INFECTION PREVENTION AND CONTROL ANNUAL REPORT APRIL 2009 MARCH and

INFECTION PREVENTION AND CONTROL ANNUAL REPORT APRIL 2009 MARCH 2010 and INFECTION PREVENTION AND CONTROL ACTION PLAN April 20010 March 2011 Report compiled by Director of Infection Prevention and Control Lincolnshire Partnership NHS Foundation Trust

Introduction The Health & Social Care Act 2008: Code of Practice for Health & Adult Social Care (Hygiene Code) on the prevention and control of infections sets out 10 criteria against which a registered provider will be judged by Care Quality Commission (CQC) inspectors on how it complies with the registration requirements for cleanliness and infection control. Legal sanctions can be applied if findings are thought to be putting patients at risk. This report sets out the Trust s compliance against each criterion and key developments during the financial year 2009/10. Criterion 1 Systems to manage 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. Governance arrangements The Board of Directors has a collective responsibility for keeping to a minimum the risk of infection. The Board discharges this responsibility in the following ways: The Director of Nursing& Strategy is the designated Director with responsibility for infection prevention and control (DIPC). This post reports directly to the Chief Executive and the Board of Directors. Infection Control Team The Trust has a service level agreement for specialist support from a Consultant Microbiologist and an Infection Control Nurse and draws on support from the Health Protection Agency, Occupational Health Specialists and facilities and estates management. In addition the Trust Matrons and a representative from the Medical Consultant body have a key responsibility for oversight of clinical practice and a network of link nurses are in place for each inpatient unit. Infection Control Committee The Infection Control Committee was chaired by the DIPC and provided quarterly reports to a Board Committee; the Clinical Quality & Risk Committee. In addition the Board of Directors received an exception report on a monthly basis setting out newly identified isolates and outbreaks and any areas of concern. The Board of Directors also received the Annual Report for 2008/09 and approved the Improvement Plan for the 2009/10. Infection Control Audits Each inpatient area was audited on a biannual basis. A report and action plan are developed. Progress with recommended actions is tracked by the Infection Control Nurse with oversight from the Infection Control Committee. In addition the Trust carried out unannounced visits and inspections of Trust sites. 2

PEAT and Cleanliness Audits In addition audits of the general environment against the PEAT criteria were carried out biannually and cleanliness audits were carried out biannually. Decontamination of Medical Devices The Medical Director is the designated lead for decontamination and was supported by the Matron Specialist Services. Policies and Procedures An Infection Control Manual is available on the Trust Intranet. framework for safe and effective practice. This sets out the Internal Audit A review was carried out in 2009 to examine evidence available to support the Trust s assessment of compliance against the Hygiene Code. The review examined the effectiveness of controls in place and was undertaken in accordance with the Internal Audit Standards for the National Health Service. Audit Opinion The findings of the audit review indicate that the Trust has established an adequate control environment in response to the requirements of the Hygiene Code. Therefore, Significant Assurance can be provided that there is a generally sound system of control designed to meet the system s objectives. However, there is greater focus being placed on the effectiveness of established control environments. This review has identified that the Trust needs to strengthen the SLA in place with ULHT for provision of an Infection Control Team and associated services and implement the low risk actions agreed within the report to strengthen evidence supporting the embeddedness of the established control environment. Actions identified have been incorporated into the ongoing Action Plan and will be managed by the Infection Control Committee. Criterion 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. Decontamination of Medical Devices The ongoing work plan and the CQC Compliance Check (Appendix A) highlight ongoing actions in relation to the maintenance of an accurate inventory of equipment, standardisation of equipment, training, and maintenance records for medical devices. The provision of equipment to service users has been recently identified as a potential issue and is currently being scoped out. The current outstanding issues identified through the CQC Compliance Check relate specifically to the monitoring of staff training (both permanent and temporary staff) including the provision of manufactures instructions and the establishment of effective maintenance records. These tasks have been delegated to the local Ward Manager and will be audited by the Infection Control random audit programme. Until 3

sufficient evidence has been obtained through the audit programme to demonstrate embedded and effective processes, these issues will remain amber on the CQC Compliance Check and will form part of the Medical Devices Group ongoing work plan. Supply and Provision of linen and laundry The linen contract and local laundry arrangements comply with HSG(95)18. Compliance of local arrangements was audited as part of the routine infection control audit programme. Policies on the Environment The Trust has a number of policies in place in relation to cleaning services, building and refurbishment, waste management, infected linen, planned preventative maintenance, pest control, drinkable and non-drinkable water, legionella and road services. Representation at the Infection Control Committee by Estates and some aspects of facilities management was poor and will be a focus for attention in the 2010/11 plan. Cleaning Services The Trust has made significant improvements in the overall assurances and processes for cleaning during 2009/10. Cleaning routines were made publically available in all inpatient areas. Additional resources for housekeeping services have been put into Langworth Ward at Witham Court and Manthorpe Centre, Grantham. A comprehensive training and competency package has been developed for all housekeeping and cleaning staff. PEAT The Trust undertook regular audits and inspections to monitor the effectiveness of the systems in place with regard to cleanliness of the environment and infection control and prevention. Hotel Services carry out the internal PEAT and Cleanliness Audits based on The National Specifications for Cleanliness in the NHS: A Framework for setting and Measuring Performance Outcomes) these are each done in rotation quarterly and looks at not only issues of cleanliness but also environmental factors such as the state of the decoration. Outcomes were communicated to Ward Managers and Matrons and reported back through quarterly PEAT meetings. Overall Audit results Cleanliness Audit May 2009 Internal PEAT Audit Nov 2009 (Highest possible score = 5) National PEAT Environment Score 2009 National PEAT Environment Score 2010 Saxon Ward 90.67% 4.45 Acceptable Good Doddington Ward 95.59% 4.69 Bungalows 1-2 96.53% Good Excellent Bungalows 4-5 96.30% 4.62 Ward 12 94.92% 4.58 Good Good Rochford Unit 91.35% 4.67 Charlesworth Ward 91.67% 4.61 Connolly Ward 96.44% 4.41 Good Good 4

Overall Audit results Cleanliness Audit May 2009 Internal PEAT Audit Nov 2009 (Highest possible score = 5) National PEAT Environment Score 2009 PHC Day Ward 87.39% 4.6 Langworth Ward 91.03% 4.59 Good Good Brant Ward 88.94% 4.41 National PEAT Environment Score 2010 Sycamore Assessment 94.42% 4.56 Not included Not included Unit Holly Lodge 68.00% 4.1 Acceptable Acceptable Manthorpe Centre 80.98% 4.57 Good Acceptable Ashley House 91.80% 4.54 Excellent Good Maple Lodge 97.43% 4.69 Excellent Excellent Francis Willis Unit 89.44% 4.5 Good Good Ash Villa 95.80% 4.51 Good Good The 2010 Patient Environment Action Team (PEAT) programme commenced in January 2010. As in previous years, all sites with ten or more inpatient beds were eligible for inclusion. There were no changes to the Trust units and wards that were required to be audited. This theoretically allows for comparison with the 2009 results to determine whether work undertaken in the last year to address PEAT has resulted in improvements to the scores. There has been one change, however, that needs to be considered when comparing scores. The National Specification for Cleanliness score, which is compiled by the Trust and included with the scoring, has increased for the excellent bracket: in previous years, a score of 85% was required to achieve excellent in the environment section; a minimum of 93% was required this year. The scores that have been achieved by the Trust show that two Trust units scored lower this year than last due to this change. Work has already commenced to address the cleanliness standards, and ensure these units achieve a higher cleanliness score in 2010/11. Bed Space Cleaning The Trust has implemented a process to ensure that all bed spaces are cleaned in accordance with NHS Cleaning Standards. Following cleaning an A4 card is placed on the bed to provide patient and members of the public with assurance of cleanliness. Criterion 3 Provide suitable accurate information on infections to service users and their visitors. The Trust makes available information relating to MRSA screening and decolonisation, C.difficile and other isolates and outbreaks as they arise. Availability of information is audited as part of the routine infection control audit programme. 5

Criterion 4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion. Information relating to the status of patients was communicated as part of the discharge and transfer processes. MRSA Screening A risk based policy for screening patients for MRSA colonisation was introduced in March 2009. Compliance with screening is audited monthly; the Trust is 100% compliant with the screening of high risk patients for MRSA. Outbreaks and New Isolates Outbreaks and New Isolates No Group G Streptococcus 2 Group A Streptococcus 0 MRSA colonisation (Previously known) 14 MRSA colonisation (Screened after 48hrs) 4 MSSA 1 C. difficile 0 Glycopeptide Resistant enterococci 0 Gentamicin-resistant coliform 0 Extended beta lactamase +ve coliform 0 Outbreaks & Incidents Outbreak type Clinical Area No. Patients Affected Norovirus Manthorpe Grantham No. Staff Closed to Affected admission & Discharges 9 6 1.10.09 6.10.09 Norovirus Langworth Ward 8 9 13.03.10 19.03.10 Norovirus Brant Ward 4 3 26.03.10 31.03.10 Criterion 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. All infections and outbreaks are reported to the Infection Control Committee and to the Health Protection Agency (HPA) as required. There have been no outbreaks or infections of sufficient severity to require reporting to the HPA in 2009/10. Data on all infections and outbreaks was shared with the HPA via the Infection Control Committee. 6

Criterion 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. Estates and Facilities Estates and facilities support is provided by NHS Lincolnshire Shared Services. A change of building / room use checklist is in place to ensure effective involvement of the Infection Control Team in the design of Trust accommodation. In addition infection control professionals have been involved in all stages of the design process for the new rehabilitation scheme. Significant improvements have been made on the processes for prioritising minor and major capital projects linked to the findings of infection control audits and environmental audits. Criterion 7 Provide or secure adequate isolation facilities. Due to the nature of the patient population, it can, at times be difficult to isolate patients to minimise the spread of infection. A local policy based on risk is in place and individual requirements for isolation are managed on a case by case basis. Criterion 8 Secure adequate access to laboratory support as appropriate. Support is provided as part of the Trust s Service Level Agreement with an accredited laboratory. Criterion 9 Have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent and control infections. The Trust has a comprehensive infection control manual which is reviewed and updated on an ongoing basis. 7

Criterion 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. Training The Trust revised its mandatory training framework in 2009. All inpatient clinical staff and housekeepers are required to have hand hygiene training on an annual basis. Hand Hygiene Training Compliance with hand hygiene training in 2009/10 is 58%. approved to increased compliance to 100% by March 2011. A trajectory has been Inoculation Incident Training (Sharps) All inpatient and substance misuse staff are required to complete training on an annual basis. Compliance rates are very low and there are problems with capturing training data. This will be a focus for the 2010/11 plan. General Infection Control Precautions All staff are required to complete general infection control training on an annual basis. There have been difficulties accessing the nationally agreed e-learning package. A local training package is in development and compliance with this training will be a key focus in the 2010/11 plan. SUMMARY Trust staff have made progress with respect to infection prevention and control (IPC) during the year. However, there are several actions that need attention in 2010/11: review of the IPC Team provision via the SLA with ULHT, adequacy of the decontamination of medical devices, environmental cleanliness scores in some parts of the Trust and increase in compliance of hand hygiene, inoculation incident and general infection control training for staff. 8

APPENDIX A Medical Devices Annual Report 2009/2010 1. Introduction This provides an update against the group s last work plan, followed by a summary of additional activities conducted by the Medical Devices Group since the last report. A work plan is then set out, which identifies the ongoing tasks for the group. The Care Quality Commission Compliance Check is presented at Appendix 1. 2. Progress against previous work plan 2.1 Inventory The Medical Devices Group (MDG) continues to utilised service representatives and the line management structure to reinforce the importance of the Trust inventory and the necessity for teams to return the annual census. However, there is a potential for individual teams/staff to purchase equipment and not complete the required inventory form and some teams failed to return the annual census update last year so accurate data is not available from Shared Services. The annual census is due again in the coming weeks; it has been decided to issue the requests to Building Managers for action rather than individual teams to limit the span of responsibility. 2.2 Standardised Product List The list of approved reusable medical devices and their individual maintenance requirements, produced in conjunction with ULHT Clinical Engineering and Support Services, has been sent directly to all Ward Managers and disseminated to other teams via the service representatives on the MDG. A more detailed list of approved medical devices that includes information on purchase cost, product life time and ongoing maintenance costs has been developed and provided to the Assistant Director of Operations and the Head of Estates and Facilities to inform future budget allocation. The current advice to services is to replace equipment as required with items from the approved product list. However, if agreement is reached to upgrade all equipment then a further piece of work will be required to assess each team s requirements. 2.3 Training The Medical Devices Group note any safety alerts or hazard notes issued by the MHRA. There is a separate system through which the alerts are distributed to all units and teams and action points recorded. The group is also notified of any untoward incidents in the Trust involving medical devices and identifies further action as required. Ward Managers have been instructed to maintain local staff training records as required by the CQC compliance framework. It was decided by the Infection Control Committee that audit of these training records would be included in the Infection Control random audit programme. This issue will remain amber on the CQC 9

compliance check report below until sufficient audit data has been received and the Infection Control Committee is happy to sign off. 2.4 Maintenance of Medical Devices A Service Level Agreement is in place with ULHT for the maintenance of medical devices. In the absence of an automated system to identify when equipment is due for servicing, it is the responsibility of the Ward/Unit Manager to maintain local records and send devices to Clinical Engineering as and when required. Ward Managers have been instructed to maintain local staff maintenance records as required by the CQC compliance framework. It was decided by the Infection Control Committee that audit of these training records would be included in the Infection Control random audit programme. This issue will remain amber on the CQC compliance check report below until sufficient audit data has been received and the Infection Control Committee is happy to sign off. 3. Additional Activities 3.1 Green is Clean Green is Clean is now sorted out large pieces of equipment are being labelled up; staff are being encouraged to use common sense when labelling up equipment and to be aware of cleaning requirements. 3.2 Provision of Equipment to Service Users It has recently come to the attention of the MDG that Occupational Therapy Services in the Older Adult division do issue some equipment to Service Users, particularly mobility aids. The extent of this issue is yet to be determined and processes around ongoing suitability checks need to be addressed. The Older Adult Services Lead Occupational Therapist is currently scoping the issues and has been invited to the next MDG to feed back. 4. Work Plan Work stream Specific Actions Review Date Lead Inventory Monitor the return on the annual census of equipment. Encourage staff participation through service representatives. Census requests to be sent to Building Managers not individual teams. Annual Review Chair of Medical Devices Group & LSS Lead Standardised Product List List of approved reusable medical devices now available. Scoping exercise conducted identifying estimated annual costs for continuous upgrade of equipment. Further work needed to determine each teams requirements to fully adhere to the approved product list is it is deemed viable by the Trust. July 2010 Chair of Medical Devices Group 10

Work stream Specific Actions Review Date Lead Training Maintenance of Medical Devices Care Quality Commission compliance check Monitor any training requirements in relation to any safety alerts. Audit local training records including provision of manufacturers instructions via the Infection Control Audit Infection Control Nurse to audit local maintenance records via the Infection Control Audit. Monitor the level of compliance against C4(b) and C4(c) July 2010 July 2010 All group members Infection Control Lead Nurse Infection Control Lead Nurse All group members Provision of Medical Devices to Service Users Issues currently being scoped out and to reported back to MDG for action. July 2010 Older Adult Services Lead Occupational Therapist 11

Appendix 1 Medical Devices Care Quality Commission Compliance Check Core Standard C4b safe use of medical devices (Provider) Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised. Element 1 The healthcare organisation has systems in place to minimise the risks associated with the acquisition and use of medical devices in accordance with guidance issued by the Medicines Healthcare products Regulatory Authority. Line of enquiry a The healthcare organisation has systems and monitoring processes in place for the management of medical devices set out by the MHRA which must include: Specific enquiry LPFT evidence Status An appointed director or board member with overall responsibility for medical devices management. An advisory group in place that includes those involved in the use, commissioning, maintenance, decontamination and decommissioning of medical devices. An organisation-wide devices management policy that covers acquisition, record keeping and equipment inventories; availability of manufacturer s instruction for use; training; repair and maintenance; single use devices; decommissioning; disposal and actions required on manufacturer s corrective action notices. Monitoring of performance on medical devices management by an annual report sent to board Appointed director Dr Mostafa Mohanna, Medical Director (MD Policy ref: 4.1) See quarterly Medical Devices Group - Terms of Reference (MD Policy ref: 4.2 & Terms of reference at Appendix B) Medical Devices Management policy in place and updated in 2009 Acquisition: Sec 5 Procurement Record keeping: Sec 4 Duties (Equipment Controllers) Equipment Inventories: Sec 10.3 (Inventory Policy COR/16) Manufacturer s instruction: Sec 7.10 & 14.1 Training: Sec 7 Repair and maintenance: Sec 10 Single use devices: Sec 12 Disposal/Decommissioning: Sec 11 Corrective action notices: Sec 13.2 Annual report produced by Medical Devices Group and reported to Clinical Governance Committee 12

Line of enquiry b The healthcare organisation ensures that its acquisition of all medical devices addresses safety by: Specific enquiry LPFT evidence Status Ensuring user experience represented in advisory group is taken account of in purchasing decisions. Operational services represented at Medical Devices Group See terms of reference Also see Medical Devices Management Policy Section 5.22 (ii) specialist staff involvement with standardisation process. Having a selection process in place that rationalises the range of medical device models See Medical Devices Management Policy Section 5.22 Line of enquiry c The healthcare organisation ensures that medical devices are used safely by permanent staff (including new staff), temporary staff and end users by: Specific enquiry LPFT evidence Status Providing appropriate training for all permanent staff (including new staff) authorised to use any medical devices. Ward Mangers/Team Coordinators responsible for staff training and maintaining training records. These are kept locally and randomly audited as part of the infection control audit; as agreed at the Infection Control Committee on the 13 th October 2009 and confirmed by e-mail to the staff group and the Committee on 16 th November 2009 Frequency and mode of training is identified in appendix K of the Medical Devices Management Policy; also see appendix L for training record from Providing appropriate training for all temporary staff and end users Ward Mangers/Team Coordinators responsible for staff training and maintaining training records. These are kept locally and randomly audited as part of the infection control audit; as agreed at the Infection Control Committee on the 13 th October 2009 and confirmed by e-mail to the staff group and the Committee on 16 th November 2009 Frequency and mode of training is identified in appendix K of the Medical Devices Management Policy; also see appendix L for training record from For end users see Medical Devices Management Policy Section 7.8 13

Ensuring clear manufacturer s instructions for use are available to all permanent staff (including new staff), temporary staff and end users authorised to use medical devices. See Medical Devices Management Policy Section 7.9; section 7.8 for end users. This information is provided as part of the training programme for each device and therefore records of manufacturers instructions being issued to staff is included in the local training record. This was confirmed to all Ward Managers/Team Coordinators by e-mail on 16 th November 2009. Line of enquiry d The healthcare organisation ensures that medical devices are maintained and repaired to original performance standards by: Specific enquiry LPFT evidence Status Having a record of medical devices and equipment that facilitate a systematic approach to medical device management. Inventory of all equipment, including medical devices, maintained by Facilities in accordance with LPFT Policy COR 16. Ward Mangers/Team Coordinators responsible for device lists and maintenance records. These are kept locally and randomly audited as part of the infection control audit; as agreed at the Infection Control Committee on the 13 th October 2009 and confirmed by e-mail to the staff group and the Committee on 16 th November 2009 Having a mechanism to obtain feedback from all users (permanent staff (including new staff), temporary staff and end users) of medical equipment on all aspects of the repair and maintenance processes. Having random audits performed on all elements of maintenance and repair to ensure that correct procedures are in place and being adhered to. Feedback can be brought to the Medical Devices Group by operational service representatives for action/information. Maintenance SLA with ULHT allows issues to be reported direct from User to Clinical Engineering. Ward Mangers/Team Coordinators responsible for device lists and maintenance records. These are kept locally and randomly audited as part of the infection control audit; as agreed at the Infection Control Committee on the 13 th October 2009 and confirmed by e-mail to the staff group and the Committee on 16 th November 2009 14

Line of enquiry e The healthcare organisation ensures that all maintenance/repair staff are competent in maintaining and repairing medical devices by: Specific enquiry LPFT evidence Status Ensuring maintenance/repair staff, including contractors, are appropriately qualified. Providing adequate training to maintenance/repair staff (including the recognition of differences between single use, single patient use and reusable devices). This training provision does not apply to contractors. Maintenance SLA with ULHT specifies qualifications for staff groups: Head of service Registered healthcare Scientist specialising in Medical Equipment management. Technical Staff BTEC National Certificate level or better and trained to the standards of the national manual in Medical Physics. Also, no equipment will be maintained until technical staff are appropriately trained. Maintenance SLA with ULHT specifies qualifications for staff groups: Head of service Registered healthcare Scientist specialising in Medical Equipment management. Technical Staff BTEC National Certificate level or better and trained to the standards of the national manual in Medical Physics. Also, no equipment will be maintained until technical staff are appropriately trained. Line of enquiry f The healthcare organisation ensures that devices designated single use are not reused: Specific enquiry LPFT evidence Status No specific enquiry Full information and guidance are provided in the Infection Control Manual at 2.10 Re-use of single use device would be a clinical incident and as such would be reported via Sentinel. All medical devices incidents are monitored by the Medical Devices Group. Element 2 The healthcare organisation has systems in place to meet the requirements of the Ionising Radiation (Medical Exposure) Regulations 2000 [IR(ME)R] and any subsequent amendments. Line of enquiry a The employer (Trust) ensures that written procedures for medical exposures are in place, as required in schedule 1. Regulation 4(1) of IR(ME)R. Line of enquiry b The employer (Trust) ensures that written protocols are in place for every type of standard radiological practice for each equipment regulation 4( ) of IR(ME)R. Line of enquiry c Arrangements are in place, which clearly describe when the organisation should notify to the Care Quality Commission, an exposure much greater that intended, as 15

required in regulation 4(5). Specific enquiry LPFT evidence Status No specific enquiries LPFT do not perform procedures that involve Ionising Radiation. Core Standard C4c Decontamination Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed. Element 1 Reusable medical devices are properly decontaminated in accordance with The Health Act 2006 Code of Practice for the Prevention and Control of Healthcare Associated Infections (Department of Health, 2006 revised January 2008) Line of enquiry a The healthcare organisation has designated a lead manager for the decontamination of reusable medical devices (Hygiene Code Duty 4b). Specific enquiry LPFT evidence Status No specific enquiry Mary Matthews Infection Control Nurse Line of enquiry b The healthcare organisation must, with a view to minimising the risk of HCAI, ensure that there are effective arrangements, for the appropriate decontamination of reusable medical devices. (Hygiene Code Duty 4f). Specific enquiry LPFT evidence Status No specific enquiry Process explained in section 2.3 of Infection Control Manual Sterilisation, Disinfection and Cleaning Guidelines ; referenced in Medical Devices Management Policy section 8 Decontamination. Trust wide Green is Clean initiative now in place to identify devices that have been cleaned ready for use. Line of enquiry c The healthcare organisation assesses the risk of acquiring HCAI and takes action to reduce or control such risks. In doing so they must have: Specific enquiry LPFT evidence Status Made a suitable and sufficient assessment of the risks to patients in receipt of health care with respect to HCAI and the decontamination of reusable medical devices (Duty 3a) Definitions are provided in the Infection Control Manual Sterilisation, Disinfection and Cleaning Guidelines of the risk category for different types of medical device. In addition, the incident reporting process identifies any incidents relating to medical 16

devices and outbreaks of infection. These incidents are monitored by the Infection Control Committee and the Medical Devices Group. Identified the steps that need to be taken to reduce or control those risks (Duty 3b) Specific guidance is provided in the Sterilisation, Disinfection and Cleaning Guidelines regarding the cleaning and decontamination of common reusable devices and information is provided to address items not listed. Record its findings in relation to duties 3a and 3b (Duty 3c) Implement the steps identified (Duty 3d) Appropriate methods in place to monitor the risks of infection such that it is able to determine whether further steps need to be taken to reduce or control HCAI (Duty 3e) Incidents involving medical devices of outbreaks of infection are investigated in line with the Incident Reporting policy and Risk Management strategy, thought which, Lessons are learnt and disseminated across the Trust. Trust wide Green is Clean initiative now in place to identify devices that have been cleaned ready for use. Cleaning Process are documented in the Sterilisation, Disinfection and Cleaning Guidelines. Full investigation reporting is completed and stored on the electronic incident management system. Any Lessons from incidents are shared with teams via the service representatives at the Medical Devices Group and the Infection Control Committee (See Terms of Reference). Trust wide Green is Clean initiative now in place to identify devices that have been cleaned ready for use. Process in place and described within section 2.19 of the Infection Control Manual Surveillance of Healthcare Acquired Infections. Rates of infection are monitored by the Infection Control Committee and reported to the Board of Directors in a quarterly report. 17

LINCOLNSHIRE PARTNERSHIP NHS FOUNDATION TRUST INFECTION PREVENTION & CONTROL ACTION PLAN 2010/11 CRITERIA EVIDENCE ACTIONS REQUIRED The Trust has a Director of Infection Prevention and Control, the Director of Nursing & Strategy who reports directly to the Chief Executive Criterion 1: The Trust has in place systems to manage 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. Annual Reports and prospective action plan to Board of Directors REPORTING/ ASSURANCE Annual Report Annual Report LEAD OFFICER CEO Director of Nursing & Strategy TIMESCALE RISK ASSESSMENT Monthly HCAI exception reports to Board of Directors and Quality reports and analysis by Infection Control Committee and ongoing Board Reports/ CQ&R Committee quarterly reports Director of Nursing & Strategy Infection Control Audit programme Bi- Annual Audits of all inpatient facilities ICC Quarterly reports ICN Infection Control Strengthen follow up ICC reports ICN/Training 18

CRITERIA EVIDENCE ACTIONS REQUIRED training programme of actions arising from Policy & Procedure audits and links to Manual capital plan. REPORTING/ ASSURANCE LEAD OFFICER dept TIMESCALE RISK ASSESSMENT Update policy & procedure manual ICC Minutes Director of Nursing & Strategy October 2010 Internal audit report Hygiene Code compliance Agree SLA for IC provision ICC Director of Nursing & Strategy/ Director of Finance & Compliance October 2010 Agree Health Community wide IC programme and priorities and risk assessment Countywide ICC Director of Nursing & Strategy October 2010 Criterion 2: The Trust provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. Deep Clean programme in place Improve evidence of compliance with National cleanliness standards Agree SLA for soft facilities management with Shared Services Quarterly report on Cleanliness ICC Facilities Manager Head of Estates & Facilities October 2010 19

CRITERIA EVIDENCE ACTIONS REQUIRED PEAT scores Improve PEAT Scores for those areas not demonstrating excellent scores REPORTING/ ASSURANCE PEAT Report to ICC LEAD OFFICER Director of Nursing & Strategy TIMESCALE November 2010 RISK ASSESSMENT AMBER Routine Cleaning Schedules in place Quarterly Updates PEAT Matrons Decontamination of Medical Devices in place Improve compliance with decontamination of common household devices i.e. nail clippers etc Incorporate into unit audits Matron Specialist services Medical Devices training plan Ensure consistent approach to training Quarterly Report to ICC Matron Specialist services AMBER Laundry supply and provision conforms to HSG (95)18 Quarterly report to ICC Facilities Manager Lack of adequate hand washing facilities Witham Court. Hand hygiene protocols in place to minimise risk. Annual report Quarterly reports on Unit Audits ICN ICN AMBER Incorporate into unit audit programme ICN September 2010 20

CRITERIA EVIDENCE ACTIONS REQUIRED REPORTING/ ASSURANCE LEAD OFFICER TIMESCALE RISK ASSESSMENT Policies on management of the environment Strengthen assurance on adherence to building policies ICC Estates Lead October 2010 Approved Dress policy Local policy to be approved Director of Operations Criterion 3: The Trust provide suitable accurate information on infections to service users and their visitors. Annual report and action plan published on Trust website HCAI Leaflets on MRSA, C Diff in place Quarterly report on unit audit programme Director of Nursing & Strategy Matrons ICP for MRSA, C Diff Monthly Audit of MRSA Pathway in place. C. Diff By Exception ICN Develop leaflet for Norovirus Consultant Microbiologist October 2010 Infection Control included in discharge letters Incorporated into Unit Audit programme and Discharge & Transfer Policy Matrons 21

CRITERIA EVIDENCE ACTIONS REQUIRED Criterion 4: The Trust Audit of Information Improved reporting in provide suitable available audit programme accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion. REPORTING/ ASSURANCE Bi-annual audit reports LEAD TIMESCALE RISK OFFICER ASSESSMENT ICN/ Matrons October 2010 Criterion 5: The Trust 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. Screening and decolonisation in place for high risk client groups All infections and outbreaks routinely reported to DIPC to approve appropriate action Monthly Audit of Compliance ICC Quarterly outbreaks report Monthly Reporting to BOD & LtPCT Director of Nursing & Strategy ICN/Matrons Monitoring Policies in place to minimise transmission of infection Minutes of ICC Unit Audit Programme ICC 22

CRITERIA EVIDENCE ACTIONS REQUIRED Progress reports on capital Criterion 6: The Trust ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection. REPORTING/ ASSURANCE LEAD OFFICER Reports to ICC Assistant Director of Operational Development TIMESCALE RISK ASSESSMENT Criterion 7: The Trust provide or secure adequate isolation facilities. Infection Control Audits Exception reports reports to DIPC & ICC Reports to ICC Exception reports to DIPC & ICC ICN Matrons Criterion 8: The Trust secure adequate access to laboratory support as appropriate. Isolation Policy Lab services in place and confirm to Clinical Pathology Accreditation Standards (UK) Ltd IC Manual SLA in Place/ Annual Accreditation Matron Acute ICT Criterion 9: The Trust have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent Policy & procedures on Trust Intranet reflect current and best practice Review Policy Manual ICC Minutes PA to Director of Nursing & Strategy Director of Nursing & October 2010 23

CRITERIA EVIDENCE ACTIONS REQUIRED and control infections. REPORTING/ ASSURANCE LEAD OFFICER Strategy TIMESCALE RISK ASSESSMENT Audit programme identifies any areas of non-compliance Strengthen follow up of action plans Quarterly report of Unit Audits ICN/ Director of Nursing & Strategy Criterion 10: The Trust 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. Occupational Health SLA Post Incident prophylaxis available Compliance with training: Hand hygiene Inoculation incidents General IC systems Improve compliance with mandatory training Exception Report to ICC Quarterly reports to ICC Training reports to ICC Team Prevent Untoward Incident Manager Training Manager/ Matrons March 2011 AMBER 24