INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2009/2010 INFECTION PREVENTION AND CONTROL COMMITTEE

INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2009/2010 INFECTION PREVENTION AND CONTROL COMMITTEE

Contents Page 1. Executive Summary 2-3 2. Pennine Care Infection Prevention & Control Strategy 3-4 3. Roles and Responsibilities 4-7 4. Policies 7 5. Service Level Agreements 8-9 6. Care Quality Commission Visit 9 7. Audits 9-11 8. Incidents 12-17 9. Training 18 10. Health Care Associated Infections (HCAI) - MRSA, Clostridium Difficile, ESBL (Surveillance) and Outbreaks 18-20 11. Antibiotic Prescribing 20 12. Cleaning and Decontamination procedure 20-21 13. Planning and Refurbishment 21 14. Flu Vaccination programme 21 Appendix A Infection Prevention and Control Audit Plan April 2010- March 2011 22-23 Appendix B Board Level Agreement 24-26 Appendix C Infection Control Training Plan April 2010 to March 2011 27 Appendix D Infection Control Work plan April 2010 to March 2011 28-29 Appendix E Infection Prevention and Control Completed Action Plan April 2009 to March 2010 30-31 Appendix F Infection Prevention and Control Action Plan April 2010 to March 2011 32-34 Appendix G CQC Action Plan 35-39 Appendix H Quality Accounts 40-42 Appendix I Monthly Monitoring Form 43-49 Appendix J 6 Monthly Environment Audit Form 50-59 1

1. Executive Summary Pennine Care NHS Foundation Trust provides specialist mental health services in a variety of community and inpatient settings across Bury, Rochdale, Oldham, Stockport, Tameside and Glossop. As an NHS organisation the Trust is committed to reducing the incidence of healthcare associated infections. The report is for the period April 2009 to March 2010. It also includes the infection control plans for April 2010 to March 2011. The report outlines the accountability arrangements for infection control in the trust. The text outlines the activities of the Trust relating to infection prevention and control that aim to minimise the risk of healthcare associated infections including surveillance, audit, quality accounts, policy development and review, incident reporting, education and training and the prevention and management of outbreaks. The trust has implemented a programme of activities to embrace new national initiatives and effectively prevent and control healthcare associated infections across the trust. The Health and Social Care Act 2008 outlines a clear code of practice for Infection Prevention and Control. Pennine Care strives to achieve excellence in all aspects of the code. The Trust registered with the Care Quality Commission against the code of practice. The board have signed an Infection Prevention and Control Board Assurance document which is the board statement of commitment to all aspects of Infection Prevention and Control (Appendix I). The successful management, prevention and control of Infection is recognised by the Trust as a key factor in the quality and safety of care of inpatients/service users as well as ensuring a clean and well maintained environment which the Modern Matrons enforce in inpatient units, drug and alcohol service and CAMHS. The Board receives regular reports in relation to Infection Prevention and Control via Risk and Clinical Governance Committee and Infection Prevention and Control Committee. Infection control incidents are reported via the risk management reporting system and root cause analysis is undertaken when cases of new MRSA, Clostridium Difficile or an outbreak occurs. The key points from 2009/2010 are: Implementation of 13 new Infection Prevention and Control Policies Development of the Infection Prevention and Control web page Development of a robust audit programme 2

Implementation of monthly Matron walkabouts with Estates and Domestic Manager Development of Training programmes o o o o Mandatory Champions Infection Control policy awareness Matrons Implementation of CQC action plan Development of Infection Prevention and Control Information Leaflets. 2. Pennine Care Infection Prevention and Control Strategy Introduction The Department of Health has published a number of guidance documents to help NHS trusts to plan and implement how they can prevent and control Health Care Associated Infections. Winning Ways: Working together to reduce Healthcare Associated Infection in England (2003) and The Health and Social Care Act 2008 Code of Practice for the Prevention and Control of Health Care Associated Infections. Good management and organisation is crucial to establishing high standards of infection control. The systems for the prevention and control of infections associated with healthcare have to address leadership, management arrangements, design and maintenance of the environment and devices, provide application of evidence based protocols and practices for both users and staff and provide education, training, information and communication. Effective prevention and control of Health Care Acquired Infection (HCAI) has to be embedded into everyday practice and applied consistently by everyone. Aim Pennine Care is committed to reducing the risk of infections to a minimum through effective infection prevention and control practice. Infection Prevention and Control will be embedded in everyday practice across the organisation. 2.1 Scope The infection Prevention and Control Strategy is concerned with the prevention of avoidable risks of infection and the control and management of all unavoidable risks of infection to patients, service users, visitors and staff. 3

2.2 Objectives To ensure that Infection Prevention and Control is an integral part of the service delivery. To ensure that healthcare acquired infections are reduced to a minimum. To maintain compliance with all requirements of Standards for better Health and the Health and Social Care Act 2008. To ensure Pennine Care have policies and procedures in place to fulfil the requirements and comply to the Code of practice for the prevention and control of healthcare associated infections as outlined in the Health and Social Care Act (2008). To work with other stakeholders to improve surveillance and to strengthen prevention and control of infection and communicable disease processes. To ensure that information is available to patients and the public about the organisations general processes and arrangements for preventing and controlling HCAI (Health and Social Care Act 2008). To ensure decontamination across the Trust meets all the National mandatory requirements. To provide education and training on prevention and control of infection to ensure staff understand their responsibilities. To ensure appropriate information is communicated relating to infection risk and outbreaks to all relevant parties. To work with the local Health Protection Agency (HPA) to ensure good infection control practices across the trust. 3. Roles and Responsibilities The Pennine Care Board and ultimately the Chief Executive carries responsibility for Infection Prevention and Control. For day to day management this is delegated to the Director of Infection Prevention and Control (DIPC). All managers and clinicians must ensure that the management of infection control risks are one of the fundamental duties. Every clinical member of staff must demonstrate commitment to reducing the risk of infection through good infection control practice. This will be implemented, monitored and evaluated through staff IPDR processes. Role of Director of Infection Prevention & Control (DIPC) The DIPC is responsible for monitoring and overseeing infection control policies and reports directly to the Chief Executive Officer and the Board. Role of Lead Nurse: Infection Prevention and Control The IPCN provides a clinical service for the prevention, surveillance investigation and control of infection for Pennine Care. 4

The IPCN will: Ensure timely advice on infection control is available to Pennine Care staff, Committees and the Board. Liaise with the Health Protection Agency when dealing with Outbreaks. Be responsible for co-ordinating infection control audits, education and training, policy and strategy development and the production of relevant infection control reports and data for use within the Pennine Care to monitor and promote improvements in practice. Role of Infection Control Champions The IC Champions are responsible for promoting good infection control practice in their work area with their colleagues, patients/service users, relatives and the environment. Role of Matrons and Ward Managers Matrons and Ward Managers are responsible for ensuring that the day to day cleaning is being implemented to the highest standard and has the authority to address issues directly with cleaning teams. Weekly checklists must be provided by the ward managers to ICN. The checklist reports must then be reported on by the matrons in their quarterly reports to ICC. The matrons and ward managers are responsible for ensuring the Champions are supported and performing their role, and have the appropriate time and resources to do this effectively. Role of the Infection Prevention and Control Committee The committee members are responsible for providing strategic advice and support to the directors, managers, clinicians and all staff and on the implementation of infection control policies. It monitors the progress of the annual control of infection programme, infection control policies, procedures, guidance and Service level Agreements (SLA), audit, cleanliness, education and root cause analysis. Role of Estates Management and Domestic Services Estates Managers and Domestic Services Managers should ensure that the environment and equipment they are responsible for are maintained to required standards in order to promote good infection control practice and ensure easy cleaning of clinical areas. Role of Service Directors/Service Managers Service Directors & Service Managers liaise closely with the IPCN to ensure infection control policies are effectively implemented and maintained. They should ensure: All staff understand clearly their responsibilities in respect of the Infection Prevention and Control Policies. New staff are adequately inducted in respect of infection control procedures relevant to their work base and their role. 5

The required time is allocated for staff to attend infection control education sessions through the mandatory training programme. All infection control risks are systematically assessed and any necessary improvements prioritized. Policies, procedures and guidance are readily available to staff. ICN are consulted on infection control issues, including specialized advice i.e. purchasing of equipment and building projects. Attendance of infection control education sessions is monitored through the Learning and Development Department. Role of the Learning and Development Team The Learning and Development Department ensure infection control is part of all induction and mandatory training programmes for staff. Arrangements are in place for staff training to be effectively recorded and maintained in staff records. Promote infection prevention and control by leading by example therefore providing a safe environment for patients, visitors and staff. A system is in place for informing managers of their staff s non-compliance and non-attendance at mandatory training sessions. Role of Health Protection Agency (HPA) The HPA will provide services to support and enable the Pennine Care to fulfill their health protection responsibilities. The HPA team will work with Pennine Care to advise and support infection control in infection control matters. Role of the Risk Management Team The risk management team will ensure infection control incident s are reported and recorded on the appropriate documentation and to the Infection Control Nurses. A robust system of risk management will be in place with action and follow up to an incident occurring. All Staff All staff are responsible for ensuring that they follow good Infection Prevention and Control practice at all times and that they are familiar with infection control policies, procedures and guidance relevant to their area of work. Staff have a duty to report breaches in good practice and take correct action as appropriate. Table 1. Membership of the Infection Control Committee Director of Infection Prevention and Control (DIPC) Deputy Director of Nursing and Integrated Governance (Deputy Chair) Lead Infection Control Nurses Patient Safety and Clinical Risk Manager 6

Chief Pharmacist Infection control nursing representative from Pennine Acute trust, Tameside & Glossop Foundation Trust and Stockport Foundation Trust. Estates Representation Medical Representation Lead Borough Representation Health Protection Agency Representation Matrons Representation Governance Manager Representation Lead Commissioning PCT infection control nurse representation 4. Policies The core Infection Prevention and Control Policy CL4 contains: Standard Precautions Education and Training Roles and Responsibilities Assurance Framework Information Available to Patients and Public Occupational Health Services Surveillance Audit & Monitoring Infection Control Guidance on Patients Who Have Died Notifiable Diseases Decontamination of Linen Definition & Explanation of Terms Other Infection Control Policies and Policies linked to Infection Control Hand Hygiene Management of Scabies MRSA Clostridium Difficile Sharps Management and Inoculation Injuries Personal Protective Equipment Vaccination Storage Pandemic Flu Medical Devices Management Aseptic Technique Waste Management Isolation and Barrier Nursing Outbreaks Management and Prevention of Head, Body and Pubic Lice Specimens Flowers and Plants in Infection Control Venepuncture Dress & Uniform Policy Cleaning Policy Death of a Patient Medicines Policy Food Safety COSHH Health & Safety The specific infection control policies were approved by the board in September 2009 7

5. Service Level Agreements (SLA) The service level agreements continue with the 3 Acute Hospital Trusts Pennine Acute NHS Trust provides specialist infection control services at Birch Hill Hospital in Rochdale, the Royal Oldham Hospital, and Fairfield General Hospital in Bury. Tameside & Glossop Foundation NHS Trust provide specialist infection control services at Tameside General Hospital and Woods Hospital in Glossop. Stockport Foundation Trust provides specialist infection control services at Stepping Hill Hospital and the Meadows in Stockport. The service is provided by Infection Control Teams based at each hospital site, comprising of Microbiologists and Specialist Infection Control Nurses. Under the SLA s the team have provided the following range of services to Pennine Care staff and patients over the past year. All wards and departments have contacted information for Infection Control Teams (e.g. office address, names & contact numbers and pager numbers). Telephone advice, to facilitate safe working practices in relation to infection prevention and control. Training and Education in all aspects of Infection Control. Including the Infection Control Link Nurse programme. (Infection control training is accessed through education and training SLA s with the 3 Acute Trusts). Details of courses are circulated via Pennine Care Central Training Dept. Induction Training for all new Pennine Care staff within Pennine Care Corporate Induction Programme, provided by Pennine Care ICN. Clinical Outbreak Management. Patient management of infections as notified by the microbiology laboratory. Monitoring and reporting Healthcare Associated Infections. Including MRSA, Extended Spectrum Beta Lactase (ESBL) and Clostridium Difficile. Staff management of infections as notified by the microbiology laboratory in conjunction with the Occupational Health Department Ward Auditing (Copies available from Infection Control Nurses). Environment audits are also undertaken by Pennine Care IPCN. 8

Access to Acute Trust Policies. Literature (Posters, Leaflets etc) currently provided by Pennine Care ICN. 6. Care Quality Commission Visit An inspection took place on 16 th and 17 th December 2009 in relation to the Trusts compliance against the Code of practice on Health Care Associated Infection s. Of the 15 measures inspected. No area of concern was seen in 12 and 3 needed improvement. The findings included: The need to audit the cleanliness of equipment. The need to ensure that staff are trained to clean equipment effectively. Review the use and organisation of store rooms. The following actions were implemented by Pennine Care NHS Foundation Trust: Each ward received a visit from the Director of Nursing and Integrated Governance. A formal Infection Control audit of all inpatient areas every 6 months. A review of the Infection Prevention and Control audit tool. The Deputy Director of Nursing to undertake unannounced visits of inpatient areas. Monthly meetings with Matrons, Estates and Infection Control. Additional Infection Control training for staff. Matrons to undertake a formal inspection of inpatient wards monthly and ward managers weekly. Additional Initiatives Implemented Cleaning schedules implemented for all equipment Audit of hospital mattresses Policy for care of mattresses Guidelines for cleaning commodes displayed on wards Programme of replacement of old commodes Implementation of Infection Prevention and Control leaflets Wards have nominated infection control champions The Trust was re-visited in relation to Infection Prevention and Control by the Care Quality Commission in February 2010 and given a clean bill of health. 7. Audits The ICN undertakes environment audits on a rolling programme any ward with problems would be re-assessed to ensure action plans were completed. 9

7.1 Infection Prevention & Control Audit Plan, April 2009 March 2010 (Updated February 2010) Location Ward Date audited By whom Fairfield General, Bury North March 2009 December 2009 FS GS South March 2009 December 2009 FS GS Hope March 2009 FS December 2009 Ramsbottom March 2009 December 2009 GS Acute GS Rhodes Place Inpatient Unit Jan 2010 CF Heathfield House, Inpatient Unit Dec 2009 CF Stockport Stansfield Place Inpatient Unit Jan 2010 FS The Meadows, Stockport Saffron Sept 2009 March 2010 Acute CF Rosewood Sept 2009 March 2010 Acute CF Linden Day Sept 2009 March 2010 Acute CF Royal Oldham Hospital Rowan 03.02.09 Sept 2009 Acute FS/KB February 2010 Cedars 15.12.09 Sept 2009 February 2010 Northside Sept 2009 February 2010 Southside 04.02.09 Sept 2009 February 2010 Birch Hill Hospital Hollingworth 18.02.09 Jan 2010 Moorside 16.02.09 FS/KB FS/KB Acute FS/KB Acute FS Acute FS Jan 2010 Hazel Jan 2010 FS Beech Jan 2010 FS Stepping Hill Hospital Tameside General Hospital Cobden Dec 2009 CF Bevan Dec 2009 CF Arden Sept 2009 February 2010 Acute CF Norbury Sept 2009 February 2010 Acute CF Davenport Sept 2009 February 2010 Acute CF Whittaker Day March 2009 CF March 2010 Ward 35 Dec 2009 FS/CF Ward 36 Dec 2009 FS/CF Prospect Place Dec 2009 FS/CF Summers Dec 2009 FS/CF Saxon Dec 2009 FS 10

7.2 Patient Environment Action Teams (PEAT Assessments) The assessments were undertaken in February 2010 and March 2010. The infection control nurse was part of the assessment team. 11

8. Incidents Incident Report Infection Control/Sharps/Needlestick/COSHH April 09 March 10 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 TOTAL 9 4 9 6 6 6 3 1 8 3 3 9 67 10 9 8 7 6 5 4 3 2 1 0 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 12

Infection Control/Sharps/Needlestick/COSHH Incidents By Cause Code Apr 09 Cause Code - Mar 10 148 - Infection Control Incident 9 35 - Contact With Bodily Fluids 7 36 - Contact With Harmful Substance - Breakag 0 37 - Contact With Harmful Substance - Cleanin 5 38 - Contact With Harmful Substance - Other 3 80 - Needlestick Injury 22 92 - Sharps - Disposal 5 94 - Sharps - Misc 15 99 - Spillages 1 Total 67 25 20 15 10 5 0 148 - Infection Control Incident 35 - Contact With Bodily Fluids 36 - Contact With Harmful Substance - Breakag 37 - Contact With Harmful Substance - Cleanin 38 - Contact With Harmful Substance - Other 80 - Needlestick Injury 92 - Sharps - Disposal 94 - Sharps - Misc 99 - Spillages Apr 09 - Mar 10 13

Apr 09 Directorate - Mar 10 Bury 7 Oldham 7 Rehabilitation & High Support 16 Rochdale 8 Specialist Services CAMHS 5 Specialist Services D&A 6 Stockport 9 Tameside & Glossop 9 Total 67 Infection Control/Sharps/Needlestick/COSHH Incidents By Directorate April 09 - March 10 Incidents Tameside & Glossop 13% Bury 10% Stockport 14% Specialist Services D&A 9% Specialist Services CAMHS 7% Rochdale 12% Oldham 10% Rehabilitation & High Support 25% Bury Oldham Rehabilitation & High Support Rochdale Specialist Services CAMHS Specialist Services D&A Stockport Tameside & Glossop 14

Infection Control/Sharps/Needlestick/COSHH Incidents by Department & Cause Code April 09 - March 10 Directorate Department Cause 1 Total Bury Community Clinics Bury 94 - Sharps - Misc 1 Irwell Unit 37 - Contact With Harmful Substance - Cleanin 1 Ramsbottom Ward 148 - Infection Control Incident 1 37 - Contact With Harmful Substance - Cleanin 1 South Ward 148 - Infection Control Incident 1 35 - Contact With Bodily Fluids 1 92 - Sharps - Disposal 1 7 Oldham Beeches 80 - Needlestick Injury 2 Ward - Northside 80 - Needlestick Injury 2 Ward - Rowan 148 - Infection Control Incident 1 80 - Needlestick Injury 1 99 - Spillages 1 7 Rehabilitation & High Support Assessment & Engagement - RHSD 94 - Sharps - Misc 2 Bevan Place RHSD 35 - Contact With Bodily Fluids 1 Cobden Unit 80 - Needlestick Injury 1 94 - Sharps - Misc 5 Heathfield House Spec Service 35 - Contact With Bodily Fluids 1 Prospects Place (LSU) 35 - Contact With Bodily Fluids 1 94 - Sharps - Misc 2 Recovery RHSD 37 - Contact With Harmful Substance - Cleanin 1 Social Inclusion RHSD 94 - Sharps - Misc 2 16 15

Rochdale Assertive Outreach Team R'dale 80 - Needlestick Injury 1 Crisis Resolution/HomeTr Rdale 148 - Infection Control Incident 1 Hazel Ward 148 - Infection Control Incident 2 Moorside Ward 148 - Infection Control Incident 2 80 - Needlestick Injury 1 Treatment Support Service JEU 80 - Needlestick Injury 1 8 Specialist Services CAMHS Hope Unit - CAMHS 35 - Contact With Bodily Fluids 1 37 - Contact With Harmful Substance - Cleanin 1 94 - Sharps - Misc 2 Springleigh CAMHS 148 - Infection Control Incident 1 5 Specialist Services D&A 5 Horsedge Street - Oldham CDA 35 - Contact With Bodily Fluids 1 92 - Sharps - Disposal 1 94 - Sharps - Misc 1 Booth St Needle Exchange 80 - Needlestick Injury 1 92 - Sharps - Disposal 1 Community Drugs Team Stockport 35 - Contact With Bodily Fluids 1 6 Stockport Arden Ward 38 - Contact With Harmful Substance - Other 1 80 - Needlestick Injury 1 92 - Sharps - Disposal 2 Councillor Lane Centre-Sector2 80 - Needlestick Injury 2 Norbury Ward 80 - Needlestick Injury 1 Saffron Ward 80 - Needlestick Injury 1 Torkington Resource Centre-S3 80 - Needlestick Injury 1 9 16

Tameside & Glossop Assertive Outreach Team T&G 80 - Needlestick Injury 1 Hyde CMHT South East - Adult 80 - Needlestick Injury 2 Management Team T&G 80 - Needlestick Injury 1 Saxon Ward (21A) 80 - Needlestick Injury 1 Summers Ward (21) 37 - Contact With Harmful Substance - Cleanin 1 38 - Contact With Harmful Substance - Other 2 Ward 35 80 - Needlestick Injury 1 9 Grand Total 67 17

9. Training Pennine Care has signed up to the NPSA Clean Your Hands Campaign, this has contributed to the increased staff awareness regarding the importance of hand washing. All areas display the posters. The number of Pennine Care NHS Foundation Trust staff who have attended Infection Prevention and Control training 2009 2010: Induction Mandatory Core Learning Unit 551 420 219 10. Healthcare Associated Infections (HAI) MRSA, ESBL s & Clostridium Difficile (Surveillance) The Department of Health requires mandatory surveillance and reporting of some types of infection, including MRSA bacteraemia, Clostridium Difficile and Extended Spectrum Beta Lactamase (ESBL) Producing E. Coli. Pennine Care is complying with this requirement through Service Level Agreements with 3 General Acute Trusts, who provide monitoring and reporting of all Health Care Associated Infections (HCAI) affecting patients in Pennine Care inpatient services. Pennine Care have had no MRSA Bacteraemias for April 2009 March 2010. All new MRSA, ESBL and Clostridium Difficile cases have a Root Cause Analysis performed by the Infection Control Nurses who then reported this to the Infection Control committee. MRSA and Clostridium Difficile now have individual policies to make it easier for staff to follow the correct procedure and staff are being updated on standard precautions to reduce the risk of cross infection. 10.1 MRSA (skin infection) Borough No of new cases Last Year Bury 0 0 Oldham 0 1 Rochdale 2 0 Tameside 0 2 Stockport 1 2 Specialist Services Rehabilitation & High Support 0 0 Total 3 5 18

10.2 Clostridium BOROUGH No of new cases Last Year Bury 1 0 Oldham 0 0 Rochdale 0 1 Tameside 0 1 Stockport 1 0 Specialist Services Rehabilitation & High Support 0 0 Total 2 2 10.3 ESBL BOROUGH No of new cases Last Year Bury 0 0 Oldham 0 0 Rochdale 0 0 Tameside 0 0 Stockport 1 0 Specialist Services Rehabilitation & High Support 0 0 Total 1 0 10.4 Other Infections TB 3 cases in Tameside, Drug and alcohol Service. Scabies 1 case in Rochdale. Lice 2 cases in Stockport. 10.5 Outbreaks The following outbreaks of Diarrhea & Vomiting were reported in Pennine Care inpatient facilities over the period 01 April 2009 31 March 2010. All outbreaks have a root cause analysis recorded they are then discussed at the Infection Control Committee. Pennine Care now report Norovirus outbreaks to the Health Protection Agency via the web site. 19

BOROUGH No of new cases Last Year Bury 2 0 Oldham 1 1 Rochdale 3 2 Tameside 2 1 Stockport 2 1 Specialist Services Rehabilitation & High Support 1 1 Total 10 6 11. Antibiotic Prescribing The Medical Director chairs the Drugs & Therapeutic Committee, which monitors the use of medicines across the Trust. Membership of the Forum includes colleagues from the Acute and Primary Care Trusts, ensuring that Pennine Care works collaboratively with partner organizations, and that agreed standards are applied consistently across the health economy. All prescribing of antibiotics within Pennine Care complies with standards of good practice observed within Primary Care and Acute Trusts. Antibiotic auditing has been implemented to monitor the policies are being followed. 12. Cleaning and Decontamination Procedure As Pennine Care is a Mental Health Trust, there is very little usage of invasive medical equipment, which would require decontamination through sterilization before reuse. The few exceptions to this would be equipment contained in emergency resuscitation, e.g. Laryngoscope blade. When required, decontamination is provided via service levels agreements with the Acute Trusts. However all equipment used for patient care must be cleaned and disinfected appropriately if it is not single patient use. Guidance on cleaning and decontamination procedures is included in the Trust Medical Devices Management Policy and the Cleaning Policy. In specific areas there has been an increase in domestic input to improve standards of cleanliness and Pennine Care has introduced our own cleaning staff. These cleaners receive infection control training and report to the Estates Department. The trust has an ongoing programme of cleanliness monitoring checks and all inpatient areas are checked on a monthly basis. A cleanliness report goes to the Infection Control Committee and any problems are highlighted and actions taken to ensure a high standard of cleanliness continues. The Infection Control Nurses meet monthly with the Estates Manager, Domestic Service Manager and Modern Matron to discuss any cleanliness and environmental issues. 20

The Matrons are on the wards regularly and walk around to assess the cleanliness and ward environment. The Matrons monitor the ward environments on a monthly basis with the Domestic Manager. Deep Cleaning The deep cleaning programme is led by the Estates Department. 13. Planning and Refurbishment During the last year a lot of the trusts buildings have been renovated and updated. The CNS: Infection Control/Physical Health is available for advice reequipment and the new building Infection Control in the Built environment (NHS Estates 2001) is used regarding advice. 14. Flu Vaccination programme As part of our winter planning arrangements, Pennine Care undertook a programme of Flu vaccinations. Flu vaccinations were offered to all inpatients over 65 years who were not able to access this from their GP due to being in hospital, and also inpatient service users under 65 years who were considered to be at high risk, due to physical health problems. Flu vaccination was also promoted for residents of long stay Forensic & High Support Units. In most cases this was accessed via GP services. The Trust also promoted the uptake of Flu vaccinations for all relevant service users and staff across all community services areas. 1 st October 31 st December 2009 Vaccinations Issued Borough Doses Ordered Doses Issued Bury 30 20 Oldham 50 35 Rochdale 50 24 Stockport 70 35 Tameside & Glossop 70 32 The above table does not include the Forensic Directorate as these services use Primary Care to access flu vaccinations. Anaphylaxis training was also offered to staff in each borough, as administration of a vaccine could not be given without this. 21

Appendix A Infection Prevention & Control Audit Plan April 2010 March 2011 Location Ward Audit Date Fairfield North July General, Bury 2010 South July 2010 Hope July 2010 Ramsbottom July 2010 Rhodes Place Inpatient Unit July 2010 Heathfield Inpatient Unit July House, 2010 Stockport Stansfield Inpatient Unit July Place 2010 The Meadows, Stockport Saffron July 2010 By whom Audit Date January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 By whom Royal Oldham Hospital Birch Hill Hospital Stepping Hill Hospital Rosewood Linden Day Rowan Cedars Northside Southside Hollingworth Moorside Hazel Beech Cobden July 2010 July 2010 July 2010 July 2010 July 2010 July 2010 July 2010 July 2010 July 2010 July 2010 July 2010 January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 January 2011 22

Location Ward Audit date Bevan July 2010 Arden July 2010 Norbury July 2010 Davenport July 2010 Tameside Whittaker Day July General Ward 2010 Hospital By whom Audit date By whom January 2011 January 2011 January 2011 January 2011 January 2011 Ward 35 July 2010 January 2011 Ward 36 July 2010 January 2011 Prospect Place July 2010 January 2011 Summers July 2010 January 2011 Saxon July 2010 January 2011 23

Appendix B Infection Prevention & Control Board Level Agreement 24

The Board of Pennine Care NHS Foundation Trust takes the prevention and control of healthcare associated infections very seriously and the Trust has implemented a programme of activities to embrace new national initiatives and effectively prevent and control healthcare associated infections. The Board is committed to comply with The Health and Social Care Act 2008 (Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance) Board Responsibilities All Executive Directors have clear infection prevention and control responsibilities in their job descriptions. The Medical Director is the Executive Director of Infection Prevention and Control (DIPC). Lead Nurse Infection Prevention and Control/Physical Health This role is established in the Trust. The job description identifies clear roles and responsibilities. The Lead Nurse: Infection Prevention and Control/Physical Health reports to the Deputy Director of Nursing. The Lead Nurse: Infection Prevention and Control/Physical Health reports directly to the DIPC and Executive Director of Operations and Nursing if significant infections such as MRSA, Clostridium Difficile and outbreaks arise. Committees Infection Prevention and Control is included in the agenda for each monthly meeting of the Trust s Board of Directors. The Infection Prevention and Control Committee take place every two months, chaired by the DIPC. The deputy chair of the committee is the Deputy Director of Nursing. The Risk and Clinical Governance Committee meets monthly and Infection Prevention and Control is on the agenda. This meeting is chaired by the Deputy Director of Nursing. Reports The Governance Department publishes monthly and quarterly dashboard reports, which identify current infection control information. An Annual Report and Annual Programmes are presented to the Infection Prevention and Control Committee and monitored by the Board of Directors. 25

These reports are sent to the DIPC and the annual programme is updated at the Infection Prevention and Control Committee. The PCT Assurance Framework document is completed monthly and signed off by the DIPC. Resources The Board has set up SLAs with all relevant acute Trusts. There is an identified DIPC. There is a Director of Capital Investment. Cleaning contracts are agreed and managed within the Capital Investment Department. Should there be a need to increase resources such as domestic staff following an outbreak, the Board is committed to funding additional resources as and when necessary to ensure highest possible standards of infection prevention and control. Audits There is a rolling programme of infection control audits and the results are reported via the Infection Prevention and Control Committee and to the Trust s Board of Directors. Education There is a rolling programme of education. All staff attend infection control training as part of their induction and mandatory training. Additional training is also undertaken if outbreaks occur or incidents occur. Board members have received Infection Prevention and Control training i.e. Hand Hygiene and the prevention and control of HCAI using RCA. Signed on behalf of the Board: Signed by John Schofield, Chairman Date Signed by John Archer, Chief Executive Date CF/FS/KH 2.9.09 26

Appendix C Infection Control Training Plan April 2010 - March 2011 April 2010 March 2011 Induction Training on Infection Control Standard Precautions including practical hand washing for all new staff April 2010 March 2011 Mandatory Training on Infection Control Standard Precautions for all clinical staff August 2010 March 2011 All staff to do the infection control e-learning April 2010 - March 2011 All clinical staff to be updated in hand hygiene techniques following the clean your hands campaign and Essential Steps August 2010 March 2011 Additional staff training on hand washing and relevant infection control guidance as required for their area of work December 2010 Sharps awareness training 27

Appendix D Infection Control Work Plan April 2010 - March 2011 Infection Control Nurse: Will provide advice and education in relation to infection control to the Trusts Hospital and community staff. Will chair the Infection Control Committee. Will work with management and other agencies to enhance the service and help control infection. Will continue to update and ensure policies are research based and up to date. Will ensure government guidelines and recommendations are implemented. Will maintain infection control records and write reports on infection control issues. Will work closely with Acute Trusts in relation to all aspects of infection control Surveillance/Audit: The Infection Control Nurse will co-ordinate surveillance to ensure that appropriate advice can be given to prevent cross infection. The Infection Control Nurse will carry out relevant audits and offer advice to staff on any audits they wish to undertake. Education: The Infection Control Nurse will provide education input on infection control and be involved in any other training issues involving staff and students in relation to infection control. The Infection Control Nurse will ensure a session on the overview of Infection Control issues is given at Induction Training The Infection Control Nurse will provide education as and when needed especially during an outbreak. 28

The Infection Control Nurse will keep up to date by attending education events, the Infection Control Nurse Association meetings, reading and interpreting relevant new documentation/guidance. Link Champions Staff: Champions personnel group will be developed by the Matrons to include other professions from the wards. The Infection Control Nurse will offer support to any nurse undertaking a relevant infection control course. The Infection Control Nurse will continue to improve links between disciplines and services. 29

Infection Prevention and Control Plan 2009/2010 All completed Appendix E Action Lead Target Date R/A/G Comments NPSA Clean Your Hands Campaign CNS: Infection Control & Physical Health Ongoing Implement Pandemic Flu Sessions and Live Practice Sessions. Lead for Pandemic Flu CNS: Infection Control & Physical Health July 2009 December 2009 Power point and video prepared first session booked 1 st July2009. Undertake Sharps Awareness Sessions in All Areas CNS: Infection Control & Physical Health June 2009 Completed Sharps re Audit Audit Department CNS: Infection Control & Physical Health July - August 2009 Audit completed. Contribute to the PEAT Assessment Head of Estates March 2010 PEAT visits completed. Effectively implement new Infection Control Policies Ensure service Users Receive Flu Vaccinations as appropriate CNS: Infection Control & Physical Health CNS : Infection Control & Physical Health/Modern Matrons July December 2009 Policy events complete all wards have new policies in file and available on the intranet October 2009 All service users who agreed to have flu vaccines have received the vaccine 30

Undertake Hand hygiene and PPE Audits in line with Essential Steps Audit Tool Audit Department/CNS: Infection Control & Physical Health October 2009 December 2009 Hand hygiene audits continue to be undertaken throughout the trust and this will now be a rolling programme of audit Undertake Infection Control Education as needed including hand hygiene All wards have an Environmental Audits carried out Annually CNS : Infection Control & Physical Health/Modern Matrons/Education and Training Department Audit Department/CNS: Infection Control & Physical Health On-going On-going training programmes continue to be rolled out across the Trust. Mandatory training and Induction training continue On-going All wards audited over the last year. Undertake infection Control Environmental Audits across all Community Settings CNS: Infection Control & Physical Health April 2009 August 2009 Community audits completed. Implement Essential Steps Audits on Enteral Feeding Develop an infection Control Web Page CNS: Infection Control & Physical Health CNS: Infection Control & Physical Health October 2009 All wards contacted on enteral feeding. No patients being treated so audit cancelled September 2009 Web page running 31

Infection Prevention and Control Plan 2010/2011 Appendix F Action complete Confident task will be complete Reasonably confident task will be completed Task not completed Action Lead Target Date R/A/G Comments NPSA Clean Your Hands Campaign Maintain evidence collection for NHSLA, CQC, Health & Social Care Act & Assurance Framework Provide Infection Control reports for the Board Develop the Infection Control Champions Role Provide an Infection Control Annual Report for the Infection Control Committee & Board CNS: Infection Control & Physical Health CNS: Infection Control & Physical Health CNS: Infection Control & Physical Health CNS: Infection Control & Physical Health/Matrons CNS: Infection Control & Physical Health Ongoing Ongoing Monthly May 2010 June 2010 Contribute to the PEAT Assessment Head of Estates March 2011 Update Infection Control Policies in line with new guidelines. CNS: Infection Control & Physical Health May 2010 32

Ensure service Users Receive Flu Vaccinations as appropriate Undertake Hand hygiene audits in line with Essential Steps Audit Tool & 5 Moments Undertake Infection Control Education as part of Mandatory and Induction training including hand hygiene. All wards have an Environmental Audits carried out 6 monthly. Undertake infection Control Environmental Audits across all Community Settings Audits of the ward environment are carried out monthly and reported to the Infection Control Committee Keep Infection Control Web Page Up to date Needle Safety devices to be implemented across the trust Unannounced visits to all inpatient areas annually CNS :Infection Control & Physical Health /Modern Matrons CNS: Infection Control & Physical Health CNS : Infection Control & Physical Health/Modern Matrons/Education and Training Department CNS: Infection Control & Physical Health Audit Department CNS: Infection Control & Physical Health Audit Department Matrons CNS: Infection Control & Physical Health CNS: Infection Control & Physical Health Deputy Director of Nursing & Integrated Governance October 2010 On-going On-going On-going training programmes continue to be rolled out across the Trust. Mandatory training and Induction training continue July 2010 & January 2011 October- November 2010 To Commence May 2010 Ongoing September 2010 Ongoing 33

Patient and visitors leaflets to be designed and posted on infection control web page To investigate infection control incidents To investigate all MRSA, Clostridium Difficile, ESBL and outbreaks of Infection using RCA Contribute to new building plans regarding Infection Control Maintain monthly meetings with estates, matrons and domestic supervisors CNS: Infection Control & Physical Health Communications CNS: Infection Control & Physical Health CNS: Infection Control & Physical Health CNS: Infection Control & Physical Health Estates CNS: Infection Control & Physical Health Estates, Matrons & Domestic supervisors May 2010 On Going On Going On Going On Going 34

Appendix G Care Quality Commission Registration Action Plan Monitoring Report Reporting Period: February 2010 Cleanliness and Infection Control - Outcome 8 / Regulation 12 Column1 Column2 Column3 Column4 Column5 Overall Concerning Item Actions Comments Completion Date Trust Lead Each ward to receive an Inspections completed. 29th January 2010 Director of Nursing inspection from the Director of Nursing Through the management CQC action plan on Complete Operational Management structure in the Trust, agenda of appropriate Structure cascade the outcome of the meetings. CQC visits Recommendation 1. The audit programme did not include audits to check the cleanliness of patient equipment such as commodes. The Trust planned to audit each ward only once a year. The Trust should review its programme of audit, to ensure there is effective checking that relevant policies and practices are being followed. Every rolling six months, each inpatient ward will receive a formal Infection Control Nurse and Modern Matron visit (The ward will receive a review 3 months later to ensure the action plans are complete). Each Month the Modern Matron and Service manager will inspect all of their wards. Each week the Ward Manager will formally inspect their ward. Each inspection will use a standardised checklist. The results of the Modern Matron and Service Manager visits Formal audit of each inpatient ward is taking place every six months. Review date and name of reviewer is clearly identified on audit reports. Ongoing. Infection Control Nurses, Modern Matrons, Service Managers and Ward Managers. 35

are to be faxed to the Infection Control Nurses for review. Review the use of the National Infection Prevention Society Audit tool and include the inspection of all patient equipment. Ensure that this is inline with Trust Policies and the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. The Deputy Director of Nursing will develop a rolling programme of monthly unannounced visits to test the process Infection Control Nurses to ensure that the Audit programme includes a review of staff awareness of the infection control policies Carry out observational studies of staff regarding standard precautions at each walk round. Including hand hygiene, Personal protective equipment, sharps and waste. Quarterly report will be presented to the Infection Control Committee using the results from the monthly Ward Inspections Additions added in line with CQC findings. commodes are specifically audited, linen /laundry rooms, store rooms and cleanliness of equipment. Complete Infection Control Nurses. With review from Performance department to cross check with Registration and assure the Board of Directors. commence April 2010 Ongoing Deputy Director of Nursing Specific policy awareness questions are asked during audit e.g. five moments of hand hygiene, needlestick. The tool will also be updated to include more policy awareness questions. Ongoing Infection Control Nurses and Clinical Effectiveness Manager. Audits ongoing. Ongoing Infection Control Nurses Infection Control Reports to Infection Control Committee 16.02.10. Ongoing Infection Control Nurses 36

Recommendation 2. There was inappropriate use of rooms and inappropriate storage of equipment at the Trust. For example, ward staff said a toilet area was now designated for storage of clean equipment items;however, the toilet was still in use and contained faeces. A single room was being used to store clean bed linen, prepare patients food and also launder items for patients. Two dirty utility rooms contained refrigerators with patients food and clean equipment. A storage room contained a wide range of clean and dirty items, including a dirty mattress, a dirty fan, open packets of food for patients and sterile supplies. This storage room also had a loft, which was open and had other items stored in it. Ensuring this will be met through Recommendation 1 actions N/A Ongoing N/A The Trust should ensure that the environment for providing healthcare is suitable, clean and well maintained. Each month the Infection Control Nurses will meet with the Modern Matrons. Monthly meetings in progress. Meeting took place on 5/2/10 Ongoing Infection Control Nurses and Modern Matrons Following an infection control visit to the units the Infection Control Nurses to meet with Estates and Domestic Supervisor to raise any issues and action plan resolution. Each ward will nominate an Infection Control Champion who will attend infection control training and be responsible for any storage and infection control issues. The Champion will report to the Modern Matrons and Infection Control Nurses. Monthly meeting with Matrons, Estates and Infection Control. Training dates set for March at Tameside 9/03/10 other borough dates set. Matron Infection Control training in place. Ongoing 28th February 2010 for nominations. Rolling training programme to Start in April 2010 Infection Control Nurses, Estates representative and Domestic Supervisor Infection Control Nurses and Ward Managers 37

Each ward will have a rota for the checking of stores. Ensuring they are clean, tidy and not over stocked. Checklist to be in place. Ensure that the storage units are used appropriately. Review this through the Environmental audits. Infection Control Team will check store cupboards on planned ward visits and spot check. Nurse in charge of each shift and champions will be responsible for ensuring that the environment is clean and tidy and reporting any areas of concern to the appropriate dept. Nurse-in-charge/Ward champion to lead. Ongoing Matrons and Ward Managers Ongoing Infection Control Nurses and Ward Managers Each month the Modern Matrons will routinely walk the wards with Estates and the Domestic Supervisor. These walkabouts are taking place in all Boroughs. Ongoing Modern Matrons, Estates representative and Domestic Supervisor Recommendation 3. We examined five commodes, which staff said were clean and ready for patients use, in three wards. None of the five had been cleaned effectively and they were soiled. Four of these commodes were also rusty, making them difficult to clean. Staff said that they had not received training in the cleaning of equipment. On two of the wards visited, medicine pots (intended to be single use only), were being washed in a sink and reused. Inspect all commodes and replace. All checked across the Trust and replaced as needed. 1st February 2010 Infection Control Nurses The Trust must ensure that it has effective arrangements for the appropriate decontamination of instruments and equipment which are detailed in appropriate policies. The Trust must take immediate action to clean dirty equipment. The Trust must have addressed the area for improvement by 1 February 2010. Clear commode cleaning instructions to be displayed on wards Instructions displayed on wards. 1st February 2010 Infection Control Nurses 38

Introduce Green Tape for clean commodes Introduced across the Trust. 1st February 2010 Infection Control Nurses and Ward Managers Add the inspection of commodes to the Inspection Checklist Added to Infection Control Audit Tools. 1st February 2010 Infection Control Nurses and Deputy Director of Nursing Ensure that the Medical Devices Policy contains effective guidance on the cleaning and decontamination of equipment. Develop and roll out a Nurses guide to cleaning of patient equipment. Guidance included in Medical Devices Policy Appendix 6 Cleaning Guidelines. Guide includes all equipment. 1st February 2010 Infection Control Nurses 1st February 2010 Infection Control Nurses Ensure all managers have received a reminder memo on the need to dispose of single-use medicine pots after 1st use. Memo sent December 2009. 1st February 2010 Infection Control Nurses and Deputy Director of Nursing 39