Infection Control Policy - Devon Partnership NHS Trust

Infection Control 

Policy: R07 

Policy Descriptor 

Under the Health and Social Care Act 2008, the Code of Practice for the 

Control and Prevention of Health Care Associated Infection (DH, 2010) 

requires all Trusts to have clear arrangements for the effective prevention, 

detection and control of healthcare associated infection, including the 

procedures to be taken in the event of an outbreak of infection. This policy 

sets out the Trust’s arrangements for the effective prevention, detection and 

control of healthcare associated infection. 

Do you need this document in a different format 

Contact PALS – 0800 0730741 or email dpn-tr.pals@nhs.net 

Document Control 

Policy Ref No & Title: 

R07 Infection Control 

Version: v5.1 

Replaces / dated: Previous R07 Infection Control Policy dated April 2010 

Author(s) Names / Job Title 

responsible / email: 

Ratifying committee: 

Director / Sponsor: 

Primary Readers: 

Additional Readers 

Penny Criddle 

Senior Infection Prevention and Control Nurse 

penny.criddle@rdeft.nhs.uk 

Infection Control Committee 

Vanessa Ford 

Director of Infection Prevention and Control 

All staff working within Devon Partnership Trust, all people who 

use the service and their visitors. Members of the public. 

Private contractors working on Trust premises, locum and 

agency staff and volunteers. 

Date ratified: 20.10.11 

Date issued: 18.11.11 

Date for review: 19.10.13 

Date archived: 

NHSLA standards reflected: 2.8 – Hand hygiene training 

Infection Control Policy 

Approved by Infection Control Committee: 20 th October 2011 

Review date: October 2013 Page 1 of 11

Contents 

1. Introduction..........................................................................................................3 

2. Purpose ...............................................................................................................3 

3. Duties ..................................................................................................................4 

4. Infection Control Assurance Framework..............................................................6 

5. Training................................................................................................................7 

6. Patient And Public Information ............................................................................8 

7. Monitoring............................................................................................................8 

8. Further Advice – Contacting The Infection Control Team ....................................8 

9. References ..........................................................................................................8 

Appendix 1 – Local Infection Control Documents .......................................................9 

Appendix 2 – Infection Control Assurance Framework .............................................10 




1. Introduction 

1.1. Under the Health and Social Care Act 2008, the Code of Practice for the Control and 

Prevention of Health Care Associated Infection (DH, 2010) requires all Trusts to have clear 

arrangements for the effective prevention, detection and control of healthcare associated 

infection, including the procedures to be taken in the event of an outbreak of infection. 

2. Purpose 

2.1. Aims – This policy will ensure that: 

• Responsibility for infection prevention and control is embedded at all levels of the 

organisation 

• Effective arrangements are in place for the provision of a full infection prevention and 

control service including policy production, surveillance, education and training, and 

audit led by an Infection Prevention and Control Team. (IPCT) 

• Infection control advice is provided by a suitably qualified and resourced team, which 

includes an Infection Control Doctor and Infection Prevention and Control Nurses, with 

administrative and information technology support. 

• The Infection Prevention and Control Team is supported by adequately resourced and 

staffed microbiology laboratories capable of promptly processing and reporting results 

on specimens sent for investigation. 

• A multi-professional Infection Control Committee is in place to advise and support the 

IPCT. 

• All healthcare personnel working within the scope of this policy are aware of the 

rationale and responsibility to maintain high standards of infection control at all times. 

2.2. Objectives 

• To reduce healthcare associated infection by providing the highest possible standards 

of infection control management within the limitations of available resources. 

• To provide locally adapted guidelines as statements of good practice based on 

systematic review of research and other evidence. Appendix 1 details the infection 

control policies and clinical care protocols in place to achieve compliance with the 

Health and Social Care Act 2008. These documents are available on the Infection 

Control pages of the intranet. 

• To generate infection surveillance data and feedback results to relevant parties in order 

to reduce mortality and morbidity and improve the quality of care. 

• To audit practice in relation to infection control policies and protocols and disseminate 

findings to appropriate groups. 

• To ensure an ongoing education programme, tailored to meet the needs of individual 

groups of staff, is available for all personnel. 




3. Duties 

3.1. Board of Directors and Chief Executive – The Board of Directors, via the Chief 

Executive, are responsible for: 

• Ensuring there are effective and adequately resourced arrangements for infection 

control within the organisation. 

• Identifying a Board level lead for infection control. 

• Ensuring that the role and functions of the Director of Infection Prevention and Control 

are satisfactorily fulfilled by appropriate and competent persons as defined by DH, 

(2004b) 

• Approving the infection prevention and control annual programme, receiving the DIPC’s 

annual report and any other reports regarding the state of infection control within the 

organisation. 

• Ensuring that appropriate systems are in place for: 

o reviewing reports and statistics on the incidence of alert organisms (e.g. MRSA, 

Clostridium difficile) and conditions, outbreaks and Serious Untoward Incidents 

• ensuring that clinical responsibility for infection prevention and control is effectively 

devolved to: 

o 

o 

All professional clinical groups in the Trust 

Clinical Directorates and matrons where appropriate. 

3.2. Director of Infection Prevention and Control – The DIPC will: 

• Oversee local control of infection policies and their implementation. 

• Be responsible for the Infection Prevention and Control Team within the healthcare 

organisation. 

• Report directly to the Chief Executive and the Board of Directors and not through any 

other officer. 

• Challenge inappropriate clinical hygiene practice as well as antibiotic prescribing 

decisions. 

• Assess the impact of all existing and new policies and plans on infection and make 

recommendations for change. 

• Be an integral member of the organisation's clinical governance and patient safety 

teams and structures, providing regular reports and decision briefings to the Safety and 

Risk Committee. 

• Produce an Annual Report on the state of healthcare associated infection in the 

organisation(s) for which he/she is responsible and release it publicly. 




3.3. Infection Prevention and Control Team – The IPCT is responsible for: 

• Ensuring advice on infection control is available on a 24-hour basis. 

• Formulating an annual Infection Prevention and Control Programme in full consultation 

with the Infection Control Committee (ICC), health professionals and senior managers. 

The programme will include surveillance of infection and audit of the implementation of 

and compliance with selected policies. 

• In liaison with other relevant staff preparing, reviewing and updating evidence-based 

policies and guidelines in line with relevant Department of Health notifications and/or 

national guidelines, when available and applicable (see Appendix 1). 

• Identifying and controlling outbreaks in collaboration with the Consultant for 

Communicable Disease Control and outbreak control group as appropriate. 

• Ensuring the provision of education to all grades of staff working within the scope of this 

policy (see Section 6). 

• Liaising with the Occupational Health Department, Consultant in Communicable 

Disease Control, the Health Protection Agency and other external services or agencies 

where applicable. 

3.4. The Infection Control Committee – Responsibilities of the ICC include: 

• Advising and supporting the IPCT. 

• Drawing to the attention of the Chief Executive, either through the DIPC or, if 

necessary, directly, any serious problems or hazards relating to infection control. 

• Considering reports on infections and infection control problems. 

• Discussing and endorsing a plan for the management of outbreaks in the Trust and 

monitoring its implementation. 

• Discussion and endorsement of a plan for the Trust’s response to major outbreaks in 

the community – the Major Incident (outbreak) Plan – and monitoring of its 

implementation. 

• Collaborating with the IPCT to develop the Annual Infection Prevention and Control 

Programme, monitor its progress, assist in its effective implementation and review the 

annual report. 

• Providing advice regarding the most effective use of resources available for 

implementation of the programme and for contingency requirements. 

• Creating, reviewing and monitoring the Infection Control Assurance Framework 

(see Section 5.0 and Appendix 2). 

• Advising on and approving all infection control policies before their submission to the 

Chief Executive for approval, and review of their implementation. 

• Promoting and facilitating the education of all grades of staff in infection control 

procedures. 




3.5. Operational Managers – Each management team will: 

• Ensure a nominated Matron provides representation at the Infection Control Committee. 

• Ensure that every ward/in-patient unit has a designated infection control link 

practitioner. 

• Ensure that recommendations from infection control audits, essential steps monitoring 

or other related infection control activities are implemented. 

• Ensure that all healthcare staff are up to date with infection control compulsory training. 

• Ensure that good infection control practice is promoted within the workplace and where 

concerns exist these are escalated to the infection prevention and control team. 

3.6. Healthcare Personnel 

3.6.1. All healthcare staff have a duty to act on and report at the earliest opportunity, 

conditions or incidents that may be deemed infectious to others, e.g. communicable/ 

notifiable diseases and resistant organisms. 

3.6.2. All healthcare staff are required to adhere to the policies, guidelines and procedures 

pertaining to the prevention and control of healthcare associated infection which 

provide a framework for safe and best practice. 

3.6.3. These guidelines are based on the recommendations of recognised national 

organisations/bodies including: 

• Department of Health Infection Control Nurses Association 

• NHS Estates Health Protection Agency 

• Health & Safety Commission Royal College of Nursing 

• Health & Safety Executive Association of Medical Microbiologists 

• Hospital Infection Society National Patient Safety Agency 

• National Audit Office Infection Prevention Society 

• Medicines & Healthcare Products Regulatory Agency (Formerly MDA) 

4. Infection Control Assurance Framework 

4.1 Appendix 2 illustrates how the Board of Directors is assured on infection control issues. Key 

strategic objectives relating to infection control are an integral component of the Trust 

assurance framework. Should any of these objectives be assessed as medium or high risk 

then they are considered for inclusion on the Trust Corporate Risk Register/Assurance 

Framework. This document is reported to the Board of Directors on a monthly basis. 

4.2 Activities to demonstrate that infection control is an integral part of clinical and corporate 

governance will include: 

• Regular presentations from the Director of Infection Prevention and Control (DIPC) 

and/or the IC Team to the Board of Directors, e.g. the presentation of the DIPC’s annual 

infection control report. 

• The review of statistics on incidence of alert organisms (e.g. MRSA, Clostridium 

difficile) and conditions, outbreaks and Serious Untoward Incidents, via monthly 




performance scorecard reporting. Review will be through the Infection Control 

Committee and the DIPC’s annual report. 

• An audit programme to ensure that compliance with policies has been met. This is 

included in the annual Infection Control Programme. 

4.3 The Infection Prevention and Control Programme is developed annually and approved by 

the Board of Directors. The programme: 

5. Training 

• Sets objectives 

• Identifies priorities for action 

• Provides evidence that relevant policies have been implemented to reduce HCAI 

• Progress against the objectives of the programme is reported in the DIPC’s quarterly 

and annual report. 

5.1. All staff working within the Trust must be trained in infection prevention and control 

procedures, including hand hygiene. This will be delivered to all staff and volunteers, both 

clinical and non-clinical, as part of induction training in accordance with the Trust Induction 

Policy. 

5.2. All staff who have direct or indirect contact with patients and/or blood and other body fluids 

will must receive an annual update in accordance with the Training Needs Analysis (see 

paragraph 5.6.1) 

5.3. Attendance at infection control training will be monitored quarterly through the Infection 

Control Committee. The committee will bring areas of concern to the attention of the 

Board of Directors. 

5.4. Workforce Planning and Development will submit reports of training attendance to unit 

managers to ensure that non-attendees are followed up. 

5.5. Staff hand hygiene leaflets are available in all ward areas and it is the responsibility of the 

manager in each area to highlight this to any temporary staff undertaking work in that area. 

5.6. Training Needs Analysis 

5.6.1. All staff are required to receive infection control training on an annual basis. 

Identification of staff groups that require training and frequency of such training can 

be found on the Learning and Development Service (LDS) electronic Training 

Needs Analysis on the Trust’s intranet: 

http://rdeweb/userdata/documents/10942/Compulsory%20Training%20Grid%20Jun 

e%2009%20MASTER%20COPY.xls 

5.6.2. The detail relating to training provided is available through the e-training prospectus 

held on Workforce Planning and Development pages of the Trust’s intranet. 




6. Patient And Public Information 

6.1. Information relating to the Trust’s general processes and arrangements for preventing and 

controlling infection can be found on the Trust’s website at 

http://www.devonpartnership.nhs.uk/Infection-Control.312.0.html&0= 

6.2. The website contains links to the Trust’s Infection Prevention and Control Annual Report, 

and an information leaflet, for service users and visitors containing practical advice about 

infection control. 

6.3. Information leaflets for MRSA, C. difficile, Norovirus and hand hygiene are made available 

for staff to provide to those who use the service to supplement verbal information. These 

are reviewed three yearly or sooner in light of significant changes in national/local practice 

and/or legislation. 

7. Monitoring 

7.1. This policy will be monitored by the Infection Control Committee and reported to the 

Quality and Safety Committee and Board of Directors as identified in the assurance 

framework attached at Appendix 2. 

8. Further Advice – Contacting The Infection Prevention and Control Team 

• Further advice can be obtained from the Infection Prevention and Control Team: 

Infection Control Doctor 

Lead Nurse 

Tel (01392) 40 2961 Tel (01392) 40 2690 

Radiopage via 01392 411611 Radiopage via 01392 411611 

Consultant Microbiologists 

Infection Control Nurses 

Tel (01392) 40 2973/ 2970 Tel (01392) 40 2355 

Radiopage via switchboard 

Consultant for Communicable Disease Control 

Tel 0844 225 3557 

Radiopage via 01392 411611 

9. References 

DH (2010) The Health Act 2008. Code of Practice on the Prevention and Control of Infections 

and related guidance. London DH Available at: < Accessed on 28/09/11. 

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123 

923.pdf 




Appendix 1 – Local Infection Control Policies, Protocols, Guidance and Guidelines 

The following is a list of current infection control documents available on the intranet. 

Infection Control Policies, Protocols, Guidance and Guidelines for Devon 

Partnership Trust 

Animals & Pets in Health Care Facilities – Guidance on 

Antimicrobial policy 

Aseptic Technique 

C.Difficile & Antibiotic Associated Colitis Guidelines 

Decontamination Policy 

Extended Spectrum Beta Lactamases (ESBLs) and Resistant AMP C Type Beta 

Lactamases (AMP Cs) 

Hand Hygiene Policy 

Herpes Simplex 


Inoculation Injury Policy 

Legionella Control Policy 

Major Outbreak Plan 

Measles Information & Guidance 

MRSA – Guidelines for the Management & Control of 

Scabies Guidance 

Source Isolation Policy 

Staff Health & Illness 

Standard Infection Control Precautions 

Surveillance and Reporting of Infectious Disease, Healthcare Associated Infection & 

Antibiotic Resistant Organisms – Policy for 

TSE Policy 

Vancomycin/Glycopeptide Resistant Enterococci (VRE/GRE) Guidelines 

Varicella Zoster (VZ) Virus (Chickenpox & Shingles) 

Viral Gastroenteritis Guidance 

Ward Closure due to a Suspected or Confirmed Outbreak of Infection 




Appendix 2 – Infection Control Assurance Framework 

Regularity 

• Monthly 

• Quarterly 

• Six monthly 

• Annually 

• Bi-yearly meetings 

• Ad hoc meetings 

• Monthly, 

Quarterly 

(full report) 

• Quarterly 

• As required 

• As required 

INFORMATION 

TREE 

TREE 

Trust Board 

of Directors 

DIPC/CE 

Safety & Risk 

Committee 

Infection Control 

Committee 

Clinical Directorates 

IC 

Error! 

Reporting 

• Monthly performance report 

• DIPC annual report 

• Key issues 

• Instant reporting of any 

emerging HCAI issues 

• Infection control report 

• Assurance report 

• Outbreak report 

• Quarterly infection control 

minutes 

(with details of all HCAI) 

• Root cause analyses 

• Outbreak reports 

• PEAG/Matron’s meetings reports 

Reports: Hand hygiene compliance charts 

Audit reports 

RESPONSE TO 

VARIANCE 

For example: 

If an outbreak 

occurs, it is 

discussed with 

DIPC and relevant 

managers who are 

updated daily. Ad 

hoc outbreak 

meetings called as 

required. 

Outbreak reports 

are circulated and 

reports taken to 

the Infection 

Control committee 

and Quality and 

Safety committee. 

Performance 

Reports to the 

Board. 

Healthcare associated infection reporting mechanisms 

Page 10 of 11

TARGET PRIMARY DRIVERS SECONDARY DRIVERS IMPROVEMENT DRIVERS 

Environment 

Equipment 

Housekeeping 

Estates 

• PEAT scores* 

• IC audit* 

• National cleaning 

standards audit* 

• PALS/complaints* 

• Modern Matron reviews 

• Safe Management of 

Healthcare Waste 

HCAI 

Human Factors 

Hand Hygiene 

Leadership 

Education 

• Audit* 

• Hand Hygiene 

monitoring* 

• Policy/leaflets 

• E-learning for Staff* 

• Practical hand hygiene 

training 

Systems 

Infection 

Control Policy 

Surveillance 

Antimicrobial Policy 

• Daily monitoring via ICNet 

laboratory surveillance 

• Rapid Norovirus testing* 

• IC Alert flag on Rio 

• Essential steps monitoring 

• Risk assessment forms 

*measurable outcomes 

Page 11 of 11

Infection Control Policy - Devon Partnership NHS Trust

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?