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«Policy Number IC01 Policy Title INFECTION PREVENTION AND CONTROL POLICY Accountable Director Director of Infection Prevention and Control Author Lead ...»

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• Having a framework to ensure that data is reported in line with the Trust’s surveillance policy and any national or regional targets with regards to Infection Prevention and Control are performance managed effectively.

• Produce and publish an Annual Infection Prevention and Control Report

• Having a process to ensure that any lessons learned from external investigations or high level enquiries are implemented across the Trust.

4.8 PolicyThe aims of this policy are to:-

• Have a management strategy in place which meets the Code of Practice and ensures that the design and maintenance of the environment meets with good Infection Prevention and Control practice.

• Inform and educate all health care workers of the important public health function in both hospital and community environments, of the prevention and control of infectious and communicable diseases, and of the application of researched practice.

• Advise healthcare workers regarding the transmission, incubation, infectivity of many common infectious diseases and the prompt action, which can reduce the spread of disease.

• Explain the principles of prevention and control of infection, decontamination and the use of protective equipment by which staff can reduce the risk of infection to themselves and to others.

• To be a vital tool for healthcare workers which embodies the principles of best practice is to follow the Standard Principles to control the spread of infection.

5.Duties In order to ensure that management systems are effective duties of staff

groups/individuals are clarified as follows:

The Chief Executive The Chief Executive on behalf of the Trust Broad has overall and final responsibility for ensuring that management systems are in place for the effective, safe management of infection prevention and control within the Trust.

These will include:

• The provision of an appropriately constituted and functioning Infection Prevention and Control Team which reports on adverse incidents, infection data, progress with the service plan, policies and annual report to an Infection Prevention and Control Committee The Trust Board receives the Infection Prevention and Control Committee minutes, and supports and approves the ICT Service Plan and Annual Report.

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• Ensuring direct links from the IPCT and the Infection Prevention and Control Committee with the Quality Assurance Committee to ensure compliance with the Health and Social Care Act 2008, guidance and best practice, and for ensuring that contracts are in place with Approved and Accredited Laboratories, ensuring that the IPCT receive laboratory reports and immediate alert organism notification.

• Ensuring that there are effective arrangements for Infection Prevention and Control within the Trust, and for ensuring direct access of the IPCT to report to the Chief Executive on all aspects of surveillance, prevention and Infection Prevention and Control.

• Ensuring the safe management of risks associated with Infection Prevention and Control and in the provision of an environment that is clean, has sufficient isolation facilities to meet the trusts needs.

Director of Infection Prevention and Control.

The Director of Infection Prevention and Control has the primary responsibility

for, and reports to, the Trust Board. Key responsibilities include:

• Production of Trust Annual Report for Infection Prevention and Control. This includes providing the Trust with regular reports/updates on issues in relation to Infection Prevention and Control

• Development of the Trust strategy for Infection Prevention and Control working in partnership with the ICT.

• Monitoring of HCAI as appropriate in the Trust and review any subsequent local investigations, determining whether further scrutiny is required

• Membership of the Trust Infection Prevention and Control Committee and raising any relevant issues

• The continuing education of the IPCT to ensure the provision of up to date expert advice on matters relating to Infection Prevention and Control, information and appropriate management of infection and infected service users.

• Ensuring that the Infection Prevention and Control team are involved in all key trust committees to provide expert advice and channels of communication regarding progress of services to Infection Prevention and Control standards and risks and that all Division Leads include an IPCN as a member of their Risk, Governance and Health and Safety Meetings

• The transmission of infection patient to patient, patient to healthcare worker, or healthcare worker to service users, can have serious consequences.

Compliance with the Health and Social Care Act 2008 DH (2010) aims to minimise the spread of infection and protect all service users and staff from unnecessary risk of infection.

• Is responsible for ensuring that there is an appropriate infrastructure in place to deliver the Trust’s Infection Prevention and Control agenda, standards of clinical competence, following the Royal Marsden clinical procedures.

–  –  –


• ensuring that surveillance is part of annual IPCT Service Plan, that this includes reporting of mandatory surveillance of healthcare associated infections and communicable diseases that meet local, regional and national guidance in monitoring, reporting, auditing of alert organisms as well as reporting to the ICC Committee and the Trust Board regularly.

The Chief Pharmacist The Trust Pharmacy Service is responsible for overseeing the auditing of antibiotic usage and compliance with the antimicrobial guidance. Quarterly audits are carried out and these are reported to the Infection Prevention and Control Committee IPCC.

The Infection Prevention and Control Doctor / Consultant Microbiologist Infection Prevention and Control Doctor / Consultant Microbiologist is responsible for providing the Trust with microbiology advice and supporting the Infection Prevention and Control Nurses. Responsibilities include

• Providing clinical leadership, in reducing preventable infection across the Trust

• Is the Deputy Chair of the Infection Prevention and Control Committee,

• Chairs outbreak meetings.

• Reporting serious outbreaks of infection to the Consultant in Health Protection.

The Director of Workforce

• The Director Workforce is responsible for the provision of corporate Induction and Mandatory Training, the inclusion of Infection Prevention and Control and Hand Hygiene Training and the recording of staff attendance.

The Corporate Director of Finance and Estates

• The Director of Estates is responsible for ensuring Infection Prevention and Control expert advice is included in all new builds, refurbishment and replacement programmes.

The Director of Facilities

• The Associate Director of Facilities is responsible for the meeting of hygiene standards and frequencies, cleaning materials and equipment, contracting for waste, laundry and legionella management.

The Division Leads

–  –  –

The Division Leads are responsible for performance management ensuring that

there are systems in place to implement the policy via:

• Ensuring that all trust staff, including agency, locum, contractors and volunteers complete corporate Induction and Mandatory Infection Prevention and Control Training, specially arranged Infection Prevention and Control Training for services and that all clinical areas have an IPCLP who attends training has time to provide cascade hand hygiene training and the audit of hand hygiene compliance.

• Are responsible for ensuring that all wards and departments achieve good standards of environmental hygiene and are provided with the adequate staff, equipment (including fit for purpose staff hand wash basins) and agreed trust products to achieve this.

• The Divisional Leads are responsible for ensuring the monthly provision of data regarding MRSA and Clostridium difficile, Blood Borne Virus Screening, Medical Device Decontamination, Indwelling medical devices, and other assurance data as per the Managers Assurance checklist (Appendix 6) are provided to the ICT on time.

The Infection Prevention and Control Nurse Manager (IPCNM)

The IPCNM is responsible for:

• The Infection Prevention and Control Service Plan and Annual Report, reporting of progress made in achieving the objectives of the plan.

• Updating the Infection Prevention and Control Policy in line with current legislation and best practice and ensuring that the ICT provide expert advice on policies associated with Infection Prevention and Control.

The Infection Prevention and Control Specialist Nurse (IPCSN)

The IPCSN is responsible for

• Leading on the educational content of the trust infection prevention and control curriculum and programme for all staff.

• Ensuring the provision of corporate induction and mandatory training, including hand hygiene training.

• Ensuring that all IPCLPs are provided with appropriate equipment and training to carry out their role in relation to cascading all training, including hand hygiene training and record management.

• Implementing and monitoring the annual Infection Prevention and Control audit programme which will audit a selection of Infection Prevention and Control Policies, procedures and practices which will annually include as a minimum. This is reported onwards to the trust board via the annual report.

• Audit of hand hygiene facilities and techniques of all clinical areas and community teams.

• Audit of sharps and clinical waste of all clinical areas and community teams

• Environmental audit of all clinical areas. The ICT will update the audit tools in line with legislation, guidance, best practice.

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• Monitoring hand hygiene compliance, via analysis of the monthly returns of Infection Prevention and Control clinical area assurance checklists, from the Modern Matrons.

• Data collected on compliance with Hand hygiene training and observational audit are reported through the Infection Prevention and Control Committee

• Planning the collation of surveillance data.

Infection Prevention and Control Nurses

The Infection Prevention and Control Nurses have the responsibility for:

• Monitoring prevalence of HCAI.

• Reporting on all aspects of surveillance, and Incidents of Infection and other adverse incidents in the trust to the Infection Prevention and Control Doctor and the DIPC

• Reporting serious outbreaks of infection to the Consultant in Health Protection

• Implementation of the annual work programme

• Working with the Division Leads, Modern Matrons, Managers and Infection Prevention and Control practitioners to improve patient care, implement legislation and guidance and best practice to improve Infection Prevention and Control compliance.

• Education of healthcare staff on infection prevention and control

• Provision of evidence/assurance for assessments in relation to Infection Prevention and Control e.g. CQC Essential Standards for Quality & Safety, Health and Social Care Act.

• For liaising with other departments and agencies with regard to the transmission of disease, and adverse incidents and infections.

• The reporting of MRSA bacteraemias, Clostridium difficile, and other alert organisms to STEISS and PHE.

• Investigating all inoculation injury incidents and reporting to the ICC.

Infection Prevention and Control Link Practitioners (IPCLP)

The IPCLPs are responsible for:

• Attending IPCLP training sessions.

• Cascading information from IPCLP training sessions to all staff within wards /departments.

• Liaising with the IPCT

• Ensuring that IPCT Team posters are displayed in clinical areas for staff and service users.

• Carrying out six monthly cascade hand hygiene training with all staff from their clinical area and returning the training records to the IPCT.

• Undertaking ward/departmental audits in accordance with the audit programme

• Carrying out the six monthly cascade hand hygiene training on all staff within the clinical area,

–  –  –

Modern Matrons

Modern Matrons are responsible for ensuring that:

• Regular audits of environmental hygiene, hand hygiene, sharps and clinical waste and legionella controls are undertaken to ensure compliance with policies and procedures.

• Liaising with and supporting the ICT in the delivery of the infection prevention and control agenda

• Action plans are undertaken to rectify any issues identified

• Monitoring cleanliness of clinical areas.

• Ensuring only safety sharps devices are purchased where possible.

Ward/Department Managers

Ward/Department managers are responsible for ensuring that:

• Staff working in areas for which that manager has responsibility are aware of and are compliant with the Trust’s infection prevention and control policy and guidelines.

• Staff attend infection prevention and control and hand hygiene training, as per Trust Training Policy.

• Agreed trust hand hygiene products, safety sharps devices, single use items, personal protective equipment, cleaning products and equipment are provided.

• Clean linen is stored correctly and used linen is managed and handled in line with this policy.

• Hand wash facilities are fit for purpose and that problems are addressed promptly.

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