Infection Prevention and ControlAnnual Report 2015-16

Infection Prevention and Control Conference 2015

Nicola Lucey Director of Nursing and Quality/ Director of Infection Prevention and ControlLisa White Head of Infection Prevention and Control

1

1.0 Executive Summary

Over the last year the Infection and Prevention team have supported the operational teams to deliver further improvements in infection prevention and control. This annual report provides a full account of this activity. In addition, new guidance and evidence has been reviewed and incorporated into policies, practice, education and guidance.

A summary of the main headlines in this annual report are outlined below:-

Trajectory MRSA bacteraemia and Clostridium difficile infection targets were achieved

MRSA screening targets were not fully met, achieving 99% compliance pertaining to 4 patients throughout the year not being screened as per policy

Catheter associated urinary tract infections and Urinary tract infection reduction targets were achieved

Compliance to Infection prevention and Control training exceeded target

National guidance has been analysed and incorporated into annual workplans

Policies have been reviewed and reflect national and best practice guidance.

KCHFT continue to work collaboratively with the Kentwide HCAI reduction group

2

INDEX

Section Page (s)

Executive Summary 2

Introduction 4

DIPC assurance 4

Healthcare Associated InfectionSurveillance

5 - 8

Incidents and Outbreaks 8-9

Flu campaign 10

National Guidance 10

Decontamination 10

Cleaning 11-13

Estates 13

PLACE 13 - 16

Audit 16 - 17

Antimicrobial stewardship 17-18

Waste 18-19

Patient Experience 19-21

Training and education (and link workers) 22

Policy Reviews 22

Staff Health 23

Collaborative Working 23

Conclusion 23

Governance Structure 24

Infection Prevention and Control Committee Terms of reference

25-31

Hygiene Code compliance 32

3

1.0 Introduction

Kent Community Health NHS Foundation Trusts’ vision is ‘to be the provider of choice by delivering excellent care and improving the health of our communities.’

Our values demonstrate the trust acts with integrity and professionalism by:

caring with compassion listening, responding and empowering leading through partnerships learning, sharing and innovating striving for excellence

Infection Prevention and Control is a key priority for the Trust and the Trust values are integral to achieving ongoing improvement in avoidable healthcare associated infections.

This year has been challenging across the whole system of the NHS ‘family’ with increased demand for complex care from the population care and new ways of working requiring staff to innovate, adapt and change at significant pace. Therefore the Trust is very proud of the staff achievements, which have successfully managed to reduce healthcare associated infections and managed infection outbreaks to support patient safe care.

1.1 Director of Infection Prevention and Control assurance

The DIPC gives the following assurances:

Kent Community Health NHS Foundation Trust is strategically compliant with the Hygiene Code. Kent Community Health NHS Foundation Trust has a zero tolerance approach to Healthcare

Associated Infections (HCAI) as stated by the Department of Health 100% of patients presenting for elective surgery are MRSA screened at pre-assessment. Every case of Clostridium difficile infection is investigated and a Root Cause Analysis

completed, with the clinical teams, to ensure lessons are learned and actions taken for non-compliances

Kent Community Health NHS Foundation Trust take part in the Post Infection Review process for all MRSA bacteraemia as part of the whole systems approach to healthcare

The Infection Prevention and Control Team carry out an annual programme of audit as required by the Hygiene Code

Kent Community Health NHS Foundation Trust use National cleaning specifications to determine cleaning frequencies and methodology within the healthcare environment

Kent Community Health NHS Foundation Trust carry out inspections of all in-patient areas in conjunction with the Patient Led Assessment of the Care Environment (PLACE)

Kent Community Health NHS Foundation Trust undertake decontamination audits and report to the Medical Devices Decontamination Committee which reports to the Board.

Kent Community Health NHS Foundation Trust has Occupational Health provision from an external provider. Screening is carried out on all staff at pre-employment checks and further surveillance and screening is carried out at agreed intervals and as necessary

Kent Community Health NHS Foundation Trust has the required infection prevention and control arrangements in place. (See Appendix 1 for Infection Prevention and Control Team Reporting Structure and Appendix 2 for Terms of Reference of Infection Prevention and Control Committee).

1.2 DIPC Reports to the Trust Board

4

The Director of Infection Prevention and Control has presented the Quality Committee and Board with the following agenda items on Infection Prevention and Control during 2015/16.

2015/16 Annual Report Quality Account 2015/16 Monthly Meticillin Resistant Staphylococcus aureus bacteraemia surveillance, progress and

areas of concern Monthly Clostridium difficile surveillance, progress and areas of concern Monthly compliance with Statutory and Mandatory Training in infection control and hand

hygiene Monthly CAUTI/UTI rates (community Hospitals only) Outbreak and incident reports Decontamination reports Carbapenemase Producing Enterobacteriacea (CPE) actions and updates Quarterly Infection Prevention and Control Updates

The DIPC acts as the liaison between the Quality Committee, Trust Board and the Infection Prevention and Control Committee.

1.3 Infection Prevention and Control Annual Programme – Review and Progress for 2015/16 Actions listed on the work plan for 2015/16 that have not been completed are: –

Source IT system for surveillance of micro –organisms – this is due to the fact that the microbiology labs IG departments will not allow data to be stored centrally outside of their governed IT processes.

2.0 Healthcare Associated Infection Surveillance

2.1 Figure 1: Healthcare Associated Infection Surveillance

Indicator Description

Target Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sept 15

Oct 15

Nov 15

Dec 15

Jan 16

Feb 16

Mar 16

Year Total

MRSA bacteraemia

0 0 0 0 0 0 0 0 0 0 0 0 0 0

MRSA screens for podiatric surgery% compliance

100 100

100 100 100

100 100 100

100 100 100 100 100 100

MRSA screens in Community Hospitals% compliance

100 100

98 100 100

100 100 97 100 93 100 100 100 99

Clostridium difficile infections

≤ 7 0 0 0 0 0 0 1 0 0 0 0 1 1

Hospital acquired UTI’s

10%less than 2014/15<178

13 16 16 13 18 17 12 15 14 16 5 12 167

Hospital acquired CAUTI’s

10%less than 2014/15<35

5 2 3 1 1 2 5 1 3 1 2 5 31

5

2.2 Clostridium difficile 2015/16

Clostridium difficile is a bacterium that is found in peoples intestines. It can be found in health people and cause no symptoms (up to 3% adults, and 66% of babies). Disease occurs when normal bacteria in the gut are altered, usually by the administration of antibiotics. This allows the Clostridium difficile bacteria to increase to high levels with the ability to cause toxins, these toxins cause diarrhoea. This has potential to lead to more serious infections with severe inflammation of the bowel.

The Public Health England Epidemiological commentary on the mandatory reporting data produced in July 2015 identified that between 2013 and 2015 Clostridium difficile rates continued to rise, and identified that the largest increase was in ‘community acquired’ cases. KCHFT are not formally set trajectories by NHS England, however their cases are formally assigned to the CCG’s, therefore targets are set and agreed with CCG’s using the national formula for trajectory setting. In 2014/15 KCHFT did record an increase in reportable Clostridium difficile infections, and utilising learning from that year put in place measures to reduce cases in 2015/16.

A route cause analysis (RCA) is undertaken on every case of Clostridium difficile infection identified as associated or attributed to KCHFT, with staff from the Acute sector and CCG invited as required to assist in learning from cases. Within the RCA a discussion is held around ‘lapses of care’ and any of these identified result in action plans and lessons for the organisation. Level 3 lapses in care are measure by the CCG, and if the Trust exceeds it’s target, the CCG can impose contract query notices on any level 3 lapses. All antimicrobial prescribing issues are escalated through the antimicrobial stewardship group, and learning shared through quality meetings and the infection prevention and control committee.

The Trust over achieved on its target of no more than 7 cases of Clostridium difficile by reporting just 1 toxin positive attributable case, with no level 3 lapses in care. The one case was at Tonbridge Cottage hospital, and the investigating team agreed there were no lapses in care identified, and the infection was deemed unavoidable, and presumed to be due to the patients underlying medical condition, as the patients had received no antimicrobials, protein pump inhibitors or been exposed to other positive patients. However, there was an identified link to a second toxin negative, antigen positive case, suggesting environmental cross contamination, and lessons were learned from the incident.

2.3 Meticillin Resistant Staphylococcus aureus (MRSA)

In 2013/14 the government introduced a new method of investigating MRSA bacteraemias, and assigning them, this was referred to as the Post Infection Review (PIR) process. Previously Acute Trusts or the CCG were attributed cases dependent on length of time patients were cared for in a location, the PIR process allowed for a full review of care providers, enabling cases to be assigned more appropriately, and introduced a ‘third party’ assignment, for cases where the panel believed the bacteraemia to have been completely unavoidable. Nationally the cases of MRSA bacteraemias have continued to fall, highlighting that a healthcare economy wide focus appears to be working.

For the second year running, there were no MRSA blood stream infections attributed to the Trust in 2015/16, although 9 cases where KCHFT staff were providing care were investigated – all were reviewed by NHS England and deemed as either unavoidable and attributed as a ‘third party assignment’, or avoidable, but attributed to another NHS organisation. In one case the Trust received commendation on the level of care provided, however in once case the Trust were

6

requested to provide evidence of changes in communication systems between primary, acute and community care. This evidence has been provided, and the actions closed.

3.1 MRSA Screening Owing to the release of new national guidance on MRSA the Trust screening policy changed, from screening all patients admitted from home to our Community Hospitals or where the patient has not been screened within the Acute Hospital, to only screening those deemed to be ‘high risk’. The risks include history of MRSA infection / colonisation, open wounds, and invasive devices. The screening policy of ensuring all patients admitted for podiatric surgery are screened prior to their operation has remained unchanged. Compliance for podiatry has remained 100% for the previous year, however compliance in community hospitals averaged 99% in the year, with a total of 374 patients being admitted who fitted the criteria for screening, but only 370 patients being screened. All missed patients were subsequently screened and found to be negative.

3.2 Figure 2: MRSA screening compliance

Apr-15

May-15

Jun-15Jul-1

5

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

88%

90%

92%

94%

96%

98%

100%

102%

MRSA screening -Community Hos-pitals

% co

mpl

ianc

e M

RSA

scre

enin

g

4.0 Hospital Acquired Catheter Associated Urinary Tract infections (CAUTIs) and Urinary Tract Infections (UTIs)

The target for 2015/2016 was to reduce both Hospital acquired CAUTIs and UTIs by 10%, and to focus on catheter care in community teams.

For this year the Trust have achieved a 16% reduction in CAUTIs (31 reported attributable cases against a target of <35) and a 20% reduction in UTIs (167 reported against a target of < 178) compared to last year. Reporting within the community services has remained difficult to assure, but the IPC team continue to work with community teams through the Trust UTI/CAUTI reduction working group to ensure there is a continued focus on reduction.

Figure 3: Community Hospital acquired UTIs and CAUTI’s

7

Apr-15

May-15

Jun-15Jul-1

5

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

0

1

2

3

4

5

6

Hospital acquired CAUTI's

Total Target (< 35 per annum)

Apr-15

May-15

Jun-15Jul-1

5

Aug-15Sep

-15Oct-

15

Nov-15

Dec-15

Jan-16Feb

-16

Mar-16

02468

101214161820

Hospital acquired UTI's

Total Target( <178 per annum)

This significant reduction was achieved through the following actions:

A continued focus on education surrounding UTIs and CAUTIs during clinical visits Implementation of a care bundle for insertion and maintenance of urinary catheters The Catheter passport re-launching and refocusing efforts on single documentation sources An Algorithm to identify appropriate urine specimens being implemented The Catheter Management Policy being implemented. Leading on Kent wide collaborative campaign to reduce these infections Focussed CAUTI/UTI reduction working group

5.0 Incidents and Outbreaks

Outbreaks

In total in 2015 / 2016 there were 11 outbreaks of infection that lead to ward closures, 6 confirmed Norovirus, 2 Diarrhoea (no confirmation of pathogens) and 3 respiratory viral outbreaks with no Influenza A this year. This is a significant reduction in the number of outbreaks occurring last year

8

(17). The IPC team continue to update and provide training on outbreaks management to staff and provide all resources required for this.

5.1 Figure 4: Outbreak summary data 2015/2016 (11 total)

Hospital Period Outbreak OutcomeFaversham Cottage Ward closed 8/4/15 –

12/4/15Viral respiratory infections

2 patients paraflu, 1 RSV, 2 Influenza A

Edenbridge hospital Ward closed 3/5/15. Opened 13/5/15

Confirmed norovirus 8 patients, 7 staff with symptoms

Hawkhurst Hospital Ward closed 17/8/15 – 26/8/15

Diarrhoea 4 patients and 5 staff symptomatic

Edenbridge Hospital Ward closed 10/09/15 to 15/09/15

Confirmed norovirus 7 patients and 10 staff affected

Sevenoaks Hospital Ward Closed 16/10/15- 22/10/15

Rhinovirus 5 patients symptomatic – 2 tested positive

Deal Hospital Wardclosed 28/11/2015 – 30/11/15

Diarrhoea 4 patients affected

Sevenoaks Hospital 1 bay closed 10/12/15 ward closed 11/12/15- 15/12/15

Confirmed norovirus 3 patients affected

Queen Victoria Hospital Herne Bay

Ward Closed 28/1/16- 1/2/16

Parainfluenza 5 patients affected

Faversham Cottage Hospital Ward closed 27/2/16 -10/3/16

Confirmed norovirus 16 patients and 10 staff affected

Deal Hospital Ward closed 5/3/16 – 18/3/16.

Confirmed norovirus 15 patients 17 staff affected

Livingstone Hospital ward closed 7/3/16 – 16/03/16

Confirmed norovirus 8 patients and 2 staff affected

Incidents

5.2 Staff Pertussis (Whooping Cough)In February 2016 there were 2 unrelated cases of staff testing positive for pertussis (Whooping cough) In both cases, the confirmed results were received too late for any public health prevention intervention, therefore in both cases incident meetings were held to identify patients that had been exposed to the staff, and letters were sent to the patients GP’s informing them of the exposure. An awareness campaign for staff was launched in March, and some exposed staff were also tested for pertussis, but found to be negative.

5.3. Varicella Zoster (Chicken pox)There was one case of chicken pox in a patient in an open ward in March 2016, whereby contact tracing required 2 staff to be tested for immunity. All staff were found to be immune, however there were issues with the OH providers systems and processes, resulting in staff not being able to work for 2 days, but results later proved this was not required. Work is now underway with the OH provider to improve their systems and processes.

9

6.0 Seasonal Flu Campaign

During 2015/16 flu season staff were given the opportunity to be vaccinated against influenza in line with the Department of Health Staff flu programme. An innovative in house vaccination programme was run, and 45.1% of frontline clinical staff received the vaccine.

An assessment of the 2015/16 staff flu campaign has been undertaken and new ideas to increase uptake are being considered.

7.0 National Guidance

7.1 Carbapenemase producing enterobacteriaceae

The Community Toolkit for managing CPE’s in community and non acute care settings was released in June 2015. The IPC team wrote and implemented a policy based on the guidance, and ensured community teams received training on this guidance.

7.2 Hygiene code – The health and Social Care act – Code of Practice on the prevention and control of infections and related Guidance.

In July 2015 the Department of Health released the latest revised Health and Social Care Act, 2008 (2010). A gap analysis was undertaken, and systems and actions are being implemented in relation to systems and processes required to provide assurance of compliance, specifically in relation to Estates and Occupational Health.

7.3 The Infection Prevention and Control commissioning toolkit The Infection Prevention and Control commissioning toolkit was published in January 2016, and KCHFT are working with our commissioners to plan implementation of the toolkit. Many of the actions will require a healthcare economy wide approach, and work is ongoing within the Kent wide HCAI reduction group to begin to address some of these.

8.0 Decontamination of medical devices.

Kent Community Health NHS Foundation Trust recognises the risks to patients, staff and others created by the use of medical devices. There is a suitable and operational system in place which manages the procurement, usage, maintenance and disposal of medical equipment, to meet the requirements of national legislation and NHS guidance and to make sure that equipment is used safely, competently and effectively for the care of our patients.

Decontamination processes are jointly managed and reported through KCHFT. The Medical Devices and Decontamination Group receive exception reports, and provide assurance for the Trust on all aspects of decontamination.

The Infection prevention and control team undertake assurance visits and audits in areas that utilise re-usable instruments, and in all outpatient departments found full compliance with decontamination processes. The dental service utilise a central decontamination service (IHSS for their general clinics, however within the prisons covered by KCHFT, local decontamination is undertaken. The CQC issued an improvement notice at Standford Hill prison after an unannounced visit in November 2015. The notice was in relation cleanliness, clutter and flooring in the dental

10

room and decontamination room. All actions required to rectify this were completed, and all prison dental services have now been recorded as compliant.

Within the year it was agreed that the dental services in 2 centres – Churchill in Ramsgate, and New Street in Sandwich will return to local reprocessing of instrumentation next year (2016/17). Prior to this commencing, assurance processes are to be agreed, a dental decontamination policy will be written, and staff will require formalised training in order to ensure compliance with HTM01-05 going forward.

In Health Sterile Services (IHSS) continue to provide the Central Sterilisation service for KCHFT for podiatry, dental and sexual health services. The Medical Devices Manager is the CSSD Lead for KCHFT and IHSS and ensure that the service runs as smoothly as possible and that any issues are dealt with in an effective and timely manner. The CSSD Lead and IHSS continue to meet regularly, and IHSS have provided evidence of ongoing independent audit compliance from Intertek.

9.0 Cleaning Services

Cleaning Services

Each site is monitored for cleanliness against the National Standards and reports are received by the IPCT monthly and included in the report to the Board. The charts below show monitoring results for environmental cleanliness within Community Hospitals.

Figure 5 : Environmental Cleaning

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15707274767880828486889092949698

100Hospital Site Audits

Faversham QVMH Sheppey Sittingbourne Deal Whit & Tank Livingstone Hawkhurst Tonbridge SevenoaksEdenbridge Gravesham

% Score

11

Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16707274767880828486889092949698

100

Faversham QVMH Sheppey Sittingbourne Deal Whit & Tank Livingstone Hawkhurst TonbridgeSevenoaks Edenbridge Gravesham

% Score

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16 Yearly %

Faversham 95.51 97.56 96.79 98.24 97.35 95.47 97.67 96.3 96.23 90.88 85.6 95.24QVMH 98.36 98.92 99.08 98.97 98.72 97.49 97.67 98.17 98.96 98.47 98.7 98.50Sheppey 96.95 95.21 96.23 96.43 95.56 95.94 94.85 95.5 94.57 95.18 94.2 95.51Sittingbourne 96.01 94.85 93.75 94.51 95.66 95.57 93.85 96.11 96.7 97.16 96.3 95.50Deal 97 97.83 96.71 98.55 97.59 98.01 97.05 97.42 98.87 98.9 99 97.90Whit & Tank 98.51 99.34 97.44 96.8 98.18 97.74 97.82 98.7 97.84 98.14 98 98.05Livingstone 97.71 97.81 97.06 95.77 97.06 96.61 97.13 93.08 95.65 94.54 97.8 96.38Hawkhurst 98.92 99.03 98.64 99.02 99.03 97.84 98.29 98.5 98.28 98.07 98 98.51Tonbridge 98.09 97.77 97.74 95.41 97.48 97.76 96.33 98.6 98.64 98.68 97.3 97.62Sevenoaks 92.25 92.41 95.29 94.6 95.47 96.85 92.66 93.93 96.34 96.28 98.3 94.94Edenbridge 93.96 97.69 94.61 94 93.43 97.77 98.01 98.85 98.91 97.8 96.50Gravesham 95.17 94.45 96.61 96.25 94.89 93.97 95.58 96.22 94.1 95.25

Sevenoaks Community Hospitals is the only site this year to have remained below the target level, only by 0.06%, this is an increase on 2014/2015 % score of 2.26% (92.68% to 94.94%). Sittingbourne’s scores have fluctuated throughout the year resulting with an overall 0.50% above the average score of 95%. Faversham score were very consistent through the year, but had a significant drop in February 2016, that did not affect the overall yearly cleaning %. All cleaning issues raised via the audit process are documented on task action list that are rectified within 24hrs of the task lists being issued.

2015/16 there was an increase in vacant positions due to additional funding being allocated for 17 WTE. This has enabled flexi positions to be introduced where new employees cover more than one site. Training of staff in post increased with hotel services staff comprising of several Infection control link workers, who provided training within their own departments.

12

During outbreaks, or increased incidence of infection, the cleaning frequencies, and products are changed to disinfectants, and there is a Trust protocol for this.

In March 2016 a new cleaning audit system – Audim was introduced to replace the out dated system – Innovise; unfortunately the two systems are not compatible. Due to the new input process of the new audit system and how this is used has resulted in some variations to the cleaning scores, hence some low % score being seen in March’s data. The new system provides more data and in a format that takes into account the split of sites between CCG’s, cleaning risk categories i.e. Very High, High, Significant and low, break down of Estates issues and Legionella reporting.

Figure. 6. Hospital Site Audits for March 2016

Mar-1684

86

88

90

92

94

96

98

100FavershamDealLinear (Deal)QVMHW&TLinear (W&T)SittSheppTonLivingstoneEdenbridgeGraveshamHawkhurstSevenoaks

10.0 Estates

The IPCT work closely with the Estates team to ensure the environment is conducive to the prevention and control of infections. IPCT are involved at an early planning stage in refurbishments, new builds and projects which involve a patient area. The IPCT risk assess any maintenance or construction activity to ensure the presence of construction workers does not pose a risk to the patients within the adjoining areas – including the removal of waste, reduction of dust within the environment and avoidance of contamination of the air supply and extract systems.

KCHFT have maintenance agreements in place with Kent and Medway Facilities (KMF) to provide assurance of compliance with requirements for water quality in all buildings where we are owners, tenants or occupiers. The Trust Water Quality and safety committee has been working with KMF and NHSPS to ensure the assurance is received by the Trust, in a timely manner, to enable any issues to be identified and rectified, and these processes are currently being reviewed.

11.0 Patient Led Assessment of the Care Environment (PLACE)

PLACE is now in its third year having replaced Patient Environment Action Team (PEAT) process which ran from 2000 – 2012. The inspection is undertaken per community hospital, as a one day assessment, each week between the period 9th March to12th June. Since the change from PEAT to PLACE in 2012 new questions and sections have been added to the paperwork in subsequent years, this means that year by year scores cannot be compared against.

13

The visits are conducted by a team of a minimum of 50% Patient assessors and 50% of KCHFT staff. This year’s assessments were also attended for the first time by NHS Property Services Staff and KCHFT Estates Team, as observers who answered any questions raised by the Patient Assessors.

The aim of PLACE assessments is to provide a snapshot of how an organisation is performing against a range of non-clinical activities which impact on the patient experience of care – cleanliness; the condition, appearance and maintenance of healthcare premises; the extent to which the environment supports the delivery of care with privacy and dignity; and the quality and availability of food and drink.

The assessment of cleanliness covers all items commonly found in healthcare premises including patient equipment; baths, toilets and showers; furniture; floors and other fixtures and fittings.

The assessment of condition, appearance and maintenance includes the above items as well as a range of other aspects of the general environment including décor, tidiness, signage, lighting (including access to natural light), linen, access to car parking (excluding the costs of car parking), waste management and the external appearance of buildings and the tidiness and maintenance of the grounds. New in this section for 2015 questions have been added regarding Access; relating to having hand rails, seating of different heights, wheelchair access - accessibility to toilets, ear loops, and space in reception / waiting areas.

The assessment of privacy, dignity and wellbeing includes infrastructural/organisational aspects such as provision of outdoor/recreation areas, changing and waiting facilities, access to television, radio, computers and telephones; and practical aspects such as appropriate separation of sleeping and bathroom/toilet facilities for single sex use, bedside curtains being sufficient in size to create a private space around beds and ensuring patients are appropriately dressed to protect their dignity.

The assessment of food and hydration includes a range of questions relating to the organisational aspects of the catering service (e.g. choice, 24-hour availability, meal times, and access to menus) as well as an assessment of the food service at ward level and the taste and temperature of food. New in this section for 2015; questions have been added relating to the availability of information relating to Food Allergens (new Legislation that came into force in December 2014). Food Taste- the scoring system has been changed to a 5 point scale from a 3 point

Dementia (New section for 2015); assessment focusses on flooring, decor and signage, but also includes such things as availability of handrails and appropriate seating and, to a lesser extent, food. The items included in the PLACE assessment do not constitute the full range of issues requiring assessment which, in total, are too numerous to include in these assessments. The National Average score for the dementia domain was relatively low at 74.51%. It is recognised that many healthcare environments are some way from being wholly appropriate for the treatment of people with dementia.

KCHFT, with the approval of the Patient Assessors completed the Dementia questions with the assistance of Rachel Daykin Lead Specialist Nurse for Dementia. This has resulted in KCHFTreporting accurate assessments of the improvements required, with an accumulative Trust score of 57.75%. The Dementia Strategy steering group are leading the improvement programme for dementia friendly environments, working with estates.

Figure. 7. KCHFT – PLACE Site Scores in 2015 14

Site Name Cleanliness Food & Hydration Privacy, Dignity and Wellbeing

Condition Appearance and

MaintenanceDementia

NATIONAL AVERAGES 97.57% 88.49% 86.03% 90.11% 74.51%

Site Averages 97.51% 90.84% 81.90% 89% 58.06%

EDENBRIDGE HOSPITAL 100% 93.62% 83.33% 88.46% 66.09%

HAWKHURST COTTAGE HOSPITAL 96.18% 85.90% 88.37% 91.41% 55.64%

SEVENOAKS HOSPITAL 90.00% 88.70% 70.50% 75.79% 51.37%

TONBRIDGE COTTAGE HOSPITAL 100% 92.37% 88.78% 96.09% 61.01%

VICTORIA HOSPITAL DEAL 97.05% 93.59% 83.62% 93.97% 50.87%

FAVERSHAM COTTAGE HOSPITAL 95.60% 81.12% 72.79% 85.71% 63.29%

QUEEN VICTORIA HOSPITAL- HERNEBAY 93.87% 91.18% 77.66% 90.00% 66.23%

WHITSTABLE & TANKERTON HOSPITAL 100% 93.17% 85.42% 87.50% 62.49%

SHEPPEY COMMUNITY HOSPITAL 100% 93.68% 88.21% 95.38% 56.03%

SITTINGBOURNE MEMORIAL HOSPITAL 98.34% 92.56% 83.17% 88.20% 56.53%

GRAVESHAM COMMUNITY HOSPITAL 99.10% 90.66% 77.36% 88.93% 50.26%

LIVINGSTONE HOSPITAL 100% 93.55% 83.55% 86.51% 56.95%

Figure. 8. Benchmarking Kent Organisational Scores

15

12.0 Audit and MonitoringThe Essential Steps programme of self-assessment is in use in all Community Hospitals and appropriate clinical teams. This monitoring tool incorporates hand hygiene, urinary catheter care, IV devices care and enteral feeding. Results of this monitoring are stored locally as CQC evidence for Outcome 8, and the results are reported to the Infection prevention and control committee – each service is required to present results minimally annually.

During 2015/16 an adapted version of the Infection Prevention Society (IPS) audit tool was used by the Infection Prevention and Control team to audit all Community Hospitals against standards of infection prevention and control, laid out in the hygiene code, and evidenced in best practice. Previously, estates and environment issues were incorporated into this audit tool however this year these were removed, and the estates team receive monthly reports from the Soft FM manager, to allow for a centralised response to these issues. In light of the change, it is not possible to compare the results of the audit this year to those previously undertaken.

12.1 Figure 9: Infection control Annual Audit results16

Organisation Name Cleanliness Food Privacy, Dignity and Wellbeing

Condition Appearance and

Maintenance

Dementia

National Averages97.57% 88.49% 86.03% 90.11% 74.51%

Trust Averages 97.59% 87.77% 84.84% 90.09% 77.44%

DARTFORD AND GRAVESHAM NHS TRUST

99.01% 90.48% 84.02% 96.07% 77.97%

MEDWAY NHS FOUNDATION TRUST

97.85% 85.28% 79.56% 81.90% 69.81%

EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST

94.44% 82.79% 77.16% 89.72% 72.19%

SOUTHERN HEALTH NHS FOUNDATION TRUST

96.22% 83.39% 89.02% 87.83% 85.23%

MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST

98.97% 91.52% 91.03% 92.32% 89.09%

KENT AND MEDWAY NHS AND SOCIAL CARE PARTNERSHIP TRUST

99.32% 90.27% 91.49% 93.95% 90.02%

KENT COMMUNITY HEALTH NHS TRUST

97.38% 90.67% 81.63% 88.87% 57.75%

Deal

Whit & Ta

nkQVMH

Favers

ham

Shep

pey

Sittingb

ourne

Gravesh

am

Seven

oaks

Tonbrid

ge

Hawkh

urst

Livingst

one

Eden

bridge

0102030405060708090

100 97 99.5 93 98 96 96 97 92 97 9891 91

Community Hospitals in-patient units 2015

8 hospitals received a GREEN rating: 96 - 100% compliance.

4 hospitals received an AMBER rating: 91 - 93% compliance.

There were no hospitals receiving a RED rating: <85% compliance.

The 3 main areas identified for improvement this year were Catheter care bundles and their full implementation Gaps in cleaning schedules of nursing equipment Hand Hygiene compliance

All areas of non-compliance produce an individual action plan which is produced by the Matron and manager, who have the responsibility to ensure actions are completed. All actions identified in these audits within the Matrons direct control have been completed.

13.0 Antimicrobial Stewardship

Antimicrobial Stewardship

The Trust has an Antimicrobial Strategy Group that is accountable to the Medicines Management Governance Group and provides reports to the Infection Prevention and Control committee. The KCHFT Antimicrobial Stewardship Committee has in place a Five Year Antimicrobial Strategy and associated action plan .The actions identified are to achieve the following objectives:

Improving infection prevention and control practices Optimising prescribing practice Improving professional education, training and public engagement

The use of antibiotics is monitored using prescribing, clinical pharmacy intervention and medicines information enquiry data on a month by month basis. Together with the results of the annual audit of antibiotic use in inpatient facilities measures to ensure optimum use of antibiotics are improved.

17

During 2015/16 a more robust system of intervention by the supplying pharmacy has been put in place. This has meant that the KCHFT Clinical pharmacist are able to intervene in timely manner to optimise patient care when prescribing is not in line with national guidance or microbiologist recommendation. This means that KCHFT has high levels of compliance with best practice.

During the coming year this year’s improvements in electronic clinical systems, particularly in dental and minor injury services, will enable contemporaneous monitoring of antibiotic prescribing in these two areas and a more proactive approach to stewardship. This combined with the national development in accessing dental prescribing data to practice and individual levels should greatly aid antimicrobial stewardship in this speciality.

Antibiotic stewardship cannot be affective if it is done in isolation and thus the sharing of data between organisations is vital. KCHFT pharmacists are active members of both the  West Kent CCG and east Kent CCGs Antimicrobial Stewardship Groups; sharing data and working on joint projects to promote antimicrobial stewardship across the whole health economy.

14.0 Waste.

14.1 Waste & Environment ServicesThe waste and environmental management service is provided to KCHFT by Kent & Medway NHS Facilities (KMF). As part of the service, KMF provide contract management, audits, training, technical advice and policy writing to KCHFT and its staff.

14.2 Waste Management PolicyThe waste management policy, procedures and guidelines are currently under review. There has been a change in legislation regarding hazardous waste producers and a new contract is due to commence on 1st September. Therefore the review has been delayed until September to ensure that all information is accurate and avoid staff confusion by any changes brought in by the new contract.

14.3 ContractsThe existing Total Waste Management (TWM) contract is due to end on 31st August and a new contract due to commence on 1st September 2016. The contract has been tendered as part of the South East NHS Total Waste Management Consortium which is comprised of 6 Acute and Non-acute NHS Trusts/Organisations in Kent & Medway. The tender process is nearly complete and the award ratification is awaited from all members. Upon contract award the existing contracts for TWM, Feminine Hygiene and Dental waste will also form part of the new TWM contract.

On 1st October 2015 all sites owned by NHS Property Services (NHS PS) and occupied by KCHFT were transferred to the KCHFT contract. This means that KCHFT pay for the invoices and are responsible for the waste management on these sites. KCHFT have historically had the contracts for all sites in the West regardless of property ownership; with NHS PS having the contracts for sites in the East. This change resulted in the transfer of 21 properties from NHS PS to KCHFT contracts.

The KMF Waste & Environment Team will also be re-tendering for the following services over the coming year; Pest Control, Grounds & Gardens and Window Cleaning.

14.4 Project Work18

The project to increase the use of offensive waste across the Trust has been put on hold until the new TWM contract commences in September. As the new contract will be different, we do not want to confuse staff with differing practices.

KMF have worked with their appointed Dangerous Goods Safety Adviser (DGSA) to develop guidance for staff on the safe management of Category ‘A’ wastes e.g. from Ebola outbreaks. Emergency kits are being deployed to set locations around the Trust and information sheets have been developed for staff on the safe packaging and transport of this waste type.

14.5 Waste Audit ProgrammeThe audit process was amended in April 2015 with a new audit form and score out of 80. There are also additional non-scoring question to ensure that information about site activity is up to date.Between 1st April 2015 and 31st March 2016, the KMF Waste and Environment Team audited a total of 42 out of the 47 sites. The 5 sites which were not completed were due to booking conflicts and will be caught up early in the 2016-17 programme.

Of the sites audited, there were 0 Red, 41 Amber and 4 Green risk ratings. All sites have been issued with actions plans to resolve any issues.

14.6 Waste Training ProgrammeBetween 1st April 2015 and 31st March 2016, the KMF Waste and Environment Team trained a total of 276 Staff over 22 sessions. In total 3 sessions were cancelled by the Learning and Development Department due to a lack of bookings. The face to face training sessions supplied by KMF are in addition to the trust e-learning package.

15.0 Patient Experience of infection prevention and control

Every month all in-patients in community hospitals are asked to participate in a 34 patient satisfaction questionnaire relating to their hospital stay. Four questions pertain to infection prevention and control:

Do you see staff wash their hands or use the hand gel before they treat you? Do staff encourage you to wash your hands or use the hand gel before meals Do staff encourage you to wash your hands or use the hand gel after going to the toilet? Is the ward that you are in clean and tidy?

The graphs below provide a month by month comparison of results.

15.1 Figure 10: Patient Infection Prevention feedback

19

April May June July August Sept Oct Nov Dec Jan Feb March0

20

40

60

80

100 99 95 97 99 97 96 98 99

Do you see staffwash / gel hands?

In figure 1 ‘do you see staff wash or gel their hands before they treat you’ for the last reporting year compliance of 95% or above has been achieved and maintained.

15.2 Figures 11 & 12: Patient Feedback on Staff Infection prevention promotion

April May June July August Sept Oct Nov Dec Jan Feb March0

20

40

60

80

100 91 91 95 96 95 96 95 93 97 95 95 97

Do staff encourage you to wash hands after using the toilet?

20

April May June July August Sept Oct Nov Dec Jan Feb March0

20

40

60

80

10086 91 91 97 92 89 89 93 92 95

86 90

Do staff offer you to clean hands before meals?

Previously, these questions were incorporated in one question, however it was not clear at which point patients were being encouraged to clean their hands, hence the questions were separated. As clearly identified above, the staff have improved on ensuring patients are encouraged to clean their hands after toileting. However, there is clear evidence that staff need to improve their encouragement around mealtimes.

15.3 Figure 12: Patient Environmental Cleanliness Feedback

April May June July August Sept Oct Nov Dec Jan Feb March0

20

40

60

80

100 99 98 99

Is the ward clean and tidy?

In figure 3 there is a consistently high standard in the cleanliness and tidiness of the ward 98% - 100%.

The Specialist Children’s services also now collate data through their patient satisfactions surveys, there are two questions pertaining to infection prevention and control:

Did you see staff wash their hands or use gel? Was the area clean and tidy?

The results of these services are presented at every Infection Prevention and Control committee, however, due to the relatively low numbers of responders, percentage compliance is often not reflective of overall opinions, however, the IPC team do follow up with any services where results are lower than would be expected.16.0 Infection Prevention and Control Training and Education

21

Infection Prevention and Control training is mandatory for all staff and compliance is monitored centrally and reported to the Board. By March 2016 Overall Trust compliance with Mandatory training reached 93.9% and Hand hygiene 92.9%, the highest rates in 3 years. Compliance amongst clinical staff was also at its highest level – 92.5% compliance with mandatory training and 91.4% compliance with hand hygiene.

Throughout the year the IPC team reviewed all training packages, and developed new E-learning resources, all approved through the education validation panel. Bespoke and targeted training is now provided at conferences, team meetings and specialist service days. External health providers have also commissioned our training, including providing KCC training for their Infection Prevention and Control Link Workers.

17.0 Link Workers Education

Kent Community Health NHS Foundation Trust continues to support and facilitate an education programme for Infection Prevention and Control Link Workers.

These staff are given time within their service to complete the aspects of their role that improve patient services, and are released to attend educational updates and meetings with the Infection Prevention and Control Team bi annually. This is an extension to their existing role and provides their colleagues with a point of contact for additional advice on infection prevention.

The Link Workers are responsible for carrying out Essential Steps monitoring (where appropriate) and hand hygiene assessments within the clinical teams, as well as working closely with the IPC team to resolve any local Infection prevention and control issues. Over 200 Link Workers are in post across the Trust and in 2015/16 the team put on 58 Link worker meetings, which provide continued professional education, audit assurance and sharing of innovations and ideas.

In October 2015, the IPC team hosted a Trust conference, predominantly for link workers, but also extended to external providers. There were over 200 attendees, who received talks and presentations from an array of experts, on outbreaks. The speakers included a consultant from Public Health England, A Consultant Microbiologist, and a nurse who worked in Sierra Leone in one of the Ebola hospitals. The conference was very well received and evaluated, and the team are already planning this year’s conference –focussing on antimicrobial resistance, and the importance of infection prevention.

18.0 Education for the IPCT

The IPCT have received ongoing education throughout 2015/16 to expand on existing knowledge and expertise. One team member has completed a post graduate certificate in infection prevention and control, and another has enrolled and commenced on the same course. A new trainee joined the team, and has successfully achieved all competencies, and completed the infection prevention and control module at Greenwich University. The other two members of the team have attended a number of conferences hosted by the Infection Prevention Society, (IPS) and one hosted by GovUK on antimicrobial resistance. Alongside the formal educational courses attended, the IPC team include a teaching section in every team meeting, with topics covered so far including Pertussis, Varicella, Water safety and hygiene and HIV.

19.0 Review and update of policies, procedures and guidance

The review and update of the IPCT policies has continued throughout 2015/16.

22

All policies and protocols are based on National guidance and are updated as new evidence is available and all Infection Prevention and Control policies are up to date. The policies /protocols reviewed and ratified this year were:

Infection Prevention and Control Policy Isolation Policy Diarrhoea Policy MRSA Screening Policy and Protocol Carbapenemase producing enterobacteriaceae Resistant Organisms Respiratory Infection in Community Hospitals Cleaning Policy Invasive devices Policy

20.0 Staff Health

Kent Community Health NHS Foundation Trust provides an occupational health (OH) service for Staff via a contract with PAM Occupational Health department. This is a new service provision, and this contract has been in place since June 2016, however some systems and processes are still not agreed, and work is ongoing to assure processes going forward. The OH providers have been asked to present quarterly at the Infection Prevention and control committee on pre-employment vaccinations, numbers of staff who are referred with needle stick injuries, skin integrity assessments, and general enquiries into staff infectious illnesses. Human Resources are working with the new provider to embed the new conract.

22.0 Collaborative Working

Throughout 2015/16 the Infection Prevention and Control team have continued to work closely and collaboratively with partner organisations, including the Kent wide HCAI reduction group, attended by Infection prevention leads from health and social care in Kent, including all Acute Trusts, all CCG’s, Kent County Council, Medway Council, Kent and Medway NHS and Social Care Partnership Trust, Medway Community Health, South East Coast Ambulance Service and Public Health England. The overall aim of the group is to adopt a healthcare economy wide approach to reduction of HCAI’s through partnership working and effective communication and pathways. The group have focussed on Community Catheter care and Clostridium difficile reduction over the last year.

23.0 Conclusion

This report highlights many improvements in Infection Prevention and Control across Kent Community Health NHS Foundation Trust, which have been sustained. Within 2015/16 particular successes were noted in reduction of Clostridium difficile infections, CAUTIs and UTIs in our community hospitals, and increased uptake of infection prevention and control training.

Focus will continue on reducing risks associated with patients in the community with long term catheters, and working collaboratively with prescribers and the medicines management team to improve antimicrobial stewardship, in light of the increasing organisms that are now multiply resistant.

The team will continue to work collaboratively internally and externally to drive forward the message of infection prevention and control, to ensure focus remains on our whole population in order to reduce health care associated infections and provide safe, effective, quality care.

23

Head of Infection Prevention and Control

Lisa White

Deputy Head of Infection Prevention and Control

Rowena Chilvers

Infection Prevention and Control Practitioners

(3 WTE)

24

Nursing and Quality Directorate

Director of Nursing & Quality

Nicola Lucey

Director of Infection Prevention and Control

April 2013

Appendix 2

TERMS OF REFERENCE

Infection Prevention & Control Committee

Document Control

Version Draft/Final Date Author Summary of changes1 Draft December

2011New Committee

2 FINAL March 2012

Accepted

3 Final June 2013 A Knox Accepted4 DRAFT September

2014L White Addition of operational team reports

and antimicrobial stewardship committee report.

5 Final October 20th 2014

L White Accepted

Review

Version Approved date Approved by Next review due

5 20/10/14 Infection Control Committee September 2015

6 12/10/15 Infection Control Committee September 2016

25

1. Statement of Purpose

This committee exists to promote quality and provide assurance to the Board in relation to all Infection Prevention and Control activities throughout Kent Community Health NHS Foundation Trust (KCHFT) and to have an overview of infection prevention and control priorities within the Trust and to ensure that this is linked with Quality agenda, clinical strategy and Governance management process. It will also provide guidance and direction on Infection prevention and control related matters within KCHFT to enable services to comply with relevant standards and legislation. This committee will challenge services to ensure there are systems in place to reduce the risk of Healthcare associated infections and promote a zero tolerance approach to HCAI.

This includes, but is not limited to:

Health and Social Care Act (2008 amended 2015) NHSLA Standards NICE Guidelines Department of Health Guidance Documents Care Quality Commission Outcome 8 – The Hygiene Code

2. Terms of Reference

2.1 To challenge, direct and support the Infection Prevention & Control Team(IPCT).

2.2 To ensure compliance with the Hygiene Code and Care Quality Commission regulations.

2.3 To ensure Infection Prevention and Control principles are incorporated into all clinical and non clinical activities of the Trust

2.4 To report to the Trust Board and Executive Team and inform them of exceptions, outbreaks and incidents and inform of actions to be taken and resources required.

2.5 To ensure compliance with all relevant local, national and international standards with regard to infection prevention & control and provide assurance on this to the Trust Board

2.6 To agree the annual infection control audit programme and monitor the results and actions stemming from the audit.

2.7 To highlight priorities for action in the Infection Prevention and Control Strategy

2.8. To monitor Infection Prevention and Control arrangements & compliance across the trust

2.9 To approve the annual Infection Prevention and Control work plan and monitor its progress and to sign off the completed DIPC annual report.

2.10 To inform the Trust Board in a timely manner of any serious problems or risks relating to Infection Prevention & Control

2.11 To monitor Healthcare associated infection against key performance indicators

2.12 To receive and approve Infection Prevention & Control policies, procedures and protocols

2.13 To receive and review risk assessments and risk management issues relating to Infection Prevention and Control and monitor Datix incidents and Serious Incidents

2.14 To receive reports from the Infection Prevention & Control team

26

2:15 To receive reports relating to cleanliness and environment from Hotel Services and Estates

2:16 To receive reports relating to antimicrobial prescribing from Medicines Management Team

2:17 To identify key standards for infection control and prevention as part of the Trust’s Clinical programme.

2:18 To ensure that robust plans for the management of outbreaks of Infection are in place and monitor their effectiveness by receiving finalised Root Cause Analysis reports

.2:19 To monitor trends in Infection control surveillance and ensure the appropriate information is

shared with the clinical and management teams.

2:20 To ensure that the appropriate Infection Prevention and Control policies and procedures are in place, implemented and monitored.

2:21 To assist in the review of any Service level agreements for contracted or commissioned services relating to Infection Prevention and Control.

2.22 To receive reports from operational services in relation to infection control

3. Responsibility

3.1 The group will be responsible for ensuring that the performance of clinical and other services in relation to Infection Prevention and Control meets all standards and legislation.

3.2 Members are responsible for submitting relevant issues & reports to the group as required and on time.

3.3 Members are responsible for dissemination of relevant information from the group to their departmental colleagues and for the implementation of any actions or reporting exceptions to this to the Group.

4. Committee Structure and Reporting

4.1 Reports will be received as described above and may vary according to the agenda.

27

Trust Board MeetingMonthly Report from IPC via Integrated Performance Report – including Cleaning Performance

Quarterly Report from IPC

Reporting Structure for Infection Prevention and Control

28

Quality

Committee

Quarterly Report from

Decontamination of Medical Devices

Group

Quarterly Report from IPC – including Cleaning

Performance. Exceptions are reported

monthly.

Infection Prevention and Control Committee

Decontamination Medical Devices Group

Minutes for Noting

Antimicrobial Stewardship Committee Minutes for noting

Water Quality and Safety Group

Minutes for Noting

4.2 The Head of Infection Prevention and Control submits a quarterly report to the Trusts’ Quality Committee and any exceptions as required.

5. Membership and Attendance

5.1 MembershipDirector of Infection Prevention and Control (Chair)Head of Infection Control (Vice Chair)Deputy Head of Infection Prevention and ControlMembers of the Infection Prevention and Control Team as requiredMember of HR Team to represent Occupational Health / Occupational health representativeHead of EstatesMedicines Management RepresentativeRepresentatives from Adult Locality DirectoratesRepresentatives from Children’s DirectoratePatient RepresentativesPublic Health England RepresentativeDental RepresentativeWaste ManagerAD of Soft FacilitiesRepresentation from the CCG as required

Members will be expected to attend all meetings and should nominate deputies to attend on their behalf if unavailable.

In Attendance

Infection Prevention and Control Team Administrator (minute taking)

5.2 Chairmanship

The chair will be held by the Director of Infection Prevention & Control (Director of Nursing and Quality).The Vice chair will be the Head of Infection Prevention and Control. The Chair will attend a minimum of 4 meetings per annum.

5.3 Quorum

The quorum will be 50% of registered members with the Chair or vice Chair present and at least one member of the Infection Prevention & Control Team present

5.4 Attendance by Others at Meetings

Any others may be co-opted onto the group as required. Members of trust staff may request to attend the group for their information. The chair must give permission for such attendance.

6. Assurance framework

All Bacteraemia and alert organisms

29

MRSA bacteraemia and screening C. difficile Infections Antimicrobial Stewardship Audit results Hand hygiene Compliance Waste Management and Environmental Cleanliness Outbreaks and clusters of Infection Training and Education attendance Policy Update programme

National reporting

All MRSA bacteraemias and Clostridium difficile infections to the relevant external organisations

Outbreaks and incidents reported as Serious Incidents where appropriate

Staff Training

Infection Control training is part of the trust wide mandatory training scheme Training is provided to all staff at induction Infection management and antibiotic treatment is part of an ongoing programme for staff Link Workers training and development

7. Sub-Groups

Infection Control will form part of the Directorate Quality Groups. The group may set up limited time sub groups to deal with specific issues and report back. Terms of reference for each sub-group shall be determined by the main group.

8. Frequency of Meetings

8.1 Meetings will be held bi-monthly

8.2 Extraordinary meetings may be organised as required

9. Support Arrangements

9.1 The chair will arrange for papers to be distributed one week prior to the meeting. Minutes will be taken by a Nursing and Quality Team Administrator.

10. Review

10.1 These terms of reference will be reviewed annually.

11. Confidentiality

11.1 The minutes of the group, unless deemed exempt under the Freedom of Information Act (2000) can be made available to the public through the meeting papers.

12. General

12.1 Reference should be made, as appropriate to the standing orders of the trust.

30

Kent Community HealthNHS Foundation TrustBoard Monthly Meeting

Quality CommitteeMonthly Meeting

Infection Prevention &Control Committee Bi-Monthly Meeting

1) Medical Devices and Decontamination Meeting2) Antimicrobial stewardship Meeting3) Water Quality and safety committee

All Kent CCG HCAI assurance

meetings

Infection Prevention and Control Governance structure.

Members of the IPCT attend and provide update reports to other groups and committees across the organisation.

Health and Safety CommitteeWaste Management GroupTrust Standards and Leadership GroupDecontamination GroupDental Quality Group

The Head of Infection Prevention and Control, or a deputy, attends the bi-monthly EKHUFT External Decontamination user Group, Kent and Medway PHE Infection Prevention and Control group, and the monthly CCG HCAI assurance meetings, and bimonthly Kent wide HCAI reduction group.

31

Infection Prevention &

Control Team

Appendix 4

Compliance with The Hygiene Code

Figure 11 shows how Kent Community Health NHS Trust has performed in 2015/16. The Trust has maintained a Green rating on all aspects of outcome 8 throughout 2015/16.

Figure 11

Compliance Criterion

What registered provider will need to demonstrate

RAG

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

Green

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

Green

3 Provide suitable accurate information on infections to service users and their visitors

Green

4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion

Green

5 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people

Green

6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection

Green

7 Provide or secure adequate isolation facilities Green8 Secure adequate access to laboratory support

as appropriateGreen

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

Green

10 Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care

Green

32