Laying the Foundations the first DIPC annual report for Dudley and Walsall Mental Health NHS Partnership Trust. Alison Geeson Head of Nursing

Director of Infection Prevention and Control (DIPC) Annual Report April 2009 to March 2010 Laying the Foundations the first DIPC annual report for Dudley and Walsall Mental Health NHS Partnership Trust Author: Prepared On Behalf Of: Alison Geeson Head of Nursing Wendy Pugh Director of Operations and Nursing/Director of Infection Prevention and Control Date: June 2010 DIPC Annual Report 2009-10 (Final) June 2010 Page 1 of 40

Contents Section Page Number List of Abbreviations 3 List of Tables and Figures 4 Definitions/Key Information 5 Executive Summary 7 1.0 Introduction 12 2.0 Description of Infection Control Arrangements 13 3.0 DIPC Report to the Trust Board 18 4.0 Infection Control and Prevention Work Plan 2009/10 18 5.0 Financial/Service Specification Issues 22 6.0 Cleaning Services 23 7.0 Surveillance 24 8.0 Occupational Health 26 9.0 HCAI Incident Reporting 28 10.0 Audit and Effectiveness 30 11.0 Hand Hygiene 31 12.0 Training and Development Activities 33 13.0 Good Practice Development 36 14.0 Conclusion 36 15.0 References 39 16.0 Appendices 40 DIPC Annual Report 2009-10 (Final) June 2010 Page 2 of 40

List of Abbreviations DWMHPT DIPC CQC ICC IGC MRSA C.Diff ESBL HCAI QIPPP CYHC NHSLA ISS NSC PEAT IPS ICNA OLM CQUIN DH HPA IPCT WHO Dudley and Walsall Mental Health NHS Partnership Trust Director of Infection Prevention and Control. An individual with overall responsibility for infection control and accountable to the registered provider The Care Quality Commission the integrated regulator of health and adult social care Infection Control Committee Integrated Governance Committee Methicillin-resistant Staphylococcus aureus Clostridium difficile Escherichia Coli Health Care Associated Infections Quality, Improvement, Prevention, Productivity, Partnership Clean Your Hands Campaign NHS Litigation Authority Integrated Services Solutions National Standard of Cleanliness Patient Environment Action Team Infection Prevention Society incorporating Infection Control Nurse Association Oracle Learning Management Commission for Quality and Innovation Department of Health Health Protection Agency Infection Prevention and Control Team World Health Organisation DIPC Annual Report 2009-10 (Final) June 2010 Page 3 of 40

List of Tables and Figures Table Page Number 1 Comparison between MRSA and Clostridium difficile 6 2 Health and Social Care Act 2008 - Code of Practice for 9 health and adult social care for the prevention and control of infections 3 Quality and Performance 2009/10 (key highlights) 18 4 PEAT Inspection Results for 2009 24 5 Anticipated PEAT Inspection Results for 2010 24 6 Injuries/Incidents During 2009/10 28 7 DWMHPT Results of Mandatory Reporting 2009/10 29 8 Infection Control Training Data 34 Figure 1 Pre-placement Health Checks During 2009/10 27 2 Infection Control Training Data 35 DIPC Annual Report 2009-10 (Final) June 2010 Page 4 of 40

Definitions/Key Information HCAI Health Care Associated Infections HCAI s are infections acquired in hospitals or as a result of healthcare interventions. They are caused by a wide variety of micro organisms by bacteria that often live harmlessly in or on our body. Whilst people are most likely to acquire HCAI s during treatment in acute hospitals, they can also occur in GP surgeries, care homes, mental health trusts, ambulances and people s own homes. In fact anywhere that people are receiving clinical treatment. Although the majority of HCAI s cause minimal harm and can be treated like any infection, particular challenges are faced from MRSA and C.difficile. For those people with MRSA or C.difficile the consequences can be severe. In addition to the pain and suffering to patients and families there are also implications for NHS resources. Evidence suggests that patients with an MRSA bacteraemia spend on average an additional 10 days in hospital and for C.difficile the additional length of stay is 21 days. Infection can cost an organisation an extra 4,000-10,000 per patient. MRSA/MRSA BACTERAEMIA - Methicillin-resistant Staphylococcus aureus MRSA is a strain of the staphylococcus aureus bacteraemia which is resistant to commonly used antibiotics. About 30% of the population have some type of staphylococcus aureus bacteria living naturally on their skin or in their nose where it usually does them no harm. MRSA can be more difficult to treat and therefore infections may become more severe. MRSA can infect surgical wounds or ulcers and more seriously if it enters the blood stream it can cause bacteraemia. C.DIFFICILE - Clostridium Difficile Clostridium difficile is a bacteria that lives in the gut of about 3% of healthy adults in England. It is kept at bay by normal gut bacteria but if those bacteria are killed by antibiotics, C.difficile can proliferate. Toxins released by C.difficile cause diarrhoea which can occasionally be very severe and life threatening. In most cases the infection develops after cross infection from another patient. Over 80% of cases of C.difficile infection are in people over the age of 65. See Table 1 for comparison between MRSA and C.difficile. NOROVIRUS Norovirus is the most common cause of gastroenteritis in hospital settings and outbreaks often lead to ward closure and major disruption in activity. Vomiting and short lived diarrhoea is the prominent symptom. During bouts of vomiting aerosol containing millions of live virus particles are released and are disseminated widely in the environment i.e. across several meters. Thorough environmental cleaning is an essential part of outbreak control management. DIPC Annual Report 2009-10 (Final) June 2010 Page 5 of 40

Secondary cases therefore occur easily, both through exposure to an infectious individual and the contaminated environment. Secondary attack rates are commonly high and staff themselves may become infected. DWMHPT has had three outbreaks of Norovirus within 2009/10 as described within the incidents section of this report (section 9). Table 1 Comparison between MRSA and Clostridium difficile (source DH 2008 Clean, safe care Reducing infection and saving lives) Comparison between MRSA and C.difficile MRSA Transmitted mainly through contact with colonised skin or contaminated equipment Eliminated from hands by using alcohol hand rub, and cleaning with most disinfectants Key risk of bloodstream infection is through piercing of skin (e.g. cannula or open wounds) Survives less well in the environment Screening for colonised patients is simple (nose and skin swab), and colonisation known to increase risk of infection and transmission C.difficile Transmitted mainly through contact with spores from infected faeces, or contact with contaminated environment and equipment Reduced by washing hands with soap ad water, and cleaning with chlorinebased disinfectants Key risk of infection is through ingesting spores, together with antibiotic treatment Spores survive very well in the environment Screening for colonised patients if inappropriate (most potential cases would not be identified, and it requires a stool sample), and colonisation without symptoms is not considered to increase risk of transmission DIPC Annual Report 2009-10 (Final) June 2010 Page 6 of 40

EXECUTIVE SUMMARY Background Dudley and Walsall Mental Health Partnership NHS Trust (DWMHPT) was established on 1 st October 2008. This report is the first DWMHPT Director of Infection Prevention & Control (DIPC) annual report and reflects an account of the organisation s infection prevention and control activities during 2009/10. The report is also intended to demonstrate a level of assurance whereby DWMHPT is compliant with the Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infection and continues to strive to deliver excellence whilst of course accepting the reality that providers of care do not operate in a sterile world. During the six month period between October 2008 and March 2009 DWMHPT concentrated on establishing it s own structures to enable the development of good management and organisational processes to ensure that high standards of infection prevention and control were established in the organisation. The partnership working with NHS Dudley and NHS Walsall respective infection control teams was crucial in establishing the infrastructure for embedding best practice in infection prevention and control within the new organisation. Given that this is the first DWMHPT DIPC annual report it is imperative to recognise that 2009/10 has been a year of organisational transition and subsequent development of a shared health and social care strategic vision for mental health services for the people of Dudley and Walsall. The Clinical and Social Care Strategic Vision 2010-2015 has included a key message that effective prevention and control of infection must be part of everyday practice and be applied consistently by everyone within the organisation. The Trust is now in a position to report both an exciting and challenging year in respect of infection prevention and control. In 2009/10 DWMHPT achieved Care Quality Commission (CQC) registration without conditions, gained NHSLA level 1 compliance, achieved compliance with Standards for Better Health and achieved all CQUIN targets. In the context of infection prevention and control, this achievement demonstrates full compliance with all performance targets relevant to the Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infection. This achievement reflects the vast amount of work that has taken place during 2009/10 at local level to ensure total organisational ownership of responsibility for infection prevention and control from Board to Ward (DH 2008). However, the industrious approach will need to continue at great pace as there is no room for complacency as we endeavour to build on the year s achievements and drive quality improvements. DIPC Annual Report 2009-10 (Final) June 2010 Page 7 of 40

Executive Highlights Positive Developments/Achievements During 2009/10 The establishment and embedding of the Director of Infection Prevention & Control (DIPC) role within the organisation The establishment, growth and development of DWMHPT Infection Control Committee (ICC) The clarification of ICC reporting structures and interface with Integrated Governance Committee (IGC) The development of local ownership infection control is everyone s responsibility within DWMHPT No incidents of MRSA Bacteraemia or Clostridium Difficile reported Significant progress with developing a robust audit framework which fully demonstrates a partnership approach across all directorates Achieving compliance with mandatory training programmes The development of a best practice model of infection control link working including the development of a local audit tool, self-assessment/competency framework and specific mental health education forums A continuing profile of Clean Your Hands campaign Successful management and containment of Norovirus outbreaks Excellent partnership working within Infection Control Teams in NHS Dudley and NHS Walsall who provide expertise to DWMHPT Challenges During 2009/10 Building a sound foundation for the effective management and delivery of systems which promote best practice in infection prevention and control Building a consistent approach to infection prevention and control across the whole Dudley and Walsall workforce whilst interfacing as one provider organisation with two distinct providers of infection control expertise Learning lessons from audit processes and embedding the learning in day to day practice Develop the contribution of DWMHPT within the local healthcare economy wide HCAI forums Developing assurance frameworks and an evidence base that will demonstrate continual quality improvement Agreeing service specifications for external provision of infection control expertise Establishing a framework of QIPPP (Quality, Innovation, Prevention, Productivity and Partnership) Developing opportunities for gathering patient experiences in relation to clean care environments Harmonising policies Testing DWMHPT approach to control and management outbreaks of Norovirus Key Deliverables for 2010/11 The Infection Control Committee work programme for 2010/11 will drive the implementation and demonstration of assurances within all the compliance criteria of The Code of Practice for health and adult social care on the prevention and control of infections under the Health and Social Care Act 2008 (Table 2). DIPC Annual Report 2009-10 (Final) June 2010 Page 8 of 40

The positive achievements within 2009/10 have built the foundation upon which to develop best practice. The challenges identified above have formed an integral part of the ICC work programme for 2009/10 and will continue to do so for the 2010/11 ICC work programme. The delivery of this work programme will be steered by the ICC as it continues it s second year of development. It will be the responsibility of the ICC to provide assurances to the DIPC and the Integrated Governance Committee (IGC) that any risks identified within the organisation are being robustly managed locally. The DIPC will continue to provide assurances to the Trust Board. It is equally important that areas of positive practice development are brought to the attention of the ICC, the IGC and as considered to be appropriate by the DIPC, to the Trust Board. Table 2 Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infections Compliance What the registered provider will need to demonstrate criteria 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. 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infection. 3 Provide suitable accurate information on infection to service users and their visitors. 4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion. 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 o other people. 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 7 Provide or secure adequate isolation facilities 8 Secure adequate access to laboratory support as appropriate. 9 Have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent and control infections. 10 Ensure, so far 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. DIPC Annual Report 2009-10 (Final) June 2010 Page 9 of 40

Conclusion This first DIPC annual report for DWMHPT has intended to give an overview of infection control and prevention activity during 2009/10. The content of this report will be the catalyst for further ICC consideration of key work priorities for 2010/11. The Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infection reflected in Table 2 will provide the framework for the ICC work programme for 2010/11. Specific Developments that the DIPC Would Wish to See During 2010/11 Building capacity to deliver excellence by recruiting an Infection Control Lead Nurse Greater involvement of service user and carers within local forums relevant to infection prevention and control A more focused effort on learning lessons from incidents and audit outcomes hence driving quality improvement The establishment of the Heads of Service roles and responsibilities with service line reporting to the ICC Developing surveillance systems Developing a clear pathway for service specifications and associated monitoring mechanisms i.e. provision of infection control team expertise and provision of microbiology services Financial review/stock take of infection control and prevention resource allocations Exploring further opportunities to capture the patient experience of cleanliness within service delivery environments Policy development work to ensure consistency across the whole organisation Sustaining partnership working across the whole health economy of Dudley and Walsall Further development and consistent implementation of incident reporting Development of expertise to present data effectively, utilisation of data analysts To develop the effectiveness of the ICC and evaluation of it s effectiveness To continue to embed the Infection Control Link Worker programme and build on best practice developments To further develop partnership working with the infection control teams across Dudley and Walsall healthcare economies Building on positive relationships with the SHA and HPA Effective communications to ensure that any new builds and estates work planning and delivery has been informed by ICC advice and guidance The further development better of quality of information for patients, carers and visitors To build on the foundations laid during 2009/10 within a framework of continuous quality improvement Dudley and Walsall Mental Health Partnership Trust has progressed an industrious level of activity in relation to the vast arena of infection prevention and control during the past year. As an organisation we have been assessed as being fully compliant by the CQC in meeting best practice standards with infection prevention and control. However, there is no room for complacency and it is the absolute intention of the DIPC and ICC to drive continuous quality improvement so DIPC Annual Report 2009-10 (Final) June 2010 Page 10 of 40

that patients receiving care have access to clean environments and staff delivering care, take pride in contributing to achieving excellent standards. A full work programme for 2010/11 will be driven by the ICC to ensure that best practice within DWMHPT is maintained and that we develop our local reputation for embedding a culture where everyone owns their responsibility for infection prevention and control. The annual work programme for 2010/11 will be formalised at the ICC meetings in July 2010 and the role of the new Heads of Service and all members of the ICC will be key to the delivery of local action plans. Further to this, DWMHPT as a registered provider of health and social care services, has identified a priority activity for 2010/11 as developing and implementing a performance and quality management framework that supports the continuous improvement of service quality and the effective management of risk. In doing so, it will strive to continue building on the foundation work described in this report to then deliver regulatory standards and be in a position to provide continuing assurance that the Trust meets the Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infection. The DIPC in final summary concludes: An industrious year, all targets have been delivered to a high quality standard, the foundations have been laid, cultures have developed positively, responsibilities have been clarified, learning has been plentiful, lessons learnt have been shared and acted on, best practice models have been developed and our internal and external reputation for good practice in infection prevention and control is gaining a sound profile. A huge amount of work has been delivered during 2009/10 and the pace will need to continue during 2010/11 within a framework of continual quality improvement. The amount of work that has occurred which is reflected in this first annual report cannot be under-estimated and the DIPC would wish to thank all staff for their hard work and contribution. However, there is no room for complacency and the industrious approach will need to continue. We can reflect on the past year positively and now move forward to become even better together in making our services cleaner and safer for everyone. DIPC Annual Report 2009-10 (Final) June 2010 Page 11 of 40

1.0 Introduction The role of the Director of Infection Prevention & Control (DIPC) was first described in Winning ways: working together to reduce healthcare associated infection in England (DH 2003) and has continued to be seen as the public face of infection prevention and control. Within Dudley and Walsall Mental Health Partnership Trust (DWMHPT) the DIPC role is within the portfolio of the Director of Operations and Nursing. A key responsibility of the DIPC is to produce an annual report. This report is the first DIPC report for DWMHPT and reflects an overview of all aspects of the organisation s infection prevention and control programme for 2009/10. This report is also a demonstration of assurance from the DIPC in relation to DWMHPT compliance with the Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection and that the organisation is moving forward in establishing a culture that reflects ownership and emphasises that infection prevention and control is everyone s responsibility. This report provides a summary of the world of infection prevention and control within DWMHPT. 2009/10 has bee a very industrious year in terms of building an infrastructure for the establishment of local systems to manage and monitor the prevention and control of infection and to ensure full compliance with the Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection. 1.1 Purposes of the Code of Practice The main purposes of the Code of Practice (Code) are: To make the registration requirement for cleaning and infection control clear to providers of health and social care services so that they know what they need to do to comply For the CQC s staff who will be judging compliance with the Code For people who use the services of a registered provider For commissioners of services (primary care trusts and councils) For the general public A key component of local work has been to develop a consistent approach across the whole organisation to ensure that all users of mental health services across Dudley and Walsall communities receive care within clean and safe environments which is provided by staff who are appropriately trained in infection prevention and control and who own responsibility for delivering best practice. Our workforce has needed to seek infection control expertise from two distinct organisations, NHS Dudley and NHS Walsall. In practical terms this has presented both challenge and opportunity, however, the partnerships that have developed during 2009/10 have had positive impact and healthy representation of all partners within the ICC have resulted in a joined up approach. During 2009/10 the organisation has developed it s identity and shared health and social care vision. Within the context of infection prevention and control, this report essentially reflects that a vast amount of work has been delivered to establish a solid infrastructure upon which we now have to build during 2010/11. DIPC Annual Report 2009-10 (Final) June 2010 Page 12 of 40

The report describes local infection control arrangements, key roles and responsibilities and local work programmes, financial and service specification summary, details of cleaning services, surveillance systems, Occupational Health issues, HCAI incident reporting including results of mandatory reporting, audit frameworks and key lessons learnt, local details of implementation of Clean Your Hands campaign (CYH), training and development activities and examples of local best practice initiatives. The report concludes with some indicators of what the DIPC would like to see happening in 2010/11. DWMHPT formally registered with the CQC and declared partial compliance with the Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection. A full work programme was implemented locally in a proactive manner to address the areas of partial compliance. The Trust was formally notified by the CQC that it s registration had been accepted without any further conditions as from 1 st April 2009. During the past year the Trust has not been externally assessed, however we acknowledge that such assessment could happen at any time and as such, make it our day to day business to meet best practice standards and strive to deliver quality improvements. It is timely to note that our Trust has recently received information from the CQC that it has achieved full CQC registration for 2010/11. 2.0 Description Of Infection Control Arrangements (Structure, Accountability and Assurance) The period of time reflected on in this report (April 2009-March 2010) demonstrates significant organisational transition. Within the transitional period it has been important to develop an overarching understanding of roles and responsibilities in relation to all members of the workforce. We are continuing this journey as the operational management structure is undergoing redesign and it is anticipated that the appointment of five Heads of Service will play a major part in delivering Key Performance Indicators (KPI s) that support the continuous improvement of service quality and the effective management of risk during 2010/11. During the past year DWMHPT has endeavoured to embed a culture of ownership of infection prevention and control responsibilities from Board to Ward. The following roles and responsibilities capture the organisational arrangements, governance and reporting structures. 2.1 The Role of the Chief Executive The Chief Executive is accountable for the provision of a safe patient and staff environment, including the prevention and control of healthcare associated infections. 2.2 The Role of the DIPC The Director of Infection Prevention & Control (DIPC) has corporate responsibility and executive authority and responsibility for ensuring the implementation of DIPC Annual Report 2009-10 (Final) June 2010 Page 13 of 40

strategies to prevent avoidable healthcare associated infections at all levels in the organisation of DWMHPT. The DIPC reports directly to the Chief Executive and assures the Trust Board on the organisations performance in relation to HCAI s providing regular reports including an annual report. The DIPC provides leadership to the infection prevention and control work programme in order to ensure a high profile for infection prevention and control across the organisation. The DIPC is a key member of the ICC and works closely with the Head of Governance (Chair of ICC) and the Head of Nursing (Vice-Chair of ICC) to ensure that systems are in place to manage and monitor the prevention and control of infection. 2.3 The Infection Control Committee (ICC) The ICC is chaired by the Head of Governance and the Vice-Chair responsibility is with the Head of Nursing. The committee has met on a monthly basis during 2009/10 and has an integrated membership of staff from all directorates and partnership organisations. The expert contribution of infection control team representatives from Walsall and Dudley health economy has been crucial during the past year and will continue to be so during 2010/11. The main purpose of the Infection Control Committee is to oversee and monitor infection control policies, procedures and processes within the Trust, to ensure compliance with the Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection. The ICC is required to provide assurances and reports to the Integrated Governance Committee (IGC). It is a key committee for discussion, development and planning of all activities resulting in the provision of assurances to the Trust Board via the DIPC (Appendix 1 ICC Terms of Reference) 2.4 The Infection Prevention and Control Teams Infection control expertise is provided by the Infection Control Lead Nurses and teams from NHS Dudley and NHS Walsall. The Infection Control Lead Nurses are key members of the ICC. The Infection Control Lead Nurses and teams within NHS Dudley and NHS Walsall contribute actively to the ICC work programme including audit, education and training programmes, policy development, day to day advice and guidance to mental health staff, visits to clinical areas, support with management of infection control outbreaks and advising the DIPC on a continuing basis. In June 2009 the World Health Organisation (WHO) escalated the flu measures to pandemic level. Intensive support from NHS Dudley an NHS Walsall Infection Control teams supported the mental health workforce to plan for the potential implications accordingly. Locally the demand for activating plans was very low as was the demand for anti-viral treatment. The National Pandemic Flu Service ceased from February 2010. The ICLN s continue to share their knowledge and expertise in relation to latest guidance and will contribute to local planning in respect of seasonal flu and swine flu. DIPC Annual Report 2009-10 (Final) June 2010 Page 14 of 40

The Infection Control Lead Nurses and associated team have greatly contributed to the CYH campaign during 2009/10 and worked in partnership with local mental health infection control link workers on local projects and programmes. During 2009/10 DWMHPT has benefited from the expertise provided by the Infection Control Lead Nurses and teams within the area of mandatory surveillance of HCAI s. Surveillance is best described as information for action and the ICC are looking to develop a wider understanding of surveillance opportunities as part of the 2010/11 work programme. Infection Control Lead Nurses provide monthly verbal updates and quarterly reports to the ICC. It is noted that working relationships with the respective Dudley and Walsall Infection Control Teams at local level have supported the early days development of infection prevention and control practices within our mental health provider organisation and their contribution has been invaluable. At time of writing this annual report it is relevant to state that the provision of expertise from NHS Walsall Infection Control Team is being reviewed and a service specification is being worked up. It is anticipated that this service specification will be completed within the first quarter and that a similar process may then follow in relation to expertise provided by NHS Dudley. It is emphasised that DWMHPT and NHS Dudley have not begun service specification discussions to any formal degree at this point in time. 2.5 Senior Managers and Service Leads The Infection Control Committee membership consists of representation from all service areas. The DIPC during 2009/10 has given clear messages to all senior managers and service leads regarding their responsibilities in the area of infection prevention and control. Key responsibilities include: Senior Managers and Service Leads have a duty to ensure that the responsibilities for prevention and control of infection are reflected in all staff members job descriptions and are incorporated into annual appraisal A responsibility to ensure that all staff receive induction training and attend ongoing infection prevention and control training in line with Trust requirements. Please note that all training must be recorded on the Trust electronic recording system via the Training and Development Department Ensuring that infection control audit audits are undertaken as agreed within the annual program and that audit findings/actions required are implemented effectively Ensuring that the results of audits, surveillance, infection outbreaks/incidents are reported in accordance with Trust guidance 2.6 The Role of the Link Worker A major development for DWMHPT has been the role of Infection Control Link Worker. A great deal of effort has been made to ensure a consistent approach to infection control link working across the whole organisation during 2009/10. As an organisation we are very proud of our infection control link workers and their contribution to infection prevention and control. The programme of work leading to DIPC Annual Report 2009-10 (Final) June 2010 Page 15 of 40

the establishment of consistent link working across all areas has been led by the Head of Nursing (Appendix 2 Outcomes of Infection Control Link Worker Short-life Working Group A Portfolio of Evidence). Infection Control Link Workers are individual staff nominated as part of their existing role to act as a local resource and point of contact for infection control and prevention of HCAI issues. The Link Workers have regular opportunities for learning and development including specific forums which have been established by the Infection Control Link Worker Best Practice Steering Group for implementation in 2010. The Infection Control Link Worker reports directly to the relevant line manager and works in partnership with the line manager and all colleagues to optimise best practice in line with standards directed by the ICC. The Infection Control Link Workers are supported by the Infection Control Lead Nurses within NHS Dudley and NHS Walsall, the Clinical Nurse Specialist (Education) and the Head of Nursing. Key responsibilities include: Championing, monitoring and ensuring best practice in infection control in their local workplace Attending regular update meetings with the Trust Infection Control Teams Actively participating in all required infection control audit activities. The Link Worker role is now established in all areas of service provision. Essentially the Link Workers now have the tools to do their job as a result of an intense work programme during 2009/10. The challenge will be in delivering a local programme of audit, implementing actions and learning lessons. The role of Infection Control Link Worker is considered to be a crucial one which needs to be developed further and supported with a robust programme of education and development during 2010/11. It is acknowledged that the link worker role is gaining momentum and all the learning from the early days of link working needs to be kept alive. This is an ongoing area of work and as such the Head of Nursing continues to chair an Infection Control Link Worker Best Practice Steering Group which is a formal sub-committee of the ICC and reports quarterly. 2.7 All Staff Responsibilities All staff working either directly or indirectly with patient care within the Trust have a responsibility to work together to ensure best practice in respect of infection control and prevention of healthcare acquired infections. The following key responsibilities of all partners are identified as referred to within DWMHPT overarching Infection Control policy. Key responsibilities include: Complying with instructions, policies and best practice guidance for infection prevention and control Ensuring that infection control incidents or issues of concern are reported to their Line Manager and that an incident report is completed in accordance with Trust policy. To undertake identified training, including refresher sessions, in infection prevention and control as necessary for their role within the Trust DIPC Annual Report 2009-10 (Final) June 2010 Page 16 of 40

2.8 Key Points In this first DIPC report it is considered important to highlight all roles and responsibilities to give a flavour that DWMHPT endorses comprehensively that infection prevention and control is everyone s responsibility During 2009/10 the ICC has given clarity to workforce roles and responsibilities which now need to be fully embedded within the day to day business of care environments to deliver continuous quality improvements for our service users and carers. 2.9 The Assurance Process for 2009/10 The Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection guides organisations towards an assurance framework which demonstrates that infection prevention and control are an integral part of quality and performance activity. Within DWMHPT the assurance process includes the following: The provision of an annual programme of activities approved and regularly monitored by the ICC (Winning Ways 2003, the Health and Social Care Act 2008) Reporting from ICC to IGC quarterly, production of the DIPC annual report which is presented to the Trust Board Achieved compliance with Standards for Better Health 2004 Gained NHSLA Level 1 compliance Patient Environment Action Team reviews Achieved all CQUIN targets in relation to mandatory reporting of MRSA and C.Difficile The first quality accounts for 2009/10 have highlighted the infection control link worker programme as a best practice example of quality improvement Adoption of various national initiatives for the reduction of HCAI s i.e. Clean Your Hands Campaign (CYHC) In it s first full year of operation the Trust has faced a challenging period and staff have worked exceptionally hard to embed underpinning processes, policies and organisational principles. The focus was to ensure the establishment of solid foundations whilst at the same time, ensuring that service delivery was maintained without disruption throughout the period of formation. The evidence of this in the context of infection prevention and control is demonstrated within the assurance processes described and as highlighted in Table 3. DIPC Annual Report 2009-10 (Final) June 2010 Page 17 of 40

Table 3 Quality and Performance 2009/10 (key highlights) Regulator Compliant Traffic Light Indicator Care Quality Commission National Health Service Litigation Authority Standards for Better Health Key Performance Indicators MRSA bacteraemia Clostridium Difficile Registration with no conditions Level 1 compliance Compliance 0% 0% Green Green Green Green Green 3.0 DIPC Reports to the Trust Board Summary The DIPC reports to the Trust Board and attends Trust Board meetings to report on infection prevention and control issues and to ensure prevention and control consideration in other operational and developmental decisions of the Board. The DIPC as appropriate assures the Trust Board on the organisations performance in relation to HCAI s. In addition, the DIPC provides assurance to the Board that policies are fit for purpose. The DIPC role has established itself during the past year as a highly visible senior authoritative individual who provides assurances to the Board that the systems are in place and the correct policies and procedures are adhered to across the organisation to ensure safe and effective healthcare and to comply with the Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection. This first annual report from the DIPC to the Board is intended to provide an overview of activity and assurance to promote further awareness and debate at Board level. 4.0 Infection Control and Prevention Work Plan 2009/10 With the establishment and development of DWMHPT ICC a comprehensive work programme has been delivered during 2009/10. In essence, the year has involved an intense focus on establishing an infrastructure to allow effective systems to manage and monitor the prevention and control of infection. With the DIPC Annual Report 2009-10 (Final) June 2010 Page 18 of 40

establishment of the CQC came a major focus upon organisations applying for registration which would indicate it s level of compliance with the Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection. In gathering evidence and information for DWMHPT application for CQC registration the ICC began to shape it s work plan for 2009/10. As from 1 st April 2009 DWMHPT acquired full registration with the CQC. Based on the local evidence available demonstrating compliance with criteria 1-10 (refer to Table 2) the priority areas of local action were agreed by the ICC in April 2009. There are local action plans available but for the purpose of this report the key areas are summarised. Criteria 1 - The Trust has in place and operates effective management systems for the prevention and control of HCAI that are informed by the risk assessments and analysis of infection incidents. Progress/Implementation A well established ICC that reports to the IGC Full compliance with NHSLA standards in relation to infection prevention and control Robust presentation of incident reporting and analysis (Appendix 10 incidents report) Effective management of outbreak of Norovirus and lessons learnt presented to ICC and Embedding Lessons Group. Delivery of a full project management approach to ensuring consistent implementation of infection control link working across the organisation. This work has been highlighted as good practice by NHS Dudley and NHS Walsall Infection Control Teams and has been nominated for national best practice awards i.e. Health and Social Care Partnership Awards The establishment of an Infection Control Link Worker Best Practice Steering Group which reports to the ICC (Appendix 3 Terms of Reference and Appendix 4 Work Plan) Established a full evidence-based local clinical audit framework which is now consistently implemented across the whole organisation by Infection Control Link Workers. Data has been collected and presented at the ICC following launch of the tool on 1 st November 2009 (Appendix 5 - Link Worker Audit Report February 10, Appendix 6 - Link Worker Audit Report June 10 and Appendix 7 Infection Control Mattress Audit) NHS Dudley and NHS Walsall have completed via their infection control teams, full audit across the three hospital sites. Managers have activated local action plans to address risk areas (Appendix 8 Findings of External Infection Control Audits) An Overarching Infection Control policy and Hand Hygiene policy have been established and implemented Development of training records which can demonstrate progress in compliance with mandatory training programmes (from 39% to 74% - see table 4/fig. 1) Baseline scoping work to develop service specifications for infection control expertise provision from NHS Walsall. This has been identified as one of 20 top DIPC Annual Report 2009-10 (Final) June 2010 Page 19 of 40

contract priorities for DWMHPT and anticipated sign-off is by the end of June 2010. Reaching a position whereby DWMHPT DIPC can report the first DIPC annual report Criteria 3 - Provide suitable accurate information on infection to service users and their visitors. Progress/implementation Information presented in all clinical areas demonstrating importance of hand hygiene. Information posters displayed in entrance and reception areas for service users and visitors pertinent to Norovirus. Communications Department have produced a range of information on HCAI which staff can access from the intranet to share with service users and carers. Work has commenced with regard to the development of a protocol for sharing information when patients move to the care of another health care or social care provider. Whilst the above progress has been made, the ICC will be prioritising further work on criteria 3 during 2010/11 to enhance the quality of current information available to service users and their visitors. Criteria 7 - Provide or secure adequate isolation facilities Progress/implementation All three hospital sites are able to provide adequate isolation precautions and facilities sufficient to prevent or minimise the spread of infection. During 2009/10 there have been two outbreaks of Norovirus within Bushey Fields Hospital and Bloxwich Hospital. Both outbreaks have been managed effectively utilising local outbreak of infectious diseases policies. The learning from these outbreaks has identified a need to harmonise local policies of NHS Dudley and NHS Walsall to form a DWMHPT Outbreak Control Policy to assist consistent policy implementation and best practice across all areas of provision within DWMHPT. Ratification of an Overarching Infection Control Policy by the IGC in January 2010. Criteria 9 - Have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent and control infections. Progress/implementation The ICC has via the Clinical Governance Facilitator conducted a stock take of policy development (Appendix 9 Policy Position Statement) identifying gaps that will form an essential part of the work programme for 2010/11. As a mental health provider organisation with infection control expertise provided by two organisations to us i.e. NHS Dudley and NHS Walsall, it has been a challenging year for our workforce as different policy structures have needed to be utilised however, local partnership working arrangements are such that DIPC Annual Report 2009-10 (Final) June 2010 Page 20 of 40

DWMHPT can now move forward with developing it s own local prevention and control of health care associated infections policies. During 2009/10 there has been a significant amount of policy work including the development and ratification of an overarching infection control policy, a hand hygiene policy and a management of sharps injury policy. Cases of MRSA bacteraemia and of C. difficile are identified as reportable incidents within the Trusts Incident, Near-miss and Serious Untoward Incident policy which have been assessed as NHSLA level 1 compliant during 2009/10, Criteria 10 Ensure, so far 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. Progress/implementation Data that was available at the start of the year 2009/10 highlighted significant areas of risk in relation to compliance with infection control training activity as a whole. The ICC subsequently approved a training plan which has been implemented during the year. The compliance data now clearly demonstrates significant improvements in mandatory training uptake (Table 7 and Fig. 2) During 2009/10 significant energy has been given to the provision of diverse training and development opportunities including Trust Induction, infection control e-learning modules, Infection Control Link Worker education and development forums. The Infection Control Link Worker initiative has significantly contributed to learning in practice and dialogue at local level about infection prevention and control has taken on great momentum during the year. The audit outcomes in relation to compliance with hand hygiene clearly demonstrate healthy compliance and benefits of local training programmes as do the observational audits carried out by Infection Control Link Workers. The key areas of progress detailed above demonstrate the significant amount of activity and delivery of local actions during 2009/10. The areas targeted were relevant to the information that DWMHPT submitted as partially compliant to the CQC. The CQC in considering our application for registration, which included an action plan to progress areas that we considered ourselves to be partially compliant with awarded DWMHPT full registration with no conditions attached. However, at local level the approach has been that there is no room for complacency and we continue as an organisation to strive for continual quality improvement in all areas of health and social care act compliance criteria. Many of the achievements of the work programme have been possible due to local partnership working between DWMHPT and infection control teams from NHS Dudley and NHS Walsall who provide the necessary expertise to mental health provider services. DIPC Annual Report 2009-10 (Final) June 2010 Page 21 of 40

5.0 Financial/Service Specification Issues It is important to state from the outset that the multi-faceted and complex arena of finance, service specification and local provision of infection control expertise and microbiology provision requires a comprehensive review to establish a meaningful baseline position for 2009/10. The current position is summarised as follows: 1. NHS Walsall currently provide a range of infection control expertise and services including input from the infection control team. For 2009/10 local services from the infection control team have been provided without any firm service specification. Current work is under way to establish a service specification. The infection control service specification with NHS Walsall is on DWMHPT top 20 list of contracts needing the service specification and agreement signing as soon as possible. The Head of Nursing and the contracting team are actively working on this at the moment with a view to sign-off by the end of June 2010. 2. NHS Dudley provides a similar range of infection control expertise and services without any service specification arrangements. It is noted that upon establishment of DWMHPT, high level discussions occurred resulting in local infection control team services continuing to be provided to DWMHPT as part of a wider health economy approach until further review. As such, during 2009/10, NHS Dudley infection control and prevention team have provided relevant support and services. 3. The ICC have established the need to enhance the current infection control expert provision from NHS Walsall and NHS Dudley and the intention is for DWMHPT to recruit an infection control Lead Nurse during 2010/11. This post will work in partnership with infection control teams in NHS Walsall and NHS Dudley and will assist the organisation of DWMHPT in providing a consistent approach to the prevention and control of HCAI. 4. Dudley Group of Hospitals and Walsall Acute Hospitals currently provide microbiology and pathology services to DWMHPT. The current position is that DWMHPT do not have contracts in place for these services and precise details on the split of charges between microbiology and pathology service provision is not readily available. These contract requirements have been highlighted as areas in need of review but at time of constructing this annual report there is no work in progress. Clearly this position requires priority review and is highlighted in this report as a priority area for local address during 2010/11. The above information is essentially a summary of the current finance/service specification position. It is however, important to note that despite the absence of formalised service specifications, the local partnerships and effective working relationships between NHS Dudley and NHS Walsall infection control teams and DWMHPT have continued to develop positively and all organisations providing infection control services to us are active members of DWMHPT ICC. DIPC Annual Report 2009-10 (Final) June 2010 Page 22 of 40