INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2011/12 Introduction The Trust takes a zero tolerance approach to preventable infections. Infection prevention and control is at the heart of good management and clinical practice and emphasis is given to prevention of healthcare associated infection, the reduction in antibiotic resistance and the improvement in cleanliness in our healthcare environments. This report has been written to provide information about infection prevention and control in Lincolnshire Partnership NHS Trust in 2011/12. This information will be of interest to patients, carers, staff and the public. In publishing this report we recognise that patients and the public need information about this aspect of hospital care in order to make decisions about their healthcare. The onward format of the report is based on the criterion as stated in the Hygiene Code. 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. 1.1 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 & Operations 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. 1.2 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. 1.3 Infection Control Committee The Infection Control Committee is chaired by the DIPC and provides quarterly reports to a Board Committee; the Quality Committee. In addition the Board of Directors receives an exception report on a monthly basis setting out newly identified isolates and outbreaks and any areas of concern. The Board of Directors also receives the Annual Report and approves the Improvement Plan for the forthcoming year. 1.4 Infection Control Audits Each inpatient area is audited on a biannual basis, and 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 carries out unannounced visits and inspections of Trust sites. 1.5 PEAT and Cleanliness Audits In addition audits of the general environment against the PEAT criteria are carried out biannually and cleanliness audits are carried out biannually. 1.6 Policies and Procedures An Infection Control Manual is available on the Trust Intranet. This sets out the framework for safe and effective practice.
Criterion 2: Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. 2.1 Decontamination of Medical Devices The Medical Director is the designated lead for decontamination and is supported by the Matron Specialist Services. The ongoing work plan and the CQC Essential Outcome 9 standards highlight the key areas for the Medical Devices group and identify compliance. The current outstanding issues identified are: Inventory returns maintaining a list of equipment in units which is updated annually returns have to be chased several times Ensuring maintenance is carried out as per contract especially air flow mattresses, profiling beds the Matron is working with back care team on this Consideration of using disposable slings for hoists is currently underway this would be better from an infection control point of view but consideration needs to be given to the impact of doing this particularly cost implications Full compliance is demonstrated against standards of decontamination in Appendix 2. 2.2 Supply and Provision of linen and laundry The linen contract and local laundry arrangements comply with HSG (95)18. Compliance of local arrangements is audited as part of the routine infection control audit programme. 2.3 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 Facilities is in place. 2.4 Cleaning Services The Trust has made significant improvements in the overall assurances and processes for cleaning during 2011/12 and will continue to monitor standards during 2012/13. The audit scores are shown in table 1. It should be noted that: in December 2011 Manthorpe was re-audited and the score had increased to 94%. in June 2012 Francis Willis Unit was re-audited and the score increased to 94.1%. Cleaning Schedules are made publically available in all inpatient areas and these are currently under review. A programme of audits is undertaken for the environment and cleanliness though hotel services. The units receive only 24hour notice that they are being undertaken to support the Trust in its assurance that cleanliness standards are consistent. A comprehensive training and competency package is in place for all housekeeping and cleaning staff. 2
Table 1 - Cleanliness Audit Scores for 2011/12 UNIT WARD DATE SCORE DATE SCORE MAIN ISSUES Carholme Court Long Leys Bungalows Department of Psychiatry PHC Francis Willis Unit Saxon Ward 11.10.11 80.00% Doddington Ward 11.10.11 82.00% Used as decant ward and scored under Ash Villa Admin Area 11.10.11 65.00% High & low level dust, kitchen requires cleaning, Bungalows 1-2 05.10.11 93.77% 26/04/2012 87.77% build up underneath soap dispensers, lime scale on taps High and low level dust, kitchen requires Bungalow 3 05.10.11 87.00% 26/04/2012 81.94% cleaning, build up underneath soap dispensers, corners and edges of flooring Bungalows 4-5 05.10.11 91.35% 26/04/2012 93.92% Minor dust issues. Ward 12 05.01.12 95.78% 13/06/2012 98.10% Minor dust issues. Rochford Unit 05.01.12 94.48% 13/06/2012 94.80% Charlesworth Ward 18.10.11 98.60% 02/05/2012 92.21% Connolly Ward 18.10.11 96.14% 02/05/2012 92.47% High level dust on hand towel dispensers and top of cupboards in toilets/bathrooms High and low level dust especially in clinic, build up underneath soap dispensers. High and low level dust, lime scale on taps, corners of flooring require attention Day Centre 18.10.11 89.44% 02/05/2012 93.20% High and low level dust but nothing major. 02.11.11 85.71% 19/06/2012 94.10% Ash Villa 17.11.11 94.46% 15.05.12 91.43% Witham Court Sycamore Assessment Unit Manthorpe Centre Langworth Ward 10.11.11 96.22% Brant Ward 10.11.11 83.46% 24/05/2012 92.17% 24.11.11 92.86% 19/04/2012 95.50% 09.12.11 77% Some high & low level dust issues. Nothing major. Big improvement. Ash Villa based at Carholme Court. Issues were high dust, dusty dispensers, dust on chair framework, and low level cobwebs behind one door and underneath a bed. Minor high & low level dust, not consistent across ward. Some chair framework. High and low level dust (minor), chair framework, underneath soap dispensers Ashley House 24.11.11 90.51% 19/04/2012 92.04% High and low level dust. Maple Lodge 06.12.11 97.90% 17/04/2012 98.80% Very slight dust in one area. Discovery House Key The Fens (male) 11/04/2012 98.25% The Wolds (mixed) The Vales (Female) 80% or below 80.1-85% 85.1-90% Above 90% 11/04/2012 90.58% 11/04/2012 96.68% Build up underneath soap dispensers, mark on wall in de-escalation area. High & low level dust. Thick dust on some skirtings, especially in bedrooms. Kitchen floor sticky, microwave dirty, canopy requires cleaning. Urine caked around toilet and floor of de-escalation room. Dust in dining area. High level dusting in kitchen, waiting area, dining room, and drinks area. Flooring requires attention. Debris underneath seats in waiting area. Kitchen bin dirty. Microwave requires cleaning. 3
2.5 Patient Environment Action Team (PEAT) The Trust undertakes 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 they look at not only issues of cleanliness but also environmental factors such as the state of the decoration. Outcomes are communicated to Ward Managers and Matrons and reported back through quarterly PEAT meetings. The meeting chair and estates lead sit on the Operational Capital Group meetings to ensure a robust relationship exists between the assessment outcomes and capital spend. The 2012 Patient Environment Action Team (PEAT) programme commenced in January 2012. 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 2011 results to determine whether work undertaken in the last year to address PEAT has resulted in improvements to the scores in some areas (table 2). Table 2 - Patient Environment Action Team Scores Site Name Privacy & Dignity Food score Environment 2009 2010 2011 2009 2010 2011 2009 2010 2011 Long Leys Court Ashley House Self Catering Self Catering Self catering Acceptable Carholme Court Acceptable Self catering Witham Court Maple Lodge Self Catering Self Catering Self catering Holly Lodge Acceptable Acceptable P. Hodgkinson Centre Francis Willis Unit Pilgrim Hospital Site Manthorpe Centre Acceptable N/A N/A N/A N/A Acceptable Ash Villa The Patient Environment Action Team (PEAT) visit inpatient units and assess against nationally agreed criteria, including the standard of cleanliness, food, environment, décor, access and signage. A PEAT inspection can be carried out by an independent team from outside of the Trust or by an internal Trust team - members include service users, matrons, Directors and Head of Facilities/Estates. Actions are identified and addressed by the relevant teams and action plans are monitored through the Patient Environment Action Group (PEAG) which also has service user representation. Work has already been undertaken to improve the areas which have dropped in rating from the previous year, new standards were added in 2010/11 related to privacy and dignity which have been addressed during 2011/12. Overall, performance has improved in two areas, remained static in 18 areas and declined in seven areas. The two areas of improvement are both at the Manthorpe Centre for environment and privacy and dignity scores. 4
Of the downward trends, three are within the environment scores for Long Leys Court, Ashley House and PHC; two within the food score for PHC and Francis Willis Unit and two within privacy and dignity score for Ashley House and Ash Villa. Since the 2011 inspection programme a significant programme of improvement works has been developed as part of the capital programme. Much of this work focuses on improving bathrooms and toilet areas as these were the areas which had an adverse effect on the 2011 scores. Work is currently being carried out at: Peter Hodgkinson centre Francis Willis unit Rochford Unit Long Leys Bungalows Maple Lodge Ashley House More extensive programmes of work will commence in 2012/13 at: Witham Court Ash Villa The catering contract has also changed since the 2011 programme and this was predicated to improve the food scores at many of the units. However, this will be re-reviewed following recent feedback from service users. PEAT scores for 2012 indicate improvements in scoring or maintenance of 2011 scores. A further work plan is being drafted for 2012/13. 2.6 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. 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 is communicated as part of the discharge and transfer processes. 4.1 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 remains 100% compliant with the screening of high risk patients for MRSA. Table 3 shows the incidence of newly identified isolates in year and table 4 shows details of incidents and outbreaks by quarter. 5
Table 3 - Newly Identified Isolates 2011/12 Type Total for year Group G Strep 0 Group A Streptococcus 0 MRSA Colonisation (Previously known) 13 MRSA Colonisation (Screened after 48hrs) 2 MSSA 0 C. difficile 0 Glycopeptide Resistant enterococci 0 Gentamicin resistant coliforms 0 Extended Beta lactamase organism 2 E Coli swab of wound 1 Table 4 Incidents and Outbreaks by Quarter 2011/12 Quarter Details 1 Nil 2 Patient on Rochford Unit had a Urinary Tract Infection. Lab reports show enterobacter cloacae. Patient isolated, notes labelled and care pathway started, asked staff to inform medical team. Asked for increased awareness for hand hygiene both with the patient, relatives and also staff (patient now discharged). Charlesworth informed by staff doctor that one patient has worms. Patient for side room and observation. Staff asked to increase hand hygiene for patient and staff. Bed linen treated as infected. 3 Rochford Unit 03.12.11 diarrhoea 10 patients and 6 members of staff with D&V. Ward 12 One patient admitted with diarrhoea 23.11.11. Specimen 27.11.11 sent to laboratory confirmed campylobacter 29.11.11 Maple Lodge One patient transferred from Ward 12-14.12.11- confirmed campylobacter. Langworth Ward One patient admitted from nursing home 05.12.11. Specimen of urine 09.12.11 confirmed Escherichia coli (ESBL). Brant Ward Patient admitted from nursing home. 02.12.11 Group C. Streptococcus in heel 06.12.11. Manthorpe Centre One patient with wound to head. Swab taken 27.12.11 confirmed Escherichia coli (sensitive) 4 Langworth Ward Outbreak of diarrhoea 26.01.12 30.01.12 5 patients with symptoms 5 members of staff with symptoms One case of confirmed norovirus Brant Ward - Diarrhoea & vomiting 12.01.12 19.01.12 12 patients in total had symptoms 5 members of staff had symptoms 2 cases confirmed norovirus 6
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 20011/12. Data on all infections and outbreaks is shared with the HPA via the Infection Control Committee. 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 support are 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 are needed 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. Laboratory support is provided as part of the Trust s Service Level Agreement. 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. 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. 10.1 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. Compliance with hand hygiene training in 2011/12 is at 91%. A trajectory has been approved to increased compliance to 95% by July 2012. Inoculation Incident Training (Sharps): All inpatient and substance misuse staff are required to complete training on an annual basis, with mandatory sharps training included in the Trust induction processes. General Infection Control Precautions: All staff are required to complete general infection control training on an annual basis as part of the mandatory training programme. Compliance with this training is 92.73%. 7
The following table details the work completed during 2011/12 showing compliance with the Hygiene Code. 8
INFECTION PREVENTION & CONTROL ACTION PLAN 2011/12 CRITERIA EVIDENCE ACTIONS REQUIRED REPORTING/ ASSURANCE LEAD OFFICER TIMESCALE RISK ASSESSMENT 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. The Trust has a Director of Infection Prevention and Control, the Director of Nursing & Strategy who reports directly to the Chief Executive Annual Reports and prospective action plan to Board of Directors Monthly HCAI exception reports to Board of Directors and Quality reports and analysis by Infection Control Committee and ongoing Annual Report Annual Report Board Reports/ CQ&R Committee quarterly reports CEO Director of Nursing & Operational Services Director of Nursing & Operational Services (DoN & Ops) Infection Control Audit programme Bi- Annual Audits of all inpatient facilities ICC Quarterly reports ICN Infection Control training programme Strengthen follow up of actions arising from audits and links to capital plan. ICC reports ICN/Training dept Policy & Procedure Manual Internal audit report Hygiene Code compliance Update policy & procedure manual Agree SLA for IC provision Agree Health Community wide IC programme and priorities and risk assessment. This is the ICC Minutes ICC Countywide ICC DoN& Ops DoN& Ops / Director of Finance & Comp Director of Nursing & Operational March 2012 9
CRITERIA EVIDENCE ACTIONS REQUIRED REPORTING/ ASSURANCE LEAD OFFICER TIMESCALE RISK ASSESSMENT 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 responsibility of Countywide ICC, LPFT unable to action. Improve evidence of compliance with National cleanliness standards. Agree SLA for soft facilities management with Shared Services. Quarterly report on Cleanliness ICC Services Facilities Manager Head of Estates & Facilities Ongoing March 2012 PEAT scores Improve PEAT Scores for those areas not demonstrating excellent scores. PEAT Report to ICC DoN& Ops March 2012 Routine Cleaning Schedules in place Quarterly Updates PEAT Matrons Ongoing 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 Ongoing Medical Devices training plan Laundry supply and provision conforms to HSG (95)18 Quarterly Report to ICC Quarterly report to ICC Annual report Matron Specialist services Facilities Manager ICN Ongoing Ongoing Lack of adequate hand washing facilities Witham Court. Hand hygiene protocols in place to minimise risk. Quarterly reports on Unit Audits Incorporate into unit audit programme ICN ICN Ongoing Ongoing 10
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 March 2012 Criterion 3: The Trust provide suitable accurate information on infections to service users and their visitors. Approved Dress policy Annual report and action plan published on Trust website HCAI Leaflets on MRSA, C Diff in place Local policy to be approved Quarterly report on unit audit programme DoN& Ops DoN& Ops Matrons Ongoing ICP for MRSA, C Diff Monthly Audit of MRSA Pathway in place. C. Diff By Exception ICN Ongoing Criterion 4: The Trust provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion. Infection Control included in discharge letters Audit of Information available Develop leaflet for Norovirus Incorporated into Unit Audit programme and Discharge & Transfer Policy Improved reporting in audit programme Consultant Microbiologist Matrons Bi-annual audit reports ICN/ Matrons Criterion 5: The Trust ensure that people who have or develop an infection are identified promptly and receive the appropriate Screening and decolonisation in place for high risk client groups Monthly Audit of Compliance Director of Nursing & Operational Services Ongoing Monitoring 11
CRITERIA EVIDENCE ACTIONS REQUIRED REPORTING/ ASSURANCE LEAD OFFICER TIMESCALE RISK ASSESSMENT treatment and care to reduce the risk of passing on the infection to other people. All infections and outbreaks routinely reported to DIPC to approve appropriate action ICC Quarterly outbreaks report Monthly Reporting to BOD & LtPCT ICN/Matrons Ongoing 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 Policies in place to minimise transmission of infection Progress reports on capital Develop rolling programme to update all inpatient facilities Minutes of ICC Unit Audit Programme Reports to ICC ICC Head of Estates & Facilities Ongoing Criterion 7: The Trust provide or secure adequate isolation facilities. Criterion 8: The Trust secure adequate access to laboratory support as appropriate. Criterion 9: The Trust have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent and control infections. Criterion 10: The Trust ensure, so far as is reasonably practicable, that Infection Control Audits Exception reports Isolation Policy Lab services in place and confirm to Clinical Pathology Accreditation Standards (UK) Ltd Policy & procedures on Trust Intranet reflect current and best practice Audit programme identifies any areas of non-compliance Occupational Health SLA Ongoing reports to DIPC & ICC Review Policy Manual Strengthen follow up of action plans Reports to ICC Exception reports to DIPC & ICC IC Manual SLA in Place/ Annual Accreditation ICC Minutes Quarterly report of Unit Audits ICN Matrons Matron Acute ICT DoN& Ops DoN& Ops ICN/ DoN& Ops Ongoing Ongoing Ongoing Ongoing 12
CRITERIA EVIDENCE ACTIONS REQUIRED REPORTING/ ASSURANCE LEAD OFFICER TIMESCALE RISK ASSESSMENT 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. Post Incident prophylaxis available Compliance with training: Hand hygiene Inoculation incidents General IC systems Improve compliance with mandatory training Training reports to ICC Training Manager/ Matrons 13
APPENDIX 2 MEDICAL DEVICES Care Quality Commission Compliance Check Outcome 11: Safety, availability and suitability of equipment Regulation 16. (1) The registered person must make suitable arrangements to protect service users and others who may be at risk from the use of unsafe equipment by ensuring that equipment provided for the purposes of the carrying on of a regulated activity is (a) properly maintained and suitable for its purpose; and (b) used correctly. (2) The registered person must ensure that equipment is available in sufficient quantities in order to ensure the safety of service users and meet their assessed needs. (3) Where equipment is provided to support service users in their day to day living, the registered person must ensure that, as far as reasonably practicable, such equipment promotes the independence and comfort of service users. (4) For the purposes of this regulation (a) equipment includes a medical device; and (b) medical device has the same meaning as in the Medical Devices Regulations 2002. Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Ensure equipment is adequate Requirement LPFT evidence Status People are safe because, where equipment is provided or used as part of the regulated activity, the equipment is: Available in sufficient quantities to meet the needs of people who use the service. Safe to be used. The Trust s Medical Devices Policy covers all aspects of Availability of equipment, safety checks, and maintenance arrangements. Medical devices group monitors compliance and reports exemptions Suitable for its stated purpose. to Infection control committee and Medicines Compliant with all relevant laws. management committee Installed, used and maintained correctly with reference to the specifications, manufacturer s instructions, legislation and appropriate guidance from expert bodies. Properly maintained, tested, serviced and renewed under a recorded programme. Stored safely and securely to prevent theft, damage or misuse. An appoved product list has been established by the Medical Devices Group in conjunction with Clinical Engineering to inform all purchasing. An Service level Agreement is in place with UHLT 14
People s needs are met because staff using any equipment do so in a way that has regard to their dignity, comfort and safety and promotes their independence by: Actively listening to their preferences and thoughts about the equipment they need and how it is used. Supporting the person to understand how and why the equipment is being used. Taking care in the way they use the equipment to make sure the person is comfortable and safe. Using the equipment in a way that ensures the person s privacy and dignity. Clinical Engineering for the maintenance and servicing of all medical equipment as required and teams have full instructions on how to access the service. A central budget is available for the replacement/purchasing of any essential medical equipment. Local maintenacne records are maintained by local teams and detailed in CQC folders. As a mental health Trust LPFT uses a limited range of medical devices. The privacy and dignity of patients is addressed through staff training and the Privacy and Dignity policy. All staff receive training on the use of medical devices as required and maintain local records and uploaded onto OLM system through L&D centre. Pertinent to the organisation is the use of resuscitation equipment which is covered in Basic Life Support and Intermediate Life Support mandatory training. Resuscitation training records are maintained by the Learning and Development Centre. Manage risk through effective procedures about equipment suitability Requirement LPFT evidence Status People are safe because, where equipment is provided as part of the regulated activity, there are clear procedures followed in practice, monitored and reviewed. Wherever necessary these include: There are estabished and effective risk assessment processes in the Trust. Risks identifed with service users (including patients refusing Identification, assessment and review of risk. treatment/assessmet with equipment) would be Where risks are identified, a plan for how these are to be managed. managed as part of a multidisciplinary decision Ensuring that all staff involved in using the equipment have the competency and skills How the equipment is maintained and used. and include best interest assessment as required. making process to meet the needs of the patient needed, and where this is not possible, know what to do to ensure the people remain safe. Maintenance arrangemnts for all approved medical 15
How staff will know what to do when a person who uses services refuses to allow use of the equipment. The arrangements for adverse events, incidents, errors and near miss reporting. These should encourage local and, where applicable, national reporting, learning and promoting an open and fair culture of safety. The training of people who use services about any equipment they are given to use themselves. Best interest meetings with people who know and understand the person using the services to ensure that treatment and care are taken that reflect the person s best interest. What will happen in the event of electricity, water or gas supply failure, or other emergencies, that affect the equipment used to meet the needs of people who use services. Where people who use services receive care, treatment or support that involves the use of medical devices, the provider has: Clear procedures that are followed in practice, monitored and reviewed for the use of medical devices. Wherever they are required these procedures include: devices are detailed on the approved product list, There is an established SLA with ULHT Clinical Engineering for the minatenace and servicing of medical equipment. Staff receive mandatory training on the use of resusitation equipment as required. other low risk devices used in practice are covered by profession/ or local peer training. The Medical Devices policy provides clear guidance to staff on responsibilites around competence. Adverse indicents and near misses are reported on the Trust's electronic incident reporting system and managed through the incident management process; all reported incidents of this nature are reviewed on a quarterly basis by the Medical Devices Group and follow up action taken if required. Equipment is only provided to service users by Trust Occupational Therapists. Training for service users receiving equipment is detailed in the PRESCRIPTION OF EQUIPMENT BY OCCUPATIONAL THERAPISTS UNDER THE LINCOLNSHIRE COMMUNITY EQUIPMENT SERVICE (LCES) guidance document. The range and type of medical devices used by LPFT is such that they would be relatively uneffected by disruption to electiciy, water or gas supplies. Some treatments such as ECT could be postponed but alternative arrangements could be put in place. Business Continuity Plans are in place for all services to ensure continued safe service delivery in emergancy situations. The Medical Devices Group has produced a standardised porcduct list in conjunction with HULT Clinical Engineering to ensure all devices purchased meet current legislative requirments and identifed best practice. This list is updated on a 16
implementing guidance issued by experts or professional bodies in relation to the medical devices used acting on alerts from an expert or professional body or a product manufacturer. People who use services receive care, treatment and support from a service that: Takes into account relevant guidance, including that from the Care Quality Commission s Schedule of Applicable Publications. quarterly basis and provided to procurement to inform all purchasing. There is an established system managed by the Risk department to respond to any Medical Devices Alerts and identify, remove or replace equipment as required. This Guidance is addressed in the Medical Devices Management Policy Lasers are not used in LPFT Single use devices are specifically addressed in the Medical Devices Management Policy. There is an established system managed by the Risk department to respond to any Medical Devices Alerts and identify, remove or replace equipment as required. Any new guidance is reviewed by the Medical Devices Group and actioned accordingly Providing personalised care through the effective use of medical devices Requirement LPFT evidence Status People who use services receive care, treatment and support that: Ensures the medical devices used to meet their needs are: not reused if they are manufactured for single use only only modified in line with manufacturer s instructions or guidance only purchased if they meet the necessary legal requirements available when they are required for use The isses identifed in section 11F are addressed through the Medical devices Management Policy. Single use devices are specifically addressed with instructions for disposal. supplied with the necessary technical information so that the risk of using them The Medical Devices Group has produced a incorrectly is minimised standardised product list in conjunction with HULT requirements and published guidance only used by the person, or by staff, once they know how to use and operate them correctly monitored while being used and action taken if they do not appear to be working permanently installed where appropriate, in accordance with manufacturer s purchased meet current legislative requirments and identifed best practice. This list is updated on a quarterly basis and provided to procurement to inform all purchasing. Clinical Engineering to ensure all devices correctly routinely maintained in line with the manufacturer s instructions and by people who Routine maintenance and repair arrangemnts for all 17
are competent to do so repaired when they break down by people who are competent to do so disposed of or recycled, safely and securely. approved medical devices are detailed on the approved product list, There is an established SLA with ULHT Clinical Engineering for the minatenace and servicing of medical equipment. Staff receive mandatory training on the use of resusitation equipment as required. other low risk devices used in practice are covered by profession/ or local peer training. The Medical Devices policy provides clear guidance to staff on responsibilites around competence. Disposal of medical devices including WEE regulations is specifically covered in the Medical Devices Management Policy. Additional prompts for specific service types Requirement LPFT evidence Status When equipment is used in a person s own home: Staff address any concerns in a timely manner where they have identified problems around the safety of the equipment. Equipment is only provided to service users by Trust Occupational Therapists. Training for service users receiving equipment is detailed in the PRESCRIPTION OF EQUIPMENT BY OCCUPATIONAL THERAPISTS UNDER THE LINCOLNSHIRE COMMUNITY EQUIPMENT SERVICE (LCES) guidance document. Concerns would be addressed immediately or escalated through the line management structure. In incident People who use services receive care, treatment and support that: Ensures equipment required for resuscitation or other medical emergencies is available and accessible for use as quickly as possible. Where the service requires it, this equipment is tamper proof. report may also apply and be completed. The Trust has an established resucitation ploicy that addresses the issues identifed in this section. Local teams conduct daily checks of resusitation equipment and these are audited by the Trust's resusitation lead. 18
APPENDIX 3 NICE: QUALITY IMPROVEMENT GUIDE INFECTION PREVENTION & CONTROL ACTION PLAN 2012/13 EVIDENCE ACTIONS ASSURANCE LEAD OFFICER TIMESCALE RATING STATEMENT 1: Trust Boards demonstrate leadership in infection prevention and control to ensure a culture of continuous quality improvement and to minimise risk to patients. Hygiene Code: Criteria 1: Guidance for compliance 1.1, 1.5 Criteria 6: Guidance for compliance 6.2 1. Evidence that the Board is up-to-date with, and has a working knowledge and understanding of, infection prevention and control. 2. Evidence that the Board has an agreed set of key performance indicators for infection prevention and control which includes compliance with antibiotic prescribing policy. The Board is expected to be proactive in ensuring continuous quality improvement by leading on, and regularly monitoring compliance with, all relevant infection prevention and control objectives, policies and procedures Achieve Department of Health targets for MRSA bacteraemia, E- coli Bacteraemia, Reduction in HCAIs across hospital settings. 95% of staff compliance with hand hygiene 6 monthly infection control audits Compliance with antibiotic prescribing guidelines Annual Report Quarterly report Present quarterly exemption reports to BoD Director with responsibility for Infection, Prevention & Control Annual report. Both to include mandatory reporting on alert organisms Board minutes Infection Control Annual Report CQC reports Occupational Health quarterly update Board Minutes Audit programme and compliance with action plans Infection control training figures Hand Hygiene compliance figures Antibiotic audit Director of Nursing & Operations (DIPC) Director of Nursing & Operations (DIPC) Medical Director Lead Pharmacist Concurrently Ongoing 19
EVIDENCE ACTIONS ASSURANCE LEAD OFFICER TIMESCALE RATING programme and compliance with action plans reported through MMC and ICC. 3. Evidence that a Board member has been assigned to lead on infection prevention and control. 4. Evidence that the agreed key performance indicators are used by the Board to monitor the Trust s infection prevention and control performance. 5. Evidence that the Trust s aims and objectives for infection prevention and control are included in the Board s Balanced score card. 6. Evidence of a Board-approved infection prevention and control accountability framework. This includes evidence of specific responsibilities allocated to staff working in, or coming into contact with, clinical areas (reflected in their job descriptions and appraisals). 7. Evidence that a mechanism is in place to report regularly to Board meetings on important infection risks and the control measures that have been implemented. Board of Directors to confirm statement of responsibility and the DIPC role. Annual requirement as part of compliance to Health and Social Care Act Standards are that LPFT is fully compliant with the requirements of the Health and Social Act 2008, CQC standards and NHSLA and to meet statutory and mandatory targets for infection control Information is triangulated for a heat map against CQC standards and external audits such as PEAT/infection control To continue to ensure that job descriptions, training programmes, SLA s and agreements with contractors/estates encompass Infection Control responsibilities Monthly HCAI exemption reports to Board outlining actions taken to reduce risk Board Minutes Board Members Completed and to be maintained Annual report Quarterly ICC reports CQC reports PEAT assessments NHSLA compliance Board report and HEAT map Job descriptions IC policy outlines a clear framework for accountability from Chief Exec downwards Supervision records for education and training Mandatory training records PDPs SLAs for estates/maintenance contracts and agreements Annual Board reports and prospective actions plans to BoD Monthly HCAI exemption reports to Board of Directors and quality reports. Risk management reports DIPC Deputy Director of Nursing and Clinical Governance DIPC DIPC Completed and to be maintained Completed and to be maintained Completed and to be maintained Completed and to be maintained 20
EVIDENCE ACTIONS ASSURANCE LEAD OFFICER TIMESCALE RATING (needlestick injuries) and Action plans and lessons learnt from RCAs 8. Evidence that the Board has agreed an annual improvement programme on infection prevention and control which is linked to the business planning cycle and has identified actions and resources. 9. Evidence that the Trust promotes a self-governance culture for infection prevention and control. This includes evidence that all staff, from Board to ward, are accountable and take ownership and responsibility for continuous quality improvement. To Provide the Trust with an annual improvement programme, including audit with clear lines of responsibilities for escalation and timely response to issues Induction and mandatory training programme emphasises that IC is every ones responsibility in line with DoH guidance Annual report Board minutes ICC minutes Quarterly update against Annual improvement work plan Training plans and figures Executive walkabouts CQC inspections Infection control audits Matron reports Infection control team audit programme DIPC Director of Nursing Completed and to be maintained Completed and to be maintained 10. Evidence that the Board is assured that monitoring mechanisms are in place in each clinical area, and that each area is accountable for compliance with relevant aspects of the code of practice. Established link nurses in each of the inpatient areas Infection control Information boards in each clinical areas Available documentation at ward level on Health and Social Care Act Link nurse attendance records to quarterly updates CQC inspection and reports and evidence files Audit outcomes and action plans for each unit and monitoring through ICC and by Matrons 6 monthly audit programme Training and supervision records Dissemination of lessons learnt from HCAI incidences Completed and to be maintained 11. Evidence of regular communication from the Chief Executive on the Trust s expectation of patients, visitors and staff in relation to infection prevention and control. Key statements issued in relation to trust key strategies around patient safety, experience and clinical effectiveness Minutes from Executive Team Road shows Posters within inpatient areas in respect to standards of cleanliness and infection control Annual Report for infection control published LPFT website Completed and to be maintained 21
EVIDENCE ACTIONS ASSURANCE LEAD OFFICER TIMESCALE RATING To be discussed at next DIPC December 2012 Infection Control meeting 12. Evidence that the Director of Infection Prevention and Control is involved in contract negotiations with commissioners on the key performance indicators for infection prevention and control. 13. Evidence that the Board demonstrates to patients, the public, staff and itself that it is making continuous progress towards meeting all relevant statements in this guide. DIPC annual report for 2011/12 to be published Director of infection, prevention and control annual report DIPC In place and maintained STATEMENT 2: Trusts use information from a range of sources to inform and drive continuous quality improvement to minimise risk from infection. Hygiene Code: Criteria 1: Guidance for compliance 1.1, 1.3 1. Evidence that processes have been put in place to learn from experiences outside the organisation in relation to infection prevention and control. This includes evidence that learning is occurring on a continual basis. 2. Evidence of regular, systematic generation and sharing of learning from Trust s own experiences of infection prevention and control including good practice and adverse events. This includes evidence that learning is based on a range of intelligence sources and is used to inform, and feed into, clinical and risk management processes. 3. Evidence that mechanisms are in place to disseminate learning among relevant staff groups The Board is to ensure mechanisms are in place for the Trust to use a range of information, in addition to surveillance date, to minimise the risk of infection to patients, Disseminate through ICC best practice, guidance documentation, through ICC and link Nurse Meetings Attendance to County Wide Infection control Meeting Attendance to County Wide HCAI Quality improvement group with representation from ULHT, LCHS, NHSL, HPA and LPFT to share best practice ICC responsibility is to review lessons learnt, promote county wide lessons and national guidance through divisions Medical Devise Alerts actioned as appropriate and disseminated to units and teams Minutes of ICC Continue to attend County Wide infection control Committee Joint working and liaison with other healthcare providers with regard to RCA investigations reports Minutes of ICC Reports of SUI on sentinel Lesson learnt reports and dissemination into divisions/teams RCA and lessons learnt disseminated and shared with ICC and Board Infection control Link Nurse meetings Minutes and action plans for quality improvement group Reports available on SHARON Mandatory Training programme Link Nurses for ICC with DIPC DIPC/Matrons Infection Control Committee members Completed and to be maintained Completed and to be maintained Completed and to be maintained 22
EVIDENCE ACTIONS ASSURANCE LEAD OFFICER TIMESCALE RATING and matrons to ward level training and support Minutes of divisional meetings Matron reports 4. Evidence that the Trust promotes a culture of learning in relation to infection prevention and control, and ensures staff have time to participate in preventive learning activities. 5. Evidence that recommendations and actions identified as being needed following an incident, surveillance or learning activities have been implemented. 6. Evidence that the continuous quality improvement cycle is informed by conclusions from robust learning methodologies Continue to promote the role of Link nurses across the Trust Infection control committee to consider all incidents/issues relating to infection and disseminate findings via matrons and management structures RCAs to be conducted for all bacteraemia, C diff and ward closures Review Monitoring systems for infection control policies. Infection control Link Nurse Minutes Infection control training Plans and attendance records Attendance of Link Nurse at Infection Control Training Sessions Minutes if ICC and quarterly reports Exemption reports RCA reports and lessons learnt Divisional/team minutes Audit Cycle Production of audit reports and action plans Quarterly reports Infection Control Team/Matrons DIPC/Matrons DIPC/Infection control Team/Matrons Hotels Services March 2013 In place 7. Evidence that the Trust works with local health partners (including health protection units) to capture and learn lessons from the management of major infection outbreaks and other HCAI-related incidents. Continued attendance and support the county wide Infection and Prevention control Committee HPA key members of Infection Control Committee Continue joint working where appropriate with acute services and primary care in relation to an MRSA and Clostridium Difficile, antimicrobial Medicines management audit report for antibiotic prescribing and quarterly progress reports on action plans RCAs and Lessons learnt reports Minutes and attendance records for county wide infection control group/lincs HCAI Quality Improvement Group DIPSC/ICC Mechanisms in place 23
EVIDENCE ACTIONS ASSURANCE LEAD OFFICER TIMESCALE RATING prescribing, and share lessons learnt. Infection control RCAs to include microbiologist and representative from Infection control team Minutes and quarterly update against infection control action plan Attendance records and infection control committee minutes Infection control team 8. Evidence that the Trust promotes innovation to minimise harm from infection, for example by promoting research opportunities, practice development initiatives and action learning sets for staff. Trust supports practice that reduce incidences of avoidable harms through promotion of evidence based care and implementation of Department of health/nice guidance quarterly reports Medical Devices minutes ICC minutes and email which disseminates current guidance around practice Link Nurse training minutes DIPC/Infection Control Team/Matrons STATEMENT 3: Trusts have a surveillance system in place to routinely gather data and to carry out mandatory monitoring of HCAIs and other infections of local relevance to inform the local response to HCAIs. Hygiene Code: Criteria 9: Guidance for compliance 9.3u 1. Evidence of an adequately resourced surveillance system with specific, locally defined objectives and priorities for preventing and managing HCAIs. The system should be able to detect organisms and infections and promptly register any abnormal trends. 2. Evidence of clearly defined responsibilities for the recording, analysis, interpretation and communication of surveillance outputs. 3. Evidence of arrangements for regular review of the surveillance programme to ensure it supports the Trust s quality improvement targets for infection prevention. The Board should ensure that there is a fully resourced and flexible surveillance system to monitor infection levels across the Trust and these are shared across the organisation to drive forward a system of continuous improvement Wards report figures monthly for MRSA, indwelling catheters to audit department as required Screening and decolonisation for high risk groups and reported Reports are submitted via audit departments Policies for MRSA, CDiff and monitoring frameworks available on internet though LPFT website Alert organisms are reported via lab to Infection control nurses to action. Surveillance reports in respect to Mandatory surveillance available on Web V Policies and procedures Sentinel Reports Infection control reports Audit programme Exemption reports to ICC and Board Reviewed through ICC DIPC DIPC/Infection control team DIPC 24