WIRRAL COMMUNITY NHS TRUST
Director of Infection Prevention and Control
Annual Report
01 April 2011 – 31 March 2012
Introduction
1. The purpose of this report is to provide assurance to Wirral Community NHS Trust Board
regarding the Infection Prevention and Control activity undertaken across the organisation
for the reporting period 01 April 2011 – 31 March 2012.
2. This report also includes activity (Appendix One) undertaken by Wirral Community NHS
Trust Infection Prevention and Control Service on behalf of NHS Wirral during the period 01
April 2011 to 31 March 2012 as part of a service level agreement.
3. This is the first Director of Infection Prevention and Control (DIPC) Annual Report for Wirral
Community NHS Trust and is a statutory requirement within The Health and Social Care
Act 2008 Code of Practice on the Prevention and Control of Infections and related
guidance.
4. The Operating Framework for 2012/13 continues to place preventing healthcare associated
infection (HCAI) as a priority for the NHS.
5. The strategic aim of Wirral Community NHS Trust Infection Prevention and Control Service
is to increase organisational focus and collaborative working so as to effectively implement
The Health and Social Care Act 2008.
6. The Infection Prevention and Control Service endeavours to provide a comprehensive
proactive service, which is responsive to the needs of staff and public alike and is
committed to the promotion of excellence within everyday practice of Infection Prevention
and Control.
7. Reducing the risk of infection through robust infection control practice is a key priority for
Wirral Community NHS Trust and supports the provision of high quality services for patients
and a safe working environment for staff.
Wirral Community NHS Trust Infection Prevention and Control Arrangements
8. Infection Prevention and Control Service 2011/12:
Director of Infection Prevention & Control (also Director of Quality and Governance)
Head of Infection Prevention and Control Service
Senior Infection Prevention and Control Nurse (Senior IPCN)
Infection Prevention and Control Nurse
Senior TB Specialist Nurse
TB/Infection Prevention and Control Nurse
Project/Information Officer
Infection Prevention and Control Administrative Support
9. The Infection Prevention and Control Service continued to provide its core functions during
the reporting period 01 April 2011- 31 March 2012 despite reduced staffing levels due to
long term absence, this has now resolved.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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Key achievements for 01 April 2011 – 31 March 2012
Zero MRSA bacteraemia attributed to services the Trust provides
Supporting risk and governance agenda within the Trust in the first year as a new
organisation
Community Dental Service assessed as compliant following Inspection by the Care
Quality Commission
Achievement of 62.5% in annual staff influenza immunisation
Implementation of third phase of Essential Steps to safe, clean care
Facilitated successful second Infection Prevention & Control Study Day
Extended the provision of education and training to health and social care providers
Care Quality Commission
10. Wirral Community NHS Trust was granted unconditional registration with the Care Quality
Commission (CQC) during this reporting period and is deemed as meeting its requirements
under the Health & Social Care Act 2008 (Criterion 8).
11. The Trust has in place an assurance framework for Infection Prevention and Control that
reflects the duties of the organisation to meet the Health and Social Care Act 2008.
Infection Prevention and Control Group
12. The Infection Prevention and Control Group is accountable to the Trust Board and reports
through the Quality and Governance Committee.
13. The Group meets bi-monthly to support the development of a proactive organisational
culture which ensures staff at all levels prioritise and engage in Infection Prevention and
Control. It continues to peer approve all infection control policies, procedures and guidance
and monitors the progress of the annual Infection Prevention and Control work programme.
14. All clinical services are required to submit Service Assurance Reports to the group on a bimonthly basis.
15. Membership is outlined in the Terms of Reference which are reviewed annually (Appendix
Two).
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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Reporting Arrangements
Diagram 1: Wirral Community NHS Trust’s reporting structure for Infection Prevention and
Control
Trust Board
Quality & Governance Committee
Infection Prevention and Control
Group
Director of Infection Prevention
and Control
Infection Prevention and Control
Service
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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Working Arrangements
16. The DIPC and Infection Prevention and Control Service attend and provide reports and/or
advice to the following groups (Table One):
Table One: Groups attended by DIPC/Infection Prevention and Control Service
Organisation
Wirral Community Trust
Group
Compliance Group
Clinical Policies and Procedures Meeting
Health, Safety & Wellbeing Group
Medicines Management Meeting
Medical Supplies Meeting
Occupational Health Task & Finish Group
Quality & Governance Committee
Quality, Patient Experience and Risk Group
Learning & Development Group
NHS Wirral
Infectious Diseases in Pregnancy
Wirral Health Protection Strategy Group
Wirral University Teaching Hospital NHS
Foundation Trust
Hospital Infection Control Committee
Catheter Associated Urinary Tract Infection
Group
Healthcare Associated Infection (HCAI)
17. Wirral Community NHS Trust does not have HCAI objectives set for MRSA or Clostridium
Difficile. All community attributed cases are reported against NHS Wirral‟s objective who
retain responsibility for HCAI reduction across the Health Economy. Wirral Community
NHS Trust has set a target of zero avoidable healthcare associated infections in the
services that it provides.
18. Wirral Community NHS Trust continues to submit the monthly HCAI Provider Assurance
Framework to NHS Wirral
Meticillin Resistant Staphylococcus Aureus (MRSA)
19. During the reporting period 01 April 2011- 31 March 2012 there were no MRSA
bacteraemias attributed to services the Trust provides.
Clostridium Difficile
20. Case reviews of each reported case did not identify that the care provided by Wirral
Community NHS Trust was a contributory factor or root cause of infection.
Outbreaks
21. There have been no outbreaks involving Trust staff or premises during the reporting period
01 April 2011 - 31 March 2012.
Infection Prevention and Control Policies and Procedures
22. All NHS Wirral policies and procedures where formally adopted by Wirral Community NHS
Trust Board. The following polices where reviewed and approved during the reporting
period 01 April 2011 - 31 March 2012:
Organisational Infection Control Policy
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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Hand decontamination
Sterilisation of Reusable Medical Devices (Dental Services)
23. All policies and guidance will be reviewed and updated during the reporting period 01 April
2012 - 31 March 2013.
Hand Hygiene
24. Improvement in hand hygiene practices continues to be a priority for Wirral Community
NHS Trust. The Infection Prevention and Control Service continue to promote hand hygiene
through:
Continuing to promote the World Health Organisations (WHO) 5 moments for hand
hygiene
Hand hygiene prompt cards given to all staff on Essential Learning for Clinical staff
Completion of hand hygiene clinical observational audit four times per year.
Education and Training
25. Infection Prevention and control training, education and hand hygiene practice is included
in:
Induction to all new staff
Essential Learning for Clinical staff which is mandatory (bi-annually) for all front line
staff
From February 2012 Infection Prevention and Control has been included in the new
mandatory Essential Learning for Non-clinical staff
26. From July 2011 the Essential Learning for Clinical staff programme was extended to 3.5
hours to include Aseptic Non Touch Technique (ANTT) training. This became a mandatory
element of infection control training for those staff required to undertake the procedure as
part of their role. ANTT is a key area for development during 2012-2013.
27. Bar Chart One shows number of staff who have attended Infection Prevention and Control
training for the reporting period 01 April 2011- 31 March 2012.
Bar Chart One: Infection Prevention and Control Training Attendance Levels
400
350
300
250
200
150
100
50
0
Attended
Essential Learning
Non Clinical Essential
Learning
Induction
379
26
145
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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28. Infection Prevention and Control training for sessional medical and dental staff was
identified as an area of work required in relation to compliance with Care Quality
Commission registration during the reporting period 01 April 2011- 31 March 2012. An
action plan is in place with training to commence in October 2012 and be completed by 31
March 2013.
29. The Infection Prevention and Control Service facilitated a successful Study Day “Cleaning
up on Infection Control - Spreading Good Practice”. This event brought together delegates
from across the Wirral Health Economy. The event evaluation was extremely positive and
the Service will be looking to repeat the event in 2012-13.
30. The Infection Prevention and Control Service have delivered three sessions for The
University of Chester as part of the NM6065 Infection Prevention and Control Module.
31. An education session for Wirral Involvement Network (LINk) regarding Infection Prevention
and Control in the community setting was delivered in collaboration with Wirral University
Teaching Hospitals NHS Foundation Trust.
Audit
32. Infection Prevention and Control clinical audit is an integral element of Infection Prevention
and Control practice as it allows the Trust to measure compliance against national
standards.
33. During the reporting period 01 April 2011- 31 March 2012; 34 Trust premises were audited
using the Infection Prevention Society standards and incorporating local policy. Appendix
Three provides comparison of 2010/11 and 2011/12 audit results. 18 audits showed an
improvement on the previous year (2010/11). All Services are required to complete action
plans as per the Trust Audit Assurance pathway. To ensure robust follow up of these action
plans the Audit Assurance pathway was reviewed in December 2011 and is now monitored
via the Infection Prevention and Control Group.
34. There have been 14 Unannounced Infection Control Visits undertaken by the Director of
Infection Prevention & Control and Infection Prevention and Control Service during the
reporting period 01 April 2011- 31 March 2012. Areas for improvement were identified at
these inspections and essential equipment to assist staff in maintaining Infection Prevention
and Control standards within the clinical environment have been purchased using CQUIN
money (approximately £17,000).
Essential Steps
35. Essential Steps to Safe, Clean Care (Essential Steps) is a framework aimed at reducing the
risk of healthcare associated infection in key clinical procedures.
36. The third phase of Essential Steps was implemented from 01 April 2011.
37. All eligible clinical services were required to observe 100% of eligible staff four times during
the reporting period 01 April 2011- 31 March 2012.
38. All eligible staff are required to complete Tool One: Hand Hygiene. Bar Chart Two
demonstrates organisational compliance with Tool One: Hand Hygiene. Although
adherence to bare below the elbows continues to be a current theme of non- compliance.
39. All eligible clinical services were required to submit their quarterly data using a web based
information management system (INCA). Compliance with Essential Steps is monitored by
the Infection Prevention and Control Service and a report analysing the data has been
completed and presented to the Infection Prevention and Control Group.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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40. Compliance has been variable but continues to improve. Issues regarding accuracy of data
have been recognised and the Infection Prevention and Control Service have worked with
the Informatics Service to improve accuracy of data for 2012-13.
Bar Chart Two: Organisational Compliance with Tool One for 2011/12
100%
90%
80%
Compliance
70%
60%
50%
40%
30%
20%
10%
0%
Score Achieved
Period 1
Period 2
Period 3
Period 4
96%
99%
99%
100%
Cleaning Services
41. Domestic services continue to be provided by Cheshire and Wirral Partnership Foundation
NHS Trust.
42. Unsatisfactory standards of cleaning have been consistently identified. Adherence to
cleaning standards is measured using C4NET by the facilities provider with a compliance
rate of set of >85%. It was identified that this level of compliance did not deliver a
satisfactory level of cleaning and this has been increased to >90%.
43. A series of joint audits were undertaken during the reporting period 01 April 2011- 31 March
2012 by the Facilities Manager and a member of the Infection Prevention and Control
Service. The Facilities Manager is required to submit a report to the Infection Prevention
and Control Group identifying areas where standards have not been met and provide
assurance that areas of concern have been addressed. This will be monitored via the
Infection Prevention and Control Group
Decontamination of Medical Devices
44. The Director of Infection Prevention and Control is the Trust Decontamination Lead.
45. The Community Dental Service is compliant with Best Practice Standards set out in The
Health Technical Memorandum (HTM 01-05) Decontamination in primary care dental
practices.
46. The Podiatry Service uses an accredited Central Sterile Supply Department (CSSD).
47. A review of cleaning wipes was undertaken across the Trust and Clinell wipes were
introduced to improve the appropriate decontamination of equipment and the environment.
48. Decontamination of equipment is a key process in the Community Equipment Store. An
announced visit identified concerns in relation to decontamination process within the unit.
A risk assessment was undertaken and action plan implemented. Staffing, cleaning
processes, protocols and training were reviewed and equipment purchased e.g. steam
cleaners. Progress against the action plan is monitored by the Infection Prevention and
Control Group and at Service Governance meeting.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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Antimicrobial Prescribing
49. Antimicrobial stewardship is a key component for reducing health care associated
infections.
50. The use of NHS Wirral Antimicrobial Guidelines by Wirral Community NHS Trust was
formally agreed by the Medicines Management Group and a quarterly review of
antimicrobial prescribing within the Trust commenced. This is an area of work that will be
further developed during 2012 -2013.
Incidents
51. There were no serious untoward incidents reported to the Quality and Governance Service
for STEIS or RIDDOR reporting.
Seasonal ‘Flu Vaccination Programme
52. The Director of Infection Prevention and Control chaired the staff flu vaccination
programme group which met regularly to plan the annual staff flu vaccination campaign. To
ensure staff had maximum opportunity to obtain a flu vaccine, sessions where delivered in
a variety of ways;
Two week programme provided by Occupational Health Department.
Provision of drop in staff vaccination clinics across Trust locations covering all shift
patterns.
Vaccination sessions at staff bases.
Opportunistic vaccination.
53. The Infection Prevention and Control Nurses supported this programme as immunisers.
54. Overall 62.5% of staff accepted the offer of flu vaccination compared to the national picture
of 43% uptake.
Tuberculosis Service (TB)
55. In response to operational issues and to address areas of concern in relation to risk and
governance the TB Service transferred to Wirral University Teaching Hospital from the 01
April 2012 to enable co-location with the Lead Respiratory Consultant responsible for TB.
Training for the Infection Prevention and Control Service
56. Table Two shows the training attended by staff within the Infection Prevention and Control
Service during the reporting period 01 April 2011 – 31 March 2012.
Table Two: Training completed by the Infection Prevention and Control Service 01 April
2011 – 31 March 2012
Director Infection
Prevention & Control
Head of Infection
Prevention & Control
Senior Infection Prevention
& Control Nurse
Training
Date undertaken
NM6065 Infection Prevention and Control February 2012
Module
Msc Research Module
September 2011
Obtained Bsc Hons Professional Practice
November 2011
Commenced Msc Advancing Leadership
for Quality (double module)
September 2011
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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Conclusion
57. Wirral Community NHS Trust is committed to continuous, sustainable improvement in
Infection Prevention and Control and supports a „zero‟ tolerance of avoidable infection and
harm to our patients and staff.
58. The appointment of the Director of Quality and Governance as Director of Infection
Prevention and Control has enabled a structure to embed Infection Prevention and Control
at a corporate level whilst creating a structure to facilitate clear leadership and quality
improvement throughout the Trust.
59. HCAI reduction and improvement of Infection Prevention and Control standards requires a
multi-partnership approach.
60. Quarterly assurance reports regarding Infection Prevention and Control activities across
Wirral Community NHS Trust will be provided to the Trust Board throughout 2012/13.
Lisa Cooper
Director Infection Prevention and Control, Wirral Community NHS Trust
Helen Oulton
Head of Infection Prevention and Control Service
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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APPENDIX ONE
NHS WIRRAL
1. Wirral Community NHS Trust Infection Prevention and Control Service continue to provide
support to NHS Wirral via a service level agreement. The Service extends across the wider
health economy and includes the provision of advice and support for schools, nurseries,
Residential/Nursing homes, General Practitioners, Dentists and the general public. The
Infection Prevention and Control Service is responsible for the monitoring, surveillance and
investigation of infections and the provision of advice regarding preventative and control
precautions.
2. The Infection Prevention and Control Service continue to provide advice and support
across the health economy e.g. General Medical and Dental Practitioners, Practice Nurses,
Nursing/Residential Care Homes, schools/early years providers and the general public on
all aspects of infection prevention and control and communicable disease.
Outbreaks
3. The Infection Prevention and Control Service have managed 22 outbreaks of
gastrointestinal infection in Wirral Care Homes. All of these outbreaks had a suspected viral
cause, none of which were confirmed. It is recognised that under reporting remains a
consistent issue.
4. Good communication is essential between secondary care and community care providers
to prevent outbreaks in communal settings and limit the opportunities for transmission. The
Infection Prevention and Control Service continued to work with WUTH to ensure effective
reporting and information sharing around outbreaks.
Bar Chart 1: Outbreaks of Viral Gastrointestinal Illness – care homes
Number of Service Users/Staff Affected by
Outbreaks of Viral Gastrointestinal Illness
Service Users
Staff
160
140
Total Number
120
100
80
60
40
20
Mar
-12
12
Feb
-
-12
Jan
-11
Dec
-11
Nov
1
Oct
-1
Se p
-11
Aug
-11
11
Jul-
Jun
-11
1
May
-1
Apr
-11
0
5. The Service also provided support to 2 schools/early years settings in managing outbreaks
of gastrointestinal infection and 2 scabies outbreaks reported during this reporting period.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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MRSA Bacteraemia Objective - 2011/2012
6. The reduction of MRSA bacteraemia remains challenging. During the reporting period 01
April 2011 – 31 March 2012.a total of eight bacteraemias were identified against an agreed
target of ten.
7. In this reporting period, cases were two post 48 hour (hospital attributed) and two pre-48
hour (community attributed) receiving care from providers (NHS and non NHS providers)
within Wirral.
8. The other cases were attributed to NHS Wirral in line with the national MRSA objective e.g.
where Wirral residents cases occurring in providers outside of Wirral could not be identified
by GP or NHS Number they were allocated to NHS Wirral.
9. Root Cause Analysis (RCA) is undertaken for all MRSA Bacteraemias identified within the
first 48 hours of hospital admission (classified as community attributed). One bacteraemia
was deemed unavoidable and one attributed to cross infection due to sub optimal infection
prevention and control practice in a care home.
10. Table four shows the annual incidence for MRSA Bacteraemia since April 2005
Bar Chart 2: Annual incidence of MRSA Bacteraemia April 2005 - March 2012
MRSA Bacteraemia
Incidence of MRSA
60
50
40
30
20
10
0
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
Clostridium Difficile Target 2011/2012
11. NHS Wirral‟s target was set as no more than 151 cases of Clostridium difficile during
2011/12. During the period 01 April 2011 to 31 March 2012 a total of 144 cases were
reported.
12. As outlined in previous NHS Wirral Annual Reports there have been significant
issues with the reporting cases of Clostridium difficile to the Infection Prevention
and Control Service. These issues were not resolved during 2011-2012. The
relocation of the microbiology laboratory and the introduction of the new I.T. system
exacerbated the problem. This issue has been raised again with NHS Wirral and
Wirral University Teaching Hospital for resolution.
13. Case reviews were completed in all reported community attributed cases. In addition to this
an audit is undertaken if a case of Clostridium difficile occurs in a care home. Where areas
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
11
of concern are identified these were escalated via NHS Wirral and the Local Authority who
contract care home services.
Graph 1: Incident of (HCAI) Clostridium Difficile age 2+ years
Incidence of (HCAI) Clostridium difficile aged 2+ years
600
500
400
300
200
100
0
Septembe
October November December
r
April
May
June
July
August
January
February
March
2011/12
14
24
39
54
68
84
99
109
2011/12 Target
8
18
34
45
54
66
79
92
119
129
138
144
107
123
131
2010/11
27
64
88
108
121
137
144
151
151
162
175
183
2010/11 Target
17
35
52
70
87
104
193
121
141
164
193
216
2009/10
17
36
67
90
107
236
131
159
186
218
249
267
2009/10 Target
25
51
76
102
310
127
153
179
207
238
275
306
2008/09
40
63
96
334
144
165
192
217
239
257
291
313
2008/09 Target
37
74
331
111
148
185
222
259
299
347
401
449
2007/08
38
87
490
134
173
213
255
291
340
387
433
480
516
Catheter Associated Urinary Tract Infections (CAUTI)
14. In May 2011 a joint presentation was delivered at the Infection Prevention Society North
West study day to demonstrate a shared health economy approach in reducing CAUTI. The
presentation was delivered by the Senior Infection Prevention and Control Nurse, W CT,
Continence Lead WCT and Matron WUTH.
15. A joint presentation was delivered by the Senior Infection Prevention and Control Nurse,
Continence Lead and Health and Well-being Lead, Department of Adult Social Services at
the Regional Safety Express Event in December 2011 held at WUTH. The presentation
demonstrated the community approach to whole health economy working. The work
continues into 2012- 2013.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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Education and Training
Graph 2:
Providers
Infection Prevention & Control Training Attendance Levels – Independent
140
120
100
80
60
40
20
0
GP Practice
Adult Care Home
Bespoke
Attended
83
125
10
DNA
13
33
0
16. Four core Infection Prevention and Control training sessions were provided for Practice
Nurses and Health Care Assistants working in general practice during the reporting period
01 April 2011 – 31 March 2012.
17. The delivery of education and training to the care home sector was reviewed in 2010 –
2011 and extended to all providers of adult health and social care in 2011-12. Four
infection prevention and control training sessions were provided free of charge. Although
the numbers of “did not attend” continued, a decrease in the “did not attend” rate was noted
from the previous year.
18. The Infection Prevention and Control Service provided support to Wirral GP Commissioning
Consortium Protected Learning event.
Audit
19. Infection control audit is an essential component of safety and quality. It ensures that
providers are contracted to provide services that are safe and fit for purpose whilst enabling
the provider to measure its compliance in practice against national standards.
20. GP practices are offered a practice audit bi-annually.
21. The Infection Prevention and Control Service supported DASS by providing infection
control audit to 4 care homes where areas of concern had been identified.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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Table 1: Infection Control Audit Independent Providers 2011-12
General Practice
Blackheath MC
Cavendish MC
Central Park MC
Claughton MC
Commonfield Road MC
Earlston Road MC
Greenway Road
Holmlands MC
Hoylake Road MC
Kings Lane MC
Liscard Group Practice
Manor Health Centre
Mill Lane Surgery
Moreton MC
St Georges MC
Silverdale MC
Somerville MC
Teehey Lane Surgery
Vittoria MC (Murty)
Vittoria MC (Edwards)
Whetstone Lane
Woodchurch MC
Care Home
Anchorage Nursing Home x 2
Birchtree Manor
Birkenhead Court & Grange x 2
Dales Rest Home
Elderholme Nursing Home
Giles Shirley Hall
The Grange Nursing Home x 2
Mother Redcaps Nursing Home
Rosebrae Nursing Home
St Georges Care Home
Westhaven Care Home
Independent Provider
Claire House
22. It is essential that Infection Prevention and Control commissioning arrangements are
embedded into emerging commissioning organisation‟s and that clear pathways are in
place. At the time of writing this report NHS Wirral has appointed a Consultant in Health
Protection (12 month temporary post) to take forward the HCAI commissioning agenda.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
14
APPENDIX TWO
Wirral Community NHS Trust
Infection Prevention & Control Group
Terms of Reference
Purpose
The purpose/role of the IPC Group is the prevention of infection throughout Wirral Community NHS
Trust (WCNHST). The IPC Group will provide assurance to the Trust Board that health care
associated infection (HCAI) is effectively managed within the Trust. It will be the forum at which all
elements of the infection prevention & control agenda will be brought together in order to realise
continuous improvement in the quality, responsiveness and patient and public experience.
Membership (Appendix A)
The IPC Group will be chaired by the Director of Infection Prevention & Control. In their absence
the Head of Infection Prevention & Control.
A member who will be unavailable for a meeting may nominate a deputy to attend in their place at
the agreement of the Chair. A quorum will be 4 members and must include a member of the IPC
Team.
The Committee will co-opt members as required.
Agendas and papers will be distributed at least four working days (or three plus a weekend) in
advance of the meeting.
Frequency
Meetings shall be held 6 times per year. Additional meetings will be called if required.
Authority
In order to facilitate the achievement of good governance, the IPC Group is authorised by the
Board to investigate any activity within its terms of reference.
Minutes of the IPC Group will be presented to the Quality & Governance Committee for
governance purposes.
Duties
In order to fulfil its role effectively, the IPC Group will:
1.
Ensure that CQC requirements for Registration are met.
2.
Drive improvements and innovation in healthcare assurance in the Trust.
3.
Advise the Quality & Governance Committee and Trust Board of the quality and risk
considerations relevant to the achievement of The Health & Social Care Act 2008, Code of
Practice for health and adult social care on the prevention and control of infections and
related guidance.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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4.
Receive assurance that the Trust meet all relevant statutory and regulatory obligations
including the Code of Practice.
5.
Review Risk in relation to HCAI on behalf of the Trust ensuring that existing risks, key
controls, assurances and incorporate action plans to deliver against gaps in assurance are
identified/monitored.
6.
Review progress against national and local targets for healthcare associated infection and
advise the Trust Board were significant risks to achievement are identified.
7.
Review the outcomes and action plans associated with all Serious Untoward Incidents for
Trust attributed MRSA bacteraemias to ensure that learning is shared.
8.
Advise the Trust Board of all significant clinical risks in relation to infection prevention, areas
for development and good practice.
9.
Receive assurance that the relevant standards in relation to IPC are being complied with and
that the risks associated with those items are identified and controlled.
10.
Ratify relevant policies, guidance and reports and review their implementation.
11.
Recommend relevant strategies and reports for approval by the Trust Board.
12.
Review the results of infection control audits.
13.
Advise and support the Infection Control Practitioner/s.
14.
Consider reports on infections and infection control problems from any department, staff
member within the Trust.
15.
Determine infection control priorities and develop an annual programme for the
implementation of new policies, guidance or directives.
16.
Work in partnership with other agencies and healthcare providers to facilitate infection control
practice.
Relationship to the Board & Reporting Arrangements
The minutes of the IPC Group shall be formally recorded by the Group Secretary and submitted to
the Trust Board and Quality & Governance Committee. The DIPC shall draw to the attention of the
Board any issues that require disclosure to the full Board, or require executive action.
Review
Terms of Reference will be reviewed annually by the IPC Group.
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
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APPENDIX A
The IPC Committee will comprise the following members:
Director of Infection Prevention & Control (DIPC)
Head of Infection Prevention & Control Service
Infection Prevention & Control Team(1)
Health & Safety Officer
Risk Management Representative
Medicines Management representative
Projects and Premises
Community Nursing representative
Salaried Dental Services representative
Sexual Health Services representative
Unplanned Care representative
Physiotherapy representative
Dietetics representative/Speech and Language representative
Podiatry representative
Specialist Nursing Service representative
WUTH Microbiologist
Occupational Health Nurse
CWP Facilities Manager
CCDC/Health Protection Agency representative
Heart Support representative
Health Visitors representative
Community Equipment representative
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
17
APPENDIX THREE
INFECTION PREVENTION & CONTROL AUDIT RESULTS
Community Trust Areas/Services
RAG System for table
100%
= 71 – 99%
= 51 – 70%
= < 50%
Full Compliance
Action Required
Urgent Action Required
Trust Priority
Service
All Day Health Centre - APH
Bebington Civic Centre - CT Rooms
Bridle Road Clinic
Cardiac, VCHC
Child Assessment rooms, VCHC
Dressing Clinic, Claughton MC
Baby Clinic, Claughton MC
Eastham Clinic
Eltham Green Clinic
Fender Way Clinic
Field Road Clinic
Greasby Clinic
Heart Assessment Centre, SCH
Heswall Clinic
Leasowe Primary Care Centre
Leg Ulcer Clinic, VCHC
Outpatients, VCH
Parkfield MC
Pasture Road Clinic (Moreton H/C)
Physiotherapy, VCHC
Physiotherapy, SCH
Podiatry - Bebington Civic Centre
Podiatry, VCHC
Prenton Clinic
Primary Care Assessment Unit
Sexual Health Services, SCH
Sexual Health Services, Miriam Medical Centre
Speech & Language, APH
Speech & Language, VCHC
St George's Medical Centre, Ophthalmic
Townfield Clinic
Victoria Park H/C
Vittoria Medical Centre
Walk in Centre - Victoria Central Hospital
West Kirby Clinic
Wheelchair Service - Ellesmere Port
Wheelchair Service - Hind Street
Wing D, 2nd Floor, VCHC
10/11
85
71
75
89
76
89
69
69
85
88
83
76
93
93
94
88
100
72
93
96
89
87
64
65
75
55
91
65
86
99
Director Infection Prevention & Control Annual Report 01 April 2011 – 31 March 2012
18
11/12
80
96
91
93
95
91
85
91
92
93
91
87
89
80
89
99
92
92
83
98
87
N/A
98
96
90
92


94
93
100

76
90
86
91
92
98
APPENDIX FOUR
WIRRAL COMMUNITY NHS TRUST
INFECTION PREVENTION & CONTROL PLAN 01 APRIL 2012- 31 MARCH 2013
PRIORITIES FOR ACTION
EXPECTED OUTCOME
LEAD
TIMESCALE
Objective 1
The organisation has systems in place to manage and monitor the prevention and control of infection
Review HCAI RCA process/reporting
Compliance with Health & Social care Act 2008
DIPC/Head of IPC
Produce an Annual Report for 2012 – 2013
June 2012
March 2013
Review and maintain evidence collection for Care Quality
Commission Compliance
Head of IPC
Quarterly Review
(June 2012;
September 2012;
December 2013;
March 2013)
Compliance with Health & Social care Act 2008
IPC Service
March 2013
Compliance with Health & Social care Act 2008,
Trust policy and national guidance
IPC Service
COMPLETE
Objective 2
Ensure the provision of evidence based, up to date and relevant infection control policies
All Policies/Guidelines to be reviewed and revised in line with
review dates and to reflect organisational change
Objective 3
Ensure effective Infection Control Audit
Prepare audit programme
Deliver audit programme
Review and implement Infection Prevention Society Quality
Improvement Tools
25-4-12
Audit score >85%
Quarterly Review
(July 2012;
October 2012;
January 2013;
April 2013)
19
PRIORITIES FOR ACTION
EXPECTED OUTCOME
LEAD
TIMESCALE
INCA – Heads of Service to maintain staff data and submit
compliance scores within agreed timeframes
Essential Steps Compliance score 100%
Head of Service
Quarterly Review
(July 2012;
October 2012;
January 2013;
April 2013)
IPC Service
Quarterly Review
(July 2012;
October 2012;
January 2013;
April 2013)
DIPC/IPC Service
Monthly
IPC Service
June 2012
Produce quarterly Essential Steps reports
Continue programme of annual unannounced visits to
clinical services
Objective 4
All staff will receive appropriate education and training in infection prevention policies and practice
Review Essential Learning (EL) training programme
Compliance with Health & Social care Act 2008,
Trust policy and national guidance
Review ANTT training
Effective prevention and control of HCAI
June 2012
Introduce ANTT competency
November 2012
To continue to provide IPC input to Essential Learning
programme
To work with Q & G to review/develop e-learning programme
which meets the needs of the Trust
Facilitate Infection Prevention & Control Study Day
Quality &Governance
Awaiting
confirmation
September 2012
Objective 5
25-4-12
20
PRIORITIES FOR ACTION
EXPECTED OUTCOME
LEAD
TIMESCALE
IPC Service
Quarterly Review
(July 2012;
October 2012;
January 2013;
April 2013)
Key clinical procedures/care processes are performed appropriately
Provide support to Continence Service to reduce catheter
associated urinary tract infections
Compliance with Health & Social care Act 2008,
Trust policy and national guidance
To conduct audit on VAD practices
Zero avoidable healthcare associated infections
attributed to Trust
December 2012
To introduce cannulation packs across the Trust
Improved Quality of Care for service users
July 2012
Objective 6
To ensure the maintenance of a clean and appropriate environment
Ensure contracts for domestic services identify standards of
cleanliness required for Trust services in line with national
guidance
Compliance with Health & Social care Act 2008,
Trust policy and national guidance
Head of Estates/Head of
Procurement &
Contracting
Increase compliance threshold of C4NET
June 2012
June 2012
Continue joint audits between IPC Team and CWP Facilities
Team
IPC Service
Quarterly Review
(July 2012;
October 2012;
January 2013;
April 2013)
IPC Service
March 2013
Objective 7
Promote ownership and engagement with infection prevention and control
Review and update patient information
25-4-12
Compliance with Health & Social care Act 2008
21
PRIORITIES FOR ACTION
EXPECTED OUTCOME
LEAD
TIMESCALE
Undertake patient led review of infection control standards
January 2013
Objective 8
To ensure WCT is compliant with national decontamination requirements
To monitor standards of Decontamination of
reusable medical devices by contracted Sterile Services
provider.
Dental Service will remain compliant with HTM 01-05
25-4-12
Compliance with Health & Social care Act 2008
and national guidance
Decontamination Lead
Quarterly Review
(July 2012;
October 2012;
January 2013;
April 2013)
Clinical Director Dental
Services
Quarterly Review
(July 2012;
October 2012;
January 2013;
April 2013)
22