INFECTION PREVENTION & CONTROL

Hand Hygiene Policy

Initiated by: Infection Prevention & Control Team Approved by: Infection Prevention & Control Group Issue Date: 2016 Review Date: 2018 Version: 2 Doc Ref: HH v2.16

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Policy Title:

Hand Hygiene Policy

Executive Summary:

The aim of this policy is to provide a standardised approach to Hand Hygiene across the Health Economy of Eastern Cheshire. Effective hand hygiene is the simplest most effective measure for preventing Healthcare associated infections (NPSA 2008). Hand hygiene is an important component of a risk management strategy, it is imperative that timely and effective hand hygiene becomes embedded as a key indicator of Patient safety and the delivery of Quality care. The guidance is for use across all healthcare settings and will enable all staff to contribute in reducing the risk of transmission of potentially harmful pathogens. The policy details procedures to be undertaken for effective hand hygiene compliance and the subsequent monitoring process. It is the individual’s responsibility to ensure they comply with the policy by ensuring they are competent practitioners. This policy is reflective of the standards required under the Health and Social Care Act 2008 (amended 2015)

Supersedes: Version 1 to reflect new Guidance

Description of Amendment(s):

Incorporates new research recommendations for EPIC 3 guidelines and organisational requirements

This policy will impact on: All staff both clinical and non-clinical

Financial Implications: None

Policy Area: Infection Control Trust Wide

Document Reference:

ECT002496

Version Number: 1 Effective Date: April 2016

Issued By: Director of Infection

Prevention and Control

Review Date: April 2018

Author: Lead Nurse Infection

Prevention and Control

Impact Assessment Date:

May 2016

APPROVAL RECORD

Committees / Group Date

Consultation: Infection Control Committee April 2016

Approved by Director: Director of Nursing, Performance

and Quality

May 2016

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Contents

Section

Heading Page(s)

1 Introduction

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2 Purpose

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3 Definitions and key terms used

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4 Preparation for hand hygiene

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5 Naked Below the Elbow

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6 Hand Hygiene

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7 Indications for hand hygiene

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Hand hygiene Technique

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9 Hand hygiene facilities

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10 Patients and visitors

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11 Training

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Audit

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Appendix A: Microorganisms residing on the surface of the skin

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Appendix B: World Health Organisation 5 moments for hand hygiene

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Appendix C: Product Selection

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Appendix D: Hand hygiene technique

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References

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Equality Analysis (impact assessment)

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1 Introduction Hand hygiene is a cornerstone to preventing the risk of transmission of infection and is perceived as a significant indicator for patient safety (NPSA. 2008). Healthcare Associated Infections (HCAI) has been attributed to 5,000 deaths per year at an estimated annual cost of £1billion.

A sustained and systematic approach to hand hygiene remains essential in practice due to the emergence of highly resistant pathogens which are increasingly difficult to treat. A preventative strategy is therefore essential in combating the risks. Current national and international guidance has consistently identified that effective hand decontamination results in significant reductions in the carriage of potential pathogens on the hands and it is therefore logical that the incidence of preventable healthcare associated infection (HCAI) is decreased, leading to a reduction in patient morbidity and mortality (Loveday et al, 2014).

Epidemiological evidence indicates that hand-mediated transmission is a major contributing factor in the acquisition and spread of infection in hospitals (Loveday et al, 2014). Despite the high profile of the importance of hand hygiene compliance nationally remains low. The World Health Organisation (WHO 2009 a & b) recommends a sustained approach towards remedying this.

The Health and Social Care Act 2008 ‘Hygiene Code’ (DOH (2008), updated 2015) requires NHS organisations to have up to date policies and procedures which minimise the risk of healthcare associated infection (HCAI). This includes evidence based hand hygiene guidelines which promote timely and effective hand decontamination.

As such all staff providing direct/indirect care in hospital and other health care settings, including the patient’s home, have a responsibility to comply with effective hand hygiene decontamination as detailed in this policy.

1.1 Organisational Responsibilities

The Chief Executive has ultimate responsibility for the implementation and monitoring of the policies in use in the Trust. This responsibility may be delegated.

The Director of Nursing, Performance and Quality will take the lead responsibility for the development and implementation of this policy with support of the Lead Nurse Infection Prevention and Control and the Infection Prevention and Control Doctor.

The Director of Infection Prevention and Control (DIPC) will oversee the implementation of this policy, in addition to challenging bad practice. Providing assurance to the board that systems and process are in place to ensure compliance with agreed standards.

The Infection Prevention and Control Team (IPCT) will have responsibility for ensuring the policy is implemented and monitored across the Trust in addition they will ensure compliance with any national initiatives or directives. Providing and supporting a sustainable programme of audit and education across the health economy.

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All Employees must ensure they are compliant with Infection Prevention and Control training and standards which are monitored through the appraisal process.

2 Purpose

This policy has been developed to inform all staff employed within East Cheshire Trust, Contractors, Agency Staff and service users on the requirements relating to hand hygiene both within clinical settings and patients own homes to reduce the risk of transmission of microorganisms which may result in a Healthcare Associated Infection.

3 Definitions of key terms used

Plain Liquid Soap A detergent soap that contains no added antimicrobial agents or additives.

Alcohol Based Products

Alcohol hand rub /gel: an alcohol containing product (can be in liquid, gel or foam) designed for rapid decontamination of hands by inactivating micro-organisms. It is essential the dispensers are kept clean with no product build up around the nozzle.

Hand Washing Conventional method using warm running water, liquid soap and disposable paper towels. This process will remove transient micro-organisms.

Hand Hygiene Refers to the combination of the process including hand washing, or the use of alcohol products, drying and moisturising hands.

Surgical Hand Preparation

Antiseptic hand wash performed preoperatively/ pre procedure to eliminate transient flora and reduce resident skin flora.

Hand decontamination Generally used to refer to hand hygiene, this encompasses use of liquid soap and water and / or alcohol based hand rubs. This process reduces the bacterial count and the physical removal of blood, bodily fluids, secretions, excretions etc.

Point of Patient Care The moment during health care activities when hand decontamination must visibly occur to prevent the transmission of micro-organisms.

Resident Flora Micro-organisms residing on the surface of the skin (see appendix A)

Transient Flora Micro-organisms colonised in the superficial layers of the skin but can be readily removed by routing hand washing (see appendix A)

Hand Hygiene is the single most important measure in preventing the spread of infection.

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4. Preparation for hand hygiene Finger nails must be kept short and clean. Artificial nails, nail varnish, nail art, nail extensions etc. must not be worn. These harbour greater levels of micro-organisms than natural fingernails which are harder to remove during hand decontamination.

Cuts and Abrasions on the hands or arms must be covered with a waterproof dressing. Any skin conditions such as boils, abscesses, eczema or psoriasis must be reported to the Occupational Health department.

5. Naked Below the Elbow (NBE)

Hand hygiene involves both the preparation and physical process of decontamination. “Naked Below the Elbow” ensures wrists and forearms are exposed, removing any items e.g. wrist watches, stoned rings, bracelets, long sleeved clothing etc. that may hinder the hand hygiene process (Loveday et al, 2014), see Uniform and dress code policy (2015). Rings, wristwatches and other jewellery worn on the hands and wrists become contaminated during work activities and prevent thorough hand hygiene procedures.

5.1 The principle of “Naked below the elbow” must be adhered to by:

All staff undertaking any form of clinical care in the Acute Trust or community

All staff based in, or whom work primarily within a clinical environment e.g ward clerks

All Trust staff who attend the clinical environment, e.g secretaries, pharmacists, estates and facilities etc

All contractors / company representatives visiting a clinical area to action work on behalf of the Trust.

The only exception to this rule is: Where a specialist role is being undertaken which demands that personal protective clothing be worn for health and safety purposes e.g. estates personnel servicing a Dekomed 190.

5.2 For religious reasons members of staff who wish to cover their forearms, wear a

Kara or Kabbalah when not engaged in direct clinical care must ensure they are able to move the items up the arm for hand washing and direct patient care. If required disposable over sleeves can be worn where gloves are used but this does not negate hand washing. Over sleeves must be disposed of as disposable gloves (DOH, 2010). If required the individual should request them through their manager (see uniform and dress code policy, 2015).

Any staff member with any portion of their forearm, wrist and/or hand in a bandage, splint, plaster cast and/or sling of any description cannot work in a clinical environment as hand contamination, and the need for hand hygiene occurs due to contact with the environment and equipment, as well as with patients. A suitable risk assessment must be undertaken with Occupational Health and the line manager to ensure patient safety and hand hygiene practice is maintained.

5.3 If Medic alert jewellery needs to be worn, this should ideally be worn off the wrist

(necklace, anklet, or attached to the uniform), rather than as a bracelet unless

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discussed directly with line manager, Occupational health and IPC (see uniform and dress code policy, 2015).

6 Hand Hygiene

Hand decontamination has a dual role to protect both the patient and the Healthcare Worker (HCW) from acquiring micro-organisms which may cause them harm. Healthcare workers have the greatest potential to spread micro-organisms that cause infection by:

Transferring micro-organisms from one patient to another / staff to patient / patient to staff.

Transferring micro-organisms from the environment to the patient; and

Transferring micro-organisms from equipment to patient.

Patients are at risk of acquiring a HCAI following contact with healthcare staff, informal carers etc. Hands must be decontaminated at critical points in order to prevent cross transmission with micro-organisms. Opportunities for hand hygiene have been encompassed by the World Health Organization as 5 key moments (WHO, 2009a) see appendix A.

Hands must be decontaminated:

Before touching a patient

Before a clean / aseptic procedure

After body fluid exposure risk

After touching a patient

After touching the patient’s surroundings

In order to ensure compliance with this principle healthcare workers must understand this in a wider context.

The Patient’s environment: relates to the patient, his/her immediate surroundings i.e. bed space. This includes dedicated equipment e.g. bedside table, locker, chairs, IV Stands etc. and equipment moved into the patient’s environment for short periods of time e.g. Vital Pac monitors.

Both healthcare staff and patients shed skin flora which contaminates the patient environment. Consequently failure to practice effective hand hygiene can transmit skin flora from the hands of healthcare staff to critical patient body sites via invasive lines or devices and pose an infectious risk to the patient.

Healthcare Environment: refers to the area outside of the patient environment this includes clinical rooms, sluices. This area has the potential to become contaminated with micro-organisms, failure to undertake effective hand hygiene can result in transmission to patients. Planned cleaning of the environment and equipment will reduce the burden of microorganisms.

The use of gloves does not negate the need for effective hand hygiene: staff must ensure they wash their hands prior to donning and immediately on removal of the gloves as per the guidance in the Standard Precautions Policy.

Home Care: Practitioners performing clinical care in a patient’s home, or none NHS

premises must be provided with, or have access to community hand hygiene packs or

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individual items i.e. healthcare grade liquid soap, moisturiser, alcohol hand rub /gel and disposable paper hand towels.

These must be dedicated for individual practitioner use and must be used as single use items. These must not be refilled due to the potential for contamination by microorganisms.

If a suitable clean basin / sink is not available alcohol hand rub / gel should be considered.

If the patient or carer provides similar items for use by the staff member in the home setting, it is the responsibility of the individual staff member to assess if it appropriate for use. Community staff must not use bars of soap in a patient’s home due to the potential of contamination with micro-organisms e.g. skink flora.

7. Indications for Hand hygiene – this list is not exhaustive, (see appendix C for

product selection).

Indication Product Used Example Variation

Entering a Clinical area

Alcohol hand rub /gel or liquid Soap and water

Arriving on the ward

Entering a patient’s home

Alcohol hand rub /gel or liquid soap and water

Arriving at patient’s home

Diarrhoeal illness including Clostridium Difficile

Liquid soap and water

Patient in isolation

If in patient’s own home and no hand wash facilities available then alcohol hand rub /gel can be used. Hands must then be washed with liquid soap and water as soon as a facility is available.

After visiting the toilet

Liquid soap and water

Performing aseptic non touch technique

Liquid soap and water at start of procedure and on removal of gloves at end of procedure

Wound care / intravenous line care

If in patient’s own home and no hand wash facilities available then alcohol hand rub /gel can be used. Hands must then be washed with liquid soap and water as soon as a facility is available.

Hands not visibly soiled for routine

Alcohol hand rub /gel Medication round /

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Indication Product Used Example Variation

decontamination Ward round if no patient contact.

Cleaning Equipment

Liquid soap and water

Commode None

Removal of gloves / PPE

Liquid soap and water

Following direct patient care

If in patient’s own home and no hand wash facilities available then alcohol hand rub /gel can be used. Hands must then be washed with liquid soap and water as soon as a facility is available.

Hands visibly soiled / potentially contaminated with bodily fluids

Liquid soap and water

If in patient’s own home and no hand wash facilities available then alcohol hand rub /gel can be used. Hands must then be washed with liquid soap and water as soon as a facility is available.

Surgical Hand Decontamination

Chlorhexidine or Iodophors (Iodine)

8. Hand Hygiene Technique

Hand washing with liquid soap and water will render the hands socially clean.

Use the six stage hand washing technique (Appendix C) when hands are visibly soiled or potentially contaminated with dirt or organic material.

8.1 Procedure

Naked Below the Elbows

Ensure wrists and forearms are exposed, removing any items that may hinder the process including any wrist watches, jewellery

Cuts and Abrasions

Abrasions on hands or arms must be covered with a waterproof dressing. Any skin conditions such as boils, abscesses, eczema or psoriasis must be reported to the Occupational Health department.

Preparation Wet hands under warm running water prior to applying one dose of liquid soap. The solution must come into contact with all

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surfaces of the hands.

Washing Hands must be vigorously rubbed together for approximately 40-60 seconds (as per appendix C). Rinse off soap.

Hand Drying Using good quality disposable paper towels dry hands thoroughly. Effective hand drying is essential to prevent damage to skin integrity. In clinical areas paper towels should be wall mounted and easily accessible in dispensers next to the sink. Paper towels should be disposed of as household waste in the appropriate waste bin which in clinical areas should be lidded and foot operated.

Taps Must be turned off using a “hands free” technique e.g. elbow taps, if available. If only hand operated taps available, these must be turned off using a clean, disposable paper towel

Nail brushes Nail brushes can damage skin leading to an increased risk of infection from microorganisms or dispersed skin scales. If a nail brush is necessary e.g. in theatres, it must be single-use and disposed of immediately after use.

Moisturisers Intact skin is a natural barrier to infection, consequently all staff need to be aware of the potential damaging effect of increased hand hygiene. Therefore staff should protect and maintain skin integrity through regular use of moisturisers

NB It is acknowledged that within the community setting access to hand wash facilities can be limited (although clinical staff carry equipment with them which includes liquid soap and alcohol hand rub /gel). Therefore community staff must make an appropriate risk assessment to ensure they are compliant with hand hygiene.

8.2 Clostridium difficile/ viral diarrhoea and vomiting When caring for symptomatic cases associated with a spore forming organism such as

Clostridium difficile and viral gastroenteritis hands must be washed with liquid soap and water. Alcohol hand rub may only be used to compliment hand washing

8.3 Alcohol Foam/gel

Alcohol hand foam/gel must be available at the point of care in all healthcare facilities. Unless hands are visibly soiled it must be used to decontaminate hands between caring for patients and between different care activities for the same patient.

Alcohol foam/gel containers must be kept clean and free from congealed gel, they must under no circumstances be topped up or refilled.

Where hand washing facilities are not available or inaccessible, alcohol foam/gel must be used.

Minimising the risk of fire and ingestion - Storage of alcohol hand foam/gel products must be kept to minimum quantities in clinical areas with no more than fifty litres held (NHSE 2005).

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A risk assessment must be undertaken when the easy availability of alcohol-based hand rubs/gels is considered unsafe e.g. paediatrics, mental health and special learning needs. The use of personal dispensers is predominantly expected within the community setting; however a risk assessment on the procedure to be undertaken will determine if these are needed within dedicated clinical areas, this assessment needs to incorporate the risk of ingestion and fire.

8.4 Alcohol Foam/ Gel use

Place enough product in your palm to thoroughly cover the hands. The solution must come into contact with all surfaces of the hand by rubbing together vigorously using the recommended key stages, see appendix C. Paying particular attention to the finger tips, the thumbs and the areas between the fingers. The solution will evaporate; consequently there is no need for rinsing or drying.

8.5 Hand Moisturiser

Intact skin is a natural barrier to infection consequently all staff need to be aware of the potential damaging effect of increased hand hygiene. Therefore staff should protect and maintain skin integrity through regular use of moisturisers throughout the day.

Hand moisturizer dispensers must be available in all clinical areas. Moisturisers should be provided in wall mounted dispensers, located in areas easily accessible for staff e.g. staff rooms but not at every hand wash basin. Dispensers should not be placed in sluice or toilet areas due to potential for contamination. The use of communal tubs should be avoided as these can become easily contaminated with skin cells etc.

9. Hand Hygiene Facilities

Inadequate hand hygiene facilities will lead to poor hand hygiene performance (WHO 2009b). Therefore the Trust will aim to provide facilities at the point of patient care.

Hand wash basins are designed solely for the purpose of hand hygiene; they are therefore maintained in a clean good condition in accordance with the Trust Legionella and Pseudomonas policy. They should not have a plug or overflow in place. In addition they should be kept free from extraneous items to reduce the risk of cross infection. Water should flow directly into the sink to avoid aerosolisation rather than the outlet drain (DOH, 2013).

Hot air dryers are not recommended in clinical settings. However, if they are used in other areas e.g. public toilets they must be regularly serviced and users must dry hands completely before moving away.

Hand hygiene technique based on the five moments is clearly displayed on the clinical sinks liquid soap and alcohol gel dispensers. This is further supplemented by appropriate posters and signage.

The liquid soap, gel and moisturiser dispensers must be easily available and be visibly clean, this must form part of the healthcare cleaning standard cleaning schedules (NPSA, 2007).

Where possible the use of hands free tap system is preferable, this includes elbow operated and sensor taps. Hand operated taps should be turned off using a clean disposable paper towel.

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Foot operated, lidded bins with the appropriate identified waste stream (usually household) must be provided. Do not use hands to lift the lid due to re-contamination.

Alcohol gel dispensers are available at the entrance to clinical areas and at the point of care. Alternative individual dispensers are used in some areas including community settings; these must be disposed of when empty and not refilled.

Staff reporting to their clinical manager with sore hands must be referred to occupational health for the appropriate treatment/advice.

10. Patients and Visitors

Patients must be offered the opportunity to wash their hands before eating, at meal times and after using the toilet, commode or bedpan.

Patients, relatives and carers should be educated on the importance of hand hygiene and encouraged to practice this both in a clinical and non-clinical setting.

Hand hygiene facilities are readily available at the entrance to clinical areas and clearly signed for visitors use.

Patients and visitors must be assured that staff have decontaminated their hands prior to patient contact and that patients and visitors are encouraged to challenge lapses in practice or to report breaches of policy to the matron, a member of staff in the department, Senior Sister, the IPCNs or the Patient Advice and Liaison Service (Nice, 2012).

11 Training

Infection Prevention and Control is a mandatory training requirement for all staff employed by the Trust. For new starters this is delivered as part of the induction programme incorporating theoretical and practical aspects.

In order to ensure competency and continual reinforcement of the importance of hand hygiene clinically based updates will be provided by the Infection Prevention team and or clinically based link nurses. This is further supported as an aspect of other key clinical skills including ANTT, Insertion and Management of Invasive devices.

Training records are held by Human Resources training team, the Infection Prevention team, and Clinical managers, evidence of this compliance will be monitored through the appraisal system and form part of the audit programme.

Promotion of hand hygiene will be delivered using screen savers, posters and dedicated awareness days.

12 Audit

Clinical areas undertake either monthly or quarterly audits in compliance with RADAR monitoring. Audit results are submitted to the Infection Prevention and Control team on a monthly basis for inclusion in the performance monitoring dashboard and presented to the Infection Control Committee. It is acknowledged that fluctuations may occur in relation to self-audit therefore the Infection Prevention and Control team will undertake a schedule of verification audits.

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Compliance with the policy standards is included in the Infection Prevention environmental and clinical audit programme.

Persistent non-compliance with the policy may result in disciplinary action being taken in line with HR policy.

Appendix A: Microbiology of the Skin

Hands are colonised by two categories of microbial flora:

Resident skin flora Normal flora or ‘commensal organisms’; forming part of the body’s normal defence mechanisms and protecting the skin from invasion harmful micro-organisms. Resident flora are found on the surface, just below the uppermost layer of the skin, are adapted to survive in the local conditions and are generally of low pathogenicity. They rarely cause disease and are of minor significance in routine clinical situations. However, during surgery or other invasive procedures, resident flora may enter deep tissues and establish infections e.g. Meticillin sensitive Staphylococcus aureus (MSSA) if transferred to a susceptible site.

Transient skin flora Made up of microorganisms acquired by touching contaminated surfaces such as the environment, equipment, patients, relative’s staff etc. They are located superficially on the skin, and are readily transferred to people or objects they come in contact with and are responsible for the majority of HCAI. They may include a range of antimicrobial-resistant pathogens. If transferred to susceptible sites such as invasive devices or wounds, these micro-organisms can cause life-threatening infections. Transmission to non-vulnerable sites may leave a patient colonised with pathogenic and antibiotic resistant organisms e.g. Meticillin Resistant Staphylococcus aureus (MRSA) which may result in a HCAI at some point in the future. Transient floras are easily removed by hand decontamination

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Appendix B

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Appendix C: Product Selection Choice of cleaning agent A decision regarding the choice of hand decontamination is influenced by the clinician’s assessment of what is appropriate for the episode of care performed. In general, effective hand washing with liquid soap and water, or the effective use of alcohol based hand rub / gel will remove transient micro-organisms and render hand socially clean (Loveday et al, 2014). Three types of cleansing agent can be used to remove micro-organisms from hands: Liquid soap preparations: used in collaboration with water removes / destroys transient microorganisms and substantially reducing resident micro-organisms during times when aseptic procedures are performed. Alcohol rub / gel: alcohol hand rub can be used on visibly clean hands as an alternative to a routine/social hand wash and is the preferred means for routine hand antisepsis (WHO, 2009a). As alcohol rub / gel cannot be used to remove dirt / organic material from hands they should not be used in isolation during outbreak situations (Loveday et al, 2014). The effective use of alcohol rub / gel reduces resident micro-organisms and their disinfectant properties destroy transient micro-organisms. They are especially useful when hand washing / drying facilities may be limited e.g. when providing care in a patient’s own home.

When caring for symptomatic cases associated with a spore forming organism such as Clostridium difficile or viral gastroenteritis etc. hands must be washed with liquid soap and water. Alcohol hand rub / gel must only be used to compliment hand washing.

Aqueous antiseptic solutions (surgical scrubs): these products commonly contain Chlorhexidine Gluconate, providone-iodine etc; they act by lifting and destroying transient micro-organisms and destroying some resident micro-organisms from the skin. These products should be used when a prolonged reduction in the number of resident flora on the skin are required for invasive procedures requiring maximum sterile barrier precautions e.g. operating theatre.

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Appendix D

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REFERENCES Department of Health (2008) - Health and Social Care Act: Code of Practice for the prevention and control of healthcare associated infections Updated 2015. DOH, London.

Department of Health (2010) - Uniforms and Work-wear: Guidance on uniform and work- wear policies for NHS employers DOH. London. Department of Health (2013) - Health Building Note 00-10 Part C: Sanitary assemblies. The Stationary Office. London. H.P. Loveday, J.A. Wilson, R.J. Pratt, M. Golsorkhi, A. Tinglea, A. Bak, J. Browne, J. Prieto, M. Wilcox (2014) - epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1. S1–S70. National Patient Safety Agency (2007) - The National Specifications for cleanliness in the NHS: A framework for setting and measuring performance outcomes. NPSA. London. National Institute for Clinical Excellence (2012) - Prevention and control of healthcare-associated infections in primary and community care - NICE clinical guideline 139. NICE. Manchester. World Health Organisation (2009a) - Hand Hygiene Technical Reference Manual: To be used by health-care workers, trainers and observers of hand hygiene practices. WHO. Geneva World Health Organisation (2009b) - WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer Care. WHO. Geneva NHS Estates Alert NHSE (2005) - available from: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4119437.pdf Last accessed 28.04.16 To be read in conjunction with all Infection Prevention and control Policies in particular; Infection Prevention and Control Standard Precautions Policy Aseptic Non Touch Technique Uniform and Dress Code Policy

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Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed?

Hand Hygiene Policy

Details of person responsible for completing the assessment:

Name: Anita Swaine

Position: Lead Nurse

Team/service: Infection Prevention and Control

State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document)

This policy has been developed to inform all staff employed within East Cheshire Trust, Contractors, Agency Staff and service users on the requirements relating to hand hygiene both within clinical settings and patients own homes to reduce the risk of transmission of microorganisms which may result in a Healthcare Associated Infection.

2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below – how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC.

Age: East Cheshire and South Cheshire CCG’s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally.

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Race:

In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British

5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK – Poland and India being the most common

3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language.

Gypsies & travellers – estimated 18,600 in England in 2011. Gender:

In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area.

Disability:

In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability

In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia

Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness.

C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted.

In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC.

Mental health – 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation:

CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation).

CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC.

Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%.

Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester

Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester

Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester

Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester

Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester

Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester

Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester

None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester

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Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers:

In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC.

2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?)

None. This policy has been written with respect to the statements made within the Department of Health Uniform guidance respecting the rights of other cultures/ religions by providing alternatives to Alcohol gel and naked below the elbows compliance.

2.3 Does the information gathered from 2.1 – 2.3 indicate any negative impact as a

result of this document?

None

3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No x Explain your response: In order to explain the requirements of the policy to people whose first language is not English, eg family members caring for a patient, staff will follow the interpretation policy. ______________________________________________________________________ GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No x Explain your response: No impacts identified. _________________________________________________________________________ DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes x No Explain your response: For disabled patients, assistance and/or communication support may be required to inform about and carry out good hand hygiene. Disabled visitors are unable to operate pedal bins to dispose of hand towels at ward entrances, hand gel is available for use at ward entrances and in bays. _________________________________________________________________________ AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No x

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Explain your response: Older patients will be supported as appropriate to carry out hand hygiene. . _________________________________________________________________________ LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently?

Yes No x Explain your response: No impact identified. _________________________________________________________________________ RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes x No Explain your response: This has been factored into the policy with appropriate recommendations incorporated. _________________________________________________________________________ CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes x No Explain your response: All visitors and carers are able to wash their hands at the entrance to the ward. For carers who are directly caring for patients, either as family members or as paid carers from an external organisation, the principles of Hand hygiene will be explained to them. _________________________________________________________________________ OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No x Explain your response: No other impacts identified. _________________________________________________________________________ 4. Safeguarding Assessment - CHILDREN

a. Is there a direct or indirect impact upon children? Yes No x

b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people:

c. If no please describe why there is considered to be no impact / significant impact on children. The same policy applies to children’s services and staff delivering them. Children will be assisted to carry out hand hygiene as required.

5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc?

Consultation has occurred through the Infection Prevention and Control group which is multidisciplinary and includes a member of the public.

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6. Date completed: 20.4.16 Review Date: 20.4.2018 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact?

Action Lead Date to be Achieved

8. Approval : At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead:

Date: 5/5/16