Infection Prevention and Control Dental Policy

Infection Prevention and Control Dental Policy

Policy Title: Infection Prevention and Control Dental Policy Executive Summary: Implementing standard universal precautions underpins safe practice in protecting, staff, patients and visitors from healthcare associated infections whilst undergoing Dental procedures Supersedes: V2 2014 Description of Reflective of national guidance and organisational Amendment(s): changes This policy will impact on: Dental Staff, laboratory staff and clinical practices Financial Implications: Laboratory screening costs Policy Area: Infection Prevention and Control Trust Wide Document Reference: DPV3 2017 Version Number: V3 Effective Date: May 2017 Issued By: Infection Prevention and Control Group Review Date: May 2020 Author(s): Anita Swaine Lead Nurse Infection Prevention and Control Impact Assessment Date: 27/04/2017 APPROVAL RECORD Consultation: Approved by: Received for information: Committees / Group Infection Prevention and Control Group Director of Nursing Quality and Performance, Director of Infection Prevention and Control Allied Health and Clinical Support Directorate SQS Date April 2017 May 2017 May 2017 2

CONTENTS Title Page 1 Introduction 4 2 Purpose 4 3 Responsibilities 4 4 Other Infection Prevention and control /Trust Policies to be adhered to in conjunction with this policy 5 5 Personal Protective Equipment requirements 5 6 Required decontamination practice 6 7 Automated Cleaning Ultrasonic Cleaning 6 8 Other decontamination processes 7 9 Preparation of Clinic areas 8 10 Training 9 11 KPI / Monitoring compliance 9 Legislation, Guidance and References 10 Appendix 1 - Pre-use log sheet for ultrasonic cleaning bath 11 Appendix 2 - Surgery Cleaning Protocols - end of session cleaning schedule 16 Appendix 3 - A - Z decontamination guidelines 17 Appendix 4 Dental Clinic flushing record 19 Equality and Human Rights Policy Screening Tool 20 3

1. Introduction Implementing standard universal precautions underpins protecting, staff, patients and visitors from healthcare associated infections whilst undergoing Dental procedures. Cross infection may occur when there is contact with blood, tissue and or bodily fluid, material and equipment. It is therefore essential that strict adherence to this policy is maintained. The Health and Social Care Act 2008 (updated 2015), Care Quality Commission standards and the Health and Safety at work Act (1974) and NICE Quality Standard (QS61) 2014 make explicit the statutory and legal duty place on NHS organisations to manage, mitigate and control the risk of transmission of Healthcare associated infections. The appropriate level of precautions to be taken for any procedure should be determined according to the extent of possible exposure to blood and body fluids, in association with evidence, and national guidance. This should be based on risk assessment, not speculation about the infectious status of the patient. Implementing these standards will ensure the risk of transmission is minimised. 2. Purpose The purpose of this policy is to detail the precautions that must be implemented by all dental teams as part of their routine practice East Cheshire Health Economy. This will reduce the risk of infection, transmission and environmental contamination from micro-organisms thereby protecting patients, carers, visitors and staff from the risk of infection 3. Responsibilities The Chief Executive has ultimate responsibility for the implementation and monitoring of policies used in the Trust, and for ensuring sufficient resources are made available to facilitate the prevention and control of healthcare associated infections. This responsibility may be delegated. The Director of Nursing, Performance and Quality, Director of Infection Prevention and Control (DIPC) will take the lead responsibility for the development and implementation of this policy with support of the Lead Nurse Infection Prevention and Control and the Infection Prevention and Control Doctor. These responsibilities include: - Challenging poor standards and holding to account as appropriate - Providing assurance to the trust Board that systems and processes are in place to ensure compliance with agreed standards. The Infection Prevention and Control Team (IPCT) will have responsibility for: - Ensuring the Dental policy is implemented and monitored throughout the trust - Ensuring the policy is updated to reflect any changes to national or local guidelines - Providing education and support to clinical staff - Undertaking a bi- annual audit programme (as per HTM01-05) of premises, and decontamination processes for reusable dental instruments - Referring to the Consultant Microbiologist / Infection Control doctor where appropriate 4

Dental Teams Leaders are responsible for ensuring that all staff: - Are aware of, and adhere to this policy - Are aware of their roles and responsibilities with regard to reducing HealthCare Associated Infections - Are aware of any patients considered high risk from an Infection Prevention and Control perspective - Inform the patient/carers of any infection status as appropriate 4. Other Infection Prevention and control /Trust Policies to be adhered to in conjunction with this policy Standard Precautions Policy Uniform and Dress Code Policy Decontamination Policy Specific Organisms e.g. TSE(CJD) Waste Policy Occupational Health: Human Immunodeficiency Virus (HIV) Clinical Employment Policy Including exposure prone procedures. Occupational Health Hepatitis B and C Clinical Employment Policy Including Exposure Prone Procedures and Haemodialysis 5. Personal Protective Equipment requirements Gloves Gloves are a single use item Gloves must be worn when direct contact with blood, body fluids, non-intact skin or mucus-membranes is anticipated Gloves must be changed between patients and different procedures on the same patient. Gloves can reduce the likelihood of contact dermatitis in staff exposed to chemical agents Gloves must be disposed of into the appropriate waste stream Hands must be decontaminated with soap and water immediately on removal of gloves Gloves MUST not be worn when answering the phone or using computer keyboards. When cleaning instruments manually heavy duty (Marigold type) gloves must be worn. If staff members suspect they are having a reaction to the gloves used they must be referred or self-refer to Occupational Health who will undertake a risk assessment to identify the problem Aprons Aprons are a single use item and MUST be changed between patients Aprons must be worn when in direct contact with blood and body fluids, mucus-membranes is anticipated When undertaking dedicated cleaning tasks including cleaning equipment Masks Face Masks must be worn during treatment in particular 5

Visors/Eye protection using the turbine or ultrasonic scaler Face masks are single patient use and must be disposed of after that episode of care FFP3 masks require staff to be appropriately trained and FIT testing before use. These MUST only be worn for specific Respiratory illness e.g. Patients with active TB however a risk assessment may be required to establish if treatment can be delayed until the period of infectivity has passed. Both staff and clients MUST wear eye protection during treatment to prevent splashes into the eye. It the eye protection is not single use, it must be cleaned between each patient with a suitable disinfection wipe. 6. Required decontamination practice Dedicated clean and dirty areas must be clearly identified, if required these must be clearly zoned Equipment must be thoroughly cleaned using an ultrasonic cleaner (set at a temperature between 28C and 30C, or at a temperature compatible with the enzymatic detergent) to remove any visible signs of debris At the start and end of the day and after the correct dissolution of enzymatic detergent and water have been added a degassing cycle for the ultrasonic bath MUST be run with the basket and lid in situ but no instruments A quarterly foil test must be undertaken (Appendix1) 7. Automated Cleaning Ultrasonic Cleaning Manufacturer s instructions must be followed at all times in relation to the ultrasonic machine. Any equipment used in it must be checked to ensure compatibility Before switching on the ultrasonic, fill the tank with an appropriate amount of water at the correct temperature and use recommended enzymatic detergent at the correct dilution Do not switch on the heater or ultrasonic unless the tank is full Fill the tank to the ridge on inner tank or top of the basket De-gas the ultrasonic prior to loading the instruments (run an empty cycle) Ensure joints or hinges are opened fully and any instrument are disassembled as appropriate before immersing in the solution Place instruments in the suspended basket and fully immerse in the cleaning solution, maintaining contact with all surfaces Do not over-load the basket or place instruments on the floor of the ultrasonic as this will result in ineffective cleaning, and may reduce the life cycle of the instruments Set the timer to the appropriate setting, then close the lid until the cycle is complete Once the cycle is complete drain the basket of the instruments, then rinse them in the designated deep decontamination sink Inspect all instruments for cleanliness, wear, and/or damage, taking the appropriate action If debris remains on the instruments it should be removed manually by submerging using clean warm water, neutral detergent and a long handled autoclavable kitchen type brush. 6

Only metal instruments should go into the ultrasonic cleaner It is essential to repeat the process if residual debris is present. Dry instruments prior to sterilisation process using a non linting disposable towel. Change water, detergent mixture every session, or more often if deemed necessary (e.g water has become heavily soiled) Log all chemical changes in the logbook 7.1 Cleaning and maintenance of the ultrasonic Always switch ultrasonic off and unplug prior to emptying Rinse out tank to remove soiling and detergent residue, leave to dry overnight As part of the maintenance process ensure the water/enzymatic detergent solution is maintained and changed at regular intervals Undertake the recommended foil test every 3 months to establish ultrasonic activity Fill the ultrasonic bath with the correct amount of water ensuring the correct temperature and add the enzymatic detergent Run a de-gassing cycle Place strips of adhesive tape across the ultrasonic bath (care must be taken not to degrade the bath surface). Cut aluminium foil into 6 strips and roll the bottom edge to act as a weight Suspend foil strips from the tape ensuring the whole of the bath is covered (3x3 grid) and the bottom of the foil is no more than 10 mm above but not touching the bottom of the ultrasonic bath. Replace the lid and run a cycle Remove strips, blot dry and examine for erosion, foil erosion should be consistent throughout the bath to indicate uniformity of cleaning Poor uniformity or no erosion indicates reduced cleaning or failure to clean. If this is the case remove the ultrasonic bath from service and send for repair/ replacement File the foil strips with date of test and signature of person undertaking the test Drain, clean and dry the bath, ensuring all foil debris has been removed then return to use. An annual validation test must be undertaken as part of a planned programme of maintenance in conjunction with estates department. 8. Other decontamination processes Manual cleaning should be kept to a minimum and used only in the absence of other options A designated sink must be used for manual cleaning, separation of clean and dirty items must occur Chemical solutions will only disinfect clean items and should only be used to disinfect items which cannot be sterilised. This can be undertaken using a disinfectant wipe. Light handles and chair buttons can be covered with impervious protective covers; these must be cleaned with disinfectant wipes. 8.1 Washer Disinfectors/ autoclaves, benchtop sterilisers Washer disinfectors are the preferred method of decontamination which must be managed in accordance with manufacturer s instructions, including: storing print outs for 2 years a programme of system checks which are undertaken daily, weekly, monthly 7

an annual health check. HTM2031 (Health Technical memorandum) must be adhered to. This requires that the water is removed/drawn from the reservoir and the chamber of the bench top steriliser daily (with the exception of single shot sterilisers that utilise a dump tank and allow fresh water for each cycle). Sterile water for irrigation should be used in all bench top steam sterilisers Check the chamber daily for cleanliness; use sterile water and dry with disposable paper towels if cleaning is required All instruments MUST be placed in sealable pouches prior to sterilisation A print out of each cycle MUST be kept as a record that the bench top steriliser is functioning correctly. This must be signed by the dental nurse and then stored as a record of tracking and traceability Temperatures must reach between 137-143C held for 3 mins with a pressure of 2.25bars Failures relating to temperatures must be reported to the Infection Prevention and Control team who will discuss with the Consultant microbiologist any further actions required The operating manual must be readily available next to the machine All prepacked items sterilised must be used within 12 months of the sterilisation process Any instruments not used in a 12 month period must be reprocessed prior to use. 9. Preparation of Clinic areas Clean clinical area including work surfaces, lights, chair with detergent wipes Flush water through the triple syringe, air rotor and ultrasonic scaler for at least two minutes at the beginning and end of the day, and for 20-30 seconds between each patient. A single Sodium Percarbonate tablet- ICX to be added to the 0.71water bottle. Ensure that the suction is working If additional items are required during a patient s clinical treatment, remove gloves, decontaminate hands with alcohol hand gel and re apply gloves once the equipment has been retrieved Clinical records/ computer keyboards must not be handled in the middle of a clinical procedure. Gloves must be removed prior to using these. At the end of a clinical session all equipment should be decontaminated using the approved process and stored correctly. This includes chair, light handles and instruments Dental unit water bottles should be filled with sterile water to reduce bacterial contamination and an ICX percarbonate tablet, at the end of the session should be emptied via the cart flushing through the system and left to dry overnight Dental syringes and scalpels should be safety devices to reduce the risk of sharps injuries Biopsy specimens sent through the post must be packaged appropriately. Each specimen must be enclosed in a primary container and sealed then wrapped to absorb leaks then placed into a plastic bag prior to placing in the padded envelope. This should be clearly labelled Pathological Specimen- Fragile with Care Toys in the waiting area must be in a good state of repair, wipable and included as part of the departments cleaning schedules Needlestick or sharps injuries must be reported as per Occupational Health policy and procedures 8

10. Training All clinical staff must attend Trust infection control mandatory training annually. Bespoke training sessions will be provided to the clinical area as required. 11. KPI / monitoring compliance The infection prevention and control team will review and investigate incidents reported relating to this policy. Dental clinics will be audited annually as part of the planned Infection Prevention and Control audit programme and in accordance with HTM01-05 requirements. 9

Legislation, Guidance and References Chief Medical Officer (2011) - Annual Report of the Chief Medical Officer Infections and the rise of antimicrobial resistance Vol 2. DH: London. Available at: http://media.dh.gov.uk/network/357/files/2013/03/cmo-annual-report-volume- 2-20111.pdf Department of Health (2013) Health Technical Memorandum 01-05: Decontamination in Primary Care Dental Practices Department of Health (2007a). Important: Advice for Dentists on re-use of endodontic instruments and variant Creutzfeldt-Jakob Disease (vcjd) East Cheshire NHS Trust (2016) - Infection Prevention and Control Cleaning Policy - Available on the Trust Infonet East Cheshire NHS Trust (2016)- Infection Prevention and Control East Cheshire NHS Trust (2016) - Infection Prevention and Control Standard Precautions Policy - Available on the Trust Infonet Infection Prevention Society (IPS) Dental Audit tools available at https://www.gov.uk/government/publications/decontamination-in-primary-caredental-practices. MHRA: Managing Medical Devices (2015) Guidance for Healthcare and Social Services Organisations available at https://www.gov/government/publications/managing-medical devices WHO (2006) - 5 moments of hand hygiene available at: http://www.who.int/gpsc/tools/five_moments/en/ 10

Appendix 1 - example Pre-use log sheet for Ultrasonic Cleaning Bath Ultrasonic Cleaning Bath Location Make/Model Serial Number Please undertake the following tests and tasks before using the above piece of equipment or according to manufacturers instructions Date and time Daily (before use if not used recently) remove and clean strainers and/or filters Daily (before use if not used recently) fill reservoir with fresh solution After first load of the session visually check first load to check cleaning efficacy Weekly: (before use if not used recently) Check condition of lid/door seal Weekly: (after first load of the session if not used recently) Perform a protein residue test on instruments Name and designation Signed 11

Appendix 1 - example FAULT RECORD Equipment Type Location Make/Model Serial Number Date and time Nature of Fault Reported to Reported by Action taken Incident form required Outcome Name and designation Signed 12

Appendix 1 - example Daily (or before each session) log sheet for washer disinfector Washer Disinfector Location Make/Model Serial Number Please undertake the following tests and tasks before using the above piece of equipment or in accordance with manufacturer s instructions. Date and time Clean all external and internal surfaces Check all filters and sprays are free from debris Check all hoses and connectors are in good condition Check door seal is undamaged and clean and operating mechanism is working order Replenish water softener Record the pre wash temperatures: use the first print out of the day: (must start below 45 c) Record the disinfection temperatures: use the first print out of the day (must stay above 90 c) Record the cycle number and retain the print out. Name and designation Signed 13

Appendix 1- example Weekly/Monthly log sheet for Washer Disinfector Washer Disinfector Location Make/Model Serial Number Please undertake the following tests and tasks before using the above piece of equipment or in accordance with manufacturer s instructions. Weekly Test Date and time Perform residual soil test Name and designation Signed Monthly Test Date and time Check all hoses are secure and no leaks Check mains power cord undamaged Check all internal parts for wear and damage Name and designation Signed 14

Appendix 1 - example Daily (or before use) log sheet for non-vacuum bench top steriliser Steriliser Location Make/Model Serial Number Please undertake the following tests and tasks before using the above piece of equipment or according to manufacturer s instructions Date and time Clean door seal, chamber, shelves and trays with a clean, damp non linting cloth Fill reservoir with fresh distilled, sterile or RO water Turn on and record cycle number in column below Record Temperature Record Pressure Record the holding time Retain print out (if available) Name and designation Signed 15

APPENDIX 2 Clinic Location Dental Surgery No. Surgery Cleaning Protocols End of session Cleaning Schedule Date and time Work Surfaces and dental carts disinfected Drawer and cupboard door handles disinfected Chair and light unit disinfected Spittoon, filters and aspirator equipment disinfected Sinks and taps cleaned Computer and key board cleaned Signed Name and designation Weekly schedule Date and time Re-process all un-dated instruments Clean all drawer fronts cupboard doors Clean operator stools Suction/Aspirator maintenance as recommended by service engineer Compressor maintenance as recommended by service engineer Signed Name and designation 16

Appendix 3 - example Decontamination of Medical or Laboratory Equipment/Devices For full details refer to East Cheshire NHS Trust Decontamination Policy A - Z DECONTAMINATION GUIDELINES Appliances Burs Bracket tables Dental Cabinetry Dental chair (including controls) Dental Instruments including hand pieces Using manual cleaning or ultrasonic bath when essential only Hand pieces using a washer disinfector orthodontic and prosthetic Rinse under clean running water until clean. Use an appropriate disinfectant according to manufacturer s instructions. Rinse thoroughly. If returning to laboratory ensure a label is attached to indicate that a decontamination process has taken place Steel burs -disposable, Diamond -pre-clean then process unless Single Use Tungsten Carbide -pre-clean then process Acrylic Trimming Burs -pre-clean then process Cover surface and use disposable instrument trays Clean with detergent/disinfectant wipe between patients Do not use alcohol based products on stainless steel. Wipe cupboard doors, drawer fronts and handles at the end of each session with a detergent/disinfectant wipe Do not use alcohol based products on stainless steel. Wipe and dry after each patient with detergent or disinfectant wipe. Do not use alcohol based products on stainless steel. Clean (using a validated process) Washer disinfector or Ultrasonic Inspect and dry Pack, Date and Autoclave Store in clean, dry conditions away from clinical environment where possible N.B Use within 12 months or re-process In addition to above: Leave bur in place during cleaning to prevent contamination of hand piece bearing DO NOT IMMERSE IN WATER Remove bur Lubricate hand piece with pressurised oil as recommended by the manufacturer, until clean oil appears out of the chuck; Clean off excess oil Pack and Sterilise in autoclave Run hand piece briefly with bur in place before use, to clear excess lubricant. Clean outside of hand piece Remove bur Do not lubricate Place in the displacement device in the washer disinfector Lubricate before placing in the autoclave Run hand piece briefly with bur in place before use for 2 minutes, to clear excess lubricant and flush water line 17

Impressions Light cure Tip Light cure Tip Matrix band holders Operating lights Spittoon Sinks Suction apparatus Water Bottles Water lines Work surfaces Rinse under clean running water until clean. Use an appropriate disinfectant according to manufacturer s instructions. Rinse thoroughly. If returning to laboratory ensure a label is attached to indicate that a decontamination process has taken place Clean with detergent, rinse and dry (Do not use sodium hypochlorite) Pre-clean and autoclave or protect with a plastic disposable cover (Check manufacturers instructions) Single use option available at all sites and must be used. Clean after each patient with a detergent/disinfectant wipe. Do not use alcohol wipe on stainless steel parts. Flush between each patient and clean with detergent/disinfectant wipe Do not use alcohol Remove debris from the trap at the end of the session and system clean according to manufacturer s recommendations Clean at the end of each session with cream cleaner and detergent wipe and leave dry. Do not use alcohol base wipes or solution on stainless steel sinks Aspirator tubing and drainage system should be cleaned at the end of each sessions according to manufacturer s instructions (Or dispose of if single use) Empty residual water at the end of each session flush through DUWLs. Rinse with sterile water. Leave inverted to air dry Flush for at least 2 minutes at the beginning and end of each day and flush for 20-30 seconds between each patient. Clean with detergent/disinfectant wipe between each patient and at the end of the session clean rooms thoroughly 18

Appendix 4 DENTAL CLINIC FLUSHING RECORD The purpose of this form is to provide assurance that water outlets, including dental chair systems, are flushed as part of the cleaning process on a weekly basis. Please continue to flush dental waterlines at the start and end of each session for two minutes and 30 seconds between each patient as per HTM 01-05. Please indicate on the form that this is being achieved Any rooms which are inaccessible or any outlet which is not being used please indicate in the form below and inform the Dental Office who in turn should contact the water quality team for further advice Water should be drawn off from cold taps for 1 minute to aid the cleaning process; this needs to be done at every dental chair cup fill and spittoon in every surgery using mains water. This action then complies with the relevant guidance. DATE CLINIC ROOM No WATERLINES DENTAL CHAIR SYSTEMS SURGERY SINKS SIGNED UNDER UTILISED OUTLETS: RO MACHINE RECORDS: 19

Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Infection Prevention and Control Dental Policy Details of person responsible for completing the assessment: Name: Anita Swaine Position: Lead Nurse Infection Prevention and Control Team/service: Infection Prevention and Control State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) The purpose of this policy is to outline the precautions to be implemented by all dental teams employed across East Cheshire Health Economy, as part of their routine practice. This will reduce the risk of infection, transmission and environmental contamination from micro-organisms hereby protecting themselves, patients, carers and visitors from the risk of infection 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). 20

Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in 2011. Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester 21

None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC. 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) None 2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a result of this document? None 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No Explain your response: For any patient whose forst language is not English, as information needs to be provided and understood, staff will follow the trust interpretation policy. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No Explain your response: No impacts identified. DISABILITY: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes No 22

Explain your response: Clinical staff will need to implement support for patients as required to manage infection control requirements against the patients disability requirements. Staff should follow the trust interpretation policy for people who are Deaf and involve the health facilitators for people with learning disabilities. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No Explain your response: No impacts identified LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes No Explain your response: No impacts identified. RELIGION / BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes No Explain your response: No impacts identified. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes No Explain your response: May need to be involved in the support of the patient post discharge. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No Explain your response: No other impacts identified. 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes No X 23

b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children. This policy applies the same as for adult patients. If any concerns are noted with any child these would be escalated via the appropriate channels. 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? This policy has been ratified by the ICG which includes a member of the public. As with the majority of IC policies it is acknowledged that staff need to support individuals who require additional controls due to infection control risks, any variance to this must be clearly documented in the patients notes as part of their clinical care 6. Date completed: 22.05.2017 Review Date: 27.05.2020 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 8. Approval : At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date: 23.5.2017 24