Infection Prevention and Control Annual Report - Northumbria NHS ...

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Appendix 1 Health and Social Care Act 2008 compliance self assessment Safeguarding and safety Outcome 8 (Regulation 12): Cleanliness and infection control Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. 8A Provide evidence to demonstrate that you are complying with the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. Green x Yellow Amber Red Summary of evidence to support the outcomes described in 8A Criterion 1: Systems to manage and monitor the prevention and control of infection. Processes - The Trust Board has a collective responsibility to approve and self-certify the Trust's Annual Plan. - Policy IC01 Infection control operational policy describes the infection prevention and control structures in the Trust and details the assurance framework. - The Trust has a Director of Infection Prevention and Control accountable directly to the Chief Executive. - An annual programme is produced. - An audit programme is in place. - Training and information is delivered to all staff. - There is an executive lead for decontamination. - The Risk Register details identified risks, and required actions to reduce or control the risk. The Risk Registers are regularly reviewed - Action plans are produced and their delivery monitored -The DIPC is accountable directly to the Chief Executive and the Board - The DIPC leads the infection control team and chairs the infection control committee - The DIPC overseas the development and implementation of infection control policies - The DIPC is a member of the Trust's Assurance Committee and Safety and Quality Committee - The DIPC produces an Annual Report which is available on the Trust's internet site. The report includes surveillance data, audit data and progress against annual programme of activity. Page 14 of 33
- The Trust Board receives regular updates from the DIPC and Modern Matrons - Surveillance data for healthcare associated infections is presented to the infection control committee every two months. Infection related serious untoward incidents are reviewed through the appropriate clinical governance processes - Root cause analysis is undertaken for every MRSA bacteraemia and C.difficile case. Lessons learnt are disseminated via the business units, and used to inform the MRSA and C.diffcile action plans - The Infection Control Team is led by the DIPC, and includes specialist nurses, and medical microbiologists, with administrative and analytical support. 24 hour cover is provided by consultant medical microbiologists. - Bed management operational guidance and the infection control isolation policy ensure that appropriate movement and placement of patients. Daily review of high risk patients is undertaken by the infection control team and clinical staff. PAS alert codes facilitates the identification of patients previously positive for MRSA and/or C.difficile. Admission screening for MRSA identifies patients admitted with MRSA. Transfer and Discharge policy and associated documentation ensures the appropriate transfer of information when patients move between healthcare facilities/providers. Outcome measures Incidence of MRSA bacteraemias (hospital acquired) Incidence of C.difficile cases (hospital acquired) Audits - Commode cleanliness - Hand hygiene - IV cannulation compliance (care plan) - Antibiotic prescribing compliance - Mattress integrity - MRSA policy compliance - C.difficile policy compliance - ICN environmental audits - departmental waste - hand hygiene - handling and disposal of linen - isolation precautions - patient equipment (general) - personal protective equipment - safe handling and disposal of sharps - ward environment - ward kitchen CQC inspection reports NHS LA standards (criterion 4.9) Orthopaedic surgical site infection surveillance Criterion 2: Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. Processes - there are designated leads for decontamination and for cleaning - lead for cleaning liaises closely with Director of Nursing, Modern Matrons and ICT in all aspects of service planning and delivery - Modern Matrons are responsible and accountable for ensuring a safe and clean care environment - Action plans are formulated to address any issues identified through PEAT inspections Page 15 of 33
Page 1 and 2: Infection Prevention and Control An
Page 3 and 4: Executive summary Healthcare associ
Page 5 and 6: the infection prevention and contro
Page 7 and 8: Figure 1: MRSA bacteraemias identif
Page 9 and 10: 10. Outbreaks Norovirus was again p
Page 11 and 12: Figure 7: Infection Control Audit C
Page 13: 19. The future Infection prevention
Page 17 and 18: National outpatient survey - cleanl
Page 19 and 20: Criterion 8: Secure adequate access
Page 21 and 22: Appendix 2 Health and Social Care A
Page 23 and 24: you ever seen staff in this hospita
Page 25 and 26: National outpatient survey - cleanl
Page 27 and 28: Appendix 3: Northumbria Healthcare
Page 29 and 30: 16 Maintain service provision to ex
Page 31 and 32: 9 Continue to enhance infection con
Page 33: Contribute to SHA Safer Care HCAI t

Infection Prevention and Control Annual Report - Northumbria NHS ...

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