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

More documents

Recommendations

Info

- Regular monitoring of cleanliness, using National Cleanliness scores, is undertaken and results reported back through business units and to Trust Board - Cleaning schedules displayed in all clinical areas - There are adequate hand hygiene facilities in clinical areas, including point of care alcohol hand rub - There are procedures in place for the cleaning of commodes and mattresses, backed up by audit processes - There are contracts in place for the supply and provision of linen and laundry - Policies and procedures are in place to ensure appropriate levels of cleanliness, building and refurbishment work is undertaken to an appropriate standard, for waste management, pest control, minimise risk of legionella, for food services and for planned preventative maintenance - The Trust has a cleaning strategy, which incorporates National Cleaning Standards, and the operational cleaning plan identifies specific roles - Cleaning schedules are publicly displayed - Procedures are in place to enable staff to request additional cleaning when required - There is a Cleaning and Disinfection policy, which details the different cleaning and disinfection requirements of equipment - Most of the decontamination of re-usable medical devices is undertaken in centralised facilities (CSSD), with some local reprocessing (endoscopes) - Traceability system in place - Part of competency assessment in medical device training covers the cleaning/decontamination Outcome measures National Cleanliness score Audits - Commode cleanliness - 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 PEAT scores - infection control - specific cleanliness (all areas except patient equipment and waste receptacles) - specific cleanliness (patient equipment) - specific cleanliness (waste receptacles) - toilet and bathroom cleanliness (excluding patient equipment and waste receptacles) - toilet and bathroom cleanliness (patient equipment) - toilet and bathroom cleanliness (waste receptacles) - environment (waste handling) - environment (linen) National inpatient survey - availability of hand wash gel for patients and visitors to use - describing the hospital rooms or wards as clean - describing the toilet and bathrooms as clean Page 16 of 33
National outpatient survey - cleanliness of outpatient department - cleanliness of toilets NHS Staff Survey - key finding 20 (hand wash materials always available) Criterion 3: Provide suitable accurate information on infections to service users and visitors. Processes - Information on infections is provided to service users and their visitors through a number of routes - there is a dedicated section on the Trusts internet site covering infection prevention and control (www.infectioncontrolnorthumbria.nhs.uk) - the DIPC’s annual report is available on the Trust’s internet site - infection control data and information is displayed in patient areas - patient information leaflets are available, which have been reviewed by a readers panel - involvement and empowerment of patients and visitors (hand hygiene is promoted to patient and visitors through display boards and twice yearly promotional events) - involvement of patient representative and governors in MRSA and C.difficile improvement programmes. - there is a telephone hotline for patients and visitors to report failures in cleanliness standards Outcome measures Incidence of MRSA bacteraemias (hospital acquired) Incidence of C.difficile (hospital acquired) CQC inspection reports National Inpatient survey - posters or leaflets asking patients and visitors to wash hands or use hand wash gel NHS Staff survey - The Trust does enough to promote the importance of hand washing to patients, service users and trust visitors Orthopaedic surgical site infection surveillance Criterion 4: Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion. Processes - patients are provided with information leaflets to take home when discharged - transfer and discharge communication includes relevant information on infections Outcome measures Audits - MRSA policy compliance - C.difficile policy compliance Criterion 5: Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people. Processes - procedures are in place to identify patient who have or who develop infections are identified promptly. Page 17 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 and 14: 19. The future Infection prevention
Page 15: - The Trust Board receives regular
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 ...

Create successful ePaper yourself

Delete template?

Save as template?