of the trust and undertaken separately thus avoiding duplication. Both auditors discussed the marking of the elements assessed to ensure that we capture as much information with regards to meeting the HSCA’s 10 elements.. It was agreed at the Trust Wide Infection Control Group (ICG) that all in patient units including the recovery service would be audited, an audit cycle was developed and if wards scored 90% or higher at every 6 months, 3 monthly if below 90% and monthly if 60% or lower through the unannounced visits structure. Once an audit is undertaken each ward / community team is provided with a copy of the audit tool, action plan with a time frame to complete and return the action plan to complete the audit process. RESULTS (General)

In-Patient:

From the audits conducted between April 2014 –March 2015 the trust has seen a significant improvement in the wards compliance from their initial visits to any subsequent revisits, Issues around sharps management, decontamination, policies and signage have been addressed both at the time of the audit and later during infection control training sessions.

Community:

The biggest challenges for community teams were around the safe carriage of sharps and waste products when travelling in the car to visit clients in their own homes. The IP&C team saw this as a significant risk to the worker and this process was looked at jointly with the Dangerous Goods Safety Officer (DGSO) to

9

check compliance with the law on their carriage and current guidance. Following this study, changes were made to ensure that community teams procure the right container to meet UN 3373 and UN 3291 through the use of the red safety box was rolled out to contain these products to meet the carriage of dangerous goods standards. There had also been inconsistencies of waste disposal at some sites due to the wrong sharps products placed in certain containers to dispose of their waste items.

AUDIT DATA RESULTS COMPARISON BY SERVICE LINE (YEAR END)

ACUTE SERVICES

OLDER ADULTS

FORENSIC & SPECIALIST SERVICES

10

REHABILITATION SERVICES

COMMUNITY SERVICES Community Teams: The trusts community teams saw a large reorganisation of their services with some units moving to new larger premises and others into hubs to enable a more efficient use of these teams for the communities that they serve. Thirteen community audits have been carried out during this reporting period. Community teams are audited annually, this year saw a significant improvement of the units audited and 2 units fell below the 90% standard ensuring compliance with the Health & Social Care Act, Eleven teams scored 90% or higher during this period. This is a fantastic effort compared to last years report and shows that infection control is being successfully implemented within these teams.

11

The biggest challenges for the community teams were around the safe carriage of sharps and waste products when travelling in the car to visit clients in their own homes. This process was looked at jointly with the IP&C team and the Dangerous Goods Safety Officer (DGSO) officer to check compliance with the law on their carriage and current guidance. Following this study changes were made to ensure that community teams procure the right container to meet UN 3373 and UN 3291 Carriage of dangerous goods standards. There had also been inconsistencies in waste disposal of sharps using the wrong coloured containers. Alcohol hand rubs were in abundance and still in use in addition to issues highlighted around the cleaning of the buildings and clinical areas.

Of the two units that failed to meet the 90% standard they were re-audited within 3 months to assure the organisation of the teams compliance. There were no teams scoring less than 70%..

SUMMARY The trust-wide unannounced visits form part of the overall Infection Prevention and Control Audit strategy and have proved enormously beneficial to ensure that all in-patient units and community teams comply with the Trust’s policies and procedures and to meet the 10 elements of the HSCA 2008. Where inconsistencies or areas that have failed to meet these standards were discovered, these were addressed quickly and action plans devised and sent to the ward / unit managers, service leads and associate directors to address any issues to ensure that they are remedied quickly and reducing risk to service users and the organisation. There was an additional benefit in these visits by providing face to face training including staff of all disciplines participating in the hand hygiene exercise using the ultra violet hand box as a tool to demonstrate both good and poor techniques in hand hygiene. 305 staff participated in this exercise. In-line with all NHS Organisations were are obliged to produce, monitor and manage any policies devised to help to protect our service users from harm acting as a guideline for safe practice, all policies are reviewed regularly and also when any new guidance is published nationally, This reporting period saw many of our policies reviewed and these are now in place. Every ward, unit and community team that was inspected had demonstrated good practice had this was re-affirmed in their individual audit report. The unannounced inspections being a valuable resource will continue throughout the year.

12

HAND HYGIENE AUDIT The trust regularly undertakes a hand hygiene audit across all inpatient services conducted by the infection control link practitioners it’s aim is to ensure that effective hand hygiene remains a solid and essential basis for the attainment of patient safety, contributing to a significant and measurable reduction in healthcare associated infections (HCAI’s).

From 2013, all older persons in-patient wards are expected to complete monthly observational hand hygiene audits. Forensic, Acute and Community Recovery Units complete the observational audit annually. The results of these audits are returned to the infection control team who compile the data into an excel spreadsheet and to ensure that all in-patient sites had participated.

Best Practice Identified: Certificates are generated upon completion of monthly / annual hand hygiene audit and displayed in the wards / units infection control notice board or at the entrance to the unit n recognition of good practice and achievement.

The above table shows that full compliance was met across all audited areas when the hand hygiene audits were undertaken. This is the third successive year that improvements have been achieved. Scoring: The audit scores are RAG rated (Red, Amber, Green) determined by their %.

Red under 70% Amber under 90% Green 90% and above

13

Figure 1: Acute Service Line

Hand hygiene audit compliance across the Acute Service Line is reported as 100% between April 2014 and March 2015. These audits are conducted by the Infection control link practitioner conducting a 20 minute observational audit on an annual basis. Figure 2: Older Persons / Specialist Services

The Older Adult service line is required to undertake a monthly hand observational hand hygiene audit as agreed with our commissioners, these audits are conducted by the link nurse for each clinical area. The 2014 – 2015 reporting period saw all units report full compliance with this guidance.

14

Figure 3: Forensic Service Line

The Forensic & Specialist service line hand hygiene audits are undertaken by their link nurses and are conducted on an annual basis and once completed forwarded to the Infection Control team. The total compliance for the Forensic service line is reported at 100% using the Lewisham hand hygiene tool. Figure 4: Community Recovery Service Line

These audits are conducted by the link nurse for each unit and they are responsible for carrying out these audits on an annual basis. All departments reported full compliance when using the Lewisham hand hygiene tool.

15

URINARY TRACT INFECTION AUDIT

The aim of this audit was to examine the amount of urinary tract infections being reported across the trust during April 2014 and March 2015 looking at the type of infection and whether a indwelling urinary device was present., also to see if there were any reasons or common trends that would explain the recent increase seen in reporting. This audit identified that the trust saw a decrease in the numbers of urinary tract infections (UTI’s) being reported with 99 cases reported over the year 2014-2015 against 193 for the 2013-2014 period.

Urinary tract infections are one of the most common type of infections reported in patients which can have a detrimental affect on their physical health as well as their mental health state. They result in prolonged hospital stays and increased costs for healthcare providers. Urine infections can affect a patients personality and behaviour and go on to cause some acute and challenging traits to manifest. Urine infections can be caused by and through poor hygiene practices, poor hydration resulting in not keeping the urinary tract healthy or also due to indwelling devices used to monitor renal function of a patient. Indwelling devices (Catheters) are a particular risk as they need to be monitored by healthcare professionals daily to make sure the device does not become contaminated or encrusted and that they are used for a specific reason and for the shortest time.

“A catheter is a ladder to the bladder” For the purpose of increased surveillance the UTI audit looked at a period 3 months snapshot audit to see how this affects the service lines and the type of infections being reported.

16

This audit period highlighted that the Older adult service line had 1 E-Coli (ESBL) urine infections that required specialist treatment due to their resistant nature to some antibiotics. The greatest number of urinary tract infections was seen within the older person service line over the financial year. This is due in part to this group of service users which may already suffer with reduced immunity and long term urinary tract problems which can and may be long standing, this makes them particularly harder to treat with the service users diminishing mental health state. All these identified urinary tract infections across all service lines were treated with antibiotics which are monitored by the SICN and the antimicrobial pharmacist, antibiotics can pose a problem if these treatments are not managed effectively. All the reported infections were closely monitored by the infection control team to ensure that the treatment they were offered was appropriate and of the shortest duration to prevent any antibiotic associated diarrhoea. If a urinary tract infection is suspected, most UTI’s are treated with a broad spectrum antibiotic for the shortest duration which is used prophylactically until we know what organism is causing the infection. Where possible a urine sample is collected and sent to the laboratory for analysis in an attempt to isolate the organism responsible, the laboratory will inform the clinician to change treatments to be more specific to that infection isolated. Service users affected with organisms that are harder to treat have their antibiotic therapy adjusted by the microbiologist to ensure that the correct antibiotic was used to treat that coliform. The reporting of urinary tract infections by clinical areas showed that only 70% of these infections had a urine specimen sent for testing to confirm a genuine infection, although the service user was treated prophylactically and then treatment was reviewed at a later date. The data captured by the wards using the reporting template and mechanisms currently in-place across the trust show a greater awareness by staff through correctly assessing the problem and earlier reporting which is enabling service users to be correctly treated to prevent long term harm and reducing suffering. The data also shows that the majority of antibiotic treatments were appropriate in treating these infections with only a few requiring further treatment and monitoring. Findings: This report has shown a decrease on last years findings, although the amount of urinary tract infections for 2014-2015 remain steady and that treatment is being commenced earlier due to better recognition and monitoring . All antibiotic usage is being closely monitored to make sure that the service user is being treated effectively for the shortest duration possible with the correct treatment to prevent antibiotic associated diarrhoea. There are often seasonal variations that occur but these are short in duration and it is recommended that we will revisit this audit again to obtain further assurance. From May 2013 the Trust Development Authority (TDA) has required the Trust to record, capture and report all catheter associated urinary tract infections (CAUTI’s). We have the necessary mechanisms currently in-place to capture this data. The only areas that regularly use indwelling urinary devices (Catheters) are the Older Adult service line and the Knole Centre (WKNRU). TRUST WIDE MATTRESS AUDIT Hospital mattresses are often used by more than one service user these can denature quickly from their excessive use by facecal staining, pin-holes or broken seals. Poor maintenance of mattresses and their covers may lead to contamination or inner surfaces of the mattress covers. Mattress covers can become damaged at any time during use or storage, for example from: needle stick; strike-through; damage from sharp objects; abrasion during handling, transport or movement; inappropriate cleaning and decontamination procedures. The damage can encourage the growth of micro-organisms, which are a

17

potential cause of cross infection. If mattresses with non-removable covers are in use it is impossible to check the level of contamination on the inside. All inpatient sites were issued with instructions on the Mount Vernon Criteria for Mattress Auditing. This followed the MHRA Notification on the correct process. The results of the 2014 /15 Trust wide mattress audit shows that a total of 423 mattresses audited within all inpatient wards or units across all service lines. 12 mattresses failed due to broken or damaged surfaces and have been replaced 411 mattresses passed the audit. The trust has embarked on upgrading the mattresses in use across the trust and this has helped to achieve this figure.

o Acute service line 4 out of 177 mattresses had failed the audit, This was a reduction on the same

period last year.

o Older adult service line 4 out of 162 mattresses failed inspection

o Forensic and specialist service line audited 138 mattresses and 2 failed

o For the Community & Recovery service line, 67 mattresses were audited and 2 failed.

The results have conclusively demonstrated the benefit of auditing the mattresses with KMPT. The report will be shared with the Health and Safety Group to look at the types of mattresses procured within the Trust and of their effectiveness. This audit will continue on an annual basis.

9. ANTIMICROBIAL PRESCRIBING AND MANAGEMENT

Effective antimicrobial stewardship within hospitals and community settings makes an important contribution to the control and prevention of Clostridium difficile (C.diff), associated diarrhoea and other health care associated infections. The Trusts Antimicrobial Prescribing and Management Policy has been devised to provide a robust structure and guidance to all trust staff on the safe use these medicines across all KMPT’s inpatient and community settings. This policy is available for all staff to access both in paper form and on the trust intranet site. Monitoring compliance and effectiveness of this document includes the need for inpatient units to submit antibiotic data to the Infection Prevention & Control Team (IP&C) when any antibiotic is prescribed. This information is collated onto a database and any concerns regarding antimicrobial prescribing is addressed between the IP & C Team, ward staff, the prescribing doctor and pharmacy staff.

10. TRAINING AND EDUCATION

Training remains high priority on the IP & C Team’s agenda, providing face to face training for staff or producing the training packages used for core training or e-learning. During the period from the 1st of April 2014 to the 31st of March 2015 a total of 1946 staff were trained in infection prevention and control through a variety of training methods which include:

e-Learning packages.

Face to face taught sessions

Ad-hoc drop in

Link Nurse training & development

18

Link Nurse 3 monthly updates

Light box hand hygiene training for in-patient & community teams

Student nurse Infection Control Training

Course

% Target

to Achieve

Overall Trust

Corporate Services

Forensic &

Addictions SL

Older People & Specialist

SL

Community Recovery

SL Acute SL

Data to 26

Feb 14 Data to 26

Feb 14 Data to 26

Feb 14 Data to 26

Feb 14 Data to 26

Feb 14 Data to 26

Feb 14

2 Year Update

Infection Control/Hand Hygiene

2 Yearly 85% 85% 76% 97% 88% 81% 79%

3 Year Update

Infection Control/Hand Hygiene

3 Yearly 85% 90% N/A 96% 88% 90% 88%

Once Only

Infection, Prevention & Control

Once 85% 90% 95% 97% N/A 90% N/A

11. LINK NURSE – PRACTITIONERS

All wards / in patient units and community teams have an identified link nurse workers in place working in partnership with the Senior Infection Control nurse to provide infection prevention and control support to their clinical areas. They undertake a one full day intensive link nurse training programme facilitated by the SICN, this enables the link practitioner to undertake training of staff within their own clinical areas. This session provides them with the skills required to facilitate this role successfully and they are continually updated through link nurse meetings and adhoc communication. Link nurse meetings are held on a quarterly basis across the organisation. They act as a communication tool and to impart information from Board to Ward and also offer network opportunities for staff. The sessions look at the role of the link nurse, the focus on reducing HCAI’s within the trust, the importance of good effective hand hygiene practices, the different organisms that affect the clinical environments and how we can manage the risks they pose, a journal club which link nurses are encouraged to advance and develop their own understanding of infection control as well as engage our service users in the fight against infection. Outside facilitators are also provided to advance their scope of practice and their understanding.

12. NEEDLESTICK / SHARPS INJURIES

Needlestick injuries occur when a needle or other sharp implement penetrates the skin. This is called a percutaneous injury. If the needle or sharp instrument is contaminated with blood or other bodily fluids, there is the potential risk of transmission of infection, and when this occurs in a work context, the term occupational exposure (to blood, body fluid or blood-borne infection) is used. Staff experiencing this type of injury risk acquiring Hepatitis B, Hepatitis C and Human immunodeficiency virus (HIV). To minimise this risk

19

to staff and patients KMPT have been using Retractable (Sharp safe) syringes across all in-patient and community teams. KMPT was ahead of the curve and introduced these across the trust in 2011. Legislation has made this mandatory for healthcare providers from May 2013. Since the introduction of these devices there has been a significant reduction in these type of injuries reported. The trust is continually trying to reduce the risk of injury to staff carrying out their duties and the infection control team is constantly reviewing the use of sharp devices to meet the need of the service.

There have been 23 reported cases of sharps injury for this year which is an increase on the previous year. 10 incidents were related to the giving of insulin although insulin can be given with retractable needles. During resuscitation training session a sharps injury was obtained as the instructor thought the epi-pen was a training device but in-fact was a live version and punctured her finger. This injury was investigated and reported, no serious injury to instructor reported. This incident is being reviewed by the Health and Safety executive. The physical health team will be reviewing the use of retractable needles to ensure that a reduction in injuries occur throughout 2015.16

13. OUTBREAKS / PERIODS OF INCREASED INCIDENCE

OUTBREAKS The amount of reported outbreaks for 2014 – 2015 was significantly lower than in previous years. This reporting period saw 3 outbreaks due to diarrhoea and vomiting and 1 period of increased incidence. In 2013- 2014 6 outbreaks were reported and in 2012 – 2013 there were 10. All outbreaks affecting the trust are reported directly to the SICN via the infection control email address or by telephone, once all facts are established the SICN visits the unit to ensure that all appropriate infection control measures are in-place. The units affected were::

Sevenscore Ward (Thanet) May 2014, 10 patients and 6 staff affected, closed for 15 days. Tulip House (Maidstone) July 2014, 4 patients affected, unit closed for 4 days. Ruby Ward (Medway) July 2014, 4 patients affected, closed for 4 days. Emerald Ward (Medway) July 2014, 3 patients affected, ward closed for 6 days.

Tulip House is reported as a period of increased incidence with no reported infection but ward closed for observation due to nature of the clients it houses.

When an outbreak of infection has been declared the SICN will undertake an Route Cause Analysis or Post Exposure Review to establish a cause and identify any learning from such events that can be shared across the trust in effort to reduce the impact of this infectious illness occurring in the future. CLOSTRIDIUM DIFFICILE TOXIN POSITIVE INFECTION There have been no reported Clostridium difficile toxin positive cases for this current year. This is the second year of zero reporting, the last case reported was in September 2012. OTHER INFECTIONS REPORTED As part of the trusts mandatory reporting of MRSA and Clostridium difficle infections all wards also reported cases of 18 dental infections, 10 wounds (including self harming), 4 episodes of scabies infestation, 18 cases of ear, nose or throat infections, 5 episodes of head lice, 7 MRSA colonisations, 51 chest infections, 10 cases of cellulitus, and 109 urine infections (including 1 ESBL Infection).

20

14. MRSA SCREENING

The Department of Health (DH) requires all NHS Trusts to record MRSA screening data for elective and emergency admissions. Within Mental Health, we do not have elective patients, therefore the DH had identified incidents of greater clinical risk. Therefore the screening criteria within KMPT is as follows: service users who are admitted to mental health wards or units having had surgery or any surgical

procedures any service user who was transferred from an Acute Trust drug users that use intravenous drugs service users who self harm service users with chronic wounds, e.g. leg ulcers or have a catheter or any other indwelling device The Knole Centre (WKNRU) in Sevenoaks was identified and deemed suitable to meet the criteria for emergency admissions, and therefore every patient will be screened on admission to the unit. With adherence to the MRSA screening policy there had been a significant reduction of MRSA colonised patients on our units. There were 7 cases of patients colonised with MRSA during this reporting year. This is compared against last years figure of 10 (2014-15) and 12 in (2013-2014).. There have been no reported cases of MRSA bacteraemia (MRSA bloodstream infection) during this last year. The last case reported was October 2011.

15. DECONTAMINATION

The IP & C Team have been working closely with the Medical Device Manager to ensure that sufficient guidance was available to staff on the safe methods of decontamination for medical devices. This is to protect all staff and service users from the transmission of micro-organisms from medical devices, associated consumables and materials used in the physical assessment, treatment, diagnosis and care of our service users. The following measures are in place: To ensure that all mattresses are fit for purpose and do not present a cross contamination risk, an

annual Trust wide mattress audit will continue, all wards are now using the Fist Test to ensure patency. Single patient use items are being used and all ward teams are questioned on audit the symbol for

single use items and ensures that these items are being used, e.g. nail clippers, disposable slings and scissors.

Disposable items and single use items are promoted and recommended e.g. bowls (that are macerable), medicine pots and disposable tourniquets.

Decontamination of rooms/wards during an outbreak or post outbreak with a chlorine based solution is used for environmental cleaning to prevent the contamination of hard surfaces, which in turn reduces the risk of cross infection. Soft furnishings such as curtains are replaced with clean ones.

Working closely with the Housekeeping teams across the trust to ensure that all IC measures are adopted and utilised to help in the fight against infection or outbreak.

The schedule for on-going cleaning audits is as follows;

Non-patient sites that score 80% and above are audited on a twice yearly basis.

Non-patient sites that score below 80% are audited on a quarterly basis.

21

Outpatient sites that score below 90% will continue to be audited on a Quarterly basis

Outpatient sites that score 90% and above will be audited on a 4 monthly basis.

In-patient Areas that score below 90% will be audited on a bi (2) monthly basis.

In-patient areas that score 90% and above continue to be audited on a Quarterly basis When a site falls below the proposed standard it must obtain one consistent pass marks at the higher level before it reverts back to the proposed schedule. The results are discussed at the trust Infection prevention and control Group meetings bi-monthly.

16. COMMODES

There are eleven wards / units across the Trust that has and uses commodes (The Older Persons Service line). All commodes use disposable macerable liners to reduce the risk of infection, All had a macerator in clean working order. Eight of the eleven units had commodes that were clean and in good working order. Where commodes were found to be in a poor condition these were reported and replaced with newer versions. Areas identified that did not attain 100% were addressed with the staff concerned during the visits. These wards monitor their commode cleanliness on a weekly basis to ensure compliance.

17. SEASONAL INFLUENZA CAMPAIGN

This year saw the trust build on it’s success and increase in the number of front line staff receiving the seasonal flu vaccine. Last year also saw the Department of Health introduce targets for providers to achieve and set a target of 75% uptake for frontline staff to be vaccinated. The programme began in October 2014 through to March 2015. The flu fighting team set dates and arranged venues across the trust to enable staff to access the vaccine as close to their place of work as possible. This helped to increase the trusts uptake from 41% in 2013 -2014 to 42% this year, in 2012 -2013 the trust only managed 25% A total of 1098 front line staff were vaccinated during the campaign. A debrief following this campaign has commenced to learn lessons and facilitate a more successful campaign in 2015-16.

18. Conclusion

Within 2014/15, the Infection Prevention and Control Team maintained and improved the standards of care for our patients in relation to infections. This has been achieved by working in partnership with internal service lines other external organisations, auditing practice that results in changes to clinical practice and ensuring that all staff are trained to a high standard.

It is to be acknowledge that the Senior Infection Control Nurse has maintained the highest of standards for infection control ensuring that all infections are responded to quickly which has led to a reduction in outbreaks from previous year

22

KMPT HYGIENE CODE COMPLIANCE 2014/15

Development Plan for Infection Prevention and Control to meet the Health and Social Care Act’s (2008) Code of Practice for the

NHS on the prevention and control of healthcare associated infections and related guidance

Compliance Criterion 1 – Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and

consider how susceptible service users are and any risks that their environment and others may pose to them.

1.1 Appropriate

management and

monitoring arrangements

should ensure that:

Self assessment Description for compliance Actions responsibility Progress

A board level agreement

outlining the boards

collective responsibility

for minimising the risk of

infections and the general

means by which it

prevents and controls such

risks

Infection Prevention and Control

(IP & C) policy in place.

Trust Wide infection Prevention

and Control Group in place.

Bi-Monthly reports to the Board.

Demonstrates sign up by the board of

directors. The report is submitted bi-

monthly

Reports to Board which

incorporate minutes from the

Trust IP & C Committee

CEO

Executive Director of

Nursing and

Governance/DIPC

The designation of a DIPC

who is accountable

directly to the CEO and

the board

Appointment of the Executive

Director of Nursing and

Governance/DIPC

DIPC in place job description reflects

roles and responsibility.

None Required CEO

The mechanism by which the board intends to ensure that sufficient resources are available to secure the effective prevention and control of infection.

Bi-Monthly Board reports Within the board minutes sign up to

resources

None Required Executive Director of

Nursing and

Governance/DIPC

Ensuring that relevant

staff, contractors and other

persons receive suitable

training and information

Face to face training is provided

for staff, as is Corporate

induction and e-learning for

clinical and non clinical staff.

Training records

All contractors have a letter.

Learning and Development

Department to monitor the

number of staff undertaking

the training

Learning and

Development Dept


23

and supervision in,

measures required to

prevent and control risks

of infection

Record of staff attendance to

training is kept by the L & D

department.

Training Policy identifies levels

of training needed for staff.

Link nurses meetings for the

Trust

Visitors Ward closure signs

Lead nurses to ensure

attendance of the link nurse

meetings

Nursing and

Governance/DIPC

Deputy Director of

Nursing /deputy DIPC

Lead Nurses

Service Managers/Service

Managers/Modern

Matrons.

Head of Facilities

A programme of audit to

ensure key policies and

practice are being

implemented

appropriately

IP & C Audits are carried out in

all service areas annually.

Monthly Hand Hygiene Audits

Annual Trust wide Mattress

audits

Annual audit of Transfer of Care

Infection Control

Documentation.

PLACE visits

Unannounced Visits (now known

as IP & C compliance to policies

and best practice visits)

Demonstrates annual audit of

compliance on a site by site basis

Implement all audit

recommendations

Implement PLACE action

Plans

¼ Cleaning audits

Implement Hand hygiene

Audit Action plans


Nursing and

Governance/DIPC,

Deputy Director of

Nursing/deputy DIPC

Senior Infection Control

Nurses

Lead Nurses

Service

Managers/Modern

Matrons

Hotel Services

A policy addressing where

relevant the admission

transfer discharge and

movement of patients

between depts. and

between healthcare

facilities

Trust wide Infection Prevention

and control policy

Clearly outlines the process for

checking HCAI’s on transfer of

care/admissions.

Ensure the Transfer check list

is used

Monitor the HCAI transferred

into the Trust from the Acute

Trusts


Nursing and

Governance/DIPC,

Deputy Director of

Nursing/deputy DIPC

IP & C Team

Service

Managers/Modern

Matrons

Designation of a

decontamination lead

The Deputy Director for

Nursing/Deputy DIPC is the lead

for decontamination

The Deputy DIPC works closely with

the Medical Devices Manager

To be monitored through the

medical devices meeting and

infection prevention and

control meeting minutes


Nursing and

Governance/DIPC

Deputy Director of

Nursing/Deputy DIPC

Medical Devices Manager

24

1.2 Risk Assessment

A registered provider should

ensure that it has:

made a suitable and

sufficient assessment of

the risks to the person

receiving care with respect

to prevention and control

of infection

identified the steps that

need to be taken to reduce

or control those risks

recorded findings in

relation to the first two

points;

implemented the steps

identified and put

appropriate methods in

place to monitor the risks

of infection to determine

whether further steps are

needed to reduce or

control infection.

Covered by the audit and service

action plans.

Bi-Monthly board report

Unannounced Infection control

visits- site reports

MRSA management and

Screening Policy

Transfer of Care infection

control documentation form

All suspected/confirmed

infections reported to the IP & C

Team

Demonstrates a rolling programme of 6

monthly unannounced visits to monitor

/ risk assess and ensure compliance

with the Hygiene Code and to provide

support to services


Nursing and

Governance/DIPC

Deputy Director of

Nursing/Deputy DIPC

Service

Managers/Modern

Matrons

IP & C Team

1.3 The role of the DIPC

in NHS

provider organisations is to:

be accountable directly to the chief executive and to the board (but not necessarily a member of the board)

be responsible for the organisation’s infection prevention and control team (IPT) or infection control team (ICT)

• oversee local prevention and

control of infection policies and

their implementation;

In DIPC job description

Demonstrates compliance to Hygiene

Code

Minutes of Patient Safety Group

meetings

None required


Nursing and

Governance/DIPC

25

• be a full member of the ICT and

regularly attend its infection

prevention and control meetings;

• report directly to the NHS board

and, in non-NHS care settings, the

registered provider;

• have the authority to challenge

inappropriate practice and

inappropriate antibiotic prescribing

decisions;

• assess the impact of all existing

and new policies on infections and

make recommendations for change;

• be an integral member of the

organisation’s clinical governance

and patient safety teams and

structures; and

• produce an annual report and

release it publicly as outlined in

Winning ways: working together to

reduce healthcare associated

infection in England.

Chairs Trust wide IP & C group

Antimicrobial Prescribing and

Management Policy

Through trust wide audit

Annual DIPC report produced

Minutes of Trust wide Infection Control

Meetings

Minutes of PCT meetings

Minutes of SHA meetings

Minutes of the local Health Protection

Unit meetings

Minutes of Patient safety and

Governance meetings

1.5 Assurance Framework

regular presentations from

the DIPC and/or the ICT

to the board. These should

include a trend analysis

for infections and

compliance with audit

programmes;

quarterly reporting to the

NHS board or registered

provider by clinical

directors and matrons

(including nurses who do

not hold the specific title

of ‘matron’ but who

operate at a similar level

of seniority and who have

Assurance Framework in place

RCA’s and audits performed

Outbreak Management Team

IP & C Team to support and

advise ward on actions to take

Assurance Framework monitors

compliance to the Hygiene Code. It is

monitored by the IP & C Team and the

Trust wide Infection Control group.

Service Managers/Modern Matrons

monitor and update this through the

modern matron forums.

The IP&C team provide bi- reports to

the board that is shared with the

Matrons at the 6 weekly meetings that

is a 2 way sharing of information

process demonstrating that infection

prevention and control are an integral

part of quality assurance


board, IC meetings, Service

Managers/Modern Matrons

Meetings

Link nurse Meetings

Service Managers to produce

a quarterly report to the

Board.

CEO


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy DIPC

IP & C Team

Service

Managers/Modern

Matrons

26

control over similar

aspects of the patient or

the patient’s

environment);

a review of statistics on

incidence of alert

organisms (for example,

but not limited to,

meticillin-resistant

Staphylococcus aureus

(MRSA) and Clostridium

difficile) and conditions,

outbreaks and serious

untoward incidents

evidence of appropriate

action taken to deal with

occurrences of infection

including, where

applicable, root cause

analysis; and

an audit programme to

ensure that policies have

been implemented;

SI meetings / minutes of

meetings

IP&C investigate RCA and

report findings to Trustwide

Infection Group who cascade any

learning throughout the Trust and

the SI Risk Manager.

1.7 The infection prevention and

control programme should:

• set objectives that meet the needs of the organisation and ensure the safety of service users;

• identify priorities for action; • provide evidence that relevant policies have been implemented to reduce infections; and • if appropriate, report progress against the objectives of the programme in the DIPC’s annual report or the IPC Lead’s annual statement.

Trust Wide Infection Prevention

and Control group

Infection Control Link Nurse

Meeting minutes

Modern Matron Meetings

Bi-Monthly Board reports

Data Surveillance

Monthly Hand Hygiene

observational audit

MRSA Screening data from the

Nursing Metrics and Infection

database

Monthly training stats

IP & C audits

Demonstrates compliance with Hygiene

Code

Continue with IP & C

programme


Nursing and

Governance/DIPC

Deputy Director of


IP & C Team

27

1.8 Infection control

infrastructure

An infection prevention and control

infrastructure should encompass:

• in acute healthcare

settings, for example, an

ICT consisting of an

appropriate mix of both

nursing and consultant

medical expertise (with

specialist training in

infection prevention and

control) and appropriate

administrative and

analytical support,

including adequate

information technology –

the DIPC is a key member

of the ICT;

• in other settings, there will be an

infection control nurse (ICN) or

another designated person who is

responsible for infection prevention

and control matters and has access

to specialist expertise as necessary;

and

• 24-hour access to a nominated

qualified infection control doctor

(ICD) or consultant in health

protection/communicable disease

control. The registered provider

should know how to access this

advice.

Trust Wide Infection Prevention

and Control group

Infection Control Link Nurse

Meeting minutes

Modern Matron Meetings


Data Surveillance

Access to Consultant/expert at

KHPU 24hours via local acute

hospital switchboard out of

office working hours.

Transfer of Care Audit

Demonstrates surveillance of HCAI’s,

monitoring of database, cleanliness

standards and collaboration with the

Health Protection Agency, Primary

Care Trusts and Acute Trusts and trust

staff

The link nurse meetings Demonstrate a

Trust wide management system for

both dissemination, imparting &

collection of information to clinical

staff and provide support from senior

Infection Control staff

Continue with IP & C

infrastructure

CEO


Nursing and

Governance/DIPC

Deputy Director of


IP & C Team

1.9 Movement of patients

There should be evidence of joint

working between staff involved in

the provision of advice relating to

the prevention and control of

infection; those managing bed

allocation; care staff and domestic

staff in planning service user

referrals, admissions, transfers,

Transfer check list

Transfer of Care Infection

Control documentation Audit

Transfer of patients from and to the

Acute Trusts and nursing homes

incorporated within the IP&C policy


Service Managers/Modern

Matrons meetings and IP & C

trust wide group


Nursing and

Governance/DIPC

Deputy Director of


IP & C Team

28

discharges and movements between

departments; and within and

between health and adult social care

facilities. Where necessary,

ambulance providers, hospitals and

primary care trusts (PCTs) may need

to be involved in such planning

Service

Managers/Modern

Matrons

Ward Managers

1.10 A registered provider must

ensure that it provides suitable and

sufficient information on a service

user’s infection status whenever it

arranges for that person to be moved

from the care of one organisation to

another, or from a service user’s

home, so that any risks to the service

user and others from infection may

be minimised. If appropriate,

providers of a service user’s

transport should be informed of any

infection.

Transfer check list and discharge

letter

Transfer of care infection

Control documentation audit


Acute Trusts and nursing homes

incorporated within the IP&C policy



Matrons meetings and IP & C

trust wide group


Nursing and

Governance/DIPC

Deputy Director of


IP & C Team

Service anagers/Modern

Matrons

Ward Managers

Compliance Criterion 2 – Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and

control of infections

2.1 With a view to minimising the

risk of infection, a registered

provider should normally ensure

that:


it designates leads for

environmental cleaning and decontamination of equipment used for diagnosis and treatment (a single individual may be designated for both areas)

Hotel Services responsible for

cleaning

Hotel Services managers in

each directorate


Matrons responsible for

ensuring that ward equipment

is decontaminated

Decontamination of medical

devices identified in the Safe

Management of Medical

Devices policy

Ensures partnership working with hotel

services in cleaning standards for all

buildings

Ensures decontamination issues for

mental health addressed.

Operational Cleaning Policy

Board Reports

Medical Devices Meetings

Hotel Services to monitor cleaning

and contract cleaners

Unannounced Visits

Monitor/report to the IC

committee


Matrons to ensure that all medical

devices e.g. commodes/beds/hoists

are decontaminated in accordance

with manufacturer’s guidance.


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP&C Team

Service

Managers/Modern

Matrons

rvices

Medical Devices

Manager

29

the designated lead for

cleaning involves

directors of nursing,

matrons and the ICT or

persons of similar

standing in all aspects of

cleaning services, from

contract negotiation and

service planning to

delivery at ward and

clinical level. In other

settings, the designated

lead for cleaning will

need to access

appropriate advice on all

aspects of cleaning

services

All aspects of cleaning services are discussed in the Trust wide Infection Prevention & Control Group in which the Deputy Director of Nursing, the Infection Prevention & Control Team and Service Managers/Modern Matrons attend.

Ensures partnership working with hotel

services in cleaning standards for all

buildings

Continue to involve Deputy

Director of Nursing, Service

Managers/Modern Matrons and

the IP & C Team in all aspects of

cleaning services


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Hotel Services

It has policies for the

environment that make

provision for liaison

between the members of

the ICT and the persons

with overall

responsibility for

facilities management;

PLACE assessment undertaken

by facilities, clinical staff and

IC staff.

Hotel Services attend all IP &

C meetings at Trust and local

level

Attendance to IC Link

meetings

Overarching policy re link with

IP & C team

Hotel Services and Facilities as members

of the I.C. committee

Continue with PLACE

assessments

Monitor attendance


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Hotel Services

in healthcare, matrons or

persons of a similar

standing have personal

responsibility and

accountability for

delivering a safe and

clean care environment


Matrons are aware of

responsibilities and

accountabilities (Job

Description’s and IP & C

policy)

Nurse in charge of shift is

aware of responsibility

regarding cleanliness standards

during their shift

This was included in the Service

Manager’s Job Description’s during the

Service Line restructuring.

To ensure that accountability and

responsibility continues to be

reflected in job descriptions


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

30

Hotel Services

Nurse in Charge of

Shift

Human Resources

Service line directors

The cleaning

arrangements detail the

standards of cleanliness

required in each part of

its premises and that a

schedule of cleaning

frequencies is publicly

available;

Cleaning schedules are openly

displayed on public view on

each ward/unit Trust wide

Demonstrates standards of cleanliness for

each area Trust Wide

Monitored through PLACE

inspection


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Hotel Services

There is adequate

provision of suitable

hand-washing facilities

and water based hand

sanitisers

Individual water based hand

sanitisers for staff available

Hand hygiene notices above all

clinical sinks

Hand Hygiene Audits are now carried out

Trust wide annually to monitor

compliance

Hand Hygiene Link Nurses/ workers on

each ward/unit promote good hand

hygiene techniques and practices for all

staff, patients and visitors

Trust Infection Prevention and Control

training includes the importance of good

hand hygiene techniques and practices.

This is demonstrated by the use of UV

light boxes.

IP & C Training

Hand hygiene Audit

Mobile Sink Unit


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Hotel Services

There are effective

arrangements for the

appropriate

decontamination of

instruments and other

equipment – these

should be incorporated

Hotel Services responsible for

cleaning

Hotel Services managers in

each directorate


Decontamination of medical devices

identified in the Safe Management of

Medical Devices policy

Service Managers/Modern Matrons

responsible for ensuring that ward

Hotel Services to monitor cleaning

and contract cleaners for cleaning

of beds/hoists/commodes

Monitor/report to the IC

committee


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

31

within appropriate

disinfection and

decontamination

policies;

Matrons responsible for

ensuring that ward equipment

is decontaminated

Board Reports

equipment is decontaminated

The IP & C Team promote the use of

single patient items and single use items

e.g. hoist slings, nail clippers, medicine

pots


Matrons to ensure that

commodes/beds/hoists are

decontaminated in accordance with

manufacturer’s guidance.

IP&C Team

Service

Managers/Modern

Matrons

Medical Devices

manager

2.2 All parts of the premises in

which it provides healthcare are

suitable for the purpose, kept clean

and maintained in good physical

repair and condition;

Cleanliness reports following

quarterly cleaning audits and

Trust wide monitoring. The

report identifies

PLACE assessment undertaken

by facilities, clinical staff and

IP & C staff.

Infection Prevention and

Control Audit

Hand Hygiene Audit

Demonstrates quarterly cleaning audits

and trust wide monitoring. Also shows

SHA deep cleaning returns

Continue to monitor standards of

cleanliness and maintenance

through the audit process


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP&C Team

Service

Managers/Modern

Matrons

Hotel Services

Estates & Facilities

2.3 Premises and facilities should

be provided in accordance with

best practice guidance. The

development of local policies

should take account of infection

prevention and control advice

given by relevant expert or

advisory bodies or by the ICT, and

this should include provision for

liaison between the members of

any ICT and the persons with

overall responsibility for the

management of the service user’s

environment

Operational Cleaning Policy

Food hygiene policy

Control of Legionella bacteria

in Trust Premises policy and

procedure

Policy for management of

asbestos containing materials in

trust Properties including

asbestos management plan

Uniform and work wear policy

Standard (Universal)

Precautions Policy

Demonstrates compliance with the

Hygiene Code

Update policies when required


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP&C Team

Service

Managers/Modern

Matrons

Hotel Services

Estates & Facilities

32

IP & C policy (infected linen)

And Service Level Agreements

(SLA) with Acute Hospital

Trusts

Standard (Universal)

Precautions Policy.

Linen discussed in IP & C

training

Waste Management policy

Compliance Criterion 3 – Provides suitable accurate information on infections to service users and their visitors


3.1 Areas relevant to the provision

of such information include:

• general principles on the prevention and control of infection and key aspects of the registered provider’s policy on infection prevention and control, which takes into account the communication needs of the service user;

• the roles and responsibilities of particular individuals such as carers, relatives and advocates in the prevention and control of infection, to support them when visiting service users; • supporting service users’ awareness and involvement in the safe provision of care; • the importance of compliance by visitors with hand hygiene; • the importance of compliance with the registered provider’s

KMPT IP & C website available

to service users/relatives/carers

on the following link

http://www.kmpt.nhs.uk/infectio

ncontrol


leaflets are available to patients,

visitors and staff on the

following subjects:

C. diff, MRSA, Noro virus, IP &

C Team, guide for patients and a

guide for visitors about infection

prevention.

Admission, transfer, discharge

and movement of service users is

addressed in the Infection

Prevention and control policy

Signage

Outbreak is defined in the


Policy

Demonstrates full compliance with DH

guidance

Ensure that the Admission

,transfer, discharge and movement

of service users form is completed

as per Trust policy

Ensure that signs and information

displayed is current



Matrons meetings and IC trust

wide group


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP&C Team

Service

Managers/Modern

Matrons

Ward Managers

Hotel Services

http://www.kmpt.nhs.uk/infectioncontrol

http://www.kmpt.nhs.uk/infectioncontrol

33

policy on visiting; • reporting failures of hygiene and cleanliness; • explanations of incident/outbreak management.

Ward Closure (Infection Control)

Policy

Isolation (Nursing) Policy

Board minutes are available for

patients, public and staff

Patients and carers are

encouraged to report concerns

regarding infection prevention

and control to staff.

Concerns regarding hygiene and

cleanliness can be reported to the

Ward Manager, Modern Matron

and the Infection Prevention and

Control Team. The IP & C Team

can be contacted via email and/or

phone by patients, visitors or

staff. Whistle blowing policy

can be used

3.2 Information should be developed with local service user representative organisations, which could include Local Involvement Networks (LINks) and Patient Advice and Liaison Services (PALS).

Service user involvement

requested through PALS

managers for IP & C meetings

Links involvement

Demonstrates full compliance with DH

guidance




wide group


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

34

Compliance Criterion 4 – Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion.


4.1 A registered provider should

ensure that: • accurate information is communicated in an appropriate manner;

• this information facilitates the provision of optimum care, minimising the risk of inappropriate management and further transmission of infection; and • where possible, information accompanies the service user.

IP & C Transfer of care

documentation check list

Outbreaks are communicated to

the KHPU. and adjacent acute

Trust’s DIPC/IP & C Team


Acute Trusts/our Trust and nursing

homes incorporated within the IP&C

policy

Annual Trust wide Transfer of Care

Infection Control Documentation audit




wide group


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

4.2 Provision of relevant

information across organisational

boundaries is covered by the

regulation requirement ‘Co-

operating with other providers’. Due

attention should be paid to service

user confidentiality as outlined in

national guidance and training

material.

Care Programme Approach

documentation


the KHPU and adjacent acute


CPA documentation would record

relevant Infection Control issues and

enable this to be shared with relevant

professionals.

Ward manager via internal records

audits.

Ward

Managers/clinical

staff

IP & C Team

Compliance Criterion 5 – Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the

infection to other people.


5.1 Registered providers, excluding personal care providers, should ensure that advice is received from suitably informed practitioners and that, if advised, registered providers should inform their local health protection unit of any outbreaks


the KHPU and adjacent acute


Reporting flow chart with

contact details are provided to all

teams

Demonstrates Compliance as per

national and local policy

Ensure that IP & C, Hand

Hygiene, MRSA screening and

Uniform and work wear,

antimicrobial prescribing and

management policies, Norovirus

management policy, outbreak

(nursing) policy and Ward Closure

policy reflect any changes in

Ward staff/Ward

Managers

Service Managers

IP & C Team

Deputy Director of

35

or serious incidents relating to infection.

IP & C policy,

Hand Hygiene Policy,

MRSA and Screening policy,

Uniform and Work wear policy,


management policy,

Norovirus management policy

Clostridium difficile policy

Isolation (nursing) Policy

Ward Closure Policy

Policy compliance is monitored

in the annual IP & C and Hand

Hygiene audits.

Bi-Monthly Board reports which

includes infection data

surveillance and training figures

Infection prevention and control

staff training programme

Staff have access to IP & C

Team and IC link nurses Trust

wide.

Unannounced IP & C visits

legislation, standards and

guidance.

Ensure all staff attend IP & C

training and the Learning and

Development Department to

monitor the number of staff

undertaking the training

Monitoring of infection

surveillance data and antibiotic

prescribing data

IP & C Team to update training

programme as required

Nursing / Deputy

DIPC


Nursing and

Governance/DIPC

5.2 Arrangements to prevent and control infection should demonstrate that responsibility for infection prevention and control is effectively devolved to all groups in the organisation involved in delivering care.

Roles and responsibilities for all

groups identified in the IP and C

policy

Responsibilities in JD’s

Infection prevention and control

staff training programme

IP & C policy, Hand Hygiene

Policy, MRSA and Screening,

Uniform and Work wear policy,


management policy, Ward

Closure policy, Norovirus

Management Policy, Clostridium

difficile policy, Isolation

(Nursing) Policy.



Ensure that IP & C, Hand

Hygiene, MRSA screening and

Uniform and work wear,


management, ward closure,

Norovirus management and

Clostridium difficile policies

reflect any changes in legislation,

standards and guidance.

Ensure all staff attend IP & C

training and the Learning and

Development Department to

monitor the number of staff

undertaking the training

Monitoring of infection

surveillance data and antibiotic

Ward staff/Ward

Managers

Service Managers

IP & C Team

Deputy Director of

Nursing / Deputy

DIPC


Nursing and

Governance/DIPC

36

prescribing data

IP & C Team to update training

programme as required

Compliance Criterion 6 – Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.


6.1 A registered provider should, so

far as is reasonably practicable,

ensure that its staff, contractors and

others involved in the provision of

care co-operate with it, and with

each other, so far as is necessary to

enable the registered provider to

meet its obligations under the Code.

6.2 Infection prevention and control

would need to be included in the job

descriptions and be included in the

induction programme and staff

updates of all employees (including

volunteers). Contractors working in

service user areas would need to be

aware of any issues with regard to

infection prevention and control and

obtain ’permission to work‘.

Confidentiality must be maintained.

6.3 Where staff undertake

procedures, which require skills

such as aseptic technique, staff must

be trained and demonstrate

proficiency before being allowed to

undertake these procedures

independently.

Aseptic Non Touch Technique

Policy

Safe Management of Aspergillus

policy

IP & C responsibilities in all

JD’s via HR and AD’s

The Control of Legionellae

Bacteria in Trust Premises policy

MRSA and Screening policy

Hand Hygiene Policy

Uniform and Work wear policy

Standard (universal) precautions

policy

IP & C information leaflets

Competency framework kept by

Learning and development

department



For Facilities Department to

continue to send IP & C

information to contractors for them

to sign up to

Monitor adherence to policies


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Facilities Department

HR

Service Line

Directors

37

Compliance Criterion 7 – Provide or secure adequate isolation facilities


7.1 A healthcare registered

provider delivering in-patient care should ensure that it is able to provide, or secure the provision of, adequate isolation precautions and facilities, as appropriate, sufficient to prevent or minimise the spread of infection. This may include facilities in a day care setting.

The majority of in-patient wards

have single sex accommodation.

Where there are still bays single

rooms are available for isolation

purposes


Policy

Norovirus (Outbreak) policy

Clostridium difficile Policy


MRSA Management and

screening Policy



Continue to monitor compliance

through the audit process and IP &

C unannounced visits


Nursing and

Governance/DIPC,

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Ward Managers

7.2 Policies should be in place concerning the allocation of patients to isolation facilities, based on local risk assessment. The risk assessment should include consideration of the need for special ventilated isolation facilities. Sufficient staff should be available to care for patients safely.


Policy




MRSA Management and

screening Policy

Policies are available and

accessible to staff, patients and

the public as they are placed in

each ward/unit or community

team setting throughout the Trust



Continue to monitor compliance

through the audit process and IP &



Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Ward Managers

38

Compliance Criterion 8 – Secure adequate access to laboratory support as appropriate


A provider should ensure that

laboratories used to provide

microbiology services in connection

with arrangements for infection

prevention and control have in place

appropriate protocols and that they

operate according to the standards

required for accreditation by

Clinical Pathology Accreditation

(UK) Ltd.

Protocols should include:

a microbiology laboratory

policy for investigation and

surveillance of HCAI; and

standard operating procedures

for the examination of

specimens.

SLA with Acute Trust’s

Microbiology Services



Non required Finance department

39

Compliance Criterion 9 – Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.


9a. Standard (universal) infection

control precautions • The policy

should be

based on

evidence-

based

guidelines,

including

those on

hand

hygiene

and the use

of personal

protective

equipment.

• The policy

should be

easily

accessible

to all

groups of

staff,

patients

and the

public.

• Complianc

e with the

policy

should be

audited.

• Information

on the

policy

should be

included in

induction

programme

s for all

staff groups


Policy

Hand Hygiene policy includes 5

moments for hand hygiene at the

point of care

Standard (Universal) Precautions

Policy





team setting throughout the

Trust.

The MRSA Screening policy is

available to the public via the

Infection Control web page on

the Trust website.

Trust wide compliance to IP & C

and Hand Hygiene policy is

audited monthly and a Trust

wide Audit report is produced

annual.

IP & C corporate induction

training includes standard

precautions and covers epic 2

guidelines for all staff groups



Review of policies to reflect any

changes to guidance relating to

standard (universal) infection

control precautions (should they

occur) is ongoing

Audit to evaluate Trust wide

compliance to policies to continue

For IP & C training programme to

continue


Nursing and

Governance/DIPC,

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team,

Service

Managers/Modern

Matrons

40

9b. Aseptic technique

Clinical procedures should be carried out in a manner that maintains and promotes the principles of asepsis.

Education, training and assessment in the aseptic technique should be provided to all persons undertaking such procedures.

The technique should be standardised across the organisation.

Audit should be undertaken to monitor compliance with the technique.

Identified in the Trust Infection

Prevention and Control policy

Staff are trained and evaluated

locally

Aseptic Non Touch Technique

Policy



Review of policies to reflect any

changes to guidance relating to

aseptic technique (should they

occur) will be ongoing


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

9c. Outbreaks of communicable infection

The degree of detail in the policy should reflect local circumstances to take into account at-risk patients and clinical specialties.

Policies for major outbreaks of communicable infection should include initial assessment, communication, management and organisation, and investigation and control.

The contact details of those likely to be involved in outbreak management should be reviewed at least annually.

Significant outbreaks should be reported as serious untoward incidents.

Formal arrangements should be

in place to fund the cost of

dealing with outbreaks

Identified in the Infection



Policy




Pandemic Flu Policy






Significant outbreaks of infection

are also reported following the

SUI process and are followed by

root cause analysis (RCA) using

the National Patient Safety

Agency’s RCA tool




Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

9d. Isolation of patients Ward Closure (Infection Control) Demonstrates Compliance as per Continue to monitor compliance Executive Director of

41

The isolation policy should be evidence-based and reflect local risk assessment of in-patients.

Indications for isolation should be included in the policy, as should procedures for the infection control management of patients in isolation.

Information on isolation should

be easily accessible to all

groups of staff, patients and the

public

Policy









Single Bedrooms available in

most wards/units

national and local policy through the audit process and IP &


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

9e. Safe handling and disposal of sharps

Relevant considerations include: risk management and

training in prevention and management of needlestick injuries;

provision of medical devices that incorporate sharps protection mechanisms where there are clear indications that they will provide safe systems of working for healthcare workers;

policy that is easily accessible to all groups of staff;

auditing of policy compliance;

and inclusion of information

on the policy in induction

programmes for all staff

groups.

Waste Management policy


policy

Taking Specimens for

Microbiological Investigations

policy

Venepuncture Policy

Inocculation (Management of

Sharps injury/splash incidents)

Policy and Procedure

The use of retractable syringes

by clinical staff are being used

Trust wide.






All IP & C staff training

programmes, including corporate

induction include the safe

management of sharps and

needlestick injuries

Waste Management training

includes safe disposal of sharps




Nursing and

Governance/DIPC

Deputy Director of

Nursing/ Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

9f. Prevention of occupational

exposure to blood-borne viruses,


Policy

Occupational Health Policy -



IP & C Team and Occupational

Health to raise awareness for the

prevention of needle sticks injuries

Occupational Health

Department

42

including prevention of sharps

injuries

Measures to avoid exposure to

blood-borne viruses should include:

immunisation against hepatitis

B;

the wearing of gloves and other

protective clothing;

the safe handling and disposal

of sharps, including the

provision of medical devices

that incorporate sharps

protection where there are clear

indications that they will

provide safe systems of

working for healthcare

workers; and

measures to reduce risks during

surgical procedures.

Management of Sharps

Injury/Splash Incident

The use of retractable syringes

by clinical staff are in use Trust

wide.

PPE’s are available for all

clinical staff

Blood and body fluid spillage

kits on every ward/unit




management of sharps and BBV

awareness

Surgical procedures are not

performed within a Mental

Health environment

through training programme

Attendance to be monitored by the


Department

Audit process

IP & C unannounced visits


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Learning &

Development

Department

9g. Management of occupational

exposure to blood-borne viruses

and post-exposure prophylaxis

Management should include:

designation of one or more

doctors to whom healthcare

staff and others may be referred

immediately for advice

following occupational blood

exposure;

provision of clear information

to healthcare staff about

reporting potential occupational

exposure – in particular the

need for prompt action

following a known or potential

exposure to human

immunodeficiency virus (HIV)

or hepatitis B; and

arrangements for post-exposure

prophylaxis for blood-borne

viruses.

Occupational Health Policy -

Management of Sharps

Injury/Splash Incident

identifying actions required post

occupational exposure




management of sharps, BBV

awareness and safe management

of blood and body fluid spillages

and actions required post

occupational exposure



IP & C Team and Occupational

Health to raise awareness for the

prevention of needle sticks injuries

through training programme

Attendance to be monitored by the


Department

Clinical audit process

IP & C unannounced visits

Occupational Health

Department


Nursing and

Governance/DIPC,

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Learning and

Development

Department

43

9h. Closure of wards, departments

and premises to new admissions A system should be in place for

the provision of advice by the

DIPC/ICT to the chief

executive and medical director.

There should be clear criteria in

relation to closures.

Management arrangements for

redirecting admissions should

be drawn up with ICT input.

The policy should address the

need for environmental

decontamination prior to

reopening.

Identified in the Trust Infection


Trust wide IP & C Group


Environmental

decontamination/deep cleaning is

identified in the Trust Infection


Ward Closure (outbreak) policy

Norovirus Management Policy



Public notice to display on

ward/unit door

Data Surveillance




Nursing and

Governance/DIPC,

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Hotel Services

9i. Environmental disinfection

policy The use of disinfectants is a

local decision, and there should

be local policies on disinfectant

use which focus on specific

infection risks.

If appropriate, the role of high-

level disinfectants to kill

bacteria, viruses and spores

should be considered

Strategic and operation cleaning

policies in place




PLACE process, IP & C Team


Nursing and

Governance/DIPC,

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Hotel Services

9j. Decontamination of reusable

medical devices

Effective decontamination of

reusable medical devices is

essential. There should be a

system to protect patients and

staff that minimises the risk of

transmission of infection from

Safe Management of Medical

Devices Policy

Agenda item on the Medical

Devices Management Meeting

IP & C Team promotes the use



Monitor in Trust wide IP & C

Group and the Medical Devices

Management Meeting


Nursing and

Governance/DIPC,

Deputy Director of

Nursing / Deputy

DIPC

44

medical devices and other

equipment that comes into

contact with patients or their

body fluids.

Decontamination is the

combination of processes,

including cleaning, disinfection

and sterilisation, used to render

a reusable item safe for further

use on patients and handling by

staff.

Reusable medical devices and

other devices should be

decontaminated in accordance

with manufacturers’

instructions and current

guidelines.

Systems should ensure

adequate supplies of reusable

medical devices and should

allow reusable medical devices

to be tracked through

decontamination processes in

order to ensure that the

processes have been carried out

effectively.

Systems should also be

implemented to enable the

identification of patients on

whom the medical devices have

been used.

of single patient/single use items.

Medical Devices

Manager

IP & C Team

Service

Managers/Modern

Matrons

9k. Antimicrobial prescribing Local prescribing should,

where appropriate, be

harmonised with that in the

British National Formulary

(BNF).

All local guidelines should

include information on the

regimen and duration of

particular drugs.

Procedures should be in place

to ensure prudent prescribing

and antimicrobial stewardship.

Antimicrobial Prescribing and

Management Policy

MRSA Management and

Screening policy

Surveillance by ICT using

infection reporting structure

includes pharmacy input



None required Executive Director of

Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

Pharmacists

IP & C Team

Service

Managers/Modern

Matrons

45

9L. Reporting HCAI to the HPA

as directed by the Department of

Health

This includes a mandatory

requirement for NHS trust chief

executives to report all cases of

MRSA bacteraemia and all cases of

C. difficile infection in patients aged

two years or older. Reporting should

include procedures for dealing with

serious untoward incidents.

Reporting structure is in place

and is identified in the IP & C

policy.

Reporting procedure flow chart

in nursing offices identifying

contact details of KHPU (looked

for during unannounced visits).

Staff to inform the KHPU of all

suspected/confirmed outbreaks,

which includes MRSA

bacteraemia and C.difficile.

IP & C training programme

identifies reporting

structure/procedure.




Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Ward Managers

Nurse in charge of

shift.

9m. Control of outbreaks and

infections associated with specific

alert organisms This should take account of local

epidemiology and risk assessment.

These infections must include, as a

minimum, MRSA, C. difficile

infection and transmissible

spongiform encephalopathies

MRSA screening policy

Norovirus management

Policy

Clostridium.difficile Policy

Prion disease (transmissible

spongiform

encephalopathies)

Vancomycin Resistant Enterococci (VRE) Policy

Meningococcal Meningitis / Septicaemia Policy

Scabies, Head lice and body lice infestation Policy

Varicella Zoster Virus (VZV) - Chickenpox and Shingles awaiting ratification

Tuberculosis Policy




infection control reporting forms,

Data surveillance

IP&C groups


Nursing and

Governance/DIPC

Deputy Director of

Nursing /Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

MRSA The policy should make provision

for:

screening of patients on

admission, which should

include screening of all elective

MRSA screening policy

identifies reasons for screening

mental health service users

(elective and emergency

admissions).




infection control reporting forms,

Data surveillance

IP & C groups


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

46

admissions by March 2009 and

provision for screening of

emergency admissions at

presentation as soon as is

practical;

decontamination procedures for

colonised patients, as

appropriate;

isolation of infected or

colonised patients;

transfer of infected or colonised

patients within NHS bodies or

to other healthcare facilities;

and

antibiotic prophylaxis for

surgery.

They may have other clinical

conditions that may put them at

risk of

MRSA infection and should be

screened for that reason.


Ward Closure policy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

C. diffi cile

The policy should make provision

for:

surveillance of C. diffi cile

infection; diagnostic criteria;

isolation of infected patients

and cohort nursing;

environmental

decontamination;

antibiotic prescribing policies;

and a statement concerning

contraindication of antimotility

agents in symptomatic

antimicrobial-associated

diarrhoea

Clostridium difficile` Policy


Ward Closure policy



To be monitored through infection

control reporting forms,

Data surveillance

IP & C groups

Drug & Therapeutic

Committee


Nursing and

Governance/DIPC,

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Transmissible spongiform

encephalopathies

The policy should make provision

for the management of known or

high-risk patients.

Prion disease (transmissible

spongiform encephalopathies)





Data surveillance

IP & C Team


Nursing and

Governance/DIPC

Deputy Director of

Nursing /Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

47

Relevant policies for other specific

alert organisms

The specific alert organisms and

matters that follow are relevant to

any acute trust. They may also be

relevant to certain other NHS bodies

to which criterion 8 applies,

depending on their spectrum of

activity.

Glycopeptide-resistant enterococci:

screening of high-risk groups;

isolation and prevention of

cross-infection; and

prophylaxis for surgical

procedures.

Acinetobacter and other antibiotic-

resistant bacteria:

surveillance of identified

patients at risk and of high-risk

environments; and

procedures for managing

infected patients to prevent

spread of infection.

Control of tuberculosis, including

multi-drug-resistant tuberculosis:

isolation of infectious patients;

transfer of infectious patients

within NHS bodies or to other

healthcare facilities; and

treatment compliance.

Respiratory viruses:

alert system for suspect cases;

isolation criteria;

infection control measures; and

terminal disinfection and

discharge.

Diarrhoeal infections:

isolation criteria;

infection control measures; and

cleaning and disinfection policy.

Vancomycin Resistant Enterococci (VRE) Policy

Tuberculosis Policy

dentifies the care of Patients with confirmed or suspected tuberculosis and Directly Observed Therapy (DOT)

Norovirus Management

Policy

Clostridium.difficile Policy

Meningitis / septicaemia

Policy

The Infection Prevention

and Control policy

identifies

cleaning/disinfection

following outbreaks

Acinetobacter Policy

VHF policy





Data surveillance

IP & C Team


Nursing and

Governance/DIPC,

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

48

Viral haemorrhagic fevers (VHF):

patient risk assessment and

categorisation;

appropriate staff to be aware of

the special measures to be

taken for nursing VHF patients,

and to be properly trained in

the application of full isolation

procedures;

confirmed cases to be handled

under full isolation measures in

a high-security infectious

diseases unit or equivalent;

handling of patient specimens

at the appropriate containment

level;

follow-up of all staff in contact

with the patient at every stage

of care; and

special measures for the

handling of all healthcare

waste.

Legionella:

premises should be

regularly reviewed for

potential sources of

infection, and a

programme should be

prepared to minimise any

risks. Priority should be

given to patient areas,

although the exact priority

will depend on local

circumstances.

Any provider that should have in

place any of the core policies

mentioned above should, having

The Control of Legionellae

Bacteria in Trust Premises

policy

49

regard in particular to the healthcare

it provides, also consider whether it

would be appropriate for it to have

in place any of the additional

policies or to take any of the

measures mentioned in Part 5 of this

Code with a view to minimising the

risk of HCAI.

If such a provider considers that it is

appropriate for it to have in place

any of those policies or take any of

those measures, it should take into

account the content of Part 5 insofar

as it is relevant to making those

arrangements, including the content

of guidance and other publications

referred to in any relevant citation.

The sufficiency and suitability of

any policy implemented in

accordance with this provision of

the Code should be monitored via

the clinical governance system, and

there should be evidence of a rolling

programme of audit, revision and

update.

All policies should be clearly

marked with a review date.

50

Compliance Criterion 10 – Ensures, so far as is reasonably practicable, that care workers are free of and are protected from exposure to

infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the

provision of health and social care.


All staff can access relevant occupational health services

In Place Demonstrates Compliance as per


Up date as new guidance is issued

Review and develop training

sessions across all services as

required.


Department to monitor attendance


Nursing and

Governance/DIPC

Deputy Director of

Nursing / Deputy

DIPC

IP & C Team

Service

Managers/Modern

Matrons

Learning &

Development

Department

Occupational Health

Dept

Occupational health policies on the

prevention and management of

communicable diseases in healthcare

workers, including immunisation,

are in place

In Place

Prevention and control of infection is included in induction programmes for new staff, and in training programmes for all staff

In Place

Training and development

department records

There is a programme of ongoing

education for existing staff

(including support staff,

agency/locum staff and staff

employed by contractors);

In Place


department records

There is a record of relevant

immunisations;

In Place

There is a record of training and

updates for all staff

In Place

51


department records

The responsibilities of each member

of staff for the prevention and

control of infection is reflected in

their job description and in any

personal development plan or

appraisal.

In place - Job descriptions Completed by IP & C team, HR

and AD’s working together.


Nursing and

Governance/DIPC

Deputy Director of

Nursing/ Deputy

DIPC

Service

Managers/Modern

Matrons

Trust-wide Board Report May 2015

infection, prevention & control - welcome to kent and ... · pdf fileinfection, prevention...

Documents