INFECTION PREVENTION AND
CONTROL
ANNUAL REPORT
2009/2010
INFECTION PREVENTION AND CONTROL COMMITTEE
Contents
Page
1.
Executive Summary
2-3
2.
Pennine Care Infection Prevention & Control Strategy
3-4
3.
Roles and Responsibilities
4-7
4.
Policies
5.
Service Level Agreements
6.
Care Quality Commission Visit
7.
Audits
9-11
8.
Incidents
12-17
9.
Training
18
10.
Health Care Associated Infections (HCAI) - MRSA, Clostridium
Difficile, ESBL (Surveillance) and Outbreaks
11.
Antibiotic Prescribing
12.
Cleaning and Decontamination procedure
13.
Planning and Refurbishment
21
14.
Flu Vaccination programme
21
Appendix A
Infection Prevention and Control Audit Plan April 2010- March 2011
22-23
Appendix B
Board Level Agreement
24-26
Appendix C
Infection Control Training Plan – April 2010 to March 2011
Appendix D
Infection Control Work plan – April 2010 to March 2011
28-29
Appendix E
Infection Prevention and Control Completed Action Plan – April 2009
to March 2010
30-31
Appendix F
Infection Prevention and Control Action Plan – April 2010 to March
2011
32-34
7
8-9
9
18-20
20
20-21
27
Appendix G CQC Action Plan
35-39
Appendix H
Quality Accounts
40-42
Appendix I
Monthly Monitoring Form
43-49
Appendix J
6 Monthly Environment Audit Form
50-59
1
1.
Executive Summary
Pennine Care NHS Foundation Trust provides specialist mental health
services in a variety of community and inpatient settings across Bury,
Rochdale, Oldham, Stockport, Tameside and Glossop. As an NHS
organisation the Trust is committed to reducing the incidence of healthcare
associated infections.
The report is for the period April 2009 to March 2010. It also includes the
infection control plans for April 2010 to March 2011.
The report outlines the accountability arrangements for infection control in the
trust. The text outlines the activities of the Trust relating to infection prevention
and control that aim to minimise the risk of healthcare associated infections
including surveillance, audit, quality accounts, policy development and review,
incident reporting, education and training and the prevention and management
of outbreaks.
The trust has implemented a programme of activities to embrace new national
initiatives and effectively prevent and control healthcare associated infections
across the trust.
The Health and Social Care Act 2008 outlines a clear code of practice for
Infection Prevention and Control. Pennine Care strives to achieve excellence
in all aspects of the code. The Trust registered with the Care Quality
Commission against the code of practice.
The board have signed an Infection Prevention and Control Board Assurance
document which is the board statement of commitment to all aspects of
Infection Prevention and Control (Appendix I).
The successful management, prevention and control of Infection is recognised
by the Trust as a key factor in the quality and safety of care of
inpatients/service users as well as ensuring a clean and well maintained
environment which the Modern Matrons enforce in inpatient units, drug and
alcohol service and CAMHS.
The Board receives regular reports in relation to Infection Prevention and
Control via Risk and Clinical Governance Committee and Infection Prevention
and Control Committee.
Infection control incidents are reported via the risk management reporting
system and root cause analysis is undertaken when cases of new MRSA,
Clostridium Difficile or an outbreak occurs.
The key points from 2009/2010 are:
•
Implementation of 13 new Infection Prevention and Control Policies
•
Development of the Infection Prevention and Control web page
•
Development of a robust audit programme
2
•
Implementation of monthly Matron walkabouts with Estates and Domestic
Manager
•
Development of Training programmes
o
o
o
o
2.
Mandatory
Champions
Infection Control policy awareness
Matrons
•
Implementation of CQC action plan
•
Development of Infection Prevention and Control Information Leaflets.
Pennine Care Infection Prevention and Control Strategy
Introduction
The Department of Health has published a number of guidance documents to
help NHS trusts to plan and implement how they can prevent and control
Health Care Associated Infections. Winning Ways: Working together to reduce
Healthcare Associated Infection in England (2003) and The Health and Social
Care Act 2008 Code of Practice for the Prevention and Control of Health Care
Associated Infections.
Good management and organisation is crucial to establishing high standards
of infection control. The systems for the prevention and control of infections
associated with healthcare have to address leadership, management
arrangements, design and maintenance of the environment and devices,
provide application of evidence based protocols and practices for both users
and staff and provide education, training, information and communication.
Effective prevention and control of Health Care Acquired Infection (HCAI) has
to be embedded into everyday practice and applied consistently by everyone.
Aim
Pennine Care is committed to reducing the risk of infections to a minimum
through effective infection prevention and control practice.
Infection Prevention and Control will be embedded in everyday practice across
the organisation.
2.1
Scope
The infection Prevention and Control Strategy is concerned with the
prevention of avoidable risks of infection and the control and management of
all unavoidable risks of infection to patients, service users, visitors and staff.
3
2.2
3.
Objectives
•
To ensure that Infection Prevention and Control is an integral part of the
service delivery.
•
To ensure that healthcare acquired infections are reduced to a minimum.
•
To maintain compliance with all requirements of Standards for better Health
and the Health and Social Care Act 2008.
•
To ensure Pennine Care have policies and procedures in place to fulfil the
requirements and comply to the Code of practice for the prevention and
control of healthcare associated infections as outlined in the Health and Social
Care Act (2008).
•
To work with other stakeholders to improve surveillance and to strengthen
prevention and control of infection and communicable disease processes.
•
To ensure that information is available to patients and the public about the
organisations general processes and arrangements for preventing and
controlling HCAI (Health and Social Care Act 2008).
•
To ensure decontamination across the Trust meets all the National mandatory
requirements.
•
To provide education and training on prevention and control of infection to
ensure staff understand their responsibilities.
•
To ensure appropriate information is communicated relating to infection risk
and outbreaks to all relevant parties.
•
To work with the local Health Protection Agency (HPA) to ensure good
infection control practices across the trust.
Roles and Responsibilities
The Pennine Care Board and ultimately the Chief Executive carries
responsibility for Infection Prevention and Control. For day to day
management this is delegated to the Director of Infection Prevention and
Control (DIPC). All managers and clinicians must ensure that the management
of infection control risks are one of the fundamental duties. Every clinical
member of staff must demonstrate commitment to reducing the risk of infection
through good infection control practice. This will be implemented, monitored
and evaluated through staff IPDR processes.
Role of Director of Infection Prevention & Control (DIPC)
The DIPC is responsible for monitoring and overseeing infection control
policies and reports directly to the Chief Executive Officer and the Board.
Role of Lead Nurse: Infection Prevention and Control
The IPCN provides a clinical service for the prevention, surveillance
investigation and control of infection for Pennine Care.
4
The IPCN will:
•
Ensure timely advice on infection control is available to Pennine Care staff,
Committees and the Board.
•
Liaise with the Health Protection Agency when dealing with Outbreaks.
•
Be responsible for co-ordinating infection control audits, education and
training, policy and strategy development and the production of relevant
infection control reports and data for use within the Pennine Care to monitor
and promote improvements in practice.
Role of Infection Control Champions
The IC Champions are responsible for promoting good infection control practice in
their work area with their colleagues, patients/service users, relatives and the
environment.
Role of Matrons and Ward Managers
Matrons and Ward Managers are responsible for ensuring that the day to day
cleaning is being implemented to the highest standard and has the authority to
address issues directly with cleaning teams. Weekly checklists must be provided
by the ward managers to ICN. The checklist reports must then be reported on by
the matrons in their quarterly reports to ICC. The matrons and ward managers are
responsible for ensuring the Champions are supported and performing their role,
and have the appropriate time and resources to do this effectively.
Role of the Infection Prevention and Control Committee
The committee members are responsible for providing strategic advice and
support to the directors, managers, clinicians and all staff and on the
implementation of infection control policies. It monitors the progress of the annual
control of infection programme, infection control policies, procedures, guidance
and Service level Agreements (SLA), audit, cleanliness, education and root cause
analysis.
Role of Estates Management and Domestic Services
Estates Managers and Domestic Services Managers should ensure that the
environment and equipment they are responsible for are maintained to required
standards in order to promote good infection control practice and ensure easy
cleaning of clinical areas.
Role of Service Directors/Service Managers
Service Directors & Service Managers liaise closely with the IPCN to ensure
infection control policies are effectively implemented and maintained. They should
ensure:
•
All staff understand clearly their responsibilities in respect of the Infection
Prevention and Control Policies.
•
New staff are adequately inducted in respect of infection control procedures
relevant to their work base and their role.
5
•
The required time is allocated for staff to attend infection control education
sessions through the mandatory training programme.
•
All infection control risks are systematically assessed and any necessary
improvements prioritized.
•
Policies, procedures and guidance are readily available to staff.
•
ICN are consulted on infection control issues, including specialized advice i.e.
purchasing of equipment and building projects.
•
Attendance of infection control education sessions is monitored through the
Learning and Development Department.
Role of the Learning and Development Team
The Learning and Development Department ensure infection control is part of all
induction and mandatory training programmes for staff.
Arrangements are in place for staff training to be effectively recorded and
maintained in staff records.
Promote infection prevention and control by leading by example therefore
providing a safe environment for patients, visitors and staff.
A system is in place for informing managers of their staff’s non-compliance and
non-attendance at mandatory training sessions.
Role of Health Protection Agency (HPA)
The HPA will provide services to support and enable the Pennine Care to fulfill
their health protection responsibilities. The HPA team will work with Pennine Care
to advise and support infection control in infection control matters.
Role of the Risk Management Team
The risk management team will ensure infection control incident s are reported
and recorded on the appropriate documentation and to the Infection Control
Nurses. A robust system of risk management will be in place with action and
follow up to an incident occurring.
All Staff
All staff are responsible for ensuring that they follow good Infection Prevention
and Control practice at all times and that they are familiar with infection control
policies, procedures and guidance relevant to their area of work. Staff have a duty
to report breaches in good practice and take correct action as appropriate.
Table 1. Membership of the Infection Control Committee
•
•
•
•
Director of Infection Prevention and Control (DIPC)
Deputy Director of Nursing and Integrated Governance (Deputy Chair)
Lead Infection Control Nurses
Patient Safety and Clinical Risk Manager
6
•
•
•
•
•
•
•
•
•
4.
Chief Pharmacist
Infection control nursing representative from Pennine Acute trust, Tameside &
Glossop Foundation Trust and Stockport Foundation Trust.
Estates Representation
Medical Representation
Lead Borough Representation
Health Protection Agency Representation
Matrons Representation
Governance Manager Representation
Lead Commissioning PCT infection control nurse representation
Policies
The core Infection Prevention and Control Policy CL4 contains:
•
•
•
•
•
•
•
•
•
•
•
Standard Precautions
Education and Training
Roles and Responsibilities
Assurance Framework
Information Available to Patients and Public
Occupational Health Services
Surveillance Audit & Monitoring
Infection Control Guidance on Patients Who Have Died
Notifiable Diseases
Decontamination of Linen
Definition & Explanation of Terms
Other Infection Control Policies and Policies linked to Infection Control
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Hand Hygiene
Management of Scabies
MRSA
Clostridium Difficile
Sharps Management and Inoculation Injuries
Personal Protective Equipment
Vaccination Storage
Pandemic Flu
Medical Devices Management
Aseptic Technique
Waste Management
Isolation and Barrier Nursing Outbreaks
Management and Prevention of Head, Body and Pubic Lice
Specimens
Flowers and Plants in Infection Control
Venepuncture
Dress & Uniform Policy
Cleaning Policy
Death of a Patient
Medicines Policy
Food Safety
COSHH
Health & Safety
The specific infection control policies were approved by the board in September
2009
7
5.
Service Level Agreements (SLA)
The service level agreements continue with the 3 Acute Hospital Trusts
•
Pennine Acute NHS Trust provides specialist infection control services at Birch
Hill Hospital in Rochdale, the Royal Oldham Hospital, and Fairfield General
Hospital in Bury.
•
Tameside & Glossop Foundation NHS Trust provide specialist infection control
services at Tameside General Hospital and Woods Hospital in Glossop.
•
Stockport Foundation Trust provides specialist infection control services at
Stepping Hill Hospital and the Meadows in Stockport.
The service is provided by Infection Control Teams based at each hospital site,
comprising of Microbiologists and Specialist Infection Control Nurses.
Under the SLA’s the team have provided the following range of services to
Pennine Care staff and patients over the past year.
All wards and departments have contacted information for Infection Control
Teams (e.g. office address, names & contact numbers and pager numbers).
Telephone advice, to facilitate safe working practices in relation to infection
prevention and control.
Training and Education in all aspects of Infection Control. Including the Infection
Control Link Nurse programme. (Infection control training is accessed through
education and training SLA’s with the 3 Acute Trusts). Details of courses are
circulated via Pennine Care Central Training Dept.
•
Induction Training for all new Pennine Care staff within Pennine Care
Corporate Induction Programme, provided by Pennine Care ICN.
•
Clinical Outbreak Management.
•
Patient management of infections as notified by the microbiology
laboratory.
•
Monitoring and reporting Healthcare Associated Infections. Including
MRSA, Extended Spectrum Beta Lactase (ESBL) and Clostridium
Difficile.
•
Staff management of infections as notified by the microbiology
laboratory in conjunction with the Occupational Health Department
•
Ward Auditing (Copies available from Infection Control Nurses).
Environment audits are also undertaken by Pennine Care IPCN.
8
6.
•
Access to Acute Trust Policies.
•
Literature (Posters, Leaflets etc) currently provided by Pennine Care
ICN.
Care Quality Commission Visit
An inspection took place on 16th and 17th December 2009 in relation to the
Trusts compliance against the Code of practice on Health Care Associated
Infection’s. Of the 15 measures inspected. No area of concern was seen in 12
and 3 needed improvement.
The findings included:
• The need to audit the cleanliness of equipment.
• The need to ensure that staff are trained to clean equipment effectively.
• Review the use and organisation of store rooms.
The following actions were implemented by Pennine Care NHS Foundation
Trust:
• Each ward received a visit from the Director of Nursing and Integrated
Governance.
• A formal Infection Control audit of all inpatient areas every 6 months.
• A review of the Infection Prevention and Control audit tool.
• The Deputy Director of Nursing to undertake unannounced visits of
inpatient areas.
• Monthly meetings with Matrons, Estates and Infection Control.
• Additional Infection Control training for staff.
• Matrons to undertake a formal inspection of inpatient wards monthly
and ward managers weekly.
Additional Initiatives Implemented
•
•
•
•
•
•
•
Cleaning schedules implemented for all equipment
Audit of hospital mattresses
Policy for care of mattresses
Guidelines for cleaning commodes displayed on wards
Programme of replacement of old commodes
Implementation of Infection Prevention and Control leaflets
Wards have nominated infection control champions
The Trust was re-visited in relation to Infection Prevention and Control by the
Care Quality Commission in February 2010 and given a clean bill of health.
7.
Audits
The ICN undertakes environment audits on a rolling programme any ward with
problems would be re-assessed to ensure action plans were completed.
9
7.1
Infection Prevention & Control Audit Plan,
April 2009 – March 2010 (Updated February 2010)
Location
Ward
Date audited
Fairfield General,
North
March 2009
Bury
December 2009
South
March 2009
December 2009
Hope
March 2009
December 2009
Ramsbottom
March 2009
December 2009
By whom
FS
GS
FS
GS
FS
GS
Acute
GS
Rhodes Place
Inpatient Unit
Jan 2010
CF
Heathfield House,
Stockport
Stansfield Place
The Meadows,
Stockport
Inpatient Unit
Dec 2009
CF
Inpatient Unit
Saffron
FS
Acute
CF
Acute
CF
Acute
CF
Acute
FS/KB
Hazel
Beech
Jan 2010
Sept 2009
March 2010
Sept 2009
March 2010
Sept 2009
March 2010
03.02.09
Sept 2009
February 2010
15.12.09
Sept 2009
February 2010
Sept 2009
February 2010
04.02.09
Sept 2009
February 2010
18.02.09
Jan 2010
16.02.09
Jan 2010
Jan 2010
Jan 2010
Acute
FS
Acute
FS
FS
FS
Cobden
Dec 2009
CF
Bevan
Arden
Dec 2009
Sept 2009
February 2010
Sept 2009
February 2010
Sept 2009
February 2010
March 2009
March 2010
Dec 2009
Dec 2009
Dec 2009
Dec 2009
Dec 2009
CF
Acute
CF
Acute
CF
Acute
CF
CF
Rosewood
Linden Day
Royal Oldham
Hospital
Rowan
Cedars
Northside
Southside
Birch Hill Hospital
Hollingworth
Moorside
Stepping Hill
Hospital
Norbury
Davenport
Tameside General
Hospital
Whittaker Day
Ward 35
Ward 36
Prospect Place
Summers
Saxon
10
FS/KB
FS/KB
Acute
FS/KB
FS/CF
FS/CF
FS/CF
FS/CF
FS
7.2
Patient Environment Action Teams (PEAT Assessments)
The assessments were undertaken in February 2010 and March 2010.
The infection control nurse was part of the assessment team.
11
8. Incidents
Incident Report – Infection Control/Sharps/Needlestick/COSHH
April 09 – March 10
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
TOTAL
9
4
9
6
6
6
3
1
8
3
3
9
67
Jan-10
Feb-10
10
9
8
7
6
5
4
3
2
1
0
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Mar-10
12
Infection Control/Sharps/Needlestick/COSHH Incidents By Cause Code
Cause Code
148 - Infection Control Incident
35 - Contact With Bodily Fluids
36 - Contact With Harmful Substance Breakag
37 - Contact With Harmful Substance Cleanin
38 - Contact With Harmful Substance - Other
80 - Needlestick Injury
92 - Sharps - Disposal
94 - Sharps - Misc
99 - Spillages
Total
Apr 09
- Mar
10
9
7
0
5
3
22
5
15
1
67
25
20
15
10
5
0
148 - Inf ection
Control Incident
35 - Contact With
Bodily Fluids
36 - Contact With
Harmf ul Substance Breakag
37 - Contact With
Harmf ul Substance Cleanin
38 - Contact With
Harmf ul Substance Other
80 - Needlestick
Injury
92 - Sharps Disposal
94 - Sharps - Misc
99 - Spillages
Apr 09 - Mar 10
13
Infection Control/Sharps/Needlestick/COSHH Incidents By Directorate
Directorate
Bury
Oldham
Rehabilitation & High Support
Rochdale
Specialist Services CAMHS
Specialist Services D&A
Stockport
Tameside & Glossop
Total
Apr 09
- Mar
10
7
7
16
8
5
6
9
9
67
April 09 - March 10 Incidents
Tam es ide & Glos s op
13%
Bury
10%
Oldham
10%
Stockport
14%
Bury
Oldham
Rehabilitation & High Support
Specialis t Services
D&A
9%
Specialis t Services
CAMHS
7%
Rochdale
Specialist Services CAMHS
Rochdale
12%
Rehabilitation & High
Support
25%
Specialist Services D&A
Stockport
Tameside & Glossop
14
Infection Control/Sharps/Needlestick/COSHH Incidents by Department & Cause Code
April 09 - March 10
Directorate
Department
Cause 1
Bury
Community Clinics Bury
94 - Sharps - Misc
1
Irwell Unit
37 - Contact With Harmful Substance Cleanin
1
Ramsbottom Ward
Oldham
Rehabilitation & High
Support
Total
148 - Infection Control Incident
37 - Contact With Harmful Substance Cleanin
1
1
South Ward
148 - Infection Control Incident
35 - Contact With Bodily Fluids
92 - Sharps - Disposal
1
1
1
7
Beeches
80 - Needlestick Injury
2
Ward - Northside
80 - Needlestick Injury
2
Ward - Rowan
148 - Infection Control Incident
80 - Needlestick Injury
99 - Spillages
1
1
1
7
Assessment & Engagement RHSD
94 - Sharps - Misc
2
Bevan Place RHSD
35 - Contact With Bodily Fluids
1
Cobden Unit
80 - Needlestick Injury
94 - Sharps - Misc
1
5
Heathfield House Spec Service
35 - Contact With Bodily Fluids
1
Prospects Place (LSU)
35 - Contact With Bodily Fluids
94 - Sharps - Misc
1
2
Recovery RHSD
37 - Contact With Harmful Substance Cleanin
1
Social Inclusion RHSD
94 - Sharps - Misc
2
16
15
Rochdale
Specialist Services CAMHS
Assertive Outreach Team
R'dale
80 - Needlestick Injury
1
Crisis Resolution/HomeTr
Rdale
148 - Infection Control Incident
1
Hazel Ward
148 - Infection Control Incident
2
Moorside Ward
148 - Infection Control Incident
80 - Needlestick Injury
2
1
Treatment Support Service JEU
80 - Needlestick Injury
1
8
Hope Unit - CAMHS
35 - Contact With Bodily Fluids
37 - Contact With Harmful Substance Cleanin
94 - Sharps - Misc
1
148 - Infection Control Incident
1
5
35 - Contact With Bodily Fluids
92 - Sharps - Disposal
94 - Sharps - Misc
1
1
1
80 - Needlestick Injury
92 - Sharps - Disposal
1
1
35 - Contact With Bodily Fluids
1
6
Springleigh CAMHS
Specialist Services D&A
5 Horsedge Street - Oldham
CDA
Booth St Needle Exchange
Community Drugs Team
Stockport
Stockport
1
2
38 - Contact With Harmful Substance Other
80 - Needlestick Injury
92 - Sharps - Disposal
1
1
2
Councillor Lane Centre-Sector2
80 - Needlestick Injury
2
Norbury Ward
80 - Needlestick Injury
1
Saffron Ward
80 - Needlestick Injury
1
Torkington Resource Centre-S3
80 - Needlestick Injury
1
9
Arden Ward
16
Tameside & Glossop
Assertive Outreach Team T&G
80 - Needlestick Injury
1
Hyde CMHT South East - Adult
80 - Needlestick Injury
2
Management Team T&G
80 - Needlestick Injury
1
Saxon Ward (21A)
80 - Needlestick Injury
1
Summers Ward (21)
Ward 35
37 - Contact With Harmful Substance Cleanin
38 - Contact With Harmful Substance Other
1
2
80 - Needlestick Injury
1
9
Grand Total
67
17
9.
Training
Pennine Care has signed up to the NPSA – Clean Your Hands Campaign,
this has contributed to the increased staff awareness regarding the
importance of hand washing. All areas display the posters.
The number of Pennine Care NHS Foundation Trust staff who have attended
Infection Prevention and Control training 2009 – 2010:
Induction
551
10.
Mandatory
420
Core Learning Unit
219
Healthcare Associated Infections (HAI) – MRSA, ESBL’s & Clostridium
Difficile (Surveillance)
The Department of Health requires mandatory surveillance and reporting of
some types of infection, including MRSA bacteraemia, Clostridium Difficile and
Extended Spectrum Beta Lactamase (ESBL) Producing E. Coli. Pennine Care is
complying with this requirement through Service Level Agreements with 3
General Acute Trusts, who provide monitoring and reporting of all Health Care
Associated Infections (HCAI) affecting patients in Pennine Care inpatient
services. Pennine Care have had no MRSA Bacteraemias for April 2009 –
March 2010.
All new MRSA, ESBL and Clostridium Difficile cases have a Root Cause
Analysis performed by the Infection Control Nurses who then reported this to the
Infection Control committee. MRSA and Clostridium Difficile now have individual
policies to make it easier for staff to follow the correct procedure and staff are
being updated on standard precautions to reduce the risk of cross infection.
10.1
MRSA (skin infection)
Borough
Bury
Oldham
Rochdale
Tameside
Stockport
Specialist Services Rehabilitation & High Support
Total
No of new
cases
0
0
2
0
1
0
Last Year
3
5
0
1
0
2
2
0
18
10.2
Clostridium
BOROUGH
Bury
Oldham
Rochdale
Tameside
Stockport
Specialist Services Rehabilitation & High Support
Total
10.3
Last Year
2
2
No of new
cases
0
0
0
0
1
0
Last
Year
0
0
0
0
0
0
1
0
0
0
1
1
0
0
ESBL
BOROUGH
Bury
Oldham
Rochdale
Tameside
Stockport
Specialist Services Rehabilitation & High Support
Total
10.4
No of new
cases
1
0
0
0
1
0
Other Infections
TB
3 cases in Tameside, Drug and alcohol Service.
Scabies
1 case in Rochdale.
Lice
2 cases in Stockport.
10.5
Outbreaks
The following outbreaks of Diarrhea & Vomiting were reported in Pennine Care
inpatient facilities over the period 01 April 2009 – 31 March 2010. All outbreaks
have a root cause analysis recorded they are then discussed at the Infection
Control Committee. Pennine Care now report Norovirus outbreaks to the Health
Protection Agency via the web site.
19
BOROUGH
Bury
Oldham
Rochdale
Tameside
Stockport
Specialist Services Rehabilitation &
High Support
No of new
cases
2
1
3
2
2
1
Last Year
10
6
Total
11.
0
1
2
1
1
1
Antibiotic Prescribing
The Medical Director chairs the Drugs & Therapeutic Committee, which monitors
the use of medicines across the Trust. Membership of the Forum includes
colleagues from the Acute and Primary Care Trusts, ensuring that Pennine Care
works collaboratively with partner organizations, and that agreed standards are
applied consistently across the health economy. All prescribing of antibiotics
within Pennine Care complies with standards of good practice observed within
Primary Care and Acute Trusts. Antibiotic auditing has been implemented to
monitor the policies are being followed.
12.
Cleaning and Decontamination Procedure
As Pennine Care is a Mental Health Trust, there is very little usage of invasive
medical equipment, which would require decontamination through sterilization
before reuse. The few exceptions to this would be equipment contained in
emergency resuscitation, e.g. Laryngoscope blade.
When required, decontamination is provided via service levels agreements with
the Acute Trusts. However all equipment used for patient care must be cleaned
and disinfected appropriately if it is not single patient use. Guidance on cleaning
and decontamination procedures is included in the Trust Medical Devices
Management Policy and the Cleaning Policy.
In specific areas there has been an increase in domestic input to improve
standards of cleanliness and Pennine Care has introduced our own cleaning
staff. These cleaners receive infection control training and report to the Estates
Department.
The trust has an ongoing programme of cleanliness monitoring checks and all
inpatient areas are checked on a monthly basis. A cleanliness report goes to the
Infection Control Committee and any problems are highlighted and actions taken
to ensure a high standard of cleanliness continues. The Infection Control Nurses
meet monthly with the Estates Manager, Domestic Service Manager and Modern
Matron to discuss any cleanliness and environmental issues.
20
The Matrons are on the wards regularly and walk around to assess the
cleanliness and ward environment. The Matrons monitor the ward environments
on a monthly basis with the Domestic Manager.
Deep Cleaning
The deep cleaning programme is led by the Estates Department.
13.
Planning and Refurbishment
During the last year a lot of the trusts buildings have been renovated and
updated. The CNS: Infection Control/Physical Health is available for advice reequipment and the new building – Infection Control in the Built environment
(NHS Estates 2001) is used regarding advice.
14.
Flu Vaccination programme
As part of our winter planning arrangements, Pennine Care undertook a
programme of Flu vaccinations.
Flu vaccinations were offered to all inpatients over 65 years who were not able
to access this from their GP due to being in hospital, and also inpatient service
users under 65 years who were considered to be at high risk, due to physical
health problems. Flu vaccination was also promoted for residents of long stay
Forensic & High Support Units. In most cases this was accessed via GP
services. The Trust also promoted the uptake of Flu vaccinations for all relevant
service users and staff across all community services areas.
1st October – 31st December 2009 Vaccinations Issued
Borough
Bury
Oldham
Rochdale
Stockport
Tameside &
Glossop
Doses Ordered
30
50
50
70
70
Doses Issued
20
35
24
35
32
The above table does not include the Forensic Directorate as these services use
Primary Care to access flu vaccinations.
Anaphylaxis training was also offered to staff in each borough, as administration
of a vaccine could not be given without this.
21
Appendix A
Infection Prevention & Control Audit Plan
April 2010 – March 2011
Location
Fairfield
General, Bury
Ward
North
South
Hope
Ramsbottom
Rhodes Place
Inpatient Unit
Heathfield
House,
Stockport
Stansfield
Place
The
Meadows,
Stockport
Inpatient Unit
Inpatient Unit
Saffron
Rosewood
Linden Day
Royal Oldham
Hospital
Rowan
Cedars
Northside
Southside
Birch Hill
Hospital
Hollingworth
Moorside
Hazel
Beech
Stepping Hill
Hospital
Cobden
Audit
Date
July
2010
July
2010
July
2010
July
2010
July
2010
July
2010
By whom
Audit
Date
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
July
2010
July
2010
January
2011
January
2011
July
2010
July
2010
July
2010
July
2010
July
2010
July
2010
July
2010
July
2010
July
2010
July
2010
July
2010
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
By
whom
22
Location
Ward
Whittaker Day
Ward
Audit
date
July
2010
July
2010
July
2010
July
2010
July
2010
Ward 35
July 2010
Ward 36
July
2010
July
2010
July
2010
July
2010
Bevan
Arden
Norbury
Davenport
Tameside
General
Hospital
Prospect Place
Summers
Saxon
By whom
Audit date
By
whom
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
January
2011
23
Appendix B
Infection Prevention & Control
Board Level Agreement
24
The Board of Pennine Care NHS Foundation Trust takes the prevention and control of
healthcare associated infections very seriously and the Trust has implemented a
programme of activities to embrace new national initiatives and effectively prevent and
control healthcare associated infections. The Board is committed to comply with The
Health and Social Care Act 2008 (Code of Practice for the NHS on the prevention and
control of healthcare associated infections and related guidance)
Board Responsibilities
All Executive Directors have clear infection prevention and control responsibilities in
their job descriptions.
The Medical Director is the Executive Director of Infection Prevention and Control
(DIPC).
Lead Nurse Infection Prevention and Control/Physical Health
This role is established in the Trust.
The job description identifies clear roles and responsibilities.
The Lead Nurse: Infection Prevention and Control/Physical Health reports to the
Deputy Director of Nursing.
The Lead Nurse: Infection Prevention and Control/Physical Health reports directly to
the DIPC and Executive Director of Operations and Nursing if significant infections such
as MRSA, Clostridium Difficile and outbreaks arise.
Committees
Infection Prevention and Control is included in the agenda for each monthly meeting of
the Trust’s Board of Directors.
The Infection Prevention and Control Committee take place every two months, chaired
by the DIPC. The deputy chair of the committee is the Deputy Director of Nursing.
The Risk and Clinical Governance Committee meets monthly and Infection Prevention
and Control is on the agenda. This meeting is chaired by the Deputy Director of
Nursing.
Reports
The Governance Department publishes monthly and quarterly dashboard reports,
which identify current infection control information.
An Annual Report and Annual Programmes are presented to the Infection Prevention
and Control Committee and monitored by the Board of Directors.
25
These reports are sent to the DIPC and the annual programme is updated at the
Infection Prevention and Control Committee.
The PCT Assurance Framework document is completed monthly and signed off by the
DIPC.
Resources
The Board has set up SLAs with all relevant acute Trusts. There is an identified DIPC.
There is a Director of Capital Investment. Cleaning contracts are agreed and managed
within the Capital Investment Department. Should there be a need to increase
resources such as domestic staff following an outbreak, the Board is committed to
funding additional resources as and when necessary to ensure highest possible
standards of infection prevention and control.
Audits
There is a rolling programme of infection control audits and the results are reported via
the Infection Prevention and Control Committee and to the Trust’s Board of Directors.
Education
There is a rolling programme of education. All staff attend infection control training as
part of their induction and mandatory training. Additional training is also undertaken if
outbreaks occur or incidents occur. Board members have received Infection Prevention
and Control training i.e. Hand Hygiene and the prevention and control of HCAI using
RCA.
Signed on behalf of the Board:
Signed by John Schofield, Chairman
Date
Signed by John Archer, Chief Executive
Date
CF/FS/KH 2.9.09
26
Appendix C
Infection Control
Training Plan April 2010
- March 2011
April 2010 –
March 2011
Induction Training on Infection Control Standard
Precautions including practical hand washing for all
new staff
April 2010 –
March 2011
Mandatory Training on Infection Control Standard
Precautions for all clinical staff
August 2010 –
March 2011
All staff to do the infection control e-learning
April 2010 March 2011
All clinical staff to be updated in hand hygiene
techniques following the clean your hands campaign
and Essential Steps
August 2010 –
March 2011
Additional staff training on hand washing and
relevant infection control guidance as required for
their area of work
December
2010
Sharps awareness training
27
Appendix D
Infection Control Work Plan
April 2010 - March 2011
Infection Control Nurse:
•
Will provide advice and education in relation to infection control to the Trusts
Hospital and community staff.
•
Will chair the Infection Control Committee.
•
Will work with management and other agencies to enhance the service and help
control infection.
•
Will continue to update and ensure policies are research based and up to date.
•
Will ensure government guidelines and recommendations are implemented.
•
Will maintain infection control records and write reports on infection control
issues.
•
Will work closely with Acute Trusts in relation to all aspects of infection control
Surveillance/Audit:
•
The Infection Control Nurse will co-ordinate surveillance to ensure that
appropriate advice can be given to prevent cross infection.
•
The Infection Control Nurse will carry out relevant audits and offer advice to staff
on any audits they wish to undertake.
Education:
•
The Infection Control Nurse will provide education input on infection control and
be involved in any other training issues involving staff and students in relation to
infection control.
•
The Infection Control Nurse will ensure a session on the overview of Infection
Control issues is given at Induction Training
•
The Infection Control Nurse will provide education as and when needed
especially during an outbreak.
28
•
The Infection Control Nurse will keep up to date by attending education events,
the Infection Control Nurse Association meetings, reading and interpreting
relevant new documentation/guidance.
Link Champions Staff:
•
Champions personnel group will be developed by the Matrons to include other
professions from the wards.
•
The Infection Control Nurse will offer support to any nurse undertaking a relevant
infection control course.
•
The Infection Control Nurse will continue to improve links between disciplines
and services.
29
Appendix E
Infection Prevention and Control Plan
2009/2010 All completed
Action
Lead
Target Date
NPSA Clean Your Hands
Campaign
CNS: Infection Control
& Physical Health
Ongoing
Implement Pandemic Flu
Sessions and Live Practice
Sessions.
Lead for Pandemic Flu
CNS: Infection Control
& Physical Health
July 2009 –
December 2009
Undertake Sharps Awareness
Sessions in All Areas
CNS: Infection Control
& Physical Health
June 2009
Sharps re – Audit
Audit Department
CNS: Infection Control
& Physical Health
July - August
2009
Audit completed.
Head of Estates
March 2010
PEAT visits completed.
Effectively implement new
Infection Control Policies
CNS: Infection Control
& Physical Health
July – December
2009
Ensure service Users Receive Flu
Vaccinations as appropriate
CNS : Infection Control
& Physical
Health/Modern
Matrons
October 2009
Contribute to the PEAT
Assessment
R/A/G
Comments
Power point and video prepared first
session booked 1st July2009.
Completed
Policy events complete all wards have
new policies in file and available on the
intranet
All service users who agreed to have flu
vaccines have received the vaccine
30
Audit
Department/CNS:
Infection Control &
Physical Health
October 2009 –
December 2009
Hand hygiene audits continue to be
undertaken throughout the trust and this
will now be a rolling programme of audit
CNS : Infection Control
& Physical
Health/Modern
Matrons/Education and
Training Department
On-going
On-going training programmes continue
to be rolled out across the Trust.
Mandatory training and Induction
training continue
Audit
Department/CNS:
Infection Control &
Physical Health
On-going
All wards audited over the last year.
Undertake infection Control
Environmental Audits across all
Community Settings
CNS: Infection Control
& Physical Health
April 2009 –
August 2009
Community audits completed.
Implement Essential Steps Audits
on Enteral Feeding
CNS: Infection Control
& Physical Health
October 2009
Develop an infection Control Web
Page
CNS: Infection Control
& Physical Health
September 2009
All wards contacted on enteral feeding.
No patients being treated so audit
cancelled
Web page running
Undertake Hand hygiene and PPE
Audits in line with Essential Steps
Audit Tool
Undertake Infection Control
Education as needed including
hand hygiene
All wards have an Environmental
Audits carried out Annually
31
Appendix F
Infection Prevention and Control Plan
2010/2011
Action complete
Confident task will be complete
Reasonably confident task will be completed
Task not completed
Action
Lead
Target Date
NPSA Clean Your Hands
Campaign
CNS: Infection Control
& Physical Health
Ongoing
Maintain evidence collection for
NHSLA, CQC, Health & Social
Care Act & Assurance Framework
Provide Infection Control reports
for the Board
CNS: Infection Control
& Physical Health
Ongoing
CNS: Infection Control
& Physical Health
Monthly
Develop the Infection Control
Champions Role
CNS: Infection Control
& Physical
Health/Matrons
May 2010
Provide an Infection Control
Annual Report for the Infection
Control Committee & Board
CNS: Infection Control
& Physical Health
June 2010
Head of Estates
March 2011
CNS: Infection Control
& Physical Health
May 2010
Contribute to the PEAT
Assessment
Update Infection Control Policies
in line with new guidelines.
R/A/G
Comments
32
Ensure service Users Receive Flu
Vaccinations as appropriate
Undertake Hand hygiene audits in
line with Essential Steps Audit
Tool & 5 Moments
Undertake Infection Control
Education as part of Mandatory
and Induction training including
hand hygiene.
All wards have an Environmental
Audits carried out 6 monthly.
Undertake infection Control
Environmental Audits across all
Community Settings
CNS :Infection Control
& Physical Health
/Modern Matrons
CNS: Infection Control
& Physical Health
October 2010
CNS : Infection Control
& Physical
Health/Modern
Matrons/Education and
Training Department
On-going
CNS: Infection Control
& Physical Health
Audit Department
CNS: Infection Control
& Physical Health
Audit Department
July 2010
&
January 2011
OctoberNovember 2010
On-going
Audits of the ward environment
are carried out monthly and
reported to the Infection Control
Committee
Keep Infection Control Web Page
Up to date
Matrons
To Commence
May 2010
CNS: Infection Control
& Physical Health
Ongoing
Needle Safety devices to be
implemented across the trust
CNS: Infection Control
& Physical Health
September 2010
Deputy Director of
Nursing & Integrated
Governance
Ongoing
Unannounced visits to all inpatient
areas annually
On-going training programmes continue
to be rolled out across the Trust.
Mandatory training and Induction
training continue
33
Patient and visitors leaflets to be
designed and posted on infection
control web page
CNS: Infection Control
& Physical Health
Communications
May 2010
To investigate infection control
incidents
CNS: Infection Control
& Physical Health
On Going
To investigate all MRSA,
Clostridium Difficile, ESBL and
outbreaks of Infection using RCA
CNS: Infection Control
& Physical Health
On Going
Contribute to new building plans
regarding Infection Control
CNS: Infection Control
& Physical Health
Estates
CNS: Infection Control
& Physical Health
Estates, Matrons &
Domestic supervisors
On Going
Maintain monthly meetings with
estates, matrons and domestic
supervisors
On Going
34
Appendix G
Care Quality Commission Registration Action Plan Monitoring Report
Reporting Period: February 2010
Cleanliness and Infection Control Outcome 8 / Regulation 12
Concerning Item
Overall
Recommendation 1.
The audit programme did not include audits to
check the cleanliness of patient equipment such as
commodes. The Trust planned to audit each ward
only once a year.
The Trust should review its programme of audit, to
ensure there is effective checking that relevant policies
and practices are being followed.
Column1
Column2
Column3
Completion Date
Column4
Actions
Comments
Each ward to receive an
inspection from the Director
of Nursing
Through the management
structure in the Trust,
cascade the outcome of the
CQC visits
Inspections completed.
29th January 2010
Director of Nursing
CQC action plan on
agenda of appropriate
meetings.
Complete
Operational Management
Structure
Every rolling six months,
each inpatient ward will
receive a formal Infection
Control Nurse and Modern
Matron visit (The ward will
receive a review 3 months
later to ensure the action
plans are complete). Each
Month the Modern Matron
and Service manager will
inspect all of their wards.
Each week the Ward
Manager will formally
inspect their ward. Each
inspection will use a
standardised checklist. The
results of the Modern Matron
and Service Manager visits
Formal audit of each
inpatient ward is taking
place every six months.
Review date and name
of reviewer is clearly
identified on audit
reports.
Ongoing.
Infection Control Nurses, Modern
Matrons, Service Managers and
Ward Managers.
Column5
Trust Lead
35
are to be faxed to the
Infection Control Nurses for
review.
Review the use of the
National Infection Prevention
Society Audit tool and
include the inspection of all
patient equipment. Ensure
that this is inline with Trust
Policies and the Code of
Practice for health and adult
social care on the prevention
and control of infections and
related guidance.
The Deputy Director of
Nursing will develop a rolling
programme of monthly
unannounced visits to test
the process
Infection Control Nurses to
ensure that the Audit
programme includes a
review of staff awareness of
the infection control policies
Carry out observational
studies of staff regarding
standard precautions at
each walk round. Including
hand hygiene, Personal
protective equipment,
sharps and waste.
Quarterly report will be
presented to the Infection
Control Committee using the
results from the monthly
Ward Inspections
Additions added in line
with CQC findings.
commodes are
specifically audited,
linen /laundry rooms,
store rooms and
cleanliness of
equipment.
Complete
Infection Control Nurses. With
review from Performance
department to cross check with
Registration and assure the
Board of Directors.
commence April 2010
Ongoing
Deputy Director of Nursing
Specific policy
awareness questions
are asked during audit
e.g. five moments of
hand hygiene,
needlestick. The tool
will also be updated to
include more policy
awareness questions.
Audits ongoing.
Ongoing
Infection Control Nurses and
Clinical Effectiveness Manager.
Ongoing
Infection Control Nurses
Infection Control
Reports to Infection
Control Committee
16.02.10.
Ongoing
Infection Control Nurses
36
Recommendation 2.
There was inappropriate use of rooms and
inappropriate storage of equipment at the Trust. For
example, ward staff said a toilet area was now
designated for storage of clean equipment
items;however, the toilet was still in use and
contained faeces. A single room was being used to
store clean bed linen, prepare patients’ food and
also launder items for patients. Two dirty utility
rooms contained refrigerators with patients’ food
and clean equipment. A storage room contained a
wide range of clean and dirty items, including a
dirty mattress, a dirty fan, open packets of food for
patients and sterile supplies. This storage room
also had a loft, which was open and had other items
stored in it.
Ensuring this will be met
through Recommendation 1
actions
N/A
Ongoing
N/A
Each month the Infection
Control Nurses will meet
with the Modern Matrons.
Monthly meetings in
progress. Meeting took
place on 5/2/10
Ongoing
Infection Control Nurses and
Modern Matrons
Following an infection
control visit to the units the
Infection Control Nurses to
meet with Estates and
Domestic Supervisor to raise
any issues and action plan
resolution.
Each ward will nominate an
Infection Control Champion
who will attend infection
control training and be
responsible for any storage
and infection control issues.
The Champion will report to
the Modern Matrons and
Infection Control Nurses.
Monthly meeting with
Matrons, Estates and
Infection Control.
Ongoing
Infection Control Nurses, Estates
representative and Domestic
Supervisor
Training dates set for
March at Tameside
9/03/10 other borough
dates set. Matron
Infection Control
training in place.
28th February 2010 for
nominations. Rolling training
programme to Start in April
2010
Infection Control Nurses and
Ward Managers
The Trust should ensure that the environment for
providing healthcare is suitable, clean and well
maintained.
37
Each ward will have a rota
for the checking of stores.
Ensuring they are clean, tidy
and not over stocked.
Checklist to be in place.
Infection Control Team
will check store
cupboards on planned
ward visits and spot
check. Nurse in charge
of each shift and
champions will be
responsible for ensuring
that the environment is
clean and tidy and
reporting any areas of
concern to the
appropriate dept.
Nurse-in-charge/Ward
champion to lead.
Ongoing
Matrons and Ward Managers
Ongoing
Infection Control Nurses and
Ward Managers
Each month the Modern
Matrons will routinely walk
the wards with Estates and
the Domestic Supervisor.
These walkabouts are
taking place in all
Boroughs.
Ongoing
Modern Matrons, Estates
representative and Domestic
Supervisor
Inspect all commodes and
replace.
All checked across the
Trust and replaced as
needed.
1st February 2010
Infection Control Nurses
Clear commode cleaning
instructions to be
displayed on wards
Instructions displayed
on wards.
1st February 2010
Infection Control Nurses
Ensure that the storage units
are used appropriately.
Review this through the
Environmental audits.
Recommendation 3.
We examined five commodes, which staff said were
clean and ready for patients’ use, in three wards.
None of the five had been cleaned effectively and
they were soiled. Four of these commodes were
also rusty, making them difficult to clean. Staff said
that they had not received training in the cleaning
of equipment. On two of the wards visited, medicine
pots (intended to be single use only), were being
washed in a sink and reused.
The Trust must ensure that it has effective
arrangements for the appropriate decontamination of
instruments and equipment which are detailed in
appropriate policies. The Trust must take immediate
action to clean dirty equipment. The Trust must have
addressed the area for improvement by 1 February
2010.
38
Introduce Green Tape for
clean commodes
Introduced across the
Trust.
1st February 2010
Infection Control Nurses and
Ward Managers
Add the inspection of
commodes to the
Inspection Checklist
Added to Infection
Control Audit Tools.
1st February 2010
Ensure that the Medical
Devices Policy contains
effective guidance on the
cleaning and
decontamination of
equipment.
Develop and roll out a
Nurses guide to cleaning
of patient equipment.
Guidance included in
Medical Devices
Policy Appendix 6
Cleaning Guidelines.
1st February 2010
Infection Control Nurses
Guide includes all
equipment.
1st February 2010
Infection Control Nurses
Ensure all managers
have received a reminder
memo on the need to
dispose of single-use
medicine pots after 1st
use.
Memo sent
December 2009.
1st February 2010
Infection Control Nurses and
Deputy Director of Nursing
Infection Control Nurses and
Deputy Director of Nursing
39
Appendix H
Quality Accounts for Infection Prevention & Control
Priority
A reduction in Healthcare Associated Infections and incidents in relation to Infection
Prevention and Control. And for the trust to be compliant with Health and Social Care
Act 2008:Code of Practice for NHS on Prevention and Control of HCAI
Current Performance
Performance in 2009/10 and 2008/09 are as follows:
Infections
MRSA
C. diff
ESBL
D&V
2009/10
3 (skin)
2
1
8 (3Norovirus confirmed)
2008/09
5 (skin)
2
1
6
There has been a 40% reduction in cases of MRSA reported, no change in
C. diff cases and an increase of 25% of reported D&V cases.
Infections 2009/10 (12 month projected)
MRSA
C. diff
ESBL
D&V
12
4
4
20
Incidents
Cause Code
148 - Infection Control Incident
35 - Contact With Bodily Fluids
36 - Contact With Harmful Substance - Breakage
37 - Contact With Harmful Substance - Cleaning
38 - Contact With Harmful Substance - Other
80 - Needlestick Injury
92 - Sharps - Disposal
94 - Sharps - Misc
99 - Spillages
Apr 08 Mar 09
20
3
1
2
8
26
10
21
0
91
Apr 09 Mar 10
7
7
0
5
3
22
5
10
1
60
There were 91 Infection Control incidents in 2008/09 and 60 in 2009/10, which is a
reduction of 34%.
Needlestick injuries have also reduced by 15% from last year.
40
Incidents 2009/10 (12 month projected)
Cause Code
148 - Infection Control Incident
35 - Contact With Bodily Fluids
36 - Contact With Harmful Substance - Breakage
37 - Contact With Harmful Substance - Cleaning
38 - Contact With Harmful Substance - Other
80 - Needlestick Injury
92 - Sharps - Disposal
94 - Sharps - Misc
99 - Spillages
30
12
5
8
12
30
15
30
8
150
How will we track improvement?
The Trust will continue to improve its monitoring systems of Infection Prevention and
Control by measuring compliance against The Health and Social Care Act 2008: Code
of Practice for NHS on prevention and control of HCAI standards and the Strategic
Health Authority Assurance Framework.
Monitoring compliance with Pennine Care NHS Foundation Trust Infection Prevention
and Control Policies by internal audits and unannounced spot checks of the
environment, and matron walkabouts.
Areas for Improvement
A number of areas have been identified that require improvement:
•
•
•
•
•
•
•
Structured audit programme, which includes cleanliness of equipment and
appropriate use of storage areas
Cleaning schedules for all equipment
Monitoring of ward environment on weekly basis by ward manager
Replacement of old equipment
Audit of hospital mattresses
Further Infection Prevention and Control training for staff
A further reduction in needlestick injuries
Aim
To reduce the risk of Health Care Associated Infections. To ensure compliance with
national standards and trust infection prevention and control policies. To increase
infection prevention awareness amongst staff through training programmes and so
reduce the number of infection control incidents.
Actions planned to Improve Performance
The Trust has a structured plan in place to improve the Infection Prevention and
Control Standards and ensure that the environment is clean, safe and well-maintained.
•
•
•
•
6-monthly audits of inpatient areas(due July 2010)
1-yearly audits of community units (as from April 2010 – due October 2010)
Ward managers will inspect the environment and equipment in their wards
weekly using a standardised tool
Matrons will undertake monthly environment inspections with Estates and
Domestic Services
41
•
•
•
•
•
•
•
Deputy Director of Nursing & Integrated Governance will undertake a rolling
programme of unannounced spot checks of wards
Infection Control nurses will meet with matrons, estates and domestics monthly
to ensure action plans are implemented
Wards will have nominated Infection Prevention and Control champions
A Cleaning Schedule has been implemented for all equipment in inpatient areas,
this will be monitored via the audit programme
Commode cleaning guidelines have been introduced
Training has been implemented for matrons, champions and mandatory training
for qualified inpatient staff
Implement needle safety devices across the Trust
How will we report this priority?
Infection Prevention and Control is reported to DIPC and Board via the Infection
Prevention and Control Committee and Risk and Clinical Governance Committee.
42
Appendix I
Pennine Care NHS Foundation Trust
Infection Control/Cleanliness Audit Tool
Matrons Ward Report
SITE
DATE
LOCATION
DIVISION
AUDITORS
WARD MANAGER
Present Yes / No
Yes
No
Comments
ENTRANCE
1
Is the floor clean?
There should be no dust in the corners
or stains from spilt drinks
(1,2,3)
2
Are high and low level surfaces clean?
Feel across the top of door frames and
picture frames. No dust should be
picked up on fingers
(1,2,3)
WARD CORRIDORS
1
Is the floor clean and intact?
There should be no dust in the corners
or along the skirting. The floor should
not have any rips or tears (1,2,3,8)
2
3
Are high and low level surfaces clean?
Feel across the top of door frames and
picture frames. No dust should be
picked up on fingers
(1,2,3)
Are walls clean and in a good state of
repair? The paint should not be flaking
and there should be no holes or
damage(1,2,3,8)
43
WARD/CLINIC OFFICE
Are computers and telephones clean?
1
Are Sani-cloths being used to clean
office equipment?
Check cleaning schedule
2
Is the office cluttered?
STAFF
1
Are any of the staff wearing nail
varnish or nail extensions? (12,13,14)
2
Are any staff wearing rings with stones
and bracelets? (12,13,14)
3
Check hand washing staff training ( all
staff must have received training in the
correct hand washing technique in the
last 12 months using the glow box)
(16,18)
BEDROOM
1
Is the bed frame clean?
Feel along frame no dust should be
picked up.(1,5)
2
Are mattresses and pillows being
checked?
(Check this is being recorded)
Check 2 random mattresses no stains
should be seen inside the cover, there
should be no rips, tears or holes. (19)
3
Is the floor clean?
No spills, dust in corners, flooring
intact?(1,2,3,8)
4
Have the walls got any paint peeling or
holes in walls?
Note room number! (5)
44
5
Are high and low level surfaces clean?
Feel along window tops, wardrobes,
picture frames and skirting rails (1,2,3)
SLUICE
1
Is the floor clean?
No spills or stains, rips or tears.
(1,2,3,8)
2
Is the room in a good state of repair?
No holes in walls or paint peeling (8)
3
Is only appropriate equipment stored in
this room?
Nothing stored under the sink and the
room is tidy
4
Has the sink got soap(is the dispenser
clean check underneath) and paper
towels (15,2)
5
Are the commodes clean?
Check underneath. Is the green tape in
place (9, 5)
6
Are the commode guidelines
displayed?
BATHROOM
1
Is the floor clean and clear of towel?
(1,2)
2
Are all items single use?
No shampoo or soap should be left
in the bathroom.(5,25)
3
Are there any inappropriate items
stored? And is the room free from
clutter?
45
No equipment should be stored in
the bathroom. (5,24)
4
Is the sink and bath, clean and in a
good state of repair?
Check the bath for scum, chips and
damage, grouting in tact with no
mould. (1,2,3,4,5,7)
5
Are shower curtains clean, no mould,
is schedule for cleaning completed
and signed. (1,7)
TOILET
1
Is the floor clean with no rips tears or
burn marks?
Does the floor smell?
(1,2,3,7,9)
2
Is the toilet clean?
When was it last cleaned?
(1,2,3,7,9)
3
Has the sink a soap dispenser and
paper towels.
(15)
LAUNDRY ROOM
1
Is the laundry room clean and tidy?
All patient clothing is in appropriate
baskets.
2
Is there any inappropriate
equipment in the room?
46
TREATMENT ROOM
1
Is the sharps bin labelled and
assembled correctly(the lid is
attached fully)?
(10,20,21,22)
2
Is the floor clean with no stains rips
or tears, no dust in corners.
(1,2,3,5,7)
3
Is equipment in date?
Check 3 different pieces of
equipment such as syringe, blood
bottle, needle. (24)
4
Is inappropriate equipment stored
in the room and nothing on the
floor?(24)
5
Is the room free from clutter?
Equipment put away and work
surface clean (1,5,7)
6
Are high and low level surfaces
clean? Check above cupboards
door frame and skirting.(1,5,7)
7
Are hand washing posters and
needle stick posters displayed?
(13,14,21)
8
Check inside medicine trolley that
it is clean and well organised. (1)
9
Has the sink got liquid soap, paper
towels, hand cream, and the
dispenser is clean underneath.
(15)
10
Check the ward have a cleaning
schedule for medical equipment
and it has been completed.(24)
11
Are medical devices clean and fit
for purpose? Check no blood
stains on the BM machine(24,25)
Yes
No
Comments
47
STORE CUPBOARD
1
Is the cupboard clean and tidy with
shelves labelled and correct
equipment being stored for that
room?
2
Are there any inappropriate items
such as broken equipment in this
cupboard?
LINEN ROOM
1
Is it clean and tidy?
2
Is the linen stored on shelves?
No linen should be stored on the
floor
3
Is there dirty linen stored in this
room? Is anything else stored in
the room.
KITCHEN
1
Is the floor clean?
(1,2,3,8)
2
Is the microwave clean?
Check inside especially the roof of
the microwave
3
Is the Fridge clean inside?
4
Are the work surfaces clean?
5
Are the cupboards clean inside?
48
CLEANERS CUPBOARD
1
Is the cupboard clean and tidy?
2
Are mops stored correctly?
On a mop rack with mop head up.
No mops should be in a bucket. No
water in the buckets(2)
3
Is there any inappropriate
equipment stored in this room?
Such as food, personal belongings
and other equipment.
ANY OTHER COMMENTS / ACTIONS REQUIRED
Compiled by: Catherine Forman/Felicity Swift
49
Appendix J
Pennine Care Foundation Trust
Infection Control Department
Division of Clinical Governance
WARD Infection Control Audit
SITE
DATE
LOCATION / DIVISION
WARD MANAGER
AUDITOR
REVIEW DATE
Standard: Kitchens will be maintained to reduce the risk of cross infection in accordance with legislation and the
Hand Hygiene Policy CL69
SECTION 1
Ward Kitchens
Yes
No
N/A
Comments
Is the area clean and tidy and in a good
state of repair?
1
2
3
4
5
6
7
8
Are you convinced that there are no
inappropriate items or equipment in the
kitchen
Are you convinced that there is no
evidence of infestation in the kitchen
Cleaning materials used in the kitchen
are identifiable (e.g. Colour coded) and
are stored separately to other ward
cleaning equipment and away from
food
Disposable towelling is used for
cleaning and drying equipment and
surfaces
Hand wash sink, liquid soap and
disposable paper towels are available
Hands are decontaminated and a clean
plastic apron is worn to serve patient
meals and drinks
Shelves, cupboards and drawers are :
a. clean and free from dust
b. in good state of repair
9
Kitchen trolleys/Klicks machines are
clean and in a good state of repair
50
10
Refrigeration/freezers are clean, free of
ice build up and there is a thermometer
with a temperature between 0-8°C in
the fridge
Ward Kitchens (Continued)
11
12
13
14
Yes
No
N/A
Comments
There is evidence that fridge
temperatures are recorded at least
weekly and appropriate action taken
when necessary
Patient and staff food in the fridge is
labelled with name and date
Are you convinced that there are no
drugs/blood for transfusion or
pathology specimens in the fridge
Microwaves are visibly clean
Bread is stored in a clean bread bin
15
16
17
18
19
20
21
All food products are within their expiry
date and opened food is covered or
stored in containers
Milk is stored under refrigerated
conditions
Ice machines/water coolers for patient
use are mains supplied and visibly
clean and a cleaning schedule is on
place
Scoop used for ice is stored outside of
the machine in a lidded container
There is a satisfactory system for
cleaning crockery and cutlery such as
central wash-up or dishwasher,
achieving disinfection temperatures
evidenced by a maintenance
programme and contingencies are in
place in the event of breakdown
No inappropriate items are stored
under the sink
Standard: The environment will be maintained appropriately to reduce the risk of cross infection.
Following the Infection Prevention & Control Policy CL4, Hand Hygiene Policy CL69, Prevention &
Management MRSA CL70, Flowers and Plants in Infection Control Policy CL72, Medical Devices
Management Policy CO16.
51
SECTION 2
Ward Environment
1
2
3
4
5
Yes
No
N/A
Comments
Bed frames, lockers, chairs and stools
are:
a. visibly clean
b. in a good state of repair
c. covered with non permeable
covering
All high and low surfaces are free from
dust
Curtains and blinds are free from
stains, dust and are cleaned at least
every 12 months.
Floors are clean and free from dust
corner areas clean
Staff are aware and have access to
domestic daily cleaning schedule
Medical equipment is visibly clean
6
7
All furniture is in good state of repair
with no rips or stains
8
Pillows are enclosed, washable with no
stains (Check 3 beds)
9
Standard mattress covers are in a good
state of repair (Select a bed at random
and undertake a mattress test)
Any Plants and Flowers on the wards
10 are on a care or cleaning schedule if
false
Examine Mattress – there should be no staining visible, on the outside and inside of the cover
Pat slides, hoists and other equipment
11
are visibly clean
12 Suction equipment is clean and dry
Are you confident the catheter is not
13 attached (clean cover acceptable in
some emergencies)
Disposable suction liners are used and
14 changed between patient use
52
Clinical Room follows Specimens Policy CL73, Aseptic Technique CL78, Medical
Devices Management policy CO16, Hand Hygiene Policy CL69 and Vaccination
Storage CL79
15
The area is clean and there is no
inappropriate items of equipment
16
Hand hygiene facilities are available in
the clinical room/clean store
17
All high and low level surfaces are free
from dust
18
19
20
21
22
23
24
All products are stored above floor level
The drug fridge is used for drug storage
only (no specimens)
The Temperature should be checked
daily and be between 2-8°C
Dressing trolleys are clean and are in a
good state of repair
Staff who carry out aseptic technique
have received updated training
All items are within date randomly
check two items
Near patient testing equipment
(Eg. blood glucose monitoring
equipment ) is clean.
Bathrooms/Toilets Medical Devices Management policy CO16, Hand Hygiene Policy
CL69
25
26
27
28
Bathrooms/washrooms sinks toilets and
accessories are clean and free from
mould
Are you convinced that there is no
evidence of inappropriate storage of
communal items, creams, talcum
powders etc. are single use only
Are you convinced the bathrooms are
not used for equipment storage
Appropriate cleaning materials are
available for staff/patients to clean the
bath between use and there is
information regarding its whereabouts
29
Hand washing facilities are available
including soap and paper towels
30
There is a facility for sanitary waste
disposal
31
Bath hoist is clean and in a good state
of repair
32
Raised toilet seats are visibly clean
53
33
34
Shower seats are clean
The bathrooms are in a good state of
repair
Dirty Utility
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
The room is clean and free from
inappropriate items
A sluice hopper is available for the
disposal of body fluids
Separate hand washing facilities are
available including soap, paper towels
and alcohol rub
Washbowls are stored clean, dry and
inverted or stored in patient lockers. If
disposable bowls are used these must
be single patient use and disposed of
as clinical waste after use
Cleaning equipment is colour coded
and a cleaning chart is displayed
Mops and buckets are stored according
to the local policy and mop heads are
laundered daily or are disposable
(single use only)
Bed pan bases are stored clean, dry
and inverted
Macerators and bed pan washers are
clean and in working order
Disposable liners are used in all
bedpan bases (including slipper pans)
where macerators are in use
Commodes are clean labelled as clean
and ready for use
Commodes are in a good state of repair
Staff are aware of the cleaning regime
for commodes
Equipment used by the Domestic Staff
is clean, well maintained and stored in
a locked area
Used instruments are safely stored in
an appropriate container prior to
collection for decontamination in HSDU
No inappropriate items are stored
under the sink
Store Rooms
50
Does each store room have a
designated and appropriate purpose
Is the store room clean and tidy
51
Are Shelves clearly labelled
52
Is the floor clean
53
54
54
55
Is everything stored above the floor
level
Are dry products stored above liquid
products
Standard: Waste is disposed of safely without the risk of contamination or injury and in accordance with
legislation. Waste Policy CO45
SECTION 3
Waste Disposal
1
2
3
4
5
6
7
8
Yes
No
N/A
Comments
Clinical waste posters and policy
available
All bags are tied, labelled and secured
before leaving the clinical area
Waste bins are visibly clean, foot
operated, lidded and in good working
order
Correct segregation of glass, clinical
and household waste
Are you convinced that clinical waste
bags are no more than 2/3 full
Disposal area is clean, locked and
inaccessible to unauthorised persons.
The correct bags are being used in the
bins
Bins are clearly labelled with which
waste stream they are for e.g. general
or clinical
Standard: Linen and laundry is managed and handled appropriately to prevent cross infection. Following
Infection Prevention & Control Policy CO4
SECTION 4
Linen and Laundry Handling and
Disposal
1
2
3
4
5
6
7
8
Yes
No
N/A
Comments
Clean linen is stored in a clean
designated area separate from used
linen (not in the sluice or bathroom)
Linen is segregated in appropriate
colour coded bags according to policy
Bags are less than2/3 full, are capable
of being secured and stored correctly
prior to disposal
Linen skips and the appropriate bags
are taken to the area required. (Staff
are not carrying soiled linen or leaving
it on the floor)
Aprons are worn when handling any
linen
Laundry rooms are clean and free from
inappropriate items
Patients clothing is stored
appropriately before during and after
washing
Equipment is in a good state of repair
and clean
55
Standard: Sharps will be handled safely to prevent the risk of needle stick injury. Following Sharps
Management & Inoculation Policy CL77
SECTION 5
Sharps Handling and Disposal
1
2
3
4
5
6
7
8
Once full the bin aperture is locked
Needles and syringes are discarded
into a sharps bin as one unit
14
Comments
All sharps bins are labelled and signed
according to hospital policy
Sharps bins are stored safely, away
from the public, out of reach of children
and above waist level, at an
appropriate height, secured by a
bracket
The temporary closure mechanism is
used when bins are not in use
11
13
N/A
All bins have been assembled correctly
10
12
No
The bins are in use comply with
national standards (UN3291, BS7320)
Bins have not been filled above the fill
line
Bins are free from protruding sharps
Clean sharps trays with integral sharps
bins are available to ensure that sharps
are disposed of at the point of use
Sharps are disposed of directly into a
sharps bin at the point of use
9
Yes
Staff are aware of the correct action to
take following needle injury and the
policy and/or poster is
available/displayed
Staff are aware of the ‘needlestick
policy’, the management of health care
workers following exposure to blood
and body fluids: hep B, hep C and HIV
Staff are aware of how to access
occupational health
Standard: There is a system in place that ensure as far as reasonably practicable that all reusable
equipment is properly decontaminated prior to use and that the risks associated with decontamination
facilities and processes are adequately managed.
All documentation must be undertaken in accordance with local policy and manufacturers’ instructions.
Following Medical Devices Management Policy CO16
56
SECTION 6
Care of Equipment
1
2
Yes
No
N/A
Comments
Staff can describe the symbol used to
indicate single use items
Staff are aware of the need for
decontamination and a certificate
before sending equipment for
maintenance/repair
Standard: The supply and use of detergents/disinfectants and antiseptics are appropriate and correctly
used to negate the risk of infection.
SECTION 7
Disinfectants and antiseptics:
1
2
Yes
No
N/A
Comments
Appropriate disinfectants and dilution
charts are available to deal with blood
spillages
Staff are aware of the correct policy for
cleaning up blood spillages
Spill packs are available and in date
3
4
A white mop and bucket are available
to nursing staff to deal with fluid spills
Standard: Hands will be decontaminated correctly and in a timely manner using a cleansing agent, at the
facilities available to reduce the risk of cross infection. Following Hand Hygiene Policy CL69
SECTION 8
Hand Hygiene
1
Yes
No
N/A
Comments
Liquid soap is available at all hand
washing sinks and must be single use
cartridge dispensers
Dispenser nozzles are visibly clean
2
3
4
5
6
7
8
9
Paper towels are available at all hand
washing sinks
The hand wash sinks are free from
used equipment and inappropriate
items
The hand wash basin and taps are
compliant with HTM 64
Access to hand wash sinks is clear
Alcohol hand rub is available for use
throughout clinical areas
Are you convinced that wrist
watches/stones rings or other wrist
jewellery are not worn by staff carrying
out patient care
Nails are short and no nail varnish is
being worn
57
10
11
12
Staff are aware of the 5 moments for
hand hygiene (ask staff)
Posters promoting hand and
decontamination are available and
displayed in areas visible to staff before
and after patient contact
Staff have received training in hand
hygiene procedures within the last
year, ask a member of staff
Moisturiser is available to staff
13
14
15
Patients are offered hand hygiene
facilities after using the
toilet/commode/bedpan and also prior
to meals e.g. hand wipe
Nursing staff use the correct procedure
for decontaminating hands (observe
practice)
Standard: Clinical practices will be based on best practice and reflect infection control guidance to
reduce the risk of cross infection to patients’ whilst providing appropriate protection to staff. NB. This
section should be undertaken over a period of time to allow for the observation of as many practice
elements as possible. Follows Personal Protective Equipment Policy CL76
SECTION 9
Clinical Practices
Personal Protective Equipment
1
2
3
4
5
Yes
No
N/A
Comments
Sterile and non-sterile gloves (powder
free) are available in all clinical areas
Hands are decontaminated following
the removal of gloves
Plastic aprons are worn as single use
items for each clinical procedure or
episode of patient care
Eye protection is available when there
is a risk of any body fluids splashing
into the face and eyes
Masks are available for use where
clinically indicated
Catheter Management follows PPE Policy CL76 & Hand Hygiene policy CL69
6
7
8
Non sterile gloves are used for
emptying urinary catheter bags
A disposable receptacle is used for
emptying urinary catheter bags
Catheter stands are in use and
catheters are not touching the floor
Isolation Precautions following Isolation and Barrier nursing Outbreaks Policy CL75,
MRSA Policy CL70, Clostridium Difficile Policy CL71 Management of Head, Body &
pubic lice policy CL74, Hand Hygiene Policy, PPE Policy and Infection Prevention and
Control Policy CL4.
9
Where a patient is being isolated for
infection control reasons, the
precautions are appropriate and
according to local policy
58
10
11
12
13
14
15
16
17
Protective clothing is readily available
upon entering the isolated room
Hand hygiene facilities are available,
accessible and clean within the room
Are you convinced that there are no
inappropriate or unnecessary items
stored in the isolation room
Appropriate information leaflets are
available to patients for common
infections
Visitors are advised that they do not
routinely need to wear protective
clothing
Domestic services staff are aware of
the local policy and procedures for
cleaning isolation rooms
Separate colour coded cleaning
equipment is in use for isolation
facilities
Isolation precautions are discontinued
when no longer necessary
Specimens. The Specimens policy is followed CL73
18
Staff are aware of how to label
specimens correctly
Specimens are stored correctly
19
20
21
Specimens for transport are stored in
the correct UN container
Specimens that are tested on the ward
are disposed of correctly
Adapted by:Felicity Swift/Catherine Forman
59
References
Department of Health (2009) The Health Act 2008 Code of Practice for the NHS on the prevention and
control of
healthcare associated infections and related guidance
Care Quality Commission (2009) Practice Alert September 2009: Mattresses
Department of Health (2003) Winning Ways- Working Together to Reduce Healthcare Associated
Infection in England
Infection Control Nurses Association (2004) Audit Tools for Monitoring Infection Control Standards
Department of Health (2006) Essential Steps to Safe Clean Care
Department of Health (2007) Essential Steps to Safe Clean Care. Inter–healthcare patient infection risk
assessment
form
Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care. Isolating
patients with
healthcare associated infection. A summary of best practice
Health Care Commission (October 2007) Investigation into outbreaks of Clostridium difficile at Maidstone
and
Tunbridge Wells NHS
Medicines and Healthcare products Regulatory Agency (2006) Managing Medical Devices Guidance for
Healthcare
and Social Services Organisations DB 2006 (05)
National Patient Safety Agency (2007) Cleanyourhands Campaign
National Patient Safety Agency (2007) National Colour Coding Scheme for cleaning materials and
equipment
National Patient Safety Agency (2008) Patient Environment Action Teams Assessments
National Patient Safety Agency (2008) Clean Hands Save Lives, Patient Safety Alert Second Edition 2nd
September
2008
Infection Prevention and Control Policies and Guidance
Pratt R J et al (2006) epic2: National Evidence –Based Guidelines for Preventing Healthcare Associated
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60