Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals

8
Have and adhere to
appropriate policies and
protocols for the
prevention and control
of HCAI.
Providers have a list of core policies in place
(List ref Act 2008 p15)
• All listed policies are in place
• An audit programme exists to audit
compliance
• Policies are widely available
• Policies are included in staff training
SWBTB (2/10) 046 (a)
DIPC Green
Overall Status:
‘MEETS’
9
Ensure as far as
practicable that
healthcare workers are
free of and protected
from exposure to
infections during the
course of their work and
that all staff are suitably
educated in the
prevention and control
of infection.
9a
9b
9c
All staff can access relevant occupational
health services
Policies are in place for prevention and
management of communicable diseases
including immunisations.
Prevention and control of infection is included
in the induction programme for new staff and
in training programmes for all staff.
• Manual of services
• Service advertised widely
• Referral system
Director of
Workforce
• Policy documents Director of
Workforce
• Training prospectus
• Registers
• Training packages
• Report to Executive Infection Control
Committee
As per 9c
9d There is a programme of ongoing education
for existing staff
9e There is a record of relevant immunisations • Records are in place
• Report to Executive Infection Control
Committee
9f There is a record of training and updates for
Overall Status:
all staff.
‘MEETS’ 9g The responsibilities of each member of staff
for the prevention and control of infection is
reflected in their job descriptions and in
PDRs.
As per 9e
• All job descriptions reflect this
• Audit of Job descriptions
• Audit of PDRs
• Report to Executive Infection Control
Committee
Director of
Workforce
Director of
Workforce
Director of
Workforce
Director of
Workforce
Director of
Workforce
Green
Green
Green
Green
Green
Green
Green
Infection Control Trust Board Assurance Framework Feb 2010 V12 6 of 6