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Infection Prevention & Control Operational Policy FINAL Aug17

Infection Control G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Infection control\infection prevention and control operational\Infection Prevention Control Operational Policy v3.0.docx of 27

Document Control

Title

Infection Prevention & Control Operational Policy

Author

Author’s job title Consultant Medical Microbiologist/Infection Control Doctor and Lead Nurse Infection Prevention and Control

Directorate Nursing

Department Infection Prevention & Control

Version Date

Issued Status Comment / Changes / Approval

1.0 Jan 08 Final Ratified by Trust Board on 16 January 2008. Published on Tarkanet.

1.1 July 2009

Revision Roles and responsibilities Appendix D changed Amends by Corporate Affairs to filename version control, contents list page numbers, header and footer, document control report and formatting. Grammar and spelling check. Hyperlinks to appendices.

1.2 August 2009

Revision Minor changes to role of IPCOG; change to quorum in IPCC ToR; Appendices A, B & C to main Appendix A changed to Appendices 1,2,3

1.3 Jan 2010 Revision Removal of SARS and Avian influenza policies from list section 5; Minor amendments to sections 8 & 17.1 Education and Training for clarity plus addition of section 19 Associated Documentation prior to NHSLA inspection. Approved at Infection Control Team meeting on 21.1.10

1.4 March 2010

Revision ToR Appendix B; from monthly to quarterly review of IPC annual plan – For approval at PSIPCC on 23.3.10 Addition of monitoring and compliance actions to meet the requirements of NHS LA minimum data set.

1.5 May 2010

Revision Approved at PSIPCC on 23 March. Minor amends by Corporate Affairs to document control report, filename, formatting, header and footer and NHSLA wording added.

2.0 April 2014

Final Major Revision. Approved by June IPCC and Published on Bob.

3.0 August 2017

Final Updates to Contact details, Terms of Reference and Job Titles

Main Contact Infection Prevention& Control Team North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – 01271 322680

Lead Director Director of Nursing

Superseded Documents



Infection Prevention & Control Operational Policy v2.0

Issue Date August 2017

Review Date August 2020

Review Cycle Three years

Consulted with the following stakeholders:

Infection Prevention & Control Committee

Approval and Review Process


Local Archive Reference G:\Infection Control Local Path Infection Control\IC Manual-Policies\New Templates from 2015\Infection Prevention & Control Operational Policy Filename Infection Prevention & Control Operational Policy vv2.1 August 2017

Policy categories for Trust’s internal website (Bob) Infection Prevention & Control Occupational Health

Tags for Trust’s internal website (Bob)



CONTENTS

Document Control................................................................................................................................... 1

1. Purpose ........................................................................................................................................... 4

2. Definitions ....................................................................................................................................... 5

3. RESPONSIBILITIES ............................................................................................................................ 5

3.1 ROLE OF THE INFECTION PREVENTION & CONTROL COMMITTEE (IPCC) ........................ 5

3.2 ROLE OF INFECTION PREVENTION & CONTROL TEAM ..................................................... 5

3.3 ROLE OF TRUST BOARD ..................................................................................................... 5

3.4 ROLE OF CHIEF EXECUTIVE................................................................................................. 5

3.5 ROLE OF NON – EXECUTIVE DIRECTOR ............................................................................. 5

3.6 ROLE OF THE DIRECTOR OF INFECTION PREVENTION & CONTROL (DIPC) ...................... 5

3.7 ROLE OF DIRECTOR OF NURSING ...................................................................................... 6

3.8 ROLE OF MEDICAL DIRECTOR ............................................................................................ 6

3.9 ROLE OF DIRECTOR OF FACILITIES ..................................................................................... 6

3.10 ROLE OF INFECTION CONTROL DOCTOR (ICD) .................................................................. 6

3.11 ROLE OF LEAD NURSES FOR INFECTION PREVENTION & CONTROL TEAM ...................... 6

3.12 ROLE OF INFECTION PREVENTION & CONTROL NURSES .................................................. 6

3.13 ROLE OF CONSULTANT MEDICAL MICROBIOLOGISTS ...................................................... 7

3.14 ROLE OF DIVISIONAL GENERAL MANAGERS ..................................................................... 7

3.15 ROLE OF LINK PRACTITIONERS INFECTION PREVENTION & CONTROL ............................ 7

3.16 ROLE OF MATRONS/SENIOR NURSES ............................................................................... 7

3.17 ROLE OF LEAD CLINICIANS/HEADS OF DEPARTMENTS .................................................... 7

3.18 ROLE OF ALL STAFF ............................................................................................................ 7

4. Contacting the Infection Prevention and Control Team ................................................................. 8

5. Infection Prevention & Control Operational Policy ........................................................................ 8

5.1 ORGANISATIONAL STRUCTURE AND RESPONSIBILITIES ................................................... 8

5.2 DEVELOPING THE ANNUAL INFECTION PREVENTION & CONTROL PROGRAMME OF WORK . 9

5.3 POLICIES .................................................................................................................................... 9

6. Monitoring Compliance with and the Effectiveness of the Policy ................................................ 10

Standards/ Key Performance Indicators ....................................................................................... 10

Process for Implementation and Monitoring Compliance and Effectiveness .............................. 10

7. Equality Impact Assessment ......................................................................................................... 11

8. References .................................................................................................................................... 12

9. Associated Documentation ........................................................................................................... 12

Appendix 1 Terms of Reference of the Infection Prevention & Control Committee............... 13

Appendix 2 - Infection Prevention & Control Team Meeting ....................................................... 25

Appendix 3 - Infection Control Link Practitioner Group Roles & Responsibilities ....................... 26



1. PURPOSE

1.1. The purpose of this document is to set out the system for the prevention and control of infection in Northern Devon Healthcare Trust, which is a key priority within the Trust’s strategic objective of patient safety. It is essential that arrangements for the organisation of infection prevention and control, and roles and responsibilities with regard to infection prevention and control are clear within the Trust. This document details the Trusts systems to manage and monitor the prevention and control of infection, as identified in Criterion 1 of the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance.

1.2. This policy should be read in conjunction with the Infection Prevention & Control Annual Plan. This Operational Policy relates primarily to the Infection Prevention & Control functions in the Trust.

1.3. The purpose of this document is to identify the position of the Infection Prevention and Control function in the organisational structure and the operational systems and assurances which are in place to ensure that infection prevention and control activity is focused, co-ordinated, owned and communicated effectively within the Trust

1.4. Implementation of this policy will ensure that:

infection prevention and control in the context of the organisational structure is identified

the infrastructure of the Infection Prevention & Control Team is made clear

individual roles and responsibilities are identified

the process for ratification and review of Infection Prevention and Control Policies is specified

the process for the provision of training and education in the Trust is identified

the process for the development of key performance indicators related to infection prevention and control is understood

the process for formation of the Annual programme of work is identified

there is identification of the inclusion of Infection Prevention and Control in clinical care protocols.

statistics relating to management of Health Care Associated Infection are made available to the general public.

a process for monitoring progress against agreed standards, targets and the annual programme is identified

1.6 The policy applies to all staff



2. DEFINITIONS

2.1 This Trustwide policy ratified by the Trust Board is a corporate framework document that enables staff to adopt safe and effective working practice. Any local policy must reflect the main policy document. All other Infection Prevention and Control policies in the Infection Control Manual on BOB fall under this framework document

3. RESPONSIBILITIES

3.1 ROLE OF THE INFECTION PREVENTION & CONTROL COMMITTEE (IPCC) The Trust has an IPCC. This is a strategic group which is accountable to the Trust Board via the Quality Assurance Committee. This committee oversees the annual infection prevention and control programme of work and provides advice, challenge and support to the Infection Prevention & Control Team. The IPCC is composed of individuals from throughout the Trust but has strong representation from the divisions. It is chaired by the Director of Nursing, Quality and Worforce/Director of Infection Prevention & Control (DIPC) and meets monthly. (See Appendix A for membership and terms of reference)

3.2 ROLE OF INFECTION PREVENTION & CONTROL TEAM

The ICNs are led in their operational work by the Lead Nurse for Infection Prevention & Control. The team consists of the Infection Prevention & Control Nurses, Consultant Medical Microbiologists. The Team provides services to the Acute Trust and under service level agreement to the Devon Partnership Trust (North Devon section).

This team meets formally once a week (see Appendix B for Agenda).

3.3 ROLE OF TRUST BOARD

The Trust Board has responsibility to ensure that adequate resources are available to secure effective prevention and control of healthcare associated infections. These should include implementing an appropriate assurance framework, infection prevention and control programme and infection control infrastructure.

3.4 ROLE OF CHIEF EXECUTIVE

The Chief Executive accepts on behalf of the Trust Board ultimate responsibility for all aspects of infection prevention and control within the Trust. This responsibility is delegated to the Executive Lead for Infection Control – Director of Nursing, Quality and Workforce / Director of Infection Prevention and Control

3.5 ROLE OF NON – EXECUTIVE DIRECTOR

The Non Executive Director with responsibility for infection control has responsibility to provide assurance to their non-executive colleagues on delivery against the infection prevention and control programme of work and delivery against key performance indicators.

3.6 ROLE OF THE DIRECTOR OF INFECTION PREVENTION & CONTROL (DIPC)

The DIPC Role is held by the Director of Nursing, Quality and Workforce. The DIPC receives expert infection prevention & control advice from the Infection Control Doctor and Lead Nurse Infection Prevention & Control.



The DIPC oversees local Infection prevention and control policies and related policies including their implementation; reports directly to the Chief Executive and Trust Board; has the authority to challenge inappropriate clinical hygiene practice and antibiotic prescribing decisions; assesses the impact of existing and new policies and plans on infection and makes recommendations for change; is an integral member of the organisation’s clinical governance and patient safety structures; monitors, reports and makes recommendations on key performance indicators and produces an annual report on the state of healthcare associated infection in the organisation and releases this publicly.

3.7 ROLE OF DIRECTOR OF NURSING

The Director of Nursing has the lead Executive Director responsibility for Infection Prevention and Control. The Director, in conjunction with the Medical Director and Infection Control Doctor, oversees implementation of the infection prevention & control strategy within all Trust services. The Director of Nursing has overall responsibility for the Infection Prevention & Control Nursing Team.

3.8 ROLE OF MEDICAL DIRECTOR

The Medical Director in conjunction with the Director of Nursing and DIPC oversees implementation of the Infection Prevention & Control strategy within all Trust services and will delegate local operational responsibility to clinical leads.

3.9 ROLE OF DIRECTOR OF FACILITIES

The Director of Facilities will ensure that timely, efficient and effective communication systems are in place to alert the Infection Prevention & Control Team to forthcoming developments, external contract reviews, refurbishments and changes to services at all stages of development. They will also ensure close liaison regarding environmental hazards and will lead on decontamination and waste management.

3.10 ROLE OF INFECTION CONTROL DOCTOR (ICD)

The Infection Control Doctor (ICD) is a Consultant Medical Microbiologist. The ICD provides expert infection prevention and control advice and guidance to the DIPC.

3.11 ROLE OF LEAD NURSE FOR INFECTION PREVENTION & CONTROL TEAM

Has responsibility for the implementation of the Infection Prevention & Control Strategy and manage the Infection Prevention & Control Nursing Team. Provides specialist advice and guidance to DIPC.

3.12 ROLE OF INFECTION PREVENTION & CONTROL NURSES

Responsible for facilitation of infection prevention initiatives, policy and guidance at directorate level; ensuring that a high standard of communication is maintained with matrons, clinical leads and ward sisters; identifying need for and implementation of projects, surveillance, policy and guidance; develop, collate and report on the findings of root cause analysis and investigations; provide an advice service on the management of clinical infections and outbreaks.



3.13 ROLE OF CONSULTANT MEDICAL MICROBIOLOGISTS

The Consultant Medical Microbiologists provide advice on the management of clinical infections and outbreaks and are responsible for highlighting Infection Prevention and Control issues to the Infection Prevention and Control team for further action.

3.14 ROLE OF ASSISTANT DIRECTORS OF OPERATIONS

Assistant directors of operations will ensure that infection prevention & control objectives from the Infection Prevention & Control annual plan are incorporated into Divisional action plans. Assistant directors of operations are responsible for ensuring that systems are in place to ensure that Infection Prevention and Control policies, practices and guidance are carried out reliably within their area of responsibility; local investigation of healthcare associated infections and highlighting areas of practice or the environment which present a risk to patient safety. They are also responsible for setting a good example of infection prevention practice, and challenging poor practice.

3.15 ROLE OF LINK PRACTITIONERS INFECTION PREVENTION & CONTROL

Link Practitioners primary objective is to contribute to the delivery of the Trust’s Infection Prevention & Control Annual Plan by monitoring standards of infection control in clinical practice. They are also responsible for the development and communication of ward/dept infection prevention action plans, regular communication with the Infection Prevention & Control Team (See Appendix C)

3.16 ROLE OF DIVISIONAL NURSES/ MATRONS AND SENIOR NURSES

Are accountable for Infection Prevention and Control in wards, departments and community teams, are key role models for good infection prevention practice and have responsibility for maintaining standards of Infection Prevention and Control practice. Also for the implementation and communication of Infection Prevention and Control initiatives and surveillance results; ensuring the clinical environment is safe and maintained to a high standard of cleanliness.

3.17 ROLE OF LEAD CLINICIANS/HEADS OF DEPARTMENTS

Lead Clinicians/Heads of Departments are responsible for ensuring that systems are in place to ensure that Infection Prevention and Control policies, practices and guidance are carried out reliably within their area of responsibility; local investigation of healthcare associated infections and highlighting areas of practice or the environment which present a risk to patient safety. They are also responsible for setting a good example of infection prevention practice, and challenging poor practice.

3.18 ROLE OF ALL STAFF

It is the responsibility of all members of staff to provide a high standard of care to patients they are involved with. This includes good infection prevention practice.

All staff have a responsibility to comply with Infection Prevention and Control policies and procedures, this includes:

Undertaking mandatory and role-specific infection prevention education and training.

Challenging poor infection prevention and control practices.



Ensuring their own compliance with Trust Infection Prevention and Control policies and procedures for example, standard precautions, hand hygiene, prevention & management of inoculation incidents.

4. Contacting the Infection Prevention and Control Team

4.1 The Infection Prevention and Control Team can be contacted in hours on 01271 322680 (ext 2680 internal at North Devon District Hospital), via bleep 011 or out of hours by contacting the on-call Medical Microbiologist via North Devon District Hospital switchboard.

5. Infection Prevention & Control Operational Policy

5.1 ORGANISATIONAL STRUCTURE AND RESPONSIBILITIES

Assurance

Assurance

Trust Board

Non Executive Lead for Infection Control

Quality Assurance Committee

Infection Prevention & Control Committee Chair: Director of Nursing/DIPC

Infection Prevention & Control Team

Provides services under Service Level Agreement to

Devon Partnership Trust

See appendix A for Terms of Reference of Infection Prevention & Control

Committee



5.2 DEVELOPING THE ANNUAL INFECTION PREVENTION & CONTROL PROGRAMME OF WORK

The ICT will develop the annual programme of work for Infection Prevention and Control between January and March each year which will be approved at Infection Prevention & Control Committee. The programme will run in accordance with the financial year.

The content of the annual programme of work will be influenced by the following:

i. National & Trust priorities.

ii. Recommendations from audits performed by the Infection Prevention & Control Team, Clinical Teams, Internal Audit or External Audit or professional bodies.

iii. Local, regional or national surveillance.

iv. Recommendations from local, regional or national incidents or outbreaks.

v. Results of Key Performance Indicators (appendix F)

vi. The results/recommendations of national Confidential Enquires.

vii. New/revised Department of Health directives/guidance.

viii. New/revised expert advice.

ix. Lessons learned from incidents and outbreaks.

Progress on the annual programme of work will be monitored monthly by the ICT and quarterly by the Infection Prevention & Control Committee.

The Infection Prevention & Control Annual Report will detail achievements from the annual programme of work and will be presented to the Quality Assurance Committee.

The annual programme of work will include infection control activity, audit, education, communication and policy revision as standard.

5.3 POLICIES

The IP&C policies stated below cover the requirement for policies as identified in Criterion 9 of the Code of Practice and are subject to regular review. Ratification and review of IP&C policies is the role of the Infection Prevention & Control Committee, in line with the Trust’s Policy for the development and management of procedural documents. The full list of infection prevention & control policies, which are found on BOB, and come under this overarching Operational Policy, are:

Animals and Pets in Hospital

Antibiotic resistant organisms

Decontamination

Endoscope decontamination

Facilities liaison

Food hygiene

Patient Isolation and Staff Exclusion

Prevention of inoculation injury

Management of inoculation injury

Intravascular devices



Isolation

Laundry

Outbreak of infection

Pest control

Single use

Standard infection control precautions

The Control of Contractors

Urinary catheter in adults

Waste

Specific conditions

o Chickenpox/shingles

o Gastrointestinal disease

o Methicillin Resistant Staphylococcus aureus

o Scabies

o Tuberculosis

o Head lice

o Transmissible Spongiform Encephalopathy Agents (TSEs)

o Viral haemorrhagic fever

o Clostridium difficile

o Respiratory infections

o CRE

o Influenza-like Illness

Miscellaneous

o Aseptic techniques

o Notifiable diseases in England and Wales

6. Monitoring Compliance with and the Effectiveness of the Policy

Standards/ Key Performance Indicators

6.1 KEY PERFORMANCE INDICATORS COMPRISE:

Compliance against the Infection Control Action Plan as monitored by the IPCC

Annual report is received by the Trust Board no later than September

6.2 Process for Implementation and Monitoring Compliance and Effectiveness

After final approval, the author will arrange for a copy of the policy to be placed on the Trust’s intranet. The policy will be referenced on the home page as a latest news release.



Information will also be included in the Chief Executive’s Bulletin which is circulated electronically to all staff.

Line managers are responsible for ensuring this policy is implemented across their area of work.

Compliance with this policy will be monitored by the Infection Prevention and Control Team and by the Infection Prevention & Control Committee.

Progress on the annual programme of work will be monitored monthly by the ICT and quarterly by the Infection Prevention & Control Committee.

The Infection Prevention & Control Annual Report will detail achievements from the annual programme of work and will be presented to the Quality Assurance Committee.

Where non-compliance is identified, support and advice will be provided to improve practice.

7. Equality Impact Assessment

The author must include the Equality Impact Assessment Table and identify whether the policy has a positive or negative impact on any of the groups listed. The Author must make comment on how the policy makes this impact.

Table 1: Equality impact Assessment

Group Positive Impact

Negative Impact

No Impact

Comment

Age X

Disability X

Gender X

Gender Reassignment X

Human Rights (rights to privacy, dignity, liberty and non-degrading treatment), marriage and civil partnership

X

Pregnancy X

Maternity and Breastfeeding

X

Race (ethnic origin) X

Religion (or belief) X

Sexual Orientation X



8. References

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; Department of Health, January 2009

9. Associated Documentation

Infection Prevention and Control Committee Terms of reference As at 17.03.17

Infection Prevention and Control G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Infection control\infection prevention and control operational\Infection Prevention Control Operational Policy v3.0.docx of 27

Appendix 1 Terms of Reference of the Infection Prevention & Control

Committee

Document Control

Title

Infection Prevention & Control Committee Terms of Reference

Author Infection Prevention & Control Team

Author’s job title

Directorate Nursing

Department Infection Prevention & Control

Version Date

Issued Status Comment / Changes / Approval

1.0 20.4.16 Final Revised membership, new format

1.1 26.4.16 Final Approved at IPCC with minor changes

1.2 01.4.17 Final Changes reflecting change to Trust structure

Main Contact Infection Prevention & Control Team Level 1 North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – 01271 322680 Tel: Internal – 2680 Email: [email protected]

Lead Director Director of Nursing

Superseded Documents IPC Terms of Reference April 2016

Document Class

Terms of Reference

Target Audience

Members of Committee

Distribution List

Members of Committee

Distribution Method

Committee meeting

Issue Date 01.04.2017

Review Date 01.04.2018

Review Cycle Annual

Local Archive Reference G:\Infection Control\IC Minutes\IPCC 2016-17\Terms of Reference Local Path IC Minutes\2016-17 Filename IPCC Terms of Reference v1.2 17.3.17




Terms of Reference

Purpose of the Committee

The purpose of the Infection Prevention and Control Committee is: - To provide leadership and support in driving delivery of infection prevention and

control activity in the Northern Devon Healthcare NHS Trust. - To promote awareness of infection prevention and control issues throughout the

organisation emphasising the individual responsibility for these amongst all staff who work within the organisation locality

- To ensure systems protocols and practices are embedded into everyday practice and applied consistently by all staff in all care settings of the Trust.

- To encourage use of infection prevention and control measures by patients and visitors

- To regularly monitor and review performance against the annual action plan in order to ensure Clinical and Non-Clinical Services and the Infection Prevention & Control Team deliver their agreed actions

- To monitor Trust, Division and Department performance targets through a dashboard and hold to account relevant managers for those results

- To ensure continuous monitoring and surveillance of the incidence of alert organisms, alert conditions outbreaks and Serious Incidents Requiring Investigation and appropriate actions to deal with infection occurrences, including input into emergency planning

- To oversee the effective implementation of most up to date version of The Health Act 2008: Code of Practice for the Prevention and Control Infections and all other relevant legislation and guidance

- To provide a point of reference for infection prevention and control issues within the organisation

- To provide support and constructive challenge to the Director of Infection Prevention and Control, the Infection Control Team and all Divisions and Departments within the organisation.

- To contribute to the wider public health responsibilities of the health and social care community in the prevention and control of infections

- To ensure effective communications are in place for the internal organisation, patients and the wider public

The Infection Prevention and Control Committee is a standing committee accountable to the Quality Assurance Committee (QAC) which is a sub-committee of the Trust Board. It is chaired by the Director of Nursing/Director of Infection Prevention and Control.



Main Functions

To assure the Trust Board that Northern Devon Healthcare NHS Trust has:

2.1 Infection Prevention and Control Action Plans

- To ensure the production of the Annual Plan by the Infection Prevention & Control Team that identifies and addresses the organisational and corporate infection control risks and priorities.

- To approve the Infection Prevention & Control Team Annual Plan - To monitor delivery against the Infection Prevention and Control Team Annual Plan

on a quarterly basis. - To receive copies of any progress reports required by the Department of Health, NHS

England South, Trust Development Authority, Care Quality Commission, New Devon Clinical Commissioning Group, or Public Health England.

2.2 Annual Report

- To provide input to the Infection Prevention and Control Team Annual Report produced by the Director of Infection Prevention and Control.

- To ensure the Annual Report is presented to the Trust Board, and made available to the public through the Trust website

2.3 Policies

- To approve all new IP&C policies and any major revisions to existing policies. - To note minor revisions to existing policies made by the Infection Prevention &

Control Team.

2.4 Other Responsibilities

- To determine priorities for the use of resources designated for infection prevention & control purposes

- To advise on whether the level of investment in the prevention and control of infections is sufficient to address any risks identified by the Director of Infection Prevention and Control or Infection Prevention and Control Team.

- To receive relevant new guidance and publications and to consider required action as necessary.

- To monitor infection prevention and control related incidents and take action as necessary.

- To monitor activities of sub groups by Standing Agenda item, such as the Matrons Charter Group, Facilities infection control group, Decontamination Committee and the Engineering Group

- To receive reports from the committee’s sub groups and act as an escalation point for those groups where barriers to the implementation of good practice or other risks have been identified

- To receive information on Antibiotic Stewardship activities that are undertaken by the Antimicrobial Working Group and who formally report to the Drugs and Therapeutics Committee



Membership

Membership shall comprise:

Role Organisation / Team

Director of Nursing/Director of Infection Prevention & Control

Northern Devon Healthcare NHS Trust

Head of Professional Practice / Assistant Director of Nursing


Consultant Microbiologist / Infection Control Doctor


Lead Nurse Infection Prevention & Control Northern Devon Healthcare NHS Trust

Divisional Nurse Planned Care Northern Devon Healthcare NHS Trust

Divisional Nurse Unscheduled Care Northern Devon Healthcare NHS Trust

Facilities Clinical Services Manager Northern Devon Healthcare NHS Trust

Facilities Manager Northern Devon Healthcare NHS Trust

Occupational Health Advisor Northern Devon Healthcare NHS Trust

Associate Medical Director Northern Devon Healthcare NHS Trust

Health & Social Care Division Northern Devon Healthcare NHS Trust

Head of Midwifery Northern Devon Healthcare NHS Trust

Podiatry Northern Devon Healthcare NHS Trust

Non-voting members:

Lead Nurse Healthcare Associated Infections, NHS Northern, Eastern and Western Devon Clinical Commissioning Group

NHS Northern, Eastern and Western Devon Clinical Commissioning Group

Health Protection Public Health England

- Details of the membership are shown in Appendix B. - The Director of Nursing shall act as Chair. Deputy chairs are Assistant Director of

Nursing and Infection Control Doctor. - Other staff may be invited to attend as appropriate.



- Members are expected to attend at least 75% of meetings. Where a joint member attends, this will count towards the joint members’ attendance. Where a deputy attends in the member’s place, this will count towards the member’s attendance. Attendance will be monitored by the Chair of the Committee.

Meetings and Conduct of Business

- A quorum will comprise of 6 voting members and include the Chair or Deputy Chair. - Meetings will be held on the last Tuesday of each month. - Meetings of the Committee will be formal and appropriate agendas and minutes

produced. Agenda and papers will normally be distributed one week prior to the meeting. Standing agenda items are shown in Appendix C.

- Amendments to minutes may only be made by agreement of committee members. - Administrative support will be provided by the PA to the Director of Nursing. - Decisions will normally be reached by the agreement of members present. If,

however, agreement cannot be reached, a vote may be held, at the discretion of the Chair. The outcome of the vote will be on the basis of a simple majority. If the votes are tied, the presiding Chair will have a second or casting vote. Only members from Northern Devon Healthcare NHS Trust are eligible to vote.

- The Terms of Reference will be reviewed annually.

Reporting Arrangements

5.1 Reports provided

- Minutes of the Committee will be received by the Quality Assurance Committee for any necessary actions.

- The Committee will provide an Annual Report which will be received by the Quality Assurance Committee and presented to Trust Board.

- Sub Groups reporting to the Committee include: o Collaborative Operational Group o Facilities Infection Control Group o Engineering Controls Group o Decontamination Committee

- Groups sending reports to the Committee include: o Antibiotic Working Group

5.2 Reporting schedule

- The reporting schedule is shown in Appendix D.

Communication and Involvement Plan

- Key stakeholders, including clinicians, patients and the public, will be involved with the work of the Committee where appropriate.



- The IP & C Committee will observe the requirements of the Freedom of Information Act 2000, which allows a general right of access to recorded information held by the Northern Devon Healthcare Trust, including minutes of meetings, subject to the specified exemptions.



APPENDIX A - STRATEGIES, POLICIES AND PROCEDURES FOR APPROVAL

Document Type Review Frequency Review Date

Terms of Reference Procedure Annual 1.4.18

Annual Plan Strategy Annual 1.4.18

Annual report Report Annual 1.6.18

IPC policies Policy 3 years



APPENDIX B - IPCC COMMITTEE AS AT MARCH 2017

Meeting Dates

Date Time Venue

Tuesday 25 April 2017 11.00am – 1.00pm Chichester Board Room

Tuesday 30 May 2017 11.00am – 1.00pm Chichester Board Room

Tuesday 27 June 2017 11.00am – 1.00pm Chichester Board Room

Tuesday 25 July 2017 11.00am – 1.00pm Chichester Board Room

Tuesday 22 August 2017 11.00am – 1.00pm Chichester Board Room

Tuesday 26 September 2017 11.00am – 1.00pm Chichester Board Room

Tuesday 24 October 2017 11.00am – 1.00pm Chichester Board Room

Tuesday 28 November 2017 11.00am – 1.00pm Chichester Board Room

Tuesday 19 December 2017 11.00am – 1.00pm Meeting Room 2, Level 0

Membership

Role Name Organisation / Team

Director of Nursing/Director of Infection Prevention & Control Darryn Allcorn


Head of Professional Practice / Assistant Director of Nursing Andrea Bell


Consultant Microbiologist / Infection Control Doctor David Richards


Lead Nurse Infection Prevention & Control (North) Fiona Baker


Divisional Nurse Planned Care Donna Knight


Divisional Nurse Unscheduled Care Charlotte Overney


Facilities Clinical Services Manager Fraser Bishop


Facilities Manager Lisa Wright


Occupational Health Advisor Jenny Rafferty


Associate Medical Director Chris Bowman




Health & Social Care Division Sarah Garnsworthy


Head of Midwifery Toby Cooper


Podiatry Lyndon White


Lead Nurse Healthcare Associated Infections, NHS Northern, Eastern and Western Devon Clinical Commissioning Group

Sara Wright

NHS Northern, Eastern and Western Devon Clinical Commissioning Group

Health Protection Nick Young Public Health England

In Attendance

Job Title Name Organisation

PA to Director of Nursing Tel: 01271 314109 (Ext: 4109)

Lucy Parr Northern Devon Healthcare NHS Trust



APPENDIX C - STANDING AGENDA ITEMS

Standing Agenda Items

1. Opening Business 1.1. Apologies 1.2. Minutes of last meeting 1.3. Matters Arising

2. Performance Monitoring 2.1. IPC Dashboard 2.2. Review of IPC Divisional Action Log and feedback from Divisions SEA

investigations: Causal themes, Summary and Progress of SEAs 2.3. Mandatory training uptake for IP & C 2.4. Spot check audits 2.5. IPC Annual Plan

3. Operational

3.1. IPC Incident reports 3.2. Communications 3.3. Policies 3.4. Risks 3.5. IP & C Products

4. Assurance from IPCC sub groups

4.1. Collaborative Operational Group 4.2. Facilities IC Group Minutes 4.3. Decontamination Group 4.4. Engineering Controls Group 4.5. Antibiotic Working Group

5. Items for Information

5.1. Report from Public Health England 5.2. Public Health England HCAI Profile for NDHT

6. Closing Business

6.1. Emerging Issues 6.2. Issues for raising with other Committees 6.3. Review of Meeting 6.4. Date of Next Meeting

Other agenda items may be added as required.



Papers copied for information to


Head of Quality and Safety Sue Pilkington Northern Devon Healthcare NHS Trust

Performance Manager Kate Ogilvie Northern Devon Healthcare NHS Trust

Infection Control Nurses Kathryn Turner Philippa Ellam


PA to Director of Nursing Lucy Parr Northern Devon Healthcare NHS Trust

Administrative contact for Committee


Infection Prevention & Control Administrator

Denise Leverton Northern Devon Healthcare NHS Trust

Abbreviations

Abbreviation Full name

IP & C Infection Prevention & Control

QAC Quality Assurance Committee



APPENDIX D - REPORTING SCHEDULE

Report Freq. Action Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Terms of Reference Annual Approve X

Annual Plan Annual Approve X

IPC Policies 3 years Approve X X X X X X X X X X X X

New Risks Monthly Note X X X X X X X X X X X X

Annual Report Annual Approve X



Appendix 2 - Infection Prevention & Control Team Meeting

The Infection Prevention & Control Team meeting will take place weekly.

The agenda will include:

Weekly Team Meeting Every 2nd Week Every 4th Week

1 Alert Organisms Alert Organisms Alert Organisms

2 Alert Conditions / Infections of Note Alert Conditions / Infections of Note Alert Conditions / Infections of Note

3 Water Test Results Water Test Results Water Test Results

4 Mandatory Surveillance Mandatory Surveillance Mandatory Surveillance

5 Incidents/Complaints requiring

immediate action

Incidents/Complaints requiring

immediate action

Incidents/Complaints requiring

immediate action

6 New Risks requiring urgent action New Risks requiring urgent action New Risks requiring urgent action

7 Enquiries requiring immediate action Enquiries requiring immediate action Enquiries requiring immediate action

8 HPR + Eurosurveillance HPR + Eurosurveillance HPR + Eurosurveillance

9 Actions / Issues for follow up Feedback from IPCC / Patient Safety/

QAC / Senior Nurse Forum / Health &

Safety Meeting

Feedback from Matrons Charter /

Capital / Facilities / Engineering

Controls / COSHH

10 Annual Plan Hand Hygiene Projects

11 Educational Projects Divisional Action Plan + Dashboard

12 Policy Updates Actions / Issues for follow up

13 Actions / Issues for follow up

INFECTION PREVENTION & CONTROL TEAM MEETING



Appendix 3 - Infection Control Link Practitioner Group Roles & Responsibilities

INFECTION CONTROL LINK PRACTITIONER GROUP

ROLES & RESPONSIBILITIES OF THE LINK PRACTITIONER

Role

The Infection Control Link Practitioners form a vital link between clinical practice in all areas of healthcare and the Infection Control Team. The success of this concept relies on two-way communication, as well as giving opportunity for Link Practitioners to facilitate good Infection Control Practice within their area of work.

Primary Objective

To contribute to the delivery of the Trust’s Infection Prevention & Control Annual Plan by monitoring standards of infection control in clinical practice.

Responsibilities

To liaise with your line manager, to promote and disseminate good infection control practice, including evidence based information, to all healthcare workers.

Liaise with staff in own area of practice to allow dissemination of current practices.

Identify both good and poor practice using strategies including audit and surveillance within your area, in particular using hand hygiene audit and high impact intervention tools.

Undertake audits personally, or on occasion when this is not possible teach a deputy and ensure data has been appropriately and fully recorded prior to data entry or postal despatch to infection control department.

Promptly undertake own data entry of hand hygiene, high impact interventions and other IC Link audit programme audits, when this facility becomes available

Print off own area hand hygiene results posters and display in locked noticeboard when this facility becomes available



Be responsible for the updating of the ward/department locked notice board with hand hygiene, high impact intervention audit results and other key information immediately on receipt.

Utilise the dashboard and audit results to identify with ward/dept manager/modern matron strategies to improve compliance with best practice standards in infection prevention and control.

Act as a facilitator/change agent when necessary within your area of practice to promote good infection control practice.

Provide education in infection control to staff within your area of practice, i.e. policy update, hand washing.

Alert the Infection Control Team of any educational needs within your area of practice that you are unable to deal with yourself. Identify individuals that would benefit from attending the High Five Clinical Update sessions.

Ensure staff know where to look up current policies on Trust intranet and are made aware of their contents.

Contribute to the agenda and programme of the Link Practitioner Group.

26th June 2009