INFECTION PREVENTION AND CONTROL POLICY

Policy Number: Version: Ratified by: Date ratified: Name of originator/author: Commissioning Infection Prevention & Control Team NHS South Essex Integrated Governance Committee NHS South Essex Board

Name of responsible committee/individual: Date issued: Review date: Target audience:

NHS South Essex

Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

CONTENTS OF INFECTION PREVENTION & CONTROL POLICY

Contents

Page

1.0 EXECUTIVE SUMMARY

2.0 SCOPE OF POLICY

3.0 BACKGROUND

4.0 INFECTION CONTROL ARRANGEMENTS

5.0 STAFF ENGAGEMENT

6.0 ROLES & RESPONSIBILITIES

7.0 INFECTION CONTROL ARRANGEMENTS

8.0 POLICY REVIEW

9.0 Equality Impact Assessment

Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

1.

EXECUTIVE SUMMARY

NHS South Essex places the utmost importance on ensuring patients safety. Minimising the risks from infection is key to that aim. This policy is directed at all Primary care and support staff. It describes in detail the roles and responsibilities allocated to different staff groups. It details the inter-linking processes that have been put in place to provide the NHS South Essex Board with assurances that infection prevention & control performance is being constantly monitored and reviewed to ensure it reflects current best practice and fulfils any specific legal obligations. To reinforce the commitment and seriousness with which NHS South Essex views good infection prevention & control practice, staff should be aware that failure to comply with this Policy may have serious medico-legal implications and may in some instances, result in disciplinary action being taken. 2. SCOPE OF THE POLICY

NHS South Essex are dedicated to strengthening prevention and control of infection, improving surveillance and ensuring patients with infections receive the most appropriate care. This Policy defines the Trusts over-arching commitment to ensuring patients, staff and visitors are cared for in an environment where best practice in the prevention and control of infection is second-nature to all staff whether they be doctors, nurses, healthcare assistants or support workers. All staff, and particularly all health care workers, have a vital part to play in helping minimise the risk of cross-infection within the South Essex boundaries. The associated infection prevention and control guidelines complement this policy and reflect national best practice. The organisations websites and intranet contains links to the Infection Prevention & Control Policy and guidance for staff use. The Infection Prevention & Control Team are also available, and happy to help, when expertise is required for specific information relating to any infection control situations that are not covered in these documents. 3. BACKGROUND

Health Care Associated Infections (HCAI) represent one of the greatest challenges in modern day healthcare. In many respects their initial development and subsequent growth, can in part, be attributed to advances in medicine. The growing problem is multi-faceted with no quick fix solutions. We have a responsibility to ensure infection prevention and control is seriously addressed with stringent control and precautions to minimise the risk of cross infection that can endanger lives.

Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

Infections acquired in healthcare can cause serious problems; they can complicate illnesses, cause distress to patients and their family, and can in some cases lead to patient death. There are also economic consequences such as the effect on bed availability and the ability to meet some Government targets. 4. INFECTION CONTROL ARRANGEMENTS

There is a significant amount of national guidance now available to enable health and social care providers and commissioners to ensure they have sufficiently effective systems and processes in place to assure patients and staff alike that the care provided is of a quality that safeguards patients in primary, secondary and community care. The most notable documents being; The Health and Social Care Act (2008) code of practice for health and adult social care on the prevention and control of infection. Essential Steps to safe, clean care (2007) Saving Lives (revised edition 2007) National Patient Safety Agency Revised Cleaning Manual ( 2009) Revised guidance on contracting for cleaning (2009) Towards Cleaner hospitals and lower rates of infection (2004) Winning Ways Working together to reduce HCAI in England (2003) Standards for Better Health 2004 Matrons charter: an action plan for cleaner hospitals (2004) Effective prevention and control of Health Care Associated Infection (HCAI) must be embedded into everyday practice and applied consistently by everyone. It is particularly important to have a high awareness of the possibility of HCAI in both patients and staff to ensure early and rapid diagnosis. This should result in effective treatment and containment of the infection. Effective action relies on an accumulating body of evidence that takes account of current practices. This evidence base should be used to review and inform practice. All staff should demonstrate good infection control and hygiene practice. The code of practice sets out how the Care Quality Commission will assess compliance with the requirements set out in Regulations made under section 21 of the Health and Social Care Act 2008, and provides guidance on how providers can meet the registration requirements relating to HCAI set out in the Regulations. As a legal requirement of their registration, organisations must protect patients, workers and others who may be at risk of acquiring an HCAI. Independent Contractors in Primary Medical Care will need to be registered with the CQC by April 2013. Failure to observe the code of practice may result in enforcement action by the Care Quality Commission as it may be used as evidence of a breach of the registration requirement 5. Staff engagement All staff are expected to understand the importance of infection prevention and control procedures, particularly the value of hand hygiene. Infection prevention &
Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

control training will be delivered via a rolling programme of education, available to staff from all areas. All staff have an implicit responsibility to ensure they abide by this policy and the associated guidelines and to take the necessary actions to prevent the spread of infections. Failure to follow the guidance may put the staff member, their colleagues and patients at risk. The Infection Prevention & Control Policy and Guidelines are available on the NHS South Essex intranet: www.see.nhs.uk/informationforgps these should be printed and stored in an easily accessible area of the workplace for reference. Patient information leaflets are also available on the Website and may be freely copied and distributed to patients, visitors etc as required. 6. ROLES AND RESPONSIBILITIES

This section sets out who is accountable for what in terms of the over-arching Infection Prevention and Control Policy. The following list is not exhaustive this policy must be adhered to by all staff working for and on behalf of South Essex Healthcare. South Essex economy Infection Prevention and Control Network Group this group will inform, influence and drive forward local policy for infection prevention and control for all health and social care providers within South Essex. 6.1 Infection Prevention & Control Teams (IPCT): a) The commissioning Infection Prevention and Control team comprises of the Director of Infection Prevention & Control, the Deputy Director of Infection Prevention & Control (who leads the commissioning team), Infection Prevention & Control Nurse, Infection Prevention and Control Auditor and an Administrator. The team will work with Independent Contractors to assist them in limiting the acquisition and spread of pathogenic microorganisms by promoting the use of scientifically based knowledge and skills, planning, surveillance, education and research, as part of the overall policy of achieving good quality health care. The over-riding responsibility to achieve safety Infection Prevention and Control practice lays with Independent Contractors. 6.2 Director of Infection Prevention and Control (DIPC): within NHS South Essex is the Executive Nurse. Their role is to oversee local control of infection policies and their implementation, the organisation and management of the Infection Prevention and Control Team and to provide a direct reporting line to the Chief Executive and the Board of NHS South Essex on all infection prevention and control issues.
Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

The DIPC, and Infection Control Team, has the responsibility for monitoring inappropriate clinical hygiene practice or antibiotic prescribing. They will assess the impact of policies and plans on infection prevention & control within the organisation and make recommendations for change. The DIPC sits within Quality, Safety, Patient experience and nursing directorate to ensure consistency and continuity of care. In addition as a commissioning organisation, the DIPC is responsible for ensuring that there are effective performance monitoring arrangements in place for all commissioned services. 6.3 The Infection Prevention and Control Team leads on the implementation of the annual work programme including education, audit and surveillance, review of guidelines and introduction of national and local initiatives. Additional responsibilities include identification of infection risks to be included on the NHS South Essex risk register, provision of evidence for the Care Quality Commission and monitoring of contracts. The team monitors, reviews and analyses performance data from the acute providers. 6.4 Primary Care Staff: have a Duty of Care to their patients, which includes ensuring stringent infection prevention & control procedures are carried out at all times. a) General Practitioners: General Practitioners have a responsibility to ensure that they and their staff abide by NHS South Essex Infection Prevention & Control protocols and procedures and to act as positive role models for good hand hygiene practices and all other infection prevention & control issues. b) Nursing staff: Are ideally placed to champion infection prevention control issues within GP surgeries. This will include HCA/HCS workers induction and rolling infection prevention and control education programmes. c) Domestic staff: are employed to maintain a clean environment and hold joint responsibility with care staff for achieving this. All domestics must have clear roles and responsibilities, which are known throughout the work area. Schedules of cleaning should be displayed, reviewed and maintained. Problems should be immediately reported to the line manager, to ensure prompt resolution. d) All other staff groups: have a responsibility to attend the Mandatory Infection Prevention & Control training, which includes the statutory hand hygiene training for clinical staff. It is vital that all staff members understand that even though they may not be directly involved in patient care, if they move around within patient care areas, they must abide by NHS South Essex Infection Prevention & Control guidance.

Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

7. Infection Control Arrangements National and Regional targets With patient safety high on the agenda, reducing HCAIs has become priority and target driven. Organisations (including independent contractors) are required to formally register with the Care Quality Commission by April 2013 There are national targets to reduce MRSA bacteraemias and Clostridium difficile within acute Trust and across the economy There are national targets to undertake MRSA screening for elective cases and emergency cases There are regionally developed infection prevention and control policies that have to be observed and implemented within each health care provider within the region All organisations need to embrace the key documents (as listed above), and implement into practice.

National to Local Strategic Progression National Improving cleanliness and reducing HCAI is one of the Department of Healths five national priorities, with the NHS Region pledging to make our health service the safest in England. This continued drive can be found in Operating Framework for the DoH. Local One of NHS South Essex QIPP projects is HCAI Reduction. Robust governance arrangements are in place for Infection Prevention and Control, and these are monitored within the organisation through: the committee structure the Project Management Office; o the QIPP project HCAI reduction is included in the planned care work streams, although it is recognised that the project spans all work streams. Independent Contractor Practice Accountabilities Each Independent Contractor Practice needs to understand the context of the above national and local directives to ensure the priorities for infection prevention and control are embraced within each care provider organisation Each Independent Contractor Practice needs to be able to demonstrate its overarching commitment to ensuring its patients, staff and others are cared for/consulted in an environment where best practice in the prevention and control of infection is
Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

second nature to its entire staff whether they are doctors, nurses, healthcare assistants or support workers. All staff have an implicit responsibility to ensure they abide by the code of practice for infection prevention and control, taking the necessary actions to prevent the spread of infections and minimise the risk of cross-infection within the South Essex boundaries. Team Infrastructure It is recognised that each Independent Contractor Practice cannot have its own Infection Prevention and control Team. Therefore expert advice will be forthcoming from the NHS South Essex Commissioning Infection Prevention and Control Team, with each Independent Contractor Practice nominating a responsible member of staff to be their own dedicated HCAI Lead. External Assurance Care Quality Commission (CQC) Patients have come to expect clean, safe care. They assume that the NHS will strive to prevent infections while they are being treated, and have an expectation that no harm will come to them through preventable infection wherever they may receive care. The CQC registration system is underpinned by the code of practice for health and adult social care for the prevention and control of infection. The code sets out Compliance Criteria are used to monitor and demonstrate assurance that care organisations are compliant with the code of practice. Organisations must, by law, comply with one overarching regulation about HCAI, which requires them to operate in a way that, as far as practicable, protects patients, workers and others from identifiable risks of acquiring an HCAI. Strategic Health Authority The SHA have provided external intensive support to its health providers over a number of years to promote and encourage compliance with the code of practice. Its programme of intensive support also provides external assurance to the Board about; the degree of compliance suggestions for improvement, and in turn; the accuracy of the public declaration Currently, their assistance is specifically around defining the role of the Commissioning Infection Prevention and Control Teams as commissioners of
Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

services and providers of an infection and prevention control service to independent contractors to avoid any conflict of interest, and ensure good governance. 8. POLICY REVIEW The responsibility for the development and updating of this policy and procedural guidelines reside with the DIPC. The policy and its procedural guidance will be reviewed annually.

Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

9. EQUALITY IMPACT ASSESSMENT

Yes/No 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems No No No No No Small potential More explicit reference to availability of resources in alternative languages and formats More explicit reference to organisations commitment to ensure that all staff and patients have access to resources to allow them to fully participate in implementing the policy (can everyone reach the hand wash? Can everyone see/read the sign?) 2. 3. Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? Is the impact of the policy/guidance likely to be negative? If so can the impact be avoided? What alternatives are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action? No No No No Small potential More explicit reference to availability of resources in alternative languages and formats Comments

4. 5. 6. 7.

No

8. Other Issues Highlighted

The document does not make reference to supporting patients in terms of how they prevent infection or reference to patient responsibilities in the implementation. This may be included in subsequent guidelines.

Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

List of Stakeholders Name Pol Toner Title Director for Infection Prevention and Control Associate Director of Infection Prevention and Control Department Quality and Nursing Directorate South Essex Cluster Quality and Nursing Directorate South Essex Cluster Quality and Nursing Directorate South Essex Cluster NHS South Essex Cluster NHS South Essex Cluster Medicines Management NHS South Essex Basildon and Thurrock University Hospital Basildon and Thurrock University Hospital Clinical Microbiology Barking, Havering and Redbridge NHS Trust Basildon and Thurrock University Hospital Essex Local Medical Committee Corporate Services NHS South West Essex Essex Health Protection Agency

Lisa Allen

South Essex Cluster Infection Prevention and Control Team Dr Rupert Halliday Dr Anil Chopra Olbusola Daramola Dr Benny Cherian Dr Carol Weary Dr Lindsey Bain

Medical Director Medical Director Antibiotic Prescribing Advisor Consultant Microbiologist Consultant Microbiologist Infection Prevention and Control Doctor Pharmacist Chief Executive Equality and Diversity Lead Public Health Consultant

Sarah Zeraschi Dr Brian Balmer Natalie Morel Dr Sally Millership

Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013

List of Stakeholders consulted as part of the policy development Lisa Allen Kathy Ramsay Lynne Powell Barbara Mallia Pol Toner Rupert Halliday Jane Foster Taylor

Infection Prevention & Control Team NHS South Essex August 2011 Review Date August 2013