Infection Control Policy - Devon Partnership NHS Trust

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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 Infection Control Policy Approved by Infection Control Committee: 20 th October 2011 Review date: October 2013 Page 6 of 11
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. Infection Control Policy Approved by Infection Control Committee: 20 th October 2011 Review date: October 2013 Page 7 of 11
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Infection Control Policy - Devon Partnership NHS Trust

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