Infection Prevention and Control Annual Report April · PDF fileInfection Prevention and...

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Infection Prevention and Control Annual Report April 2016/ March 2017

and

Annual Programme of Work April 2017/ March 2018

Produced by: Director of Infection Prevention and Control - Dawn Slater

and

Infection Prevention and Control Manager - Deborah Pudner

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Heading Page Number

Introduction 3

The Code of Practice 4

Description of Infection Prevention and Control Arrangements and Structures within LSW 6

Role of the Director of Infection Prevention and Control 6

Role of the Infection Prevention and Control Team 6

Role of the Infection Prevention and Control Committee 7

Role of Locality/Deputy Managers and Line Managers 7

Role of the Matrons and Managers 7

Role of the Infection Prevention and Control Link Practitioner 8

Role of Professional Training and Development Team 9

Role of Risk Management 9

Role of all Staff 9

Estates Report 9

Kiers Report 10

Hotel Services Report 11

Seasonal Flu Vaccine Programme Report 12

Occupational Health and Wellbeing Report 13

Antimicrobial Surveillance Report 22

Audits 23

Locality Audit Results 24

External Inspections 31

Cleanliness and Maintenance Monitoring 33

Healthcare Associated Ward Surveillance 41

Outbreaks 42

Infection Prevention and Control Training Activities and Displays 44

Income Generation 44

Summary 45

Areas of Concern 45

Appendix A Detailed Annual Plan 2017/18 46

Appendix B C difficile Reduction and Maintenance Plan 2017/18 52

Appendix C MRSA and MSSA Sepsis Reduction and Maintenance Plan 2017/18 60

Appendix D Procedure for Management/Communication of Suspected Norovirus Outbreak

65

Appendix E Infection Prevention & Control Policy List and Review Dates 71

Appendix F Infection Prevention and Control Liaison Practitioners Roles and Responsibilities

73

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The Infection Prevention and Control Team

Introduction

Management and organisational processes for infection prevention and control are embedded

throughout Livewell Southwest (LSW). They are crucial to make sure that high standards of

infection prevention and control (including cleanliness) are recognised and maintained by all LSW

staff. This annual report fulfils its statutory requirements under The Health and Social Care Act

2008, The Code of Practice 10 criteria. These criteria are regulations that are measured against in

accordance with CQC standards. LSW has registered with the Care Quality Commission and have

acknowledged full compliance with the Health and Social Care Act (commonly known as the

Hygiene Code).This report informs the Board of the progress being made to reduce Health Care

Associated Infections (HCAI).

Steven Cowan IPC Support Assistant

Deborah Pudner IPC Manager

Gemma Small IPC Assistant Practitioner

Val Radmore

IPC Sister Dawn Slater Director IPC

Sandra Marshall IPC Staff Nurse

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Compliance criterion

What the registered provider will need to demonstrate

Evidence of implementation

1 Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them.

Surveillance, Care plans, Audit and action plans, RCA, outbreak management, IPC policies, ICLP, incident forms, training, admission screening, annual Patient Lead Assessments in Care Environments (PLACE), Annual programme of work, cleaning schedules on the wards/units, IPCC, DIPC, water management group and policy, decontamination lead, customer service feedback, cleanliness monitoring, Matrons charter, CQC inspections.

2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.

Environmental audits, equipment audits ,availability of cleaning equipment/products, cleanliness monitoring, linen and laundry audits and policy, Matrons charter, access to HH products, HH audits, HH facilities, outbreak management, PLACE, isolation facilities, estates annual programmes of work including Legionella control, hotel services annual programme of work including waste management, food handling, enhanced Clean and deep clean schedules, pest control, Safe disposal and management of sharps.

3 Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.

Antimicrobial surveillance programme including audit and education carried out by pharmacy, RCA, Medicines Governance Group.

4 Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion.

Verbal and written communication with those involved in care, policies, patient information leaflets, sample results, mandatory reporting to CCG, RCA, surveillance, HH posters placed in clinical areas, care plans, PLACE, ICLP, training, appropriate HH facilities for patient, staff and visitors, audits, outbreak management, communication between services and other organisations, reports.

5 Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people.

Communication between services and other organisations, care plans, patient information leaflets, job descriptions, training, access to occupational Health and Wellbeing , written IPC advice for contractors, bank staff and non LSW staff, isolation facilities, enhanced and deep clean precautions/isolation,

The Code of Practice

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isolation daily review care plans, samples/results, admission screening, observations/MEWS/NEWS, sepsis flow charts, sample collection, sample results to ensure correct treatment is give promptly, policies.

6 Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection.

Compliance with training, policies and procedures, report poor performance, immunisation, incident reporting, Occupational Health and wellbeing advice, staff screening, written IPC advice for contractors, bank staff and non LSW staff, audit.

7 Provide or secure adequate isolation facilities. Single room, IPC precautions, enhanced cleaning, equipment cleaning, deep cleans, own toilet/commode if no on suite facilities, appropriate PPE, HH and HH facilities, policy.

8 Secure adequate access to laboratory support as appropriate.

Compliance with safe transport of specimens, obtaining samples and monitoring for results, advice from on call microbiologist, surveillance.

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

See list of up to date policies page 75-76, they are all on the intranet for staff to access, surveillance, monitoring, IPC advice, patient information leaflets.

10 Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection.

Occupational health and wellbeing advice, policy, immunisation, education, PPE, HH, awareness of inoculation procedures, correct use of cleaning products, risk assessments and incident reporting, safe disposal and management of sharps, line management.

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Description of Infection Prevention and Control arrangements and

Structures within LSW The LSW Board and ultimately the Chief Executive Officer has responsibility for infection

Prevention and control throughout LSW. The day to day management is delegated to the Director

of Infection Prevention and Control (DIPC). All managers and clinicians are responsible for the

management of IPC risks, which are a fundamental part of their duties. Every clinical member of

staff is commitment to reducing the risk of HCAI, through standard infection prevention and control

measures.

Role of the Director of Infection Prevention and Control The DIPC is an integral member of the Safety and Quality Committee and:

• Manages local control of infection prevention and control policies and their

implementation.

• Is responsible for the Infection Prevention and Control Team.

• Reports directly to the Chief Executive and the Board.

• Challenges inappropriate clinical hygiene practice as well as antibiotic prescribing

decisions.

• Evaluates the impact of all existing and new policies and plans on infection and makes

recommendations for change.

• Is an integral member of the organisation's clinical governance and patient safety teams

and structures

• Produces an annual report on healthcare associated infections within LSW.

• The DIPC also monitors the progress of the annual IPC detailed programme of work,

infection control policies, procedures and guidance.

Role of the Infection Prevention and Control Team (IPCT) The IPCT devise and implement a robust Annual Programme of Work to reduce HCAI. This is

achieved by working in collaboration with all wards and departments. The IPCT performs a

number of activities to minimise the risk of infection to patients, staff and visitors and:

• Provide advice on all aspects of infection control relating to patients and visitors

• Managing outbreaks of infection.

• Conduct programmes of education which includes induction, mandatory, Healthcare

Certificate and Infection Control Link Practitioner (ICLP) training.

• Undertaking audit and targeted surveillance.

• Formulate policies and procedures.

• Maintaining a reduction strategy for alert organisms.

• Interpret and implement national guidance at local level.

• Involvement with refurbishment, new building and equipment projects.

• Work alongside Pharmacist to monitor antibiotic stewardship.

The IPCT utilises a proactive approach with the emphasis on being visible on the wards and so

making their accessibility for guidance and advice a priority. This in turn has led to an improved

IPCT image i.e. being a regular familiar face rather than only visit for a once yearly audit or when

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there are problems. The IPCT work closely with hotel services and the estates team, together they

carry out annual environmental audits, to ensure that the environment is well maintained. The

IPCT and hotel services also carry out bi-weekly environmental cleanliness monitoring, using the

National Patient Safety Agency Specification for Cleanliness Guidance. All observations from our

visits are fed back to locality managers, Matrons and ward managers for actions, should any arise.

Infection Prevention and Control Team Establishment

Director of Infection Prevention and Control

IPC Manager

IPC Senior Sister

IPC Staff Nurse

IPC Assistant Practitioner

IPC Support Assistant

Role of the Infection Prevention and Control Committee The IPCC is chaired by the DIPC who is responsible for providing strategic advice and support to

Directors, Locality Managers, Clinicians and all healthcare workers on the implementation of

LSW IPC policies. The committee also provides assurance the Chief Executive and Board on all

aspects of infection prevention and control.

Role of Locality/Deputy Managers and Line Managers All managers must ensure that their area of responsibility is compliant with the hygiene code.

Managers should ensure that their Provider Compliance Assessment (PCA) reflects their area,

taking into account hand hygiene and IPC audit scores.

They are also responsible for ensuring that:

All staff clearly understand their responsibilities in respect of the IPC policies.

All new staff are adequately inducted in respect of infection control procedures, relevant to

their work base and their role (all new staff attend induction).

Required time is allocated for staff to attend IPC education sessions through the

mandatory training programme and managers support this attendance.

All infection control risks are systematically assessed and any necessary improvements

prioritised.

Staff and other stakeholders are regularly consulted and informed on infection control

issues and their opinions are taken into account in formulating and reviewing existing IPC

policies and procedures.

Policies, procedures and guidance are readily available to all staff.

IPCT are consulted on infection control issues, including specialised advice i.e. purchasing

of equipment and building projects.

Role of the Matrons and Managers Matrons and ward managers are responsible for ensuring that their ward environments are

maintained at high levels of cleanliness. They also have the authority to address any issues

directly with domestic staff or house-keepers. Weekly cleaning checklists are provided by the ward

managers and stored on the Infection Prevention and Control shared drive. These checklists are

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then reported on by the matrons, in their matrons charter reports. The matrons and ward

managers are responsible for ensuring the ICLP are supported when performing their role and

have appropriate time and resources to do this effectively. Audit and ongoing work undertaken by

the ICLP is included in the Matrons charter and submitted to the Infection Prevention and Control

Committee.

Role of the Infection Prevention and Control Link Practitioner All ICLP have a job description outlining their job roles and responsibilities (Appendix F) and are

expected to participate in a number of activities and to promote and enhance high standards of

infection prevention and control practices within their area of work. They are also responsible for

disseminating any new infection prevention and control information, which is obtained when

attending ICLPs meetings that are organised, chaired and presented by the IPCT. The ICLP group

meetings take place quarterly and provide an opportunity for all links to keep themselves up to

date with infection prevention and control topics, issues and evidence based practice

guidelines. ICLPs are encouraged to present to the group and share best practice. The

presentations that have been shared this year have been of a very high standard and very well

researched. Our ICLPs have worked hard this year and as always we like to recognise the support

that we receive from them. This year it has been difficult to decide which of our ICLPs have been

outstanding. We are pleased to say that our ICLP in the community award went to Carol Collinson

from Plymstock clinic for her hard work and responsiveness when resolving issues. Katy

Coombes on Kingfisher ward who has been very active in sharing learning from infections that

have occurred, to reduce risk of recurrence and, has created an interesting and lively information

board for everyone to see. Team of the year went to Edgcumbe ward, where all of the

multidisciplinary team take infection control issues into consideration when undertaking care with

their patients, for keeping the IPCT updated and having an easy to read board when we visit.

Team of the year Edgcumbe ward Carol Collinson from Plymstock clinic

Katy Coombes from Kingfisher Ward

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Role of Professional Training and Development Team Arrangements are in place for staff to attend induction, healthcare certificate and mandatory training programmes which include IPC. Arrangements are in place for staff training to be

effectively recorded and maintained in staff records. A system is in place for informing managers

of their staff’s non-compliance and non-attendance at mandatory training sessions.

Role of Risk Management The risk management team ensure IPC incidents are reported and recorded on appropriate

documentation. A robust system of risk management is in place with action and follow up to

incidents occurring.

Role of all Staff All staff are responsible for ensuring that they follow standard IPC measures at all times and are

familiar with IPC policies, procedures and guidance relevant to their area of work. All staff have a

duty of care to report any breaches in best practice and are required take action as appropriate.

Mandatory and induction training is provided for all levels of staff, and staff are responsible for

ensuring that they are up to date with their infection prevention and control mandatory and

essential training.

Estates Report (by Keith Houghton Estates Manager) The Estates team as a whole continue to take their responsibilities regarding infection prevention

and control extremely seriously. The team have worked well with all other teams within Livewell

Southwest. An Estates representative has accompanied the IPC team and Hotel Services on

numerous environmental audit visits and works required following these visits, have been

prioritised and carried out as funding allows. Capital funding through NHS Property Services (NHS

PS), who is our landlord for the majority of our properties continues to be challenging. Numerous

works planned for 2016-17 have not yet received the necessary funding and, this will have had a

Yvonne Place from The Thornberry Centre took

first place in the Infection Prevention Society

National awards, where she was named Link

Practitioner of the Year. The awards were

presented at a glitzy gala dinner with a 1920’s

theme. “Yvonne is not afraid to challenge more

senior staff and liaises with relevant clinicians

and mangers in order to identify

sustainable solutions to the problems the

setting encounters. She has been active in

the ‘Surviving Sepsis’ arena as there are

patients within her department who have lost

limbs due to sepsis.”

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detrimental effect on some IPC work. Any urgent work that has been identified has been funded

through the Estates maintenance budget. This however has had an unfortunate negative impact

on other maintenance tasks. All IPC works that are outside of normal estates maintenance require

funding from one source or another and this will continue to be the case going forwards. This is

likely to necessitate teams providing the budget for these non-maintenance tasks. Where this is

part of a larger capital project, funding streams through NHS PS may be problematic but these

issues are outside of our control. We will continue to work with all members of the organisation to

try and overcome any such obstacles.

The team continue to receive on-going training and continue to promote good hygiene techniques

and practices throughout the organisation.

Water Safety continues to be a priority for LSW and we have maintained good quality water

services throughout the majority of sites. Exceptions to this are The Cumberland Centre and

Tavistock Hospital. Positive legionella samples continue to be an issue at Cumberland. We

continue to manage this in a safe manner and are pressing NHS PS, for a permanent solution.

Water circulation temperatures have been out of specification at Tavistock. Again, this is not a

dangerous situation at present and we are evaluating the potential issues and means of

addressing them. The system is dosed with a silver/copper solution to maintain an acceptable

water quality.

Reviews of the water system risk assessments have been completed and any works arising from

these are being addressed through our estates team.

One major area of achievement during the year has been the refurbishment and remodelling of the

operating theatre at Tavistock Hospital. This project was delivered with great emphasis being

placed upon the requirements of the IPC team. Mandatory bio-burden testing of the air quality and

the full validation of the theatre suite was completed with satisfactory results prior to the unit being

accepted back from the contractor. Some minor IPC issues are outstanding but will be captured

under normal planned and reactive work.

Forthcoming works include a redesign of areas within Lee Mill Hospital and IPC will be consulted

on areas affecting infection prevention and control. There is a major capital programme planned

for the next 12 months. This work will be managed by Resound on behalf of NHS PS with

representation at capital meetings by LSW estates team where IPC issues can be highlighted and

included in the works programme.

Kiers (by Ian Ratcliff)

Toolbox talks continue to be given to existing contractors and also to new contractors, instructing them to be bare below the elbows if appropriate whilst working on site.

Macerators – we are trialling with manufacturers Haigh, a new model of macerator on Skylark Ward (west). This machine has enhanced features, which enable hands-free operation, thus eliminating hand contact with potentially contaminated surfaces. The surfaces of this machine are made from anti-microbial plastic.

We are concurrently trialling with Haigh, a new disinfection product, Techcare, which is used to disinfect the macerator after each operational cycle. Test results from these trials are due imminently.

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Working with Techcare, we are about to undertake a trial with their product on the showers and toilet pods on the wards. Results of this limited trial will be available early summer.

Annual cleaning of the air handling ductwork to the Minor Operations rooms and the Gymnasium will be carried out in July.

Annual risk assessments of all remaining ductwork will be carried out late spring, with any necessary cleaning taking place in July.

Water – legionella sampling continues to yield 100% negative results.

Hotel Services Report (by Sharon Veitch Hotel Services Manager)

Catering / Food Safety

Over the last 12 months, Hotel Services have reviewed and managed e-learning for Levels 1 and

2 Food Safety Training. This training is provided by Creative Learning Solutions and provides an

interactive learning programme with a multiple choice exam at the end. Recently, we have

introduced e-learning for Level 2 Food Safety Refresher Training and Food Allergy Training. These qualifications are mandatory for all Livewell Southwest food handlers including Hotel

Services staff, nursing staff, occupational therapists and community staff who provide or assist

patients with catering. For example, the patient meal services, therapy groups for activities of

daily living or planned discharges back to their homes. Staff who prepare and cook patient meals

or work in Livewell Southwest catering facilities must hold the Level 2 qualification, whilst staff who

have minimal food handling, ie assist in feeding, making beverages etc., must hold the Level 1

qualification. Both of these e-learning training packages are reviewed and accredited by the

Environmental Health Office. The Food Safety Officer for Livewell Southwest is Diane Craddock

with support from Sharon Veitch, Hotel Services Manager. Both Diane and Sharon have achieved

the Advanced Food Hygiene Certificate (CIEH) and their Teacher Trainers Certificate (CIEH) to

enable them to provide this training and food safety advice. During the last year 2016 / 2017 313

staff have enrolled to attain the appropriate Food Safety qualification. Diane provides food safety

monitoring. This includes regular monitoring of internal practices and processes, the cleanliness

of kitchens including OT kitchens and undertaking yearly audits for the infection control team.

Speech and Language Team are providing dysphagia training to catering staff to help them better

understand eating and swallowing disabilities. The SALT on PNRU are providing training

specifically for the staff based on their ward.

Regular menu meetings are held within the team to review patient comments / outcomes from

patient consumer groups. A new three week menu was designed for the Recovery Units (Lee Mill

Hospital, Syrena and Greenfields) and this was created following input from service users, ward

staff, ward managers and Sandra Pinch, Modern Matron. Glenbourne Unit have regular patient

support groups and they discuss menu choices available to them and alternative options.

All Livewell Southwest kitchens have been audited by the Environmental Health Officer and

achieved the highest score possible with ‘5’ and no recommendations highlighting that excellent

standards of cleaning are carried out and maintained in our kitchen preparation areas. Plym

Bridge House was audited on 27th February 2017 and achieved an outstanding 5 star rating.

The Livewell Community Cafes were officially launched at the beginning of April 2015. This has

given Livewell Southwest the opportunity to work very closely with the voluntary sector in

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27% 29% 33% 46% 0%5%

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2014 2015 2016 2017

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Seasonal Flu Vaccine Programme

supporting voluntary workers within the catering team. The Wellbeing Team and Hotel Services

Team have joined together to promote healthy eating. In addition to our cafes, Livewell have

introduced snack vending machines at Tavistock Hospital, Glenbourne Unit, Cumberland Centre

and PT&D Beauchamp Centre providing a range of healthy snacks and drinks to purchase

Domestic Services

The Hotel Services Management Team provide domestic awareness training to all staff who

provide a cleaning service in the organisation. This includes our domestic and site assistant

services. The course covers the safe use of chemicals, COSHH and more importantly how to

clean. We instruct on how to clean to eliminate infections and prevent cross contamination,

including norovirus, MRSA, E Coli and Pseudomonas. We use colour coded equipment as per

NHS policy and ensure staff understand why this system is in place. The training includes

Legionella Awareness Training and Hep B inoculation advice (produced by Occupational Health &

Wellbeing). During 2016 / 2017 40 staff received this training.

As a team we undertake regular unannounced cleaning checks to ensure that high standards are

being maintained. Every two weeks infection control and hotel services will undertake these

checks together. We work closely with Hotel Services Team Leaders and Ward Managers to

maintain cleaning standards.

Cleaning schedules for all premises have been reviewed and are standardised across the whole of

the organisation.

Hotel Service staff ensure that the environment and equipment they are responsible for is

maintained to required standards in order to promote high standards of cleanliness within all our

clinical areas. We always ensure that cleaning is maintained to the standard required by Livewell

Southwest in all clinical areas and that there are adequate supplies of consumables in order to

facilitate this.

As a team, we are continually striving to improve practices and standards.

Seasonal Flu Vaccine Programme (by Jan Potter Head of Wellbeing) The 2016/17 annual staff flu campaign has been the most successful to date. Uptake of the flu

vaccination has steadily increased over the last 4 years:

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Although the final figure will not be published until the end of March 2017, evidence suggests that

most people, who intend to be vaccinated, will have done so by the end of December 2016.

Since 2014, we have built on the peer vaccinator model, with the aim of increasing the number of

people who can give a flu jab, and also increase the convenience and opportunity to be

vaccinated. Over 40 individuals have received training within the organisation and have

collectively administered on 1300 vaccines to colleagues. IPC have been particularly prominent in

the campaign, as they are engaged with all clinical areas and have been able to offer “roving

clinics” in response to need.

The campaign has not been without its challenges, as there have been a significant number of

teams relocated to new sites, and the geographical footprint of the organisation now takes in

South Hams and Tavistock. This has been addressed by ensuring that there has been as much

opportunity as possible in all areas, with our three minor injury units (Tavistock, Kingsbridge and

Cumberland centre) making themselves available during opening hours.

The Campaign was coordinated by myself, but relies heavily on the goodwill of staff to put

themselves forward as vaccinators, as well as support from senior managers to enable staff to be

released for training and running peer clinics. Justine Dalton, wellbeing team administrator, has

had the unenviable task of monitoring the uptake figures, and inputting all 1300 consent forms

onto a data base, in order for two lucky people to win an iPad.

Occupational Staff Health and Wellbeing Report (by Mary Bowers

Occupational Health &Wellbeing Advisor) Local Care Centre Clinics

Full day clinics at the Local Care Centre are continuing on 2 Fridays per month. Staff members

can attend for immunisations, blood tests and skin assessments; appointments can continue to be

booked for this service on our appointments number: (4) 37222 Option 1 or email plh-

[email protected]. Alternatively, staff may attend drop in clinics

at OH&WB, Derriford Centre for Health & Wellbeing, Derriford Hospital on Mondays 8.10am –

11.30am, Wednesdays 12.40pm – 14.00pm & Thursdays 13.00pm – 15.00pm. Please see below

for the activity data for this reporting period.

Flu Clinics

OH&WB offered a combination of booked appointments and drop in clinics for Livewell Southwest

staff at the LCC on alternate Fridays or to attend drop-in clinics at Derriford Hospital. Drop in

clinics were also held at several other Livewell satellite sites.

3. For Trusts with Hospitals Only Livewell 26 September- 31 January 2017

Survey Coverage

How many hospitals are there in this trust?

3

mailto:[email protected]


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Of the hospitals in the trust, how many provided data?

3

4. Total Number of Health Care Workers

Survey Coverage

Number of HCWs involved with Direct Patient Care

2024

Number of HCWs NOT involved with Direct Patient Care

608

Total number of HCWs 2632

5. Uptake Data

(A) Number of HCWs involved in direct patient care on day of data extraction.

Seasonal Flu Vaccine Uptake

(B) Number in (A) vaccinated between 1st Sept & end of survey month (Seasonal Flu)

(C) % in (A) vaccinated between 1st Sept & end of survey month (Seasonal Flu)

All Doctors (excluding GPs) 85 38 44.7%

Qualified Nurses, midwives and health visitors (excluding GP Practice Nurses)

773 324 41.9%

All other professionally qualified clinical staff, which comprises of:-

508 219 43.1%

Qualified scientific, therapeutic & technical staff (ST&T),

Qualified allied health professionals (AHPs)

Other qualified ST&T

Qualified ambulance staff

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Support to Clinical Staff, which comprises of:-

658 362 55.0%

Support to doctors & nurses

Support to ST&T staff

Support to ambulance staff

Total (Calculated by system) 2024 943 46.59

Vaccinations also given to the following staff groups:

All other staff without direct patient contact

222

GRAND TOTAL 1165

DPC % uptake: C29/B29*100 = 46.6 Trust total % uptake: C38/B12*100 = 44.26

Electronic Pre-Placement Screening - Portal

Electronic pre-placement screening for Livewell Southwest candidates continues via the portal.

The OH&WB nurse team will continue to process the forms upon receipt and email HR

Recruitment, the Appointing Manager (where known) and the Candidate (if email address

supplied) the outcome of the screening. Where we receive no or only partial immunisation history

we continue to advise on what is required.

Advice Line

Managers and employees can seek advice from the Occupational Health and Wellbeing

Department by emailing [email protected] or by telephone on 01752 437222

(internal 37222) and selecting option 1 Monday – Friday 8am – 4pm.

Health & Wellbeing

Our role is to assist in minimising work related ill health and to maximise good general health in

the workplace supporting Livewell Southwest to manage attendance and performance.

We continue to offer a full range of services including: Musculoskeletal Assessment, Treatment

and Advice; Health Surveillance, Counselling & Mental health fitness for work, Mediation and a

range of psycho-educative group work / training courses, e.g. Self-Care course, Guided Self Help

e.g. Managing Stress, Building Resilience course, Wellness Recovery Action Plan (WRAP) and

relaxation, (these require Manager approval).

Where requested or appropriate, our clinicians have attended Case Conferences to provide OH

advice in complex or difficult cases.


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Any Doctor F2F Review 12

Any Dr F2F Initial 218

Any Dr Telephone Initial 3

Case conference 2

Consultant F2F initial 47

Consultant F2F review 24

Consultant Telephone - Initial 1

Consultant Telephone - Review 1

Ill Health Retirement F2F 4

Ill Health Retirement Query – Admin only 3

Pre-placement OH Dr face to face 9

Pre-placement OH Telephone Consultation 1

Pre-placement Full HQ follow- up 3

Speciality Dr Initial 7

Speciality Dr Review 22

Speciality Dr Telephone Review 1

Case conference 2

Counselling – Session 346

Counselling Assessment Triage Call 164

Counselling Telephone Session 5

Drop In Session 42

Guided self-help Initial consultation 24

Guided self-help Review consultation 75

Building Resilience Session 1 4

Building Resilience Session 2 5

CASE – Day 1 4

CASE – Day 2 3

Relaxation Group Sessions 9

Self-Care Course(SCC) – Week 1 2

SCC – Week 2 1

SCC – Review – 3 months 1

SCC – Review – 12 months 2

Counselling Assessments –Management and self-referrals 89

Mediation initial meeting with employee 8

Mediation F2F Joint Session 7

OHSP Initial Consultation (Mental Health) 51

OHSP Initial Telephone Consultation (Mental Health 1

OHSP Review (Mental Health) 69

Pre-placement MH Advisor Face to Face 4

Pre-placement MH Advisor F2F follow-up 1

Self-Referral Assessment 32

WRAP Part 1 2

WRAP Part 2 3

WRAP review & Questionnaire at 3 months – Phone 1

Pre-placement Physio Face to Face 1

Physio – Assessment 56

Physio – Review 31

Physio – WPV 7

VDU Checklist 5

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VDU Checklist Assessed 1

VDU Checklist Requested 31

Nurse Advisor Telephone Initial Assessment 1

Pre-placement Nurse Face to Face 1

DNA Data February 2016 – January 2017

OH Physician F2F Initial – Cxd by client on day 9

OH Physician – Cxd by client 2 days before 3

OH Physician - Cxd by OH&WB 18

OH Physician Initial – DNA 22

OH Physician Review – DNA 5

Str/Speciality Dr F2F Review – Cxd by client 2 days before 1

Pre-placement OH Dr F2F – Cxd by client 2 days before 2

Pre-placement OH Dr F2F – DNA 1

Management/OH Referral – Assessment – Cxd by client on day 2

Management/OH Referral – Assessment – DNA 4

Self-Referral Assessment - DNA 2

Ill Health retirement F2F – Cxd by OH&WB 1

Case Conference – Cxd by client 2 days before 1

Case Conference – Cxd by OH&WB 1

Case Conference – DNA 1

Assessment Triage Call – Cxd by client on day 2

Counselling Session – Cxd by client on day 38

Counselling Session – Cxd by client 2 days before 9

Counselling Session – Cxd by OH&WB 11

Counselling Session – DNA 18

Counselling Telephone – Session – Cxd by client 2 days before 1

Guided Self Help – Initial Consultation – Cxd by client on day 3

Guided Self Help – Initial Consultation - DNA 1

Guided Self Help – Review Consultation – Cxd by client on day 4

Guided Self Help – Review Consultation – Cxd by client 2 days before

2

Guided Self Help –Consultations – Cxd by OH&WB 5

Guided Self Help – Review Consultation – Arrived too late 1

Guided Self Help – Review Consultation – DNA 2

Mediation F2F Joint Sessions – Cxd by OH&WB 2

Mediation F2F Joint Sessions – DNA 1

Mediation F2F Initial meeting with employee – DNA 1

OHSP Initial Consultation – Cxd by client on day 3

OHSP Initial Consultation – DNA 2

OHSP Review – Cxd by client on day 2

OHSP Review – Cxd by client 2 days before 2

OHSP Appointments – Cxd by OH&WB 13

OHSP Review – DNA 5

Building Resilience Session 1 – Cxd by client on day 1

Building Resilience Session 1 – Cxd by HR/Mgr 2 days before 1

Building Resilience Session 1 – Cxd by client 2 days before 1

18

Building Resilience Session 1 – DNA 1

Relaxation Group Session 1 – DNA 1

Physio Assessment – Cxd by client 2 days before 1

Physio Appointments – Cxd by OH&WB 3

Physio Assessment - DNA 3

Physio Review – Cxd by client on day 2

Physio Review – Cxd by client 2 days before 1

Physio Review – DNA 6

Physio – WPV – DNA 1

Contamination Incident Report – February 2016 – January 2017

Preventative Measures Attention should be given to assessing each incident to determine if any of the risks can be reduced. Trend

22 Contamination incidents were reported from February 2016 to January 2017; showing an

average of less than 2 incidents per month.

Type of Incident

Contamination by sharps continues to be reported as the main reason, 19 in total.

1

3

2

3

5

2

1

0 0

2

1

2

0

1

2

3

4

5

6

Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17

Contamination Incidents in the Preceding 13 months

Series1 Average

17

3 2

0

5

10

15

20

Needlestick (PCE) Mucous membranes (MCE) Other sharp (PCE)

Feb 16 - Jan 2017 Type of Incident

19

Recipient’s Profession

During this reporting period Nursing Professionals and Health Care Assistants sustained the most

incidents; as per the last reporting period.

. Where the Incident Occurred

The area reporting the highest incidence is again within the patient’s home (n=7). 2 incidents

were also reported within the Local Care Centre.

11

7

1 1 1 1

0

1

2

3

4

5

6

7

8

9

10

11

12

NursingProfessionals

HCA MedicalProfessionals

Dentist SupportWorker

Ancillary Staff

Feb 2016 - Jan 2017 Employee (Recipient's) Profession

7

2

1

1

1

1

1

1

1

1

1

1

1

1

1

0 1 2 3 4 5 6 7 8

Patients Home

Local Care Centre

Syrena House

Dental Access Centre

Extra Care Area CAMHS

East Locality

Harford

Outpatients

Greenfields

Residential Home

Robin - CAM

Skylark Ward

Stoke Dameral Community College

South Hams Hospital

Unknown, not reported to OH&WB

Feb 16 - Jan 17 Where did the incident occur

20

Was the Source ‘High Risk’?

Reporting Issues

It is apparent that Trust policy is not being followed by all staff;

A proportion of Incidents are not reported on Safeguard or to Occupational Health &

Wellbeing On occasions risk assessments are not being undertaken and/or not forwarded

to OH&WB as required.

Advice & Assistance

For advice or assistance regarding any aspect of contamination incidents please contact our Duty

Nurse on (4) 37222 Option 4 (8am – 4pm) Monday – Friday, alternatively please e-mail plh-

[email protected].

Livewell Southwest: Activity Data February 2016 – January 2017

Contaminations

3 month blood borne virus screening 15

6 month blood borne virus screening 14

Contamination incident/questionnaire 22

Immunisations

BCG history & scar check 104

BCG Vaccination 6

Chest X-ray 2

Health Screening – Subsequent Documentary Evidence 4

Hepatitis A Vaccinations 5

Hepatitis B Accelerated 1st 2

Hepatitis B Booster 95

15

3 3

1

0

2

4

6

8

10

12

14

16

No Unknown, notreported to

OH&WB

Unknown Yes

Feb 16 - Jan 17 High Risk Source?



21

Hepatitis B Accelerated (2ndcourse) vaccinations 9

Hepatitis B Primary Course vaccinations 205

Immunisation Certificate Request 57

Immunisation Review 202

Immunisation History Discussion 4

Immunisation Status 1

Mantoux 2TU Result 4

Mantoux Test 2TU 5

Measles and Rubella Vaccination 2

MMR Vaccinations 13

Rubella Vaccination 1

Twinrix Vaccinations 2

Serology

Hepatitis B Accelerated Serology 3

Hepatitis B Antibodies 30

Hepatitis B Markers 7

Hepatitis B Primary Serology 36

Hepatitis B Surface Antigen 4

Hepatitis C Serology 5

History of Varicella virus infection 62

HIV Antibodies 1 & 2 4

Measles Serology 77

MMR Evidence 2

Quantiferon blood test 40

Rubella Serology 65

Twinrix (Hep B) Serology 1

Varicella Virus antibody test 14

Skin

Initial skin assessment 12

Review Skin assessment 6

Dermol 500 – 500ml bottle 19

Baktolan Protect – 100ml tube 14

Strep A Initial Screening 4

Strep A Skin Assessment (Hands) 1

DNA Data February 2016 – January 2017

Hepatitis B Accelerated 2nd – DNA 2

Hepatitis B Antibodies – Cxd by client on day 1

Hepatitis B Booster – Cxd by client on day – Operational Demands 1

Hepatitis B Booster – Cxd by client on day 2

Hepatitis B Booster – Did Not Attend 1

Hepatitis B Primary 2nd – Cxd by client on day 1

Hepatitis B Primary Serology – Cxd by client on day 1

Immunisation Review – Cxd by client on day 8

Immunisation Review – Cxd by client 2 days before 5

Immunisation Review – Cxd by OH&WB 2

Immunisation Review – DNA 16

Immunisation Review- Arrived Late, Appointment rebooked 1

22

Initial Skin Assessment - DNA 3

Mantoux Test 2TU – Cxd by OH&WB 2

Mantoux Test 2TU – Cxd by client on day 1

Mantoux 2TU Results – Cxd by client on day 3

Mantoux 2TU Results – Cxd by OH&WB 2

Antimicrobial Surveillance (by Deborah Reeves, Advanced Clinical

Pharmacist) In 2015 the Lead Clinical Pharmacist (Antimicrobial Lead) developed an audit tool based on the

‘Start smart then Focus – Antimicrobial Stewardship Toolkit for English Hospitals’. Initially this was

used on Skylark, Kingfisher and Plym Neuro wards. It was then trialled on the Acute Adult Mental

Health wards (Bridford and Harford) and the Older Persons’ Mental Health Wards (Edgcumbe and

Cotehele). The plan for 2016 was to use this tool in all inpatient areas bi-monthly. It was

appreciated that the challenge in this would be the availability of staff to carry out the data

collection.

During the first half of 2016 data collection continued on Kingfisher, Skylark and Plym Neuro

wards by the Lead Clinical Pharmacist. This data demonstrates that there is still an issue with

indications not being included on the drug charts (40% included) but that there is an improvement

in prescriptions being reviewed after 48/72 hours (67%) and in there being a duration or review

date on the chart (70%). The prescription has complied with guidelines (drug choice, dose and

duration) in 80% of cases.

There has been monthly data collection on Bridford and Harford wards. This has been carried out

by the pharmacy technicians. Drug chart data has been recorded well but some of the data from

patient notes is lacking. From the drug chart data it is clear that indications and review dates are

often not included.

There has been some data collection on Cotehele and Edgcumbe. This has been performed by

the Lead Clinical Pharmacist and one of the ward pharmacists. Again the data collected has not

always been complete. In all cases audited (6) there was no indication on the drug chart.

However, in all cases cultures had been sent before antibiotic treatment started.

In August 2016 the Lead Clinical Pharmacist noted that there was still a need to identify and train

persons to perform the data collection.

Other advances in 2016 has been attendance of the Lead Clinical Pharmacist at the Antimicrobial

Surveillance Group meetings at Derriford and the provision of further training sessions on

Antimicrobial Stewardship to patients and inpatient teams.

The ward pharmacists have continued to review all antimicrobial prescriptions for their

appropriateness and to promote compliance with current prescribing guidelines.

Since November 2016 the position of Antimicrobial Lead has been vacant. In April 2017 this

position will be taken on by the new post of Principal Clinical Pharmacist and this person will be

taking the antimicrobial surveillance agenda forward.

23

90% 78% 95% 97% 97% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012-2013 2013-2014 2014-2015 2015-2016 2016-2017

PER

CEN

TAG

E R

ESU

LT A

TTA

INED

5 Yearly Comparison of Hand Hygiene Results 2012-2017

Audit Results The IPCT use the Infection Prevention Society Quality Improvement Tools, which reflect local

policy, when carrying out their annual audit plan. Using these tools provides evidence of best

practice and safeguards patient safety. They are used to evaluate areas of care that are doing well

and those that need approving upon.

Audit standards:

• Green 85% and above Pass

• Amber 76-84% Average

• Red 75% and below poor standards

• Wards are expected to carry out monthly observational Hand Hygiene (HH) audits and the community and outpatient teams are expected to carry out an annual audit.

• HH audits must achieve 95% or above for a pass. Any ward HH audit that does not achieve this score must be carried out again within a two week period, to maintain patient safety.

• If an audit is not submitted the ward will automatically score 0% and this is reflected in the audit scores.

• All other audits must achieve 85% or above for a pass, again any audit that does not achieve this, must be carried out within a two to four week period.

• Locality managers are responsible for ensuring that all teams carry out their audits and re-auditing when necessary.

24

Locality Audit Results

North Locality

service Deputy Manager locality Manager PPE Sharps Equip HH Environment IPCM

Estover Health Care Centre (HV) Linda Trebilcock Ian Lightley 100% 100% 100% 100% 88% 95%

Long Term Condition Linda Trebilcock Ian Lightley 100% 100% 100% 100% NA 95%

Community Therapy Linda Trebilcock Ian Lightley 100% NA 100% 100% NA 100%

Family Nurse Partnership Linda Trebilcock Ian Lightley NA NA 100% 100% NA 100%

District Nurses (Thornberry) Linda Trebilcock Ian Lightley 90% 100% 100% 100% NA 100%

CMHT Southway Linda Trebilcock Ian Lightley 91% 100% 100% 100% 88% 100%

School Nursing (Admin Block) Linda Trebilcock Ian Lightley 100% 100% 100% 100% NA 100%

Adult's SALT Linda Trebilcock Ian Lightley NA NA 91% 100% NA 100%

Children's SALT Plym (Plymstock) Linda Trebilcock Ian Lightley NA NA NA 100% NA 94%

Children's SALT North (Honicknowle) Linda Trebilcock Ian Lightley 91% NA NA 100% 93% 93%

Children's SALT South West (Cumberland) Linda Trebilcock Ian Lightley NA NA 100% 100% 100% 91%

East Locality


End of Life multi visit team Claire Journeaux Christine Little 100% NA NA 100% NA 100%

District Nurses and Special Care Team Claire Journeaux Christine Little 100% 100% 95% 76% NA 100%

Community Therapy Claire Journeaux Christine Little 100% 100% 100% 100% NA 100%

Long Term Conditions Claire Journeaux Christine Little 89% 100% 100% 100% NA 95%

OPH/Complex Dementia/ Functional Community Teams Claire Journeaux Christine Little 100% 100% 100% 100% NA 100%

Huntington's Service Claire Journeaux Christine Little NA NA NA 100% NA 100%

Continuing Healthcare Claire Journeaux Christine Little NA NA NA 95% NA 100%

CMHT (Ridgeview) Claire Journeaux Christine Little 100% 93% 90% 100% 97% 93%

Health Visitors (Plymstock) Claire Journeaux Christine Little 100% NA 100% 100% 88% 100%

Complex Care Team (Harbour) Claire Journeaux Christine Little 100% 100% 100% 95% 85% 100%

Falls Claire Journeaux Christine Little 100% NA 100% 100% NA 100%

25

Memory Service Claire Journeaux Christine Little

100% NA NA 100% NA 100%

South Locality


CMHT (Avon House) Michelle Fogg Lori Ashton 90% 100% 100% 100% 74% 95%

Continence (Beauchamp) Michelle Fogg Lori Ashton 100% NA 100% 100% NA 100%

DN Team (Beauchamp Nicky Stidever) Michelle Fogg Lori Ashton 100% 100% 100% 100% NA 100%

District Nurse LCC Michelle Fogg Lori Ashton 100% 100% 100% 100% 100% 100%

District Nurse Cumberland Michelle Fogg Lori Ashton 100% 100% 100% 100% 98% 96%

Health Visitors Michelle Fogg Lori Ashton NA NA NA 100% NA 91%

Long Term Condition Team Michelle Fogg Lori Ashton 89% 100% 100% 100% NA 95%

Community Therapy Michelle Fogg Lori Ashton 100% 100% 100% 100% NA 97%

Tissue Viability Team Michelle Fogg Lori Ashton 100% 100% 100% 100% NA 100%

West Locality


Community Forensic Team Ian Veale Anne Prue 100% 92% 100% 94% 92% 92%

Asylum Seekers Ian Veale Anne Prue 100% 92% 100% 94% 92% 92%

Cardiac and Respiratory Services Ian Veale Anne Prue 100% NA 100% 100% NA 90%

CMHT (Avon) Ian Veale Anne Prue 90% 100% 100% 100% 74% 95%

Health Visitors (The Beacon) Ian Veale Anne Prue 100% 100% 85% 100% NA 100%

Long Term Conditions Ian Veale Anne Prue 100% 100% 100% 100% NA 95%

Parkinson's Team (Beauchamp) Ian Veale Anne Prue NA NA NA 100% NA 100%

Personality disorder service (Riverview) Ian Veale Anne Prue NA NA 100% 100% 81% 79%

Specialist Eating Disorder and Assessment Service (SEDCAS) Ian Veale Anne Prue NA NA NA NA NA 94%

West DN Ian Veale Anne Prue 100% 94% 95% 100% NA 94%

Community Therapy Ian Veale Anne Prue 100% NA 88% 95% NA 95%

26

City Wide Steven Hunt and Tracy Clasby


Psychotherapy Disorder Service/Options (1st Floor) Steve Hunt Tracy Clasby NA NA NA 100% 81% 0%

Therapy Space Steve Hunt Tracy Clasby NA NA 100% 0% 99% 100%

Learning Disability Service (Westbourne) Steve Hunt Tracy Clasby 100% 95% 100% 100% 49% 95%

Out Pt Sheald Steve Hunt Tracy Clasby NA NA 100% 100% 90% 95%

Ward Sharps Equip PPE HH Environment IPCM Linen isolation Cath Care Cath Insertion Laundry

Cotehele 96% 96% 100% NA 98% 96% 100% 100% NA NA 97%

Edgcumbe 96% 96% 100% NA 98% 96% 100% 100% 100% 100% 97%

City Wide Lisa Gimigham and Tracy Clasby


Assertive Outreach Service (Riverview) Lisa Gimigham Tracy Clasby 90% 96% 93% 100% 83% 96%

Home Treatment Team (Riverview) Lisa Gimigham Tracy Clasby 90% 96% 93% 100% 83% 96%

Adult Psychatric Liaison / OP Psychatric Liaison (Derriford) Lisa Gimigham Tracy Clasby NA NA 100% 100% NA 80%

City Wide Dan Stevens and Tracy Clasby


Glenbourne OT Department Dan Stevens Tracy Clasby 100% 96% 100% 100% NA 96%

Neurodevelopmental Children's Day Program (Early Intervention) Dan Stevens Tracy Clasby 91% NA 82% 100% 76% 89%

Complex CAMHS/Revive Dan Stevens Tracy Clasby 91% NA 100% 0% 86% 100%

Community CAMHS Dan Stevens Tracy Clasby NA NA NA 100% NA 0%

27

Ward Sharps Equip PPE HH Environment IPCM Linen isolation Laundry

Bridford 100% 100% 100% NA 99% 100% 94% 100% 97%

ECT 100% 100% 100% NA 95% 100% 100% NA NA

Harford 100% 95% 100% NA 95% 100% 100% 100% 97%

Plymbridge House 100% 100% 100% 93% 88% 100% 100% 100% 88%

City Wide Helen O’Toole and Tracy Clasby


Podiatry Helen O'Toole Tracy Clasby 100% 100% 100% 100% 93% 100%

Prosthetics Rehab (The Thornberry Centre) Helen O'Toole Tracy Clasby 100% 100% 100% 100% 96% 100%

Weight Management Helen O'Toole Tracy Clasby NA NA 100% 100% 100% 85%

Orthotics Helen O'Toole Tracy Clasby 100% 100% 100% 100% 91% 100%

LCC Out patients Helen O'Toole Tracy Clasby 100% 97% 93% 100% 95% 97%

Cumberland Outpatients Helen O'Toole Tracy Clasby 100% 100% 100% NA 95% 100%

Cumberland Podiatry Helen O'Toole Tracy Clasby 100% 100% 92% 100% 80% 100%

X Ray (Cumberland) Helen O'Toole Tracy Clasby NA NA NA NA 80% NA

Ultrasound (Cumberland) Helen O'Toole Tracy Clasby NA NA NA NA 88% NA

Physio (Cumberland) Helen O'Toole Tracy Clasby NA NA NA NA 92% NA

CCASH Helen O'Toole Tracy Clasby 100% 100% 100% 100% 95% 100%

Vocational Service (Steps)(Westbourne) Helen O'Toole Tracy Clasby NA NA NA 100% NA 100%

Community Recovery Team (Beauchamp) Helen O'Toole Tracy Clasby NA 100% NA 100% NA 94%

Ward Sharps Equip PPE HH Environment IPCM Linen isolation Laundry

Greenfields 100% 95% 100% NA 85% 100% 100% 100% 100%

Lee Mill 100% 100% 100% NA 93% 100% 100% 100% 94%

Syrena 97% 100% 100% NA 99% 97% 100% 100% 100%

28

Community Urgent Care Locality James Glanville and Sarah Pearce


Early Support Discharge James Glanville Sarah Pearce 100% 100% 100% 100% NA 100%

Day Therapy James Glanville Sarah Pearce 100% 100% 100% 100% 91% 100%

Ward Sharps Equip PPE HH Environment IPCM Linen isolation

Cath Care

Cath Insertion

Enteral Feeding

PVD insert

PVD CC

Kingfisher 100% 97% 100% NA 94% 100% 100% 100% 92% NA 100% 100% 100%

PNRU 100% 97% 100% NA 87% 100% 100% 100% 100% 100% NA 100% 100%

Skylark 100% 91% 91% NA 93% 100% 100% 100% 100% 100% 100% 100% 100%

Lou Higgins and Sarah Pearce

service Deputy Manager locality Manager PPE Sharps Equip HH Environment IPCM Linen

Acute Care at Home Lou Higgins Sarah Pearce 100% 92% 100% 100% NA 100% NA

Robin Acute Community Assessment Hub Lou Higgins Sarah Pearce 100% 100% 97% 100% 93% 100% 100%

MIU Cumberland Nikki Johnson Sarah Pearce 100% 100% 100% 100% 93% 100% NA

DN OH/Twilight Lou Higgins Sarah Pearce 100% 100% 100% 100% NA 100% NA

Integrated Hospital Discharge Mary Cox Sarah Pearce NA NA NA 100% NA 100% NA

Recovery At Home Lou Higgins Sarah Pearce 90% 100% 100% 90% NA 100% NA

Kingsbridge MIU Lou Higgins Sarah Pearce 100% 100% 100% 100% 93% 100% NA

Community Crisis Response Team Lou Higgins Sarah Pearce 100% NA 100% 100% NA 100% NA

29

Tavistock Locality Amanda Trafford

service Deputy Manager

locality Manager PPE Sharps Equip HH Environment IPCM Linen

Tavistock MIU NA Amanda Trafford 100% 100% 100% 100% 98% 100% NA

Tavistock Physio NA

Amanda Trafford 100% 100% 100% 100% 98% 100% 93%

Tavistock OPD NA

Amanda Trafford 100% 100% 100% 100% 96% 100% NA

Tavistock Theatre NA

Amanda Trafford 100% 100% 100% 100% 93% 100% 100%

Tavistock Tavyside and Lifton DN’s NA

Amanda Trafford 100% 94% 100% 0% NA 97% NA

Tavistock Yelverton DN’s NA


Tavistock Abby DN's NA


Tavistock Clinic NA Amanda Trafford 100% 100% 92% 0% 96% 100% NA

Tavistock Community Therapy NA Amanda Trafford 100% 100% 100% 100% NA 100% NA


Cath Care

Cath Insertion

Enteral Feeding

PVD insert

PVD CC

Tavistock 100% 100% 100% NA 90% 100% 88% 100% 100% NA 100% 85% 100%

Kingsbridge Locality Lewis Bell and Sharon Scoging


Kingsbridge OT Lewis Bell Sharon Scoging 100% NA NA 100% 91% 100%

Kingsbridge Physio Lewis Bell Sharon Scoging 100% 100% 100% 100% 91% 100%

Kingsbridge Out Patients Lewis Bell Sharon Scoging 90% 100% 94% 100% 91% 100%

30

Ivybridge DN'S Lewis Bell Sharon Scoging 100% 87% 100% 93% NA 87%

Kingsbridge DN's Lewis Bell Sharon Scoging 100% 100% 95% 93% NA 100%

Therapies Ivybridge Lewis Bell Sharon Scoging 100% NA 100% 96% NA 76%


Cath Care

Cath Insertion

Enteral Feeding

PVD insert

CVD CC

Kingsbridge 94% 100% 100% NA 89% 94% 100% 100% 100% NA NA NA 100%

31

External Inspections Patient-lead Assessments of the Care Environment (PLACE) PLACE’s main priority is to ensure that patients are cared for in a clean safe environment. They also look to ensure patients are cared for with compassion and, in a dignified manner. These asessesments are carried out in partnership with Healthwatch Plymouth and Healthwatch Devon along with staff from LSW. Results from these assessments are published nationally for the general public to see. Next year Hotel Services will be leading and co-ordinating PLACE. The areas that were visited by PLACE this year along with their scoring rates are listed below:

Glenbourne Lee Mill

32

Plymbridge House Kingsbridge Hospital Tavistock Hospital

33

Mount Gould Hospital

Care Quality Commission A team of over 70 CQC inspectors visited LSW in June 2016. In their report they stated that LSW

have robust infection control policies and procedures and, staff adhered to these across all

servicess.

Cleanliness and Maintenance Monitoring To ensure that high standards of cleanliness are maintained throughout LSW, Hotel Services and

the IPCT carry out bi-weekly monitoring using: A framework for setting and measuring

performance outcomes (the National specification for cleaning in the NHS). These are in addition

to our audit annual programme of work. Any concerns arising from our observations are sent to the

Estates department, Locality Managers, Matrons and Ward Manager for their attention. The

Matrons monitor the issues raised and report further concerns in their matron’s charter and at the

Infection Prevention and Control Committee. Using this monitoring process helps to highlight

areas of concern and helps to prioritise individual work plans/programmes.

34

Monitoring

41

Healthcare Associated Infection Ward Surveillance The Department of Health introduced mandatory reporting on specific healthcare associated infections

in 2001. LSW are fully compliant with all mandatory reporting and this is the fifth year that LSW have

not had any MRSA sepsis cases to report. We have an MRSA screening policy in place for staff to

adhere to. Patients who have been transferred from another hospital or care setting, or are admitted

and are known to have been previously colonised with MRSA are screen for MRSA on admission to

our wards. This screening process was implemented in October 2014. LSW adopt a 50 day rule (DIPC orchestrated) in which patients, who have been screened on

admission, are rescreened for MRSA carriage if they have an extended stay in hospital beyond 50

days. This gives assurance and transparency that patients are not acquiring MRSA during a prolonged

stay in our services. We have had no MRSA cross transmissions picked up on our 50 day screening

rule for the past two years.

MRSA admission in-patient screening compliance

Apr/16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17

MRSA Screening

100% 100% 100% 100% 100% 100% 99% 99% 100% 100%

Threshold 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

This year we had one MSSA sepsis to report and after carrying out a root cause analysis the source of

this infection, was from an MSSA knee wound infection. This was recorded as unavoidable.

We have reported four E-coli sepsis infections this year as opposed to eight last year.

Ward Month Source Recorded as

Skylark April Unknown Unavoidable

Edgcumbe April Soft Tissue Unavoidable

PNRU October CAUTI Avoidable

Kingfisher February CAUTI Unavoidable

The rational for the PNRU sepsis being recorded as avoidable was due to observations not being

carried out effectively and the MEWS not always being documented. Recommendations and

solutions have been made and implemented from the RCA outcomes.

This year we have reported four C–diff Toxin positive infections. Three of these patients were

treated with antibiotics and, had a history of type 6/7 stools before admission to LWS. The fourth

patient had a history of C-diff toxin positive and, had a relapse whilst an in-patient at LWS. The

severity of the C diff toxin infections were reported as mild. There were no cross transmission of C-

diff to other ward patients or wards. All of the C-diff infections were recorded by CCG as

unavoidable.

42

0

1

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of

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as o

ccu

red

Norovirus Outbreaks 2012 - 2017

Norovirus 2012 -2013Norovirus 2013 -2014Norovirus 2014 -2015

Outbreaks

0

2

4

6

8

10

2012 -2013

2013 -2014

2014 -2015

2015 -2016

2016 -2017

Nu

mb

er

of

Infe

ctio

ns

Sepsis and C Diff Infection Rate Graph 2012 - 2017

MRSA Bacteraemia (Sepsis)

MSSA Bacteraemia (Sepsis)

E-Coli Bacteraemia (Sepsis)

C Diff

0

1

Nu

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occ

ure

d

Influenza A Outbreaks 2012 - 2017

Influenza A 2012 - 2013





43

0

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as

occ

ure

d

Influenza B Outbreaks 2012 - 2017

Influenza B 2012 - 2013





The Infection Prevention and Control Team (IPCT), Hotel services and Locality/Ward Managers

have managed four outbreaks this year.

Learning outcomes from these outbreaks were:

Ward staff implemented the outbreak policy effectively and kept a list of affected patients and staff,

and kept the IPCT updated on a daily bases.

NHS Professionals were informed and all bank healthcare workers were offered two to three day’s

work on the effected wards.

Staff and patients were made aware of implementing good hand hygiene measures, using liquid

soap and running water.

Enhanced environmental cleaning and decontamination was implemented quickly, to prevent

further spread.

Hotel services, the IPCT and ward staff all worked well together, to maintain high standards of

care and to prevent further spread of the infection.

There were some areas for improvement and these included:

Ward staff must obtain samples as soon as the patient becomes symptomatic.

Ward staff must inform the IPCT when infections are suspected or confirmed.

Patients should be put into isolation and doors to these side rooms must be kept closed at all

times. Unless a risk assessment has highlighted that putting a patient into isolation or keeping the

doors closed, would be detrimental to a patient’s care. In these circumstances clear

documentation as to why the patient remains in an open bay or why the isolation doors remain

open, must be clearly written in the patient’s nursing records.

44

Infection Prevention & Control Training Activities and Displays The IPCT deliver induction and mandatory training to all members of staff within LSW. The IPCT

annually review their training sessions to ensure that the training meets the needs of the

organisation.

The IPCT also promote IPC through promotional days and through effective communication using

either the LSW Newsletters or through display stands. World Health Organisation 5th May 2016

saw the IPCT celebrate Clean Your Hands Day with an information stand in the reception area of

Mount Gould's Local Care Centre. It offered Patients, staff and visitors a variety of information on

hand hygiene technique and the prevention of infection. People were able to test the effectiveness

of their own hand washing methods using a ‘glitterbug’ lotion and an ultraviolet light box.

This year the IPCT also organised an event to promote sepsis awareness to the general public.

This event not only promoted sepsis awareness but also raised £1,741.90 for the UK Sepsis Trust.

This figure was achieved with the help of the LSW Director of Finance Dan O’Toole, who matched

the monies that were collected on the promotional fund raising day, which was held at Central

Park, Plymouth.

The IPCT presenting a cheque for £1,741.90 to Melissa Mead (Ambassador for the UK Sepsis Trust), who accepted it

on behalf of the UK Sepsis Trust.

Income Generation

The IPCT have been commissioned to provide independent training and audits to private sectors

within the Plymouth area. Money that has been generated has gone back into the IPCT budget.

This year we have purchased more teaching aids to help to deliver practical hand hygiene and

mask fit training.

45

Summary

The IPCT have continued to promote and sustain high standards of IPC throughout LSW. As a

team the IPCT have continue to work closely with all LSW staff, to enhance best practice and

support teams to implement safe clean care. This year the IPCT have succeeded in:

Completing their Annual Programme of work.

Producing and updating patient information leaflets.

One of LSW ICLP’s was named Link Practitioner of the Year by the Infection Prevention

Society.

Producing a ICLPs competency booklet to help develop professional knowledge and

competencies.

Aiding with the standardisation of observation charts and documentation.

Helped to roll out the staff seasonal flu vaccine programme.

Future planned improvements include: To continue to have a zero infection prevention and control attitude towards people

acquiring a healthcare associated infection.

To continue to provide a framework for assurance including surveillance, audit, policies and

education.

To continue to sustain the role of the ICLPs.

To continue to promote and enhance best practice throughout LSW.

To aim to reduce Gram negative infections.

To continue to update our IPC web page, with the help of the communications team.

To produce an IPC resource booklet for all LSW staff to access.

To organise and deliver an IPC Study Day for public sectors to attend.

To continue to increase the awareness of sepsis throughout LSW and the public sector.

To sustain our involvement with the staff seasonal flu campaign.

Areas of concerns PNRU continues to present a challenging environment; the ward does not house any on-

suite isolation facilities. All the bays are open plan and are unable to provide adequate isolation, for minor outbreaks on the ward.

Tavistock hospital requires some refurbishment; the ward does not have a fully operational domestic cupboard. There are no low level amenities for the disposal of contaminated water. Domestic staff have to fill and empty their buckets in the ward sluice.

Some patient areas need to improve upon their cleanliness and maintenance programmes. They have not achieved acceptable scores in our scheduled bi-weekly planned monitoring nor in their annual environment audit programme. I believe that the services based at Westbourne and Avon House will be relocating soon, as the environment is not fit for purpose which has been highlighted by the locality managers.

Some teams are not compliant with the Health and Social Care Act, Ten Codes of practice. These audits support teams provide evidence of best practice, safeguard patient safety and are also required by CQC when they carry out their inspection. Locality managers are responsible for ensuring that their teams are compliant with these ten codes.

46

The HCAI Lead for the CCG reviewed the LSW Annual IPC report and commented:

Clear adherence to Code of Practice

Good work demonstrated on seasonal flu vaccination programme, noted that this is particularly impressive as it is largely a goodwill programme.

Noted good IPC commentary in CQC inspection report.

Good dissemination of learning outcomes from outbreaks.

Areas of concern shows clear insight into current problems.

MRSA and C diff reduction plans comprehensive but similar reduction plan for E coli (or MSSA), which may be more relevant. Please thank the team, on behalf of the CCG, for producing a detailed and thorough report.

47

Appendix A

Infection Prevention and Control Team Detailed Plan 2017/18

This plan forms an appendix to the Infection Prevention and Control Report for LSW for the period April 2017 - March 2018 Director of Infection Prevention and Control (DIPC), Infection Prevention and Control Team (IPCT), Infection Prevention and Control Committee (IPCC), Infection Control Link Practitioners (ICLP), Clinical Commissioning Group (CCG)

48

Surveillance Lead Timescale Progress

Daily surveillance of HCAI

IPCT/Matron/Ward Manager Daily Monthly reporting to the Health, safety and performance committee

Reports to clinical areas and IPCC RCA performed by ICLP/managers. Action plans and learning discussed at ward meetings

MRSA and CPE screening

Matron/Ward Managers On notification

Data collected in the Quality Safety and Performance book and reports sent to IPCC, Health, Safety and performance committee, Professional Practice Safety & Quality Committee and CCG

Surveillance of MRSA, E Coli, MSSA sepsis and Clostridium Difficile

IPCT On notification

RCA performance by the IPCT and learning opportunities fed back to locality and ward managers. Data collected in the Quality Safety and Performance book and reports sent to IPCC, Health, Safety and Performance Committee, Professional Practice Safety & Quality Committee, and CCG

Reduction and maintenance plans

DIPC/IPCT/Locality Manager Ward manager/Matron/IPCC/Pharmacy

April 2017/18

In place and are reviewed with

49

for MRSA and Clostridium Difficile.

Director appropriate policy.

Identify hot spots IPCT Ongoing Policy

Outbreak management

Locality Manager/Matron/Ward Manager/IPCT

On notification

Policy

Audit Lead Timescale Progress

Infection Prevention and Control In patient clinical practice audits

Locality Manager/Matrons/Ward Manager/ICLP

April 2017/18

As scheduled in audit plan

Infection Prevention and Control outpatient and community clinical practice audits

Locality and Team managers/ICLP April

2017/18


Saving Lives audits Specialist nurses/ICLP/IPCT April

2017/18


Decontamination

Estates manager/DIPC April

2017/18

On going

In-patient services The IPCT will undertake patient equipment audits to provide evidence of best practice

IPCT/Locality Manager/Matrons/ICLP’s April

2017/18


Outpatient and community services will undertake their own decontamination and care of patient equipment audits to provide evidence of best practice

Locality and Team Managers/ICLP’S April

2017/18


Podiatry and Dental The Decontamination Lead will continue to provide advice and support to both the Dental and Podiatry Teams in the continuation of their decontamination systems to provide safe care to patients.

Estates/ Locality Manager /Podiatry Managers

April 2017/18

As and when required

Mattress/Pillow/couch audits

ICLPs/Matrons Monthly for high volume patient movement. Three

Stored on the IPC shared drive

50

monthly for low volume patient movement.

Hand hygiene adult inpatient areas

ICLPs/Matrons Monthly Stored on the IPC shared drive and results sent to Matrons, ward manager and Locality Managers

Hand hygiene outpatient, community areas

Locality Manager/ Matrons/ICLPs Annually unless results are below 95%. Audits that do meet the benchmark will need to be repeated monthly until 95% is achieved

Stored on the IPC shared drive and results sent to Matrons and Locality Managers

Patient environmental audits

IPCT, Hotel Services, Estates, Locality Managers/Matrons/Ward Manager

Annually unless results are below 85%. Audits that do not meet the benchmark will need to be repeated

Stored on the IPC drive and results sent to Matrons, Ward Managers, Locality Managers, Estates and Hotel Services

Linen, Sharps, Infection Prevention and Control management and PPE audits

IPCT/Locality Manager/Matron/Ward Manager

Annually unless results are below 85%. Audits that do not meet the benchmark will need to be repeated

Stored on the IPC drive and results sent to Matrons, Ward Managers and Locality Managers

Education/Training Lead Timescale Progress

New staff to attend induction training which includes infection prevention and control Hand hygiene, standard precautions Inoculation injury training

Training department/IPCT/HR/Ward Manager/Locality Manager

All new staff updated programme for 2017/18

In place and ongoing

All staff to attend Training Department/IPCT/Locality All staff In place and

51

mandatory training which includes infection prevention and control, inoculation injury training

Manager/Matron/Ward Manager updated programme for 2017/18

ongoing

ICLP meetings are chaired by the IPCT which provide educational sessions for ICLP to disseminate back to colleagues

IPCT Quarterly In place and on going

Policies Lead Timescale Progress

Infection Prevention and Control policies

IPCT/DIPC April 2017/18

In place with reviews every three years

Specialist advice Lead Timescale Progress

The IPCT provide specialist advice and support in the event of an outbreak.

IPCT/Locality Manager As and when required

In place and on going

The pharmacy team promote and sustain antimicrobial stewardship throughout LSW

Pharmacy Director April

2017/18

Report to the IPCC

Occupational Health Wellbeing specialist advice and support

Occupational Health Wellbeing Department

April

2017/18

Report to the IPCC, Health and Safety committee and other relevant meetings

Training programme for antibiotic stewardship

Pharmacy April

2017/18


Antibiotic prescribing practices are monitored

Pharmacy April

2017/18


Procurement Lead Timescale Progress

The IPCT will work in conjunction with All Managers, Risk, finance and the Procurement Team for the purchasing of any new Medical Devices or patient equipment

IPCT/Locality Managers/Managers/Procurement/Risk Management Teams

April 2017/2018


Service users involvement

Lead Timescale Progress

Patient experience questionnaire to actively sought

Patient experience Manager/Hotel services manager

April 2017/2018


52

recommendations

Patient-lead assessment of the care environment

Patient experience Manager, Hotel Services

April 2017/18

Annually

Refurbishments and new builds

The IPCT will work in conjunction with Locality Managers, Estates and finance to ensure IPC is considered and complied with in all building projects

IPCT/ Locality Managers/Estates April 2017/18


53

Appendix B

Clostridium Difficile: Reduction and Maintenance Plan

April 2017/2018

The purpose of this document is to assure the organization that there are arrangements in place to

manage effectively all cases of Clostridium Difficile and reduce the risk of cross transmission and

thus prevent outbreaks.

The Clostridium Difficile reduction target requires Livewell Southwest (LSW) to have zero

tolerance for C Difficile.

54

Activity Actions Lead (s) Timeframe Current position

Evidence/assurance of completion

Management of individual cases

Isolation of any patient with diarrhoea within 4 hours(unless unable to due to clinical need)

Infection Prevention and control Team (IPCT), Locality manager

Ongoing, daily review

In place Outcome of infection prevention and control audits, RCA

A meeting with the manager and medical lead of the unit will be held every case of C.Diff Locality manager will be informed as the responsible senior manager

IPCT immediate In place Minute of meetings

Review of case by IPCT or the nurse in charge of the ward if a weekend or Bank holiday) on the day of diagnosis and daily thereafter to include Patient isolation, Review of antibiotic therapy, Appropriate treatment for C.Difficile, Continued implementation of enhanced cleaning, PPE, Monitoring of clinical status, Escalation and referral as appropriate . Root cause Analysis (RCA) and review of all cases of Health care Acquired (HCAI) Outbreak meeting and

IPCT, Locality manager, Ward manager, pharmacy

Earliest opportunity.

In place IPCT, documentation, reporting to the LSW board, prescription chart, RCA

55

Ribotyping if more than 2 or more new HCAI on a ward within 28 days

Hand hygiene compliance in all clinical areas to be above 95%

Matrons, ward managers, ICLP

ongoing The areas that are not compliant must receive input from their matrons. Hand hygiene audits and audit results are presented to the board on a monthly basis

Board reports, hand hygiene audits and action plans

Diagnosis All diarrhoeal stools (take the shape of the container or Bristol stool Chart 6-7) to be tested for C. Difficile

The laboratory

ongoing In place Surveillance, RCA and recommendations from RCA

Diagnostic tests for C. Difficile

The laboratory

ongoing In place Reported to the board, professional Practice Safety & Quality committee, Clinical Commissioning Group

Surveillance Active surveillance of incidence and severity of C. Difficile with feedback to clinical areas

IPCT ongoing When required

Bi- monthly reporting to the board

RCA of all cases IPCT Matrons

ongoing When required

Monthly reporting to the board

any deaths related to C. Difficile must be subject to SIRI

IPCT DIPC, Directors, CEO

immediately When required

Serious incident requiring investigation

56

process

4. Antibiotic controls

Antibiotic pharmacist to perform antimicrobial duties

Pharmacist Director

ongoing When required

Antibiotic pharmacist job diary.

Ward pharmacist to participate in antimicrobial controls, including audit and active interventions to improve compliance with the policy

Locality Pharmacist and Pharmacist Director

ongoing in place Audits

Audits evidence of compliance with LSW guidelines on antimicrobial prescribing

Pharmacist and Pharmacist Director

ongoing in place Antibiotic yearly audits

Action plans as a result of audit data

Locality Managers

ongoing in place Patient record and Root Cause Analysis

Follow up of non-compliance with LSW guidelines on anti-microbial prescribing

Medical Director, Pharmacy Director

ongoing in place Documented follow ups and reporting to the board

5. Environmental cleaning

Ward and other clinical areas to be cleaned as per cleaning policies

Ward Managers and Hotel Services Manager

ongoing in place Cleaning schedules, Hotel service audits ,Matrons weekly checklist, Matrons charter , Domestic awareness training

Patient equipment, particularly items such as commodes, will be cleaned and signed off after every use

Matrons ward managers; all staff

ongoing in place Matrons Charter and IPCT audits

Weekly ward manager environmental checklist

Ward managers matrons

ongoing in place Checklists

57

Detergent/ bleach clean for all cases of C.Difficile

Ward manager and Hotel Services Manager

ongoing in place Hotel services records ( copy to be placed in patient record),

Isolation room/bay receive enhanced Bleach/detergent clean. Twice daily check by ward manager

Ward manager and Hotel Services Manager

ongoing in place Hotel services records (copy to be placed in patient record)

6. Education Education of all staff, patients and visitors, on the clinical features, transmission, epidemiology and control of C.Difficile.

IPCT, Clinical staff and Hotel Services Manager

ongoing in place

Domestic Awareness Training (attendance records) Patient information leaflets, domestic awareness training

Rolling programme of training for hotel services staff on the clinical features, transmission, epidemiology and control of C.Difficile, to ensure proper cleaning of clinical areas

Hotel services Manager.

ongoing in place Domestic awareness training, Training attendance figures

7. Other controls

Review use of proton pump inhibitors in inpatients

Medical staff and Pharmacist Director

ongoing in place Prescription reviewed if suspected of C.Difficile and stopped if it is safe to do so

58

Management of patients with Clostridium difficile

Ensure that patients with unexplained diarrhoea have appropriate investigations and, if

possible, are isolated

If Clostridium difficile suspected in a patient with diarrhoea

Collect stool specimen. Using the same Microbiology form, request: 1. Microscopy, culture and sensitivity (first 5 days of admission). 2. Clostridium difficile toxin.

N.B. Ensure there is enough samples - quarter fill specimen pot.

Inform Infection Prevention and Control Team. Await toxin result from Microbiology (24 – 48 hours)

If Symptomatic with diarrhoea

Isolate immediately to single room with

ensuite toilet/own commode. If side room not available,

seek Infection Control Advice

Implement the following measures

normal stools for 48 hours Or negative toxin results

Patient can be brought out of isolation after discussion with IPCT

No clearance specimen required.

Normal treatment of patient, including basic IC Measures

Ensure vacated bed

space is thoroughly

enhanced cleaned

with Actichlor Plus

Drug therapy

If toxin positive or severe symptoms

stop anti-motility agents and

antibiotics/PPI if possible.

Commence 10 day course of oral

Metronidazole or Vancomycin

Depending on the severity.

Hand washing

Strict hand decontamination

BEFORE & AFTER any contact with the

patient or their environment – this

includes all staff & visitors. Wear

appropriate protective clothing.

Cleaning

Thoroughly

clean room daily as

per Guidelines

for Cleaning Isolation Rooms.

Recurrence Of

symptoms

Refer to the C-diff

reduction and

maintenance plan

Appendix A

59

Hand washing is the single most important measure to prevent cross-infection

Environment & protective clothing

Care for patients in a single room where possible

Patient must have a designated toilet or commode that is for their individual use only

Wear gloves and disposable apron for contact with faeces

Wear eye protection if risk of eye splash

Remove gloves and aprons before leaving patient’s room/bed area

Patient hand hygiene must be encouraged after they have used the toilet/commode

On leaving the room/bed area all staff must wash their hands with soap and running water

Cleaning, linen, curtains

Damp dust bed area and clean room twice daily, or more frequently if required, with Actichlor plus

Commodes must be cleaned after each use with detergent and bleach

Toilets must be cleaned twice daily or more frequently if required

For spillages and on discharge – clean room/bed area thoroughly with Actichlor plus. The curtains must be changed after discharge

Treat linen as infected and dispose of as ‘contaminated’ in soluble bags and then place in linen bags.

All Waste: Treat all waste, including household, as clinical waste

Dedicated patient equipment must be used and should be wiped with sporicidal wipes after

use.

Death: No special precautions are required when handling the deceased

Visitors In general, other than observing good hand hygiene practice, visitors do not need to follow the

same precautions unless they are assisting with the nursing care of a patient:

Report to nurse in charge before visiting patient

Wash hands with soap and water before and after patient contact

No requirement for visitors to wear personal protective equipment Visitors to other departments The patient may visit other departments. Please inform department in advance. If possible the

patient should be ‘last on the list’, and visits should be kept as short as possible. Equipment or

couches must be cleaned after use with detergent/bleach solutions.

60

Discontinuation of precautions

These precautions can be discontinued on the advice of the IPCT when the patient has normal

stools for 48 hours. If precautions are discontinued then the room must be cleaned as above and

curtains changed

61

Appendix C

Healthcare Associated Infection

MRSA Sepsis

Reduction and Maintenance Plan

April 2017/18

62

Infection Prevention and Control Team

Review date April 2018

The purpose of this document is to assure Livewell Southwest that there are arrangements in

place to effectively manage and reduce all cases of Healthcare Associated MRSA and MSSA

Sepsis thus, to prevent cross transmission and outbreaks.

Livewell Southwest has no set targets for MRSA sepsis in its in-patient services but strive to

continue to prevent all avoidable cases.

63

Activity Actions Lead(s) Time frame

Current Position

Evidence/assurance of competition

MRSA Screening

Admissions to be screened only if they transferred from another hospital/care setting have previously been MRSA positive or have a lesion.

Ward staff and ward managers

2017/18

In place Documentation on admission screening, reports to the board and Safety and Quality (S&Q) Monthly reports to Clinical Commissioning Group (CCG)

RCA on all new cases of MRSA

Matrons, ward managers

2017/18

In place Reports to the Board and S&Q Monthly reports to CCG

Management of individual cases

Continue to follow local and national policy and guidance to reduce MRSA

IPCT, Ward managers, ward staff

2017/18

In place MRSA policy, Care Plan, Isolation Daily Review

Patients previously colonised with MRSA will be identified on admission by the clinical alert on patients medical notes/System One/Transfer letter

Admission staff 2017/18

In place Patient alerts on patient notes /system One records

Isolation of any patient with MRSA within 4 hours (unless risk assessment identifies this as a risk to the patient)

Ward managers, ward staff

2017/18

In place Audit, RCA, Care plans, Isolation Daily Review

Hand Hygiene compliance in all clinical areas to be above 95%

Locality Managers, Matrons, Ward managers ICLP

2017/18

In place Audits, Action plans, reports to the Board and S&Q

Review by medical staff on the day of diagnosis. Review of antibiotic therapy /suppression therapy treatment for MRSA.

Medical staff, Ward Manager, Ward Staff, Ward Pharmacist

2017/18

In place Reports to the Board and S&Q Patient records, Prescription charts

All standard infection prevention and control measures to remain in place as well as

Ward staff, Hotel services, IPCT

2017/18

In place Cleaning schedules, Audits, Isolation Daily Review, Care Plan, reports to the Board and S&Q

64

implementing an enhanced clean of patient’s room and on suite.

Periods of incidence (defined as 2 or more cases on the same ward within 28 days)

Outbreak meeting to be set up if two or more cases on a ward within 28 days of each other.

DIPC, IPCT, Locality Manager, Matrons, Ward Manager

2017/18

In place Reports to the Board and S&Q, Minutes of the meeting, Outbreak report, Daily review

RCA of all new MRSA HCAI. RCA completed and reported to the IPC Committee and Board.

Locality Manager, Matrons, Ward managers, IPCT

2017/18

In place Report to Board and safety and quality meeting, Monthly reports to CCG, RCA, Action plan

Environmental and patient equipment annual audits to be performed and compliance to be 85% or above.

IPCT, Matrons, Ward managers

2017/18

In place Audits, Report to Board and safety and quality meeting, Action Plans, Cleaning schedules

Ward managers/House keepers to perform daily environments and equipment checks

Ward staff, House keeper

2017/18

In place Cleaning schedules

Surveillance to be monitored by the IPCT

IPCT 2017/18

In place Daily surveillance documentation Enquiry forms

Any deaths related to MRSA Sepsis must be reported to PHE. Any death will be subject to SIRI process.

Locality Managers Matrons, Ward Manager, DIPC , IPCT, Directors, CEO

2017/18

In place Report to Board and safety and quality meeting, Serious incident requires investigating

Antibiotic Controls

Antimicrobial Lead Pharmacist to perform antimicrobial duties

Principal Clinical Pharmacist

2017/18

In place Antimicrobial Lead, Pharmacist records and reports, IPCC Meetings

Ward pharmacist to participate in antimicrobial controls, including audit and active interventions to improve compliance with the policy

Ward pharmacists, Principal Clinical Pharmacist

2017/18

In place Audits Action Plans

Audit evidence of Principal 2017/1 In place Antibiotic annual audits

65

compliance with LSW guidelines on antimicrobial prescribing

Clinical Pharmacist

8 Action Plans

Action plans as a result of audit data

Locality managers

2017/18

In place Report to Board and safety and quality meeting, Action plan

Follow up noncompliance with LSW guidelines on antimicrobial prescribing

Medical director, Principal Clinical Pharmacist

2017/18

In place Report to Board and safety and quality meeting.

Environmental cleaning

Ward and other clinical areas to be cleaned as per LSW decontamination policy

Matrons ward managers Hotel services IPCT

2017/18

In place Matrons charter, IPC Audit, PLACE, Cleaning schedules, Bed space flow chart, Care Plan

Patient Equipment cleaning

Evidence that patient equipment has been decontaminated effectively particularly commodes

Matrons, ward staff IPCT

2017/18

In place Matrons charter, IPC audit, Action Plans, Cleaning schedules

Education Induction and Mandatory training for all staff. Additional training if required

IPCT Hotel services

2017/18

In place Attendance sheet, ESR

IPC Committee

Surveillance reports to be reported to the committee bi- monthly

IPCT 2017/18

In place Surveillance records , Report to Board and safety and quality meeting, Monthly reports to CCG

66

Appendix D

Livewell Southwest Procedure for Management/Communication of Suspected Norovirus Outbreak

2017/18

Alert Triggers Action By Whom Response

Green

Known outbreaks in the

community.

No Known Outbreaks with the

Hospital setting

Raise awareness to all

community and ward based

Healthcare workers that

Norovirus is in the

community via outbreak

email list

Initiate Responsible visiting

(Remind all visitors not to

visit if they have had

symptoms or contact with

someone with symptoms

within the last 48 hrs)

IPCT

IPCT/Locality Manager/Matron/Ward Manager/Ward Sister/on call co-ordinator

Community teams to prioritise their work

load before visiting patients in

closed/restricted areas.

Locality managers to cascade information to all in and outpatient areas. Production and placement of posters at entrances.

All patients that present a risk of Norovirus should be isolated immediately.

67


Keep reviewing surveillance

data on Norovirus activity

e.g. PHE outbreak updates.

Remind all staff if they have

had symptoms to remain off

work for 48hrs after the last

symptom. Remind all staff

to be vigilant with HH and

to use liquid soap and

running water.

IPCT/Locality Manager/Matron/Ward Manager/Ward Sister/on call co-ordinator

Outbreak communication via email,

communication team. Placement of poster

at entrance to wards and outpatient areas.

Yellow

Suspected cases on 1 ward

Cases confined to side rooms

Follow actions in Green and

in addition:

Isolate patients in side

room. If patients are unable

to be isolated in side rooms

the affected ward will be

closed to admissions

(unless affected wards are

at Glenbourne as these

wards cannot be closed

due to its client group).No

transfers or movement from

the ward unless in a

medical emergency.

Closure/restriction of wards & bed moves is the decision and responsibility of the Ward Manager /Matron and the registered Locality Manager, with advice from the IPCT

Inform on call co-ordinator, Clinical Directors, Hotel services, PHNT and PHE.

68


Enhanced cleaning in affected side rooms as per outbreak policy.

Instigate outbreak monitoring

Report outbreaks to PHE

Hotel Services

IPCT/Locality Manager/Matron/Ward Manager/Ward Sister/on call co-ordinator IPCT

Ward own team and relief to be mobilised

to instigate enhanced cleaning. Consider

need for agency staff if ward staff unable

to carry out required additional cleaning.

Implement Outbreak Policy

Communication via outbreak email

If cases contained and resolved without

spread organise a deep clean and return

to Green

If cases spread out of side rooms to the

rest of the ward move to Amber

Amber

Suspected cases on 2 wards Follow actions in Green &

Yellow, in addition:

Close ward(s) (unless

affected wards are at

Glenbourne as these wards

cannot be closed due to its

client group) and

continue/instigate Outbreak

Closure/restriction of

wards & bed moves is

the decision and

responsibility of the

Ward Manager / Matron

and the registered

Locality Manager, with

Liaise with, Clinical Directors; ward sisters,

on call co-ordinator, Hotel services, PHNT,

and PHE.

69


Policy.

Convene outbreak meetings and establish actions to reduce impact on bed capacity.

Provide daily updates of closed wards Information of bed closures cascaded to PHNT, PHE, Community Teams & all LSW healthcare workers

Raise awareness of outbreak to reduce unnecessary visitors to the wards

advice from the IPCT

IPCT/Hotel Services/Locality Manager/Matron/Ward Manager/Ward Sister/ Multi-disciplinary team

IPCT/Locality Manager/Matron/Ward manager/ward sister

IPCT/Locality Manager/Matron/Ward Manager/Ward Sister/on call co-ordinator/Communication Team IPCT/Locality Manager/Communication Team

Assess ward(s) affected and likely duration of outbreak and liaise with, Clinical Directors, PHNT, and PHE

Liaise with, Clinical directors, Hotel services, PHNT, and PHE Press release

Press release

If wards are resolved without further

spread organise a deep clean and return

70


to Green

If spread to further wards move to Red

Red

3 to 5 wards closed Follow Green, Yellow &

Amber and in addition:

Convene daily outbreak meetings and establish actions to address reduced bed capacity

Daily assessment of closed wards

Restricted visiting to be

initiated:

No visitors on closed wards

without prior agreement

with the nurse in charge

Visiting to all wards

restricted to immediate

family or close friends.

IPCT/Hotel Services/Locality Manager/Matron/Ward Manager/Ward Sister/ Multi-disciplinary team IPCT/Hotel Services/Locality Manager/Matron/Ward Manager/Ward Sister/ Multi-disciplinary team IPCT/Locality Manager/Matron/ward managers/ward sisters/ On call co-ordinator/ Communications team

Liaise with, Clinical Directors, PHNT, on call Co-ordinator and PHE.

IPCT/On Call Co-ordinator to review closed wards daily including weekends Restricted Visiting posters to remain in place at entrances to wards and outpatient areas Public announcement via local

radio/press/web site

71


If wards resolved without spread to any

further wards organise a deep clean and

return to Green

If spread continues to further wards move

to Black

Black

More than 5 wards closed Follow Green, Yellow,

Amber, Red & in addition:

Continue with daily

outbreak meetings and

establish actions to address

reduced bed capacity and

service delivery

Provide information on

current situations:

IPCT to provide details of

on-going advice to close

wards including weekends

Daily meetings

IPCT/Locality Manager/Matron/Ward manager/Ward Sister/Multi-disciplinary team

IPCT/Locality

Manager/Matron/Ward

manager/Ward

Sister/Multi-disciplinary

team

Assess wards daily

72

Appendix E IPC Policy List and Review dates POLICY LIST

NAME VERSION PUBLISHED/MINOR UP-DATES

REVIEW FREQUENCY REVIEW DATE

Clostridium Difficile 3.7 Jun 2016 3 years after publish / earlier if evidence changes

Jul 2019

Cystic Fibrosis 2 Jan 2016 3 years after publish / earlier if evidence changes

March 2019

Decontamination Guidelines and Procedures

1.5 Nov 2016 3 years after publish / earlier if evidence changes

Dec 2018

Gylcopeptide-Resistant and Vancomycin-Resistant Enterococci

4 April 2016 3 years after publish / earlier if evidence changes

May 2019

Haemorrhagic Fevers Guidelines 1.2 May 2017 3 years after publish / earlier if evidence changes

May 2020

Hand Hygiene Policy and Procedure 2.1 Jan 2017 3 years after publish / earlier if evidence changes

Sep 2018

Healthcare-Associated Infections: The reporting mechanism

2.4 Jan 2015 3 years after publish / earlier if evidence changes

May 2018

Infection Control Hot Spot Strategy 1.5 Jan 2015 3 years after publish / earlier if evidence changes

Jan 2018

Guidelines for the Infection Prevention and Control in put into design


Jan 2018

Infection Prevention and Control Policy 2 Jun 2016 3 years after publish / earlier if evidence changes

March 2019

Management of patients with suspected or confirmed respiratory virus infections

2 April 2016 3 years after publish / earlier if evidence changes

May 2019

73

NAME VERSION PUBLISHED/MINOR UP-DATES

REVIEW FREQUENCY REVIEW DATE

Inoculation (Contamination) Incidents incorporating Blood Bourne Virus Standard Operation Procedure

2.2 Nov 2016 3 years after publish / earlier if evidence changes

July 2018

Isolation and management of the infected patient

2.4 Feb 2017 3 years after publish / earlier if evidence changes

April 2019

Linen Policy 2 March 2017 3 years after publish / earlier if evidence changes

March 2020

Meticillin-resistant Staphylococcus Aureus

9.7 July 2015 3 years after publish / earlier if evidence changes

Feb 2018

Management of an outbreak in a clinical area


May 2019

Pets in Hospital settings 7.4 Nov 2015 3 years after publish / earlier if evidence changes

Jan 2019

PVL-Associated Staphylococcal Infections, Management and Control

2.4 July 2015 3 years after publish / earlier if evidence changes

Sep 2018

Management and Control of Resistant Gram-Neg Bacteria

2.7 May 2017 3 years after publish / earlier if evidence changes

May 2020

Scabies: Management and Guidance 7.4 Nov 2015 3 years after publish / earlier if evidence changes

Jan 2019

Safe management and disposal of Sharps 6.8 Jan 2017 3 years after publish / earlier if evidence changes

Dec 2018

Transmissible Spongiform Encephalopathies and its Prevention in Healthcare

3.6 Dec 2015 3 years after publish / earlier if evidence changes

Feb 2019

Control Of Tuberculosis 3.5 March 2017 3 years after publish / earlier if evidence changes

March 2020

74

Appendix F

Infection Prevention and Control Liaison Practitioners

Roles and Responsibilities

The Infection Prevention and Control Liaison Practitioner (ICLP) are expected to participate in the following activities:

Activities: Requirements:

1. Attend quarterly meetings and relevant study days or a deputy if unable to attend

Attend a minimum of 3 meetings per year

Consider presenting project work

Share good practice

Participate in meeting evaluations

Aim to attend at least 1 study day per year ( when available)

2. Liaise and communicate between the clinical area and the Infection Prevention and Control Team (IPCT)

Maintain regular contact with the IPCT in relation to:

Patient related issues (e.g. outbreaks, isolation)

Healthcare Associated Infections (HCAI)s

Infection Prevention & Control (IP&C) practices

Staff related issues

Environment issues (cleaning, refurbishments)

3. Communicate IP&C issues to the ward/department manager and other staff

Communicate with all staff to ensure:

Dissemination of up to date IP&C information

Awareness of IP&C best practice

Staff are informed of new IP&C policies

75

Act as resource

4. Act as a resource concerning basic IP&C issues After receiving education from the IPCT:

Provide basic IP&C information to staff, patients and their relatives

Refer other requests for further information to IPCT

5. Undertake hand hygiene audits

Assist the IPCT with audits and action plans as requested

Conduct audits within time scale advocated by the IPCT, monthly for all in-patient areas.

Community teams to undertake 6 monthly glo box hand hygiene audits, re audit 3monthly if unsatisfactory results.

Complete action plan

Ensure action plan is implemented in collaboration with the ward/department manager

Feedback any issues of concern to the IPCT

6. Assist the IPCT during an outbreak of infection

Promptly make contact with the IPCT if an outbreak is suspected

Whilst on duty, assist the IPCT with management aspects

Ensure (in conjunction with other clinical staff) that relevant documentation is completed

Ensure all members of staff are aware of the Outbreak Policy

Disseminate the contents of the outbreak report to the clinical staff

Assist the IPCT with auditing the recommendations detailed in the outbreak report

Activities: Requirements:

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7. Participate in IP&C activities These may include:

IP&C week activities

Audits,

Product evaluation

Cleanliness audits

Assist with Root Cause Analysis on HCAI’s

Provide in-house IP&C training. for all staff, keep records and ensure training is recorded on ESR

Attend annual Mandatory Training. This list is not exhaustive

8. Participate in the education of clinical and non-clinical staff The following teaching topics are recommended

Hand hygiene

Sharps awareness

Intravenous therapy

MRSA

Clostridium Difficile

Outbreak management

Aseptic Technique This list is not exhaustive

9. Compile and maintain your own Professional Portfolio Make regular entries into the portfolio of all IP&C activities

Display skills of self-directed learning and practicing as a reflective practitioner

Highlight issues to advance clinical practice

Maintain competencies required to undertake the ICLP role. ( as identified throughout this document)

10. Compile and update an Infection Control resource folder The file will include:

Minutes from meetings

Audit results and action plans

Infection Control hand-outs

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Up to date journal articles

11. Produce an Infection Control Information Board The education board will:

Display Infection Control topics relevant to the clinical area

Display IP&C audit results and action plans

Display cleaning schedules

Display information relevant and understandable for staff, patients and the public.

display

IPCT to monitor availability of relevant Infection Control Study

Days/ courses

Ongoing

This list is not exhaustive; there may be other infection prevention and control issues which may at times need to be addressed.

Infection Prevention and Control Annual Report April · PDF fileInfection Prevention and...

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