INTRODUCTION · Web viewMajor outbreaks of communicable disease– Viral Diarrhoea and Vomiting...

INFECTION PREVENTION POLICY

Version 9

Name of responsible (ratifying) committee Infection Prevention Management Committee

Date ratified 06th September 2019

Document Manager (job title) Infection Prevention Lead Nurse

Date issued 30th September 2019

Review date 29th September 2021

Electronic location Infection Control Policies

Related Procedural Documents Infection Prevention Policies

Key Words (to aid with searching)

Infection prevention; Infection control; Infection control committees; Hospital hygiene; Healthcare associated infection; Cleaning; Decontamination; Hand Hygiene; Staff health and safety; Risk factors; Duties; Infection monitoring systems; Risk management; Training; Clinical guidelines

Version TrackingVersion Date Ratified Brief Summary of Changes Author

9 6th September 2019

Updated Team structure and new Organisational structure reflected

IPT

8 May 2016 Updated Team structure, Vascular Access included IPT

Title of Policy : Infection Prevention PolicyVersion: 9Issue Date: 30th September 2019 Review Date: 29th September 2021 (unless requirements change) of 17

CONTENTS

QUICK REFERENCE GUIDE............................................................................................................3

1. INTRODUCTION............................................................................................................................4

2. PURPOSE......................................................................................................................................4

3. SCOPE...........................................................................................................................................4

4. DEFINITIONS.................................................................................................................................4

5. DUTIES AND RESPONSIBILITIES................................................................................................5

6. PROCESS....................................................................................................................................10

7. TRAINING REQUIREMENTS.......................................................................................................12

8. REFERENCES AND ASSOCIATED DOCUMENTATION...........................................................13

9. EQUALITY IMPACT STATEMENT...............................................................................................13

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS........................................15

EQUALITY IMPACT SCREENING TOOL...........................................................................................16


QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily explain the key issues within the body of the document

1. There are a number of core clinical protocols for Infection Prevention and Control

a) Standard Infection Prevention and Control Precautions - Standard (Infection Control) Precautions Policy

b) Aseptic Technique– Aseptic Technique Policyc) Major outbreaks of communicable disease– Viral Diarrhoea and Vomiting Prevention

and Management Policy, Control of Tuberculosisd) Isolation of patients – Isolation Policye) Safe handling and disposal of sharps – Needlestick Sharps Injuries (NSI) &

Contamination Policyf) Prevention of occupational exposure to blood-borne viruses including prevention of

sharps injuries– Needlestick Sharps Injuries (NSI) & Contamination Policyg) Management of occupational exposure to blood-borne viruses and post exposure

prophylaxis. – Needlestick Sharps Injuries (NSI) & Contamination Policyh) Closure of wards, departments and premises to new admissions. – Clostridium Difficile

Infection – Prevention and Management Policy; Staphylococcus aureus (MRSA and MSSA) Management Policy; Viral Diarrhoea and Vomiting Prevention and Management Policy

i) Disinfectionj) Decontamination of reusable medical devices – Decontamination of Reusable Medical

Devices Policyk) Single-use medical devicesl) Antimicrobial prescribing – Antimicrobial Prescribing Policym) Reporting of infection to Public Health England or local authority and mandatory

reporting of HCAI to Public Health England n) Control of outbreaks and infections associated with specific alert organisms taking

account of local epidemiology and risk assessment. – Management of Outbreaks of Viral Diarrhoea and Vomiting, Policy for the management of MRSA and other antibiotic resistant micro-organisms

o) CJD/vCJD – CJD Policy – Management of Patientsp) Safe handling and disposal of waste – Waste Handling Policy

Policies can be found via the intranet; http://pht/PoliciesGuidelines/Pages/default.aspx

2. The provision of information to patients and visitors

3. An annual Infection Prevention assurance framework, in the form of an action plan.


http://pht/PoliciesGuidelines/Pages/default.aspx

1. INTRODUCTION

Portsmouth Hospitals NHS Trust (the Trust) recognises that it has a duty of care to protect patients, staff, contractors and visitors from infection and supports the need for effective systematic arrangements for surveillance, prevention and control. It is therefore committed to reducing the incidence of healthcare associated infections and, more importantly, maintaining that reduction.

For many common infections and infectious diseases, early recognition and prompt action can reduce the spread of disease, the severity of the illness and the number of people infected and Trust expects its staff to adhere to Infection Prevention and Control (IPC) Guidelines to ensure high standards of care are applied to protect patients, staff and visitors from unnecessary exposure to infection.

2. PURPOSE

The purpose of this policy is to explain the principles of infection prevention and control and to define the responsibility and accountability of each member of staff in ensuring that those principles are adhered, so that the Trust can be assured that our prevention and control measures are robust and appropriate.

3. SCOPE

This Policy applies to all staff, both clinical and non-clinical, employed by Portsmouth Hospitals NHS Trust, and also to all visiting staff including tutors, students, agency/locum staff and contractors.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4. DEFINITIONS

Infection Prevention and Control: processes to prevent and reduce to an acceptable minimum the risk of the acquisition of an infection amongst patients, health care workers and any others in the health care setting

Healthcare Associated Infection (HCAI): any infection that arises as a result of healthcare, regardless of the care setting. It includes hospital, primary and community care acquired infections.

Infection: when organisms in or on the body have started to multiply and/or invade a part of the body where they are not normally found. The body develops a reaction leading to disease or illness.

Cross Infection: the transfer of organisms from one person to another, this may or may not lead to illness or disease.

Colonisation: the presence of organisms in or on the body (including wounds), but without any sign of illness or disease. The body is colonised with many organisms the majority of which cause no harm and some are actually beneficial.

Communicable Disease: infection which is capable of spreading from person to person.Title of Policy : Infection Prevention PolicyVersion: 9Issue Date: 30th September 2019 Review Date: 29th September 2021 (unless requirements change) of 17

Spread of Infection is usually spread by one of the following means:- Direct Contact: Contact with contaminated blood, body secretions or fomites

particularly by staff hands that have become contaminated by body to body contact or the inanimate environment, and by transfusion of contaminated blood

Indirect Contact: Through equipment, medical devices or processes of care or the environment in which healthcare is provided.

Air Borne Spread: contaminated skin scales, aerosol spread via droplets from coughing and sneezing.

Vectors: third parties such as mosquitoes, ticks etc can carry infectious agents.

5. DUTIES AND RESPONSIBILITIES

Trust BoardThe Trust Board has overall responsibility for ensuring there are effective strategic, corporate and operational arrangements in place to maintain an effective infection prevention and control programme and that appropriate financial resources are in place to support that programme. To support this responsibility the Trust Board receives a monthly infection report provided by the Infection Prevention Team (IPT).

Chief ExecutiveThe Chief Executive has overall responsibility for ensuring that there are robust processes in place to ensure effective infection prevention procedures are in place but delegates this responsibility to the Medical Director in his capacity as the Director of Infection Prevention & Control (DIPC).

The Medical DirectorThe Medical Director, in his role as DIPC and Chair of the Infection Prevention Management Committee, is responsible for:

Providing oversight, assurance and strategy on infection prevention (including cleanliness) to the Trust board

Reporting directly to the Chief Executive and the Board Leading the Trust’s infection prevention team Overseeing the implementation of local infection prevention policies and practices;

measuring and assessing their impact and recommending any required changes Challenging inappropriate infection prevention and control practice and antibiotic

prescribing decisions Set and challenge standards of cleanliness Being a member of the infection prevention and antimicrobial stewardship committees

and regularly attend infection prevention meetings Being an integral member of the organisation’s clinical governance and patient safety

teams and structures, including water safety group Presenting an annual report to the Trust Board and external stakeholders, on the

organisation’s position in respect to healthcare associated infections. When approved, the document will be released publicly via the Trust intranet and internet.

Infection Prevention Management CommitteeThe Committee, chaired by the Medical Director in his role as the Director of Infection Prevention and Control (DIPC), meets on a quarterly basis and is responsible for:

Discussing, approving and monitoring the Infection Prevention (IP) strategy The development of IP policies, guidelines and standards Setting and monitoring local priorities related to IP Ensuring compliance with national standards by development and implementation of

robust monitoring systems across the health community served by the IPT


Coordinating and monitoring IP activity across the whole health economy through the implementation of an annual programme of work, in accordance with national standards and evidence based best practice

Evaluating the impact of infection on service delivery Directing and supporting the IPT Identifying organisational learning and development requirements of Trusts across the

whole health economy Ensuring the effective implementation of the HCAI Plan Receiving and reviewing reports from infection prevention and control projects e.g.

endoscopy and theatre compliance with decontamination and IP standards; making any required recommendations to Trust Boards across the whole health economy

Reviewing trend analysis from the IPT, of incidences of sentinel organisms to ensure long term review and, through the Chair, taking any actions as identified by the trends

Receiving and reviewing reports from the IPT on adverse incidents and near misses and recommending any change in practice or policy as highlighted by those reports

Providing Trust Boards across the whole health economy with an annual report on activity, outcomes and recommendations for change

Serious Incident Review Group (SIRG)SIRG provides a high level forum in which to oversee and monitor the reporting and review of serious incidents, ensuring that recommendations arising from Serious Incident investigations are implemented as required and that organisational learning has taken place. In addition the group will escalate any appropriate risks to the Quality & Performance Committee for inclusion on either the Assurance Framework or the Risk Register.

Performance and Accountability MeetingsThe purpose of the Performance and Accountability is to establish and maintain an assurance framework through which the Board can monitor the arrangements in place to achieve a satisfactory level of internal control, safety and quality.

Specialty/Care Group/Divisional Governance CommitteesThe Committees are responsible for:

Receiving reports from the Learning and Development Team on staff attendance at IP training

Monitoring compliance with training through ESR. Continual monitoring of staff attendance at IP training, to ensure compliance Monitoring any adverse events and near misses associated with IP training Overseeing the implementation of associated action plans Undertaking monthly reviews of the divisional risk registers, including the monitoring of

risks identified through the audits of IP Escalating any issues that, for whatever reason, cannot be resolved to the Risk

Assurance Committee for discussion and potential transfer to Trust Risk Register

Infection Prevention (IPT)The IPT consists of a Lead Nurse, a Manager/Analyst, single and dual role clinical nurse specialists and practitioners, and Surveillance/Data support staff. The IPT is supported by the Infection Prevention and Control Doctor, who is a Consultant Microbiologist.


The core functions of the Team fall into the following four domains:


The IPT is responsible for:

Providing expert reactive and proactive information and advice to all staff, patient, relatives and carers in respect of healthcare associated infections and the prevention and control of those infections

Providing strategic advice to enable to Trust to meet necessary standards of care and fulfill its obligations under the Health and Social Care Act 2008

Providing a specialist Vascular Access service for patients through cannulation placement of Peripherally Inserted Central Catheters (PICCs) and Midlines, which includes education and competency assessment of practitioners within the Trust

Act as an expect resource for all vascular access i.e., portacaths and hickman lines Providing a comprehensive IP education programme incorporating induction training,

annual mandatory refresher training and education tailored to the needs of the Trust. Timely isolation and the enforcement of strict transmission precautions for all enteric

and respiratory pathogens The prevention and management of outbreaks resulting from uncontrolled transmission

of infection Constantly reviewing the IP education programme to ensure it remains in line with best

practice and legislation Ensuring all policies and guidelines are in line with best practice and legislation Contributing to the annual IP plan, in consultation with the IPMC and key stakeholders Contributing to the production of the Annual Report Collating and reporting MRSA and Clostridium Difficile data to the Trust Board, IPMC

and to each care group/division in accordance with national and local requirements Collating and reporting MSSA and E.coli data to the Trust Board, IPMC and to each

care group/division in accordance with national and local requirements Providing expert management of infection outbreaks / incidents Advising on aspects of decontamination, including levels of equipment decontamination

and cleaning Auditing of IP practices, and from the result of the audit developing priorities for

targeted surveillance at local level Advising on the procurement of new equipment in relation IP issues Advising on IP issues prior to commissioning of new buildings and upgrading Trust

premises Reviewing, in collaboration with others, the status of the environment and the

effectiveness of the facilities management services, including cleaning, in order to provide a safe and clean environment for patient care.

Facilitating the identified and trained group of link staff, ensuring they work within defined roles and are empowered to continually raise the standards of IP

Conducting root cause analyses of relevant infection incidents Reviewing and responding appropriately to adverse incidents / near misses related to

infection prevention and control Working in collaboration with and liaising with Public Health England, Clinical

Commissioning Group and GP’s, social services and other local agencies Ensuring the provision of information to patients and visitors so that they are aware of

their role in the prevention of healthcare associated infections The water quality and safety schedule of work to ensure that the quality of water in all

clinical areas is of the required standard

Infection Prevention Doctor The Infection Prevention Doctor is responsible for:

Working with and supporting the IPT by providing guidance and advice on matters relating to microbiological issues e.g., antibiotic prescribing, laboratory issues and surveillance.

Attending quarterly IPMC meetings and other relevant IP meetings and panels


Advise and support Laboratory Manager/Pathology Manager/DIPC in regards to infection prevention and control issues.

Reporting antimicrobial stewardship activities to the Trust board via the DIPC and IPMC

Infection Prevention Lead NurseThe Lead Nurse is responsible for:

The strategic and operational management of infection prevention and control across the organisation, including management of the IPT and the production of an annual IP programme, through adoption of national evidence based practice

Providing specialist expert advice and ensuring adequate advice is available to all staff at all times

Ensuring the development of robust IP policies and practices, including those involving decontamination and water safety and quality

Producing the Annual Trust IP Report, including the annual action plan, to allow this to be presented to the Trust Board by the DIPC, for onward dissemination through the divisional structures

Ensuring the provision of a high quality infection prevention service to the Trust. Leading and managing the IPT and ensuring the responsibilities above are achieved.

Infection Prevention Manager/AnalystThe Analyst is responsible for:

Managing the scientific data collected by the IPT, as well as the administration Team functions

Collating and reporting of the Trust’s data on healthcare associated infections, in particular, the Trust’s performance against national and local trajectories

Collating and disseminating data from audits, conducted by the wards and the IPT Collating information for inclusion in the Annual Trust IP Report, including the annual

action plan Weekly feedback through infection dashboards, infection board reports and running

daily alerts. Supporting the IP Lead Nurse in the management of the IPT to ensure full service

delivery at all times

Senior Lead Nurses, Matrons & Ward ManagersIn respect of this policy, managers are responsible for:

Ensuring dissemination and supporting implementation Integrating compliance into the Appraisal and Performance framework for all staff Ensuring appropriate evidence of compliance is gained during the appraisal process Ensuring staff are released for IP training Taking appropriate action following review of the monthly HR dashboard to ensure

compliance with, and staff attendance at IP training. Driving a culture of cleanliness and hand hygiene. Taking appropriate action following receipt of audit results Supporting the Link Advisors by ensuring dedicated time for them to undertake their

role in the prevention and control of infection Ensuring there is adequate training and equipment for staff to safely decontaminate

equipment Ensuring equipment decontamination is performed in line with local, national and

manufacturers’ guidance Ensure each ward/area has a designated IP link advisor Ensure wards, including near patient environment, is clutter free, to allow environment to

be cleaned effectively.


Ensure appropriate signage is displayed on infectious cubicles.

Infection Prevention Link Advisors: Advisors must:

Ensure they undertake all appropriate trainingo A one-day course delivered by the IPT for new link advisors or as a refresher for

current advisors every 2-3 years.o Courses run at least bi-annually depending on requirements

Continually raise the standards of IP, including hand hygiene Provide IP training to colleagues on an ad-hoc basis and at regular ward meetings Ensure IP audits are undertaken Ensure that results of all audits are fed back to the IPT and to Matrons, through the CSC

structure Develop action plans, in conjunction with the IPT and Matrons; to rectify any deficiencies

highlighted by the audits

All StaffAll staff are responsible for:

Ensuring they have received appropriate IP training in the last twelve months Never knowingly place a patient, member of staff or Trust visitor at risk from an

infection. Working to the IP standards set out in the Trust’s IP guidelines and policies, Challenging poor IP practice and seek support from the IPT as required Reporting any adverse incidents in accordance with Trust policy Reporting any suspected infection outbreaks to the IPT Communicating proactively and reactively with the IPT Obtaining advice from Occupational Health if they are concerned over their own risks Ensure wards, including near patient environment, is clutter free to allow environment to

be cleaned effectively.

Patient Advisory and Liaison ServiceThe Service is responsible for supporting the Trust’s policies and procedures for IP by advising and influencing the public with regard to hand washing

6. PROCESSTo ensure there is a robust framework in place for the Prevention and Control of Infection, the Trust has adopted a number of key approaches:

6.1 Core Clinical Protocols for Infection Prevention These protocols form the basis of the Trust’s Infection Prevention Policy and are:

q) Standard Infection Prevention and Control Precautions - Standard (Infection Control) Precautions Policy

r) Aseptic Technique– Aseptic Technique Policys) Major outbreaks of communicable disease– Viral Diarrhoea and Vomiting Prevention

and Management Policy, Control of Tuberculosist) Isolation of patients – Isolation Policyu) Safe handling and disposal of sharps – Needlestick Sharps Injuries (NSI) &

Contamination Policyv) Prevention of occupational exposure to blood-borne viruses including prevention of

sharps injuries– Needlestick Sharps Injuries (NSI) & Contamination Policyw) Management of occupational exposure to blood-borne viruses and post exposure

prophylaxis. – Needlestick Sharps Injuries (NSI) & Contamination Policyx) Closure of wards, departments and premises to new admissions. – Clostridium Difficile

Infection – Prevention and Management Policy; Staphylococcus aureus (MRSA and Title of Policy : Infection Prevention PolicyVersion: 9Issue Date: 30th September 2019 Review Date: 29th September 2021 (unless requirements change) of 17

MSSA) Management Policy; Viral Diarrhoea and Vomiting Prevention and Management Policy

y) Disinfectionz) Decontamination of reusable medical devices – Decontamination of Reusable Medical

Devices Policyaa) Single-use medical devicesbb) Antimicrobial prescribing – Antimicrobial Prescribing Policycc) Reporting of infection to Public Health England or local authority and mandatory

reporting of HCAI to Public Health England dd) Control of outbreaks and infections associated with specific alert organisms taking

account of local epidemiology and risk assessment. – Management of Outbreaks of Viral Diarrhoea and Vomiting, Policy for the management of MRSA and other antibiotic resistant micro-organisms

ee) CJD/vCJD – CJD Policy – Management of Patientsff) Safe handling and disposal of waste – Waste Handling Policy

Policies can be found via the intranet; http://pht/PoliciesGuidelines/Pages/default.aspx

6.2 Information available to patientsPatients and visitors play an important part in the prevention and control of infection. To enable them to do so, they must be supplied with the appropriate information and support. The Trust utilises a number of methods for this, including:

6.2.1 Information available on the internet

6.2.2 The Infection Prevention Team

Distributes leaflets on: Hand hygiene, Clostridium difficile, Influenza, Viral Gastroenteritis, MSSA, Group A Strep, Acinetobacter, E.coli, ESBL, Scabies, VRE, PICC line and Midline care for the use of patients, visitors and staff.

Visit all in-patients with known Clostridium Difficile, MRSA, MSSA, E coli and other infectious conditions to discuss how this may effect them and their families and to explain treatments

Participate in partnership groups and public/media forums Pursue infection prevention forums i.e. twitter, facebook, press, internet.

6.2.3 All patients, visitors and other members of the public are informed, as a minimum that they must:

Wash their hands with soap and water or if appropriate apply alcohol gel to physically clean hands.

Report any concerns or problems they see or experience that may lead to transmission of infection.

Adhere to all pre-admission advice on how to keep themselves safe from infection

6.2.4 Wall prompts:

Red stripes outside clinical areas with alcohol gel attached Large poster displays in the main entrances Hand-gel dispensers in the main entrances Purehold Hygiene handles in specific locations

6.3 Infection Prevention Assurance Framework6.3.1 The Trust’s framework for providing assurance on implementation of required

actions to ensure a safe and clean environment for our patients, staff and visitors


http://pht/PoliciesGuidelines/Pages/default.aspx

takes the form of an annual action plan. The plan is developed by the IPT and Infection Control Doctor, and ratified by the IPMC, prior to presentation to the Trust Board

6.3.2 In addition, any issues considered by the Trust Board to be a Prevention and Control of Infection risk to the achievement of our strategic objectives are placed on the Trust’s Assurance Framework and Trust Risk Register, which are reviewed by the Quality and Performance Committee and Trust Board on a monthly basis.

6.4 Managing Risks6.4.1 Quality assurance processes such as audit, peer review, internal and external

scrutiny are employed to monitor the level of risk, against defined national and local infection control standards

6.4.2 Reports are produced and disseminated to monitor risks:Weekly Infection Prevention DashboardsWard accreditationPerformance reviews

6.4.3 Any identified risks are placed on the divisional Risk Registers, which are reviewed monthly at the specialty/care group/divisional Governance Committees; for progress against the action plans developed to mitigate or resolve the risks

6.4.4 Division’s are required to report on the management of risks:

Via the Trust heatmap At performance reviews, chaired by the Chief Nurse

6.4.5 Any risks that cannot, for whatever reason, be managed locally are escalated to the Quality and Performance Committee for discussion and potential inclusion on the Trust Risk Register of Board Assurance Framework

7. TRAINING REQUIREMENTS

7.1 Prevention and Control of Infection forms part of the Trust’s Core Essential Skills and Training requirements, as identified by the Training Needs Analysis

7.2 Prevention and Control of Infection training forms part of mandatory Trust induction

7.3 All staff are required to undergo annual Prevention and Control of Infection updates. This is provided either by direct teaching or e-learning

7.4 Ad hoc Prevention and Control of Infection training is provided by Infection Prevention and Control by drop-in sessions and audit days. This is supplemented by the Link Advisors as part of regular ward meetings.

7.5 The uptake of training is tracked by the Learning and Development Team, using ESR and attendance is monitored through quarterly reports disseminated through the HR dashboard.

7.6 Ward and Line Managers are responsible for ensuring that any staff members who do not attend this mandatory training are followed up on an individual basis.

7.7 The requirement for IPC is also integrated into the Appraisal and Performance framework and monitored through the staff appraisal process

In addition, awareness is raised through:


Participation in National Infection control week Participation in specialty specific days e.g. National Rheumatology Day Trust Hand Hygiene for the public and other visitors is included as part of the Trust

open day

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Department of Health (2002 a) Getting ahead of the curve: action to strengthen the microbiology function in the prevention and control of infectious diseases. London. HMSO.

Department of Health (2003) Winning Ways: Working together to reduce healthcare associated infection in England. London. HMSO.

Department of Health (2004) Standards for Better Health. London. HMSO.

Department of Health (2004) A matron’s charter: An action plan for cleaner hospitals London. HMSO

Department of Health (2004) Towards cleaner hospitals and lower rates of infection. London. HMSO

Department of Health (2005) Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA. London. HMSO

Department of Health (2006) Going further faster: Implementing the Saving Lives delivery programme. London. HMSO.

Department of Health (2015) The Health and Social Care Act 2008: Code of practice on the prevention and control of infections and related guidance.

Department of Health (2010) Equity and Excellence: Liberating the NHS.

Infection Control Nurse Association (2004) Audit tools for monitoring infection control standards 2004.

National Institute for Clinical Excellence (2011) Healthcare-associated infections: prevention and control

National Institute for Clinical Excellence (2012) Infection Control: Prevention of healthcare-associated infections in primary and community care.

9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

All policies must include this standard equality impact statement. However, when sending for ratification and publication, this must be accompanied by the full equality screening assessment tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy Documentation

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:


Working together for patientsWorking together with compassionWorking together as one teamWorking together always improving

This policy should be read and implemented with the Trust Values in mind at all times.


10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum requirement to be monitored

Lead Tool Frequency of Report of

Compliance

Reporting arrangements

Lead(s) for acting on

Recommendations

Regular attendance at IPMC meeting

John Knighton

CSC representation log

Quarterly Infection Prevention Management Committee

Divisional leads

Infection Prevention attendance at other Trust forums i.e. RAC, SIRG

Debbie Keyte

CSC representation log

As required

Infection Prevention protocols

Debbie Keyte

IP report Annually Infection Prevention Management Committee

Divisional leads

This document will be monitored to ensure it is effective and to assure compliance.

The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.

The details of the monitoring to be considered include:

The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);

The lead for ensuring the audit is undertaken The tool to be used for monitoring e.g. spot checks, observation audit, data collection; Frequency of the monitoring e.g. quarterly, annually; The reporting arrangements i.e. the committee or group who will be responsible for

receiving the results and taking action as required. In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on the Trust Intranet Trust Intranet -> Policies -> Policy Documentation

The lead(s) for acting on any recommendations necessary. recommendations necessary.


EQUALITY IMPACT SCREENING TOOLTo be completed and attached to any procedural document when submitted to

the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Infection Prevention Policy

Date of Assessment 28/08/2019 Responsible Department

Infection Prevention

Name of person completing assessment

Kathryn Noble Job Title Infection Prevention Manager/Analyst

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

Age No

Disability No

Gender reassignment No

Pregnancy and Maternity No

Race No

Sex No

Religion or Belief No

Sexual Orientation No

Marriage and Civil Partnership No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents

Stage 2 – Full Impact Assessment

What is the impact Level of Mitigating Actions Responsible


http://www.legislation.gov.uk/ukpga/2010/15/contents

Impact (what needs to be done to minimise / remove the impact)

Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance CommitteeClinical Service Centre Procedural Document: Clinical Service Centre Governance CommitteeCorporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee


INTRODUCTION · Web viewMajor outbreaks of communicable disease– Viral Diarrhoea and Vomiting...

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Transcript of INTRODUCTION · Web viewMajor outbreaks of communicable disease– Viral Diarrhoea and Vomiting...