Manchester Mental Health
and Social Care Trust
Policy Review
Date of Trust Board: 26th February 2009
Agenda Item: 18
Name of Policy:
Infection Prevention and Control
Name: Carol Harris
Author by Title:
Title: Deputy Director of Nursing
Tel: 0161 882 1061
Enquiries to:
Lead Nurse, Infection Prevention and Control
Date prepared:
February 2009
Purpose of Policy:
Replaces policy number 7 Infection Prevention and Control
Policy, November 2007
Key Point/s:
• Outlines the principles and responsibilities associated with the
prevention and control of infection in a health and social care
setting shared with other employers.
• Supports the Infection Prevention and Control Policies utilised by
the 3 acute hospital sites occupied by MMHSCT.
• Informs all members of Trust staff about the structure and
activities of infection control within MMHSCT and defines roles
and responsibilities.
• Describe how staff members can access infection control advice.
Policy reviewed by:
Name of Committee:
Date:
Status:
Approved/Rejected/Amended
Operational Risk and Governance
10/02/09 Approved
Committee
Infection Control Group
11/02/09
Approved
Implementation:
Communication Plan:
Yes
Training Plan:
Yes
Implementation Plan:
Yes
Equality Impact
No
Assessment:
Date for further review:
February 2011
Recommendation:
To approve
Trust Board Paper
Page 1 of 19
Date of Board 26th February 2009
Agenda Item: 18
DRAFT POLICY
Operational Risk & Governance Committee 10/02/09
Name of Policy: Infection Prevention and Control
Changes for Board Approval as detailed below:
Current paragraph / section
Proposed paragraph / section
Trust Board Paper
Page 2 of 19
Date of Board 26th February 2009
Agenda Item: 18
DRAFT POLICY
Operational Risk & Governance Committee 10/02/09
Manchester Mental Health and Social Care Trust
Prevention and Control of Healthcare Associated Infections
Contents
Section
Page
1 Policy
5
2 Aim
5
A
SECTION A: MANAGEMENT ARRANGEMENTS FOR PREVENTION AND
5
CONTROL OF INFECTION
1
Management arrangements overview
6
2
Roles and responsibilities of named Individuals within MMHSCT.
6
3
The Executive Director of Nursing on behalf of the Chief Executive
6
4
The Lead Nurse for Infection Prevention and Control
7
5
The Infection Control Team
7
5.5 Key Responsibilities of the Infection Control Team
8
5.6 MMHSCT Infection Control Team
8
6
Locality Directors, Clinical Directors and Service Managers
9
7
Modern Matrons
9
8
Ward / Team and Departmental Managers
9
9 Pharmacists
9
10
All health care workers including all clinicians and other service providers
10
(including PFI partner staff) who come into contact with the clinical
environment
11
Policy for the transfer of patients
10
12
Maintaining a Clean and appropriate environment for Health care.
10
13
Provision of information on HCAI to patients and the Public
11
14
Laboratory Support
11
B
SECTION B: CLINICAL CARE PROTOCOLS
11
1
Policies and Procedures
11
2
12 Core Protocols
11
Trust Board Paper
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Date of Board 26th February 2009
Agenda Item: 18
DRAFT POLICY
Operational Risk & Governance Committee 10/02/09
3
Infection Control Audit
13
4 Surveillance
14
5
Saving Lives Framework
14
C
SECTION C: HEALTH / SOCIAL CARE WORKERS
14
1
Occupational Health Services
14
2
Training & Education for Trust Employees
14
3 Policy
Implementation
15
4
Monitoring, evaluation, review and assurance
16
5 Strategy
16
6 Risk
Assessment
16
Appendix 1 - Meeting Map
18
Appendix 2 - Infection Control Strategy
19
Trust Board Paper
Page 4 of 19
Date of Board 26th February 2009
Agenda Item: 18
DRAFT POLICY
Operational Risk & Governance Committee 10/02/09
Manchester Mental Health and Social Care Trust
Prevention and Control of Healthcare Associated Infections
1 Policy
1.1 Manchester Mental Health and Social Care Trust (hereafter referred to as MMHSCT)
recognises the obligation placed upon it by The Health Act 2006 – Code of Practice for
the Prevention and Control of Health Care associated Infections. MMHSCT supports the
principle that infections should be prevented wherever possible or, where this is not
possible, minimised to an irreducible level and that effective systematic arrangements
for the surveillance, prevention and control of infection are provided within MMHSCT.
1.2 It is the policy of MMHSCT to include the individual responsibility of every member of
staff to participate in the prevention and control of infection and to comply with their
Health and Safety, Control of Substances Hazardous to Health (COSHH) and other
legislation and regulations applying to the safe provision of health care.
1.3 This policy is designed to outline the principles and responsibilities associated with the
prevention and control of infection in a health and social care setting shared with other
employers. It has been prepared to support the Infection Prevention and Control
Policies utilised by the 3 acute hospital sites occupied by MMHSCT.
2 Aim
2.1 The aim of this policy and accompanying procedures and guidelines apply to all
members of staff employed by MMHSCT, Trust partners including host acute Trusts and
Private Finance Initiative (PFI) partners / service providers, agency and bank staff
contracted by MMHSCT.
2.2 This document informs all members of Trust staff about the structure and activities of
infection control within MMHSCT and defines roles and responsibilities. It will also
describe how staff members can access infection control advice.
The Policy is set out below under the 3 sections of:
Section A:
Management Arrangements for Prevention and Control of Infection
Section B:
Clinical Care Protocol
Section C:
Health / Social Care Workers
SECTION A MANAGEMENT ARRANGEMENTS FOR PREVENTION AND CONTROL OF
INFECTION
This section details the management arrangements for the Prevention and Control of
Infection in Manchester Mental Health and Social Care Trust. A reporting structure is
provided in Appendix 1.
Trust Board Paper
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Date of Board 26th February 2009
Agenda Item: 18
DRAFT POLICY
Operational Risk & Governance Committee 10/02/09
1
Management arrangements overview
1.1
Management arrangements for MMHSCT structure for infection prevention and
control are included in MMHSCT Infection Control Group Terms of reference. They
are updated on an annual basis and approved and will be monitored by MMHSCT
Board and Infection Control Group.
1.2
The annual programme for Infection Control will contain clearly defined objectives and
identify priorities for action including an audit programme.
1.3
The progress report on the annual Plan will be incorporated within the Infection
Control Annual Report.
1.4
Infection Control is incorporated within the governance framework of the localities
through a Locality Infection Control group. The key functions of these groups are;
(a) To act upon surveillance information on alert organisms;
(b) To discuss untoward incidents of infection that have occurred within the
locality / service area (hereafter ‘locality’ is used to represent service areas
also) including Methicillin Resistant Staphylococcus
aureus (MRSA)
bacteraemias/outbreaks of infection and monitor implementation of lessons
learned;
(c) To monitor local implementation and progress of the annual plan;
(d) To receive and action where necessary reports from the local services;
(e) To monitor compliance with training and audit and oversee action plans;
(f) To provide representation at MMHSCT Infection Control Group;
(g) To provide representation to the host Trust’s Infection Control Committee.
2
Roles and responsibilities of named Individuals within MMHSCT.
2.1
The roles and responsibilities of named individuals within the organisation, with
regard to their duty to protect patients from the risks of acquiring healthcare
associated infection, are identified below in accordance with the Code of Practice,
2006 section 2.
3
The Executive Director of Nursing on behalf of the Chief Executive will;
3.1
Act as the Director of Infection Prevention and Control (DIPC)
3.2
Report directly to MMHSCT Chief Executive and the Trust Board on infection
control
issues.
3.3
Ensure that there is an appropriated constituted and functioning Infection Control
Team and that resources and support is provided to support its activities.
3.4
Ensure that an annual infection control report is produced and circulated to the
Trust Board and all managerial, medical and nursing leads.
3.5
Ensure that an annual infection control programme is produced and approved by the
ICC.
3.6
Review the formal arrangements for infection control as required.
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Operational Risk & Governance Committee 10/02/09
3.7
Ensure that there is an appropriate infection control group for MMHSCT.
3.8
Ensure that there is appropriate representation to the 3 acute Trust’s Infection Control
Committees.
4
The Lead Nurse for Infection Prevention and Control will:
4.1
Be responsible for the day-to-day co-ordination of infection prevention and control in
MMHSCT.
4.2
Co-ordinate MMHSCT’s work with the infection prevention and control services
provided, through service level agreements by the acute Trusts on each hospital site.
4.3
Support and provide expert advice to the Executive Director of Nursing
4.4
Provide regular reports in line with MMHSCT’s integrated governance framework and
reporting arrangements.
4.5
Support the monitoring and the ongoing development of the service level agreements
with all service providers relating to infection prevention and control including
cleanliness and maintenance of the patient environment.
4.6
Evaluate regularly control of infection measures with a view to constant improvement
within clinical practice and policies.
4.7
Participates and leads, on clinical trials/audits/surveys or equipment trials.
4.8
Advise and help develop action plans that impact outside of own professional sphere
in planning for the care of a patient with an Infection Prevention and Control issue.
(E.g. advising PFI partners).
4.9
Act as a change agent and recognise service needs taking a pro-active role in the
development of services.
4.10 Maintain and develop the Infection Prevention and Control Liaison Network both
internally and externally to the Trust ensuring benchmarking and best practice.
5
The Infection Control Team
5.1
MMHSCT’s Infection Prevention and Control Team is made up of identified
professionals via SLA arrangements and the Lead Nurse from MMHSCT. It is
supported by identified roles within MMHSCT.
5.2
The Infection Control Team provides an infection control service to MMHSCT and
reports to the Infection Control Group, which reports through the Operational Risk
and Governance Committee to MMHSCT Board.
5.3
Members of MMHSCT Infection Control Team are listed below:
(a) MMHSCT’s Lead Nurse for Infection Prevention and Control;
(b) 3 Acute Trust Infection Control Nurses via SLA arrangements;
(c) The Consultant Microbiologists from each acute Trust via SLA
arrangements.
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5.4
The infection Control Team is also supported by MMHSCT’s own:
(a) Modern Matrons from each service area;
(b) Infection Control Link Nurses in each clinical area.
5.5
Key Responsibilities of the Infection Control Team:-
5.5.1 To make medical and nursing decisions on a 24 hour basis about the prevention and
control of infection, providing advice to all grades of staff on the management of
infected patients and other infection control problems;
5.5.2 To provide education and training on the prevention and control of Health Care
Associated Infections (HCAI) to all staff sharing Manchester Mental Health and Social
Care Trust workplaces;
5.5.3 To liaise with the Occupational Health Services on relevant staff health issues;
5.5.4 To liaise with clinical teams on the development of standards, audit and research;
5.5.5 To liaise with the PFI providers and trust partners on issues relevant to the prevention
and control of infection within the Organisation;
5.5.6 To ensure that MMHSCT is updated on new or amended clinical protocols or
changes in practice
5.6
MMHSCT Infection Control Team (as defined above) will;
5.6.1 Provide information and advice to all Trust staff, service users and carers about the
management and prevention of healthcare associated infection (HCAI);
5.6.2 Produce and review and share all infection control policies and procedures, involving
clinical teams as appropriate;
5.6.3 Provide education and training in infection control for Trust staff;
5.6.4 Advise upon infection control audits in specific locations or services within the
Trust and assist with findings/recommendations;
5.6.5 Participate in developing a programme of infection control audits at
ward/departmental/service
level;
5.6.6 Contribute to the review and analysis of adverse incident reports relating to infection
control and report these to the Infection Control Group;
5.6.7 Contribute to root cause analysis of adverse incidents relating to infection control
issues;
5.6.8 Work with bed management and services to ensure appropriate placement of patients
to minimise the risk of infection.
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Operational Risk & Governance Committee 10/02/09
6
Locality Directors, Clinical Directors and Service Managers will;
6.1
Ensure that there are designated infection control leads that represent all areas of
clinical practice within the Locality;
6.2
Oversee the application of this policy and associated procedures into their
service;
6.3
Seek to ensure its implementation is undertaken within their management
structure to maintain adequate prevention and control of HCAI;
6.4
Provide appropriate additional resources during outbreaks of infection within their
locality;
6.5
Ensure that infection prevention and control is recognised within the locality
governance
structure;
6.6
Provide assurance that infection control surveillance, policies, training and
audits are being adhered to within their locality.
7 Modern
Matrons
will;
7.1
Support the Infection Control Team;
7.2
Liaise closely with their managers, ward and department managers, host Trust
Infection Control Nurses, other ICT members and other advisors to ensure the
proactive prevention and control of infection as detailed in the relevant procedures;
7.3
Review controls following incidents and day-to-day adherence to safe work
systems;
7.4
Maintain a regular programme of audit and inspection and oversee the
implementation of action plans;
7.5
Represent MMHSCT’s Infection Control Group at local monitoring meetings with
support services.
8
Ward / Team and Departmental Managers will;
8.1
Ensure that infection control procedures are made known to all staff including
agency and service providers and are implemented within their workplace;
8.2
Ensure via day to day supervision, safety inspection or incident investigation, or tasks
involving risk of cross infection prevention and control are supervised effectively.
Alternatively where the risk is assessed as high, this reported through DATIX and
management and control measures are implemented.
9
Pharmacists will:
9.1
Monitor the use of and adherence to the host trust antibiotic policies;
Trust Board Paper
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Operational Risk & Governance Committee 10/02/09
9.2
Report monitoring or diversion from policies via DATIX incident reporting;
9.3
Participate in the audit of policies as agreed with the infection control team;
9.4
Report to the Chief Pharmacist for Manchester Mental Health and Social Care Trust
on the above.
10
All health care workers including all clinicians and other service providers
(including PFI partner staff) who come into contact with the clinical
environment
10.1
All Trust staff are required to attend mandatory Trust Induction. All clinical staff or
staff whose work exposes them to risks of infection must undertake annual update
training in infection control;
10.2
Comply with the infection control policies and procedures especially in relation to
hand hygiene;
10.3
Inform the Infection Control Team about any service user requiring isolation;
10.4
Inform the Infection Control Team of suspected outbreaks of infection;
10.5
Obtain advice from the Occupational Health Department if they have concerns
about their risk of transmitting infection;
10.6
Participate actively in auditing infection control procedures in their ward/ department
including audit of high impact interventions;
10.7
Report any adverse incidents relating to infection control via DATIX, MMHSCT’s
incident reporting System (HIRS) and inform their manager.
11
Policy for the transfer of patients
11.1
MMHSCT will use the Care Programme Approach and Standards for Admission and
Discharge in relation to the admission, transfer discharge and movement of service
users and this is available on MMHSCT Intranet;
11.2
When the Standards for Admission and Discharge are reviewed in March 2009,
infection prevention and control considerations will be included. Until March 2009,
where there is a known risk related to HCAI, MMHSCT will adopt the local host Trust
policy for the transfer of patients.
12
Maintaining a Clean and appropriate environment for Health care.
12.1
The following actions are in place in order to minimise the risk of HCAI within the
environment in accordance with the Code of Practice, 2006 section 4;
12.2 Arrangements are in place with each host Trust or the Local Authority to provide
cleaning services and maintenance for the environment. The details of the service
provider are maintained by Locality Directors / Service Managers;
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12.3
Where host Trusts use external service providers, formal monitoring of the contracts
is carried out by the host Trust, informed by locality monitoring meetings;
12.4
There are established cleaning schedules/planned preventative measures in place in
each area, which form part of the contract and these, are monitored on an ongoing
basis by the PFI partners and the Acute Trust’s Monitoring Officers. Compliance to
the schedules is monitored and reported on. Joint Monitoring meetings between
MMHSCT & the service providers are held on a monthly basis in each Locality. Any
operational issues regarding cleaning services are addressed via these forums;
12.5
Performance of the contracts are reported to MMHSCT Management Board by the
Director of Estates and Facilities;
12.6
The manager within MMHSCT Estates and Facilities Department, with lead
responsibility for new builds/refurbishment of existing facilities seeks advice on all
new projects/schemes from the Infection Control Team;
12.7
Output specifications contained within the service level agreements with the host
Trusts will include:
(a) Planned preventative maintenance;
(b) Pest Control;
(c) Legionella Policy;
(d) Food Services;
(e) The supply and provision of linen and laundry to comply with current
Health service guidance (HSG (95) 18).
12.8
The Director of Nursing undertakes the executive lead for decontamination of re-
useable medical equipment;
12.9
There is a decontamination group that is a sub group of the Infection Control
Committee;
12.10 The Chairperson of the Decontamination Group is a member of and reports to the
host Trusts’ Infection Control Committees. (See ICC Terms of reference)
12.11 MMHSCT participates in the national “Clean
your hands” Campaign & “Think Clean”
Events. Alcohol hand rub is available at the point of care (personal dispensers are
best practise when caring for mental health patients for whom permanently-sited
dispensers may pose a risk). Compliance with the NPSA Patient Safety Alert,
September, 2008 will be audited in March 2009 and then in line with the audit
programme.
13
Provision of information on HCAI to patients and the Public
13.1
All leaflets and written information available for the public and service users of
Manchester Mental Health and Social Care Trust is located on MMHSCT Website,
ward infection control notice boards and service user welcome packs. These are
audited in line with the audit programmes;
13.2
Each Ward has an Infection Control Notice Board with information for the public
including staff training, recent audits, and outbreaks. There is an agreed standard for
the information provided and boards are audited every 6 months with
recommendations made;
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13.3
Information on the complaints procedure is available on MMHSCT’s website.
14 Laboratory
Support
14.1
Laboratory support is provided by the acute Trusts via the Infection Control Service
arrangements. The laboratory is accredited (CPA) which means that it is a quality
assured service and meets the satisfactory monitoring arrangements;
14.2
Laboratory policies for each acute Trust will be held with the host Trust’s Infection
Control Policies (a 'surveillance policy' that cross references this service) and this
policy is available to staff within the locality via the infection control policy manual.
SECTION B: CLINICAL CARE PROTOCOLS
MMHSCT uses the clinical care protocols developed by each of the acute Trusts to ensure
that the care provided to service users is consistent with that provided by the local infection
control services that are provided via SLA arrangements.
In the event of a significant difference in practice across the 3 acute Trusts, the Lead Nurse
for Infection Control will alert MMHSCT and recommend further actions.
1
Policies and Procedures
1.1
Infection control policies and procedures are available on the Trust Intranet via a link
for each Locality;
1.2
Policies and procedures will reflect relevant current legislation, published
professional guidance and best practice;
1.3
The policies and procedures will be produced in consultation with relevant
professional groups within the acute trusts and endorsed by the acute Trusts’
Infection Control Committees;
1.4
The policies will be authorised by the acute Trusts’ own corporate arrangements.
The Lead Nurse for Infection Control will then present these to MMHSCT Operational
Risk and Governance Committee to recommend they are adopted;
1.5
The acute Trusts will review the policies every two years or sooner if legislation or
guidelines change;
1.6
Policies will be audited in accordance with Annex 2 of the Code of Practice,
2006 (see Infection Control Audit Policy);
1.7
Clinical protocols and procedures will be developed by the acute Trusts and adopted
for MMHSCT via the Infection Control Group;
1.8
Each Locality will use the host Trust antibiotic policies.
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2
A list of the 12 core protocols are listed below;
The location of each protocol for each Locality is provided on the intranet under the
Locality Infection Control link.
2.1
(1)
Standard (Universal) Infection Control precautions
Hand
Hygiene
Protective
Clothing
Glove
Policy
2.2
(2)
Aseptic Technique: ANTT visual aid programme
2.3
(3)
Major Outbreaks of Communicable Infection
2.4
(4)
Isolation of Patients
2.5
(5)
Safe handling and Disposal of Sharps
2.6 (6)
Prevention of Occupational Exposure to BBV’s and including
prevention of sharps injuries
2.7
(7) Management of Occupational Exposure to BBV’s and Post Exposure
Prophylaxis
2.8
(8)
Closure of wards, departments and premises to new admissions. (Viral
Gastroenteritis Policy
2.9
(9) Disinfection
Policy.
2.10
(10) Antimicrobial Prescribing
2.11
(11)
Reporting HCAI to the health Protection Agency (HPA) as directed by
the Department of Health (DH).
2.12
(12)
Control of infections with specific alert organisms taking account of
local epidemiology and risk assessment. (These must include, as a
minimum, MRSA, Clostridium difficile Infection and Tuberculosis
(including MDR TB).
2.13
Additional Clinical care protocols related to Infection Prevention and Control can
found under the Locality links on the intranet.
3
Infection Control Audit
3.1
Regular monitoring of compliance with infection control policies will be reflected in
The Infection control annual audit programme. The annual audit programme will
include;
3.2
Audit of Infection Control core protocols/ policies (as defined in section 10 of the code
of practice 2006);
3.3
Audit of infection control policies on the management of patients with
MRSA/Clostridium difficile;
3.4
Audit of Surveillance programmes for MRSA/C. diff;
3.5
Programme of implementation of the High Impact Interventions (Saving Lives) local
audits;
3.6
Audit of Hand Hygiene;
3.7
Audit of Environment;
3.8
Audit of Patient Shared Equipment;
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3.9
Where appropriate Audit of ANTT (Aseptic Non-Touch Technique);
3.10
Audit of patient information leaflets;
3.11
Patient information leaflets to be audited (Patient IPC admission leaflets);
3.12
NPSA: Clean hands saves lives (ALERT September 2008);
3.13
Audit of sharp’s management: Awareness, Equipment & Practice;
3.14
Audit of the evaluation of Infection Control Training given at MMHSCT.
3.15
Corporate /Locality action plans. Results and action plans from audit will be reviewed
at locality or MMHSCT Infection Control Group as appropriate. A full report will be
presented to the Infection Control Committee.
4 Surveillance
4.1
National mandatory surveillance and other appropriate monitoring of health care
associated (HCAI) will be undertaken by the ICT;
4.2
Results of surveillance of alert organisms will be fed back to Clinicians;
4.3
The ICT will work with the Localities to interpret and act upon surveillance
data.
5
Saving Lives Framework
5.1
The Trust will use the ‘Saving Lives’ framework to help to assess compliance within
clinical practice;
5.2
Clinical leads/Directors, Matrons and Ward/Departmental Managers are taking local
ownership to ensure that the High Impact Interventions (HII’s) guidelines are
incorporated into clinical practice and the templates will be used to guide clinical
practice.
SECTION C: HEALTH / SOCIAL CARE WORKERS
1
Occupational Health Services
1.1
The Occupational Health Service will provide the following services to all Trust
employees through a service level agreement:
(a) Healthcare screening for communicable diseases and relevant
immunisations;
(b) Emergency treatment for staff exposed to health care infections and
follow up treatment/care as appropriate/necessary;
(c) Identification and management of staff with hepatitis B, C, and HIV
infected health care workers and restricting their practice as necessary in
accordance with DoH guidance;
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(d) Participating in the control of outbreaks of infection that involve/have
implications for health care workers;
(e) Monitor and report the incidence of sharps injury to health care workers
and be responsible for promoting safe practice including overseeing the
use of needle stick prevention devices.
2
Training & Education for Trust Employees
Training Needs Analysis for Trust employees
2.1
All Trust employed staff must attend Infection Control training at Trust Corporate
Induction. All Clinical / Social Care staff or staff whose work exposes them to risks of
infection must undertake annual mandatory infection control training. MMHSCT staff
who are required to attend infection control mandatory training are:
(a) Medical staff (including Consultants);
(b) Nursing
staff;
(c) Allied Healthcare Professionals;
(d) Social Care staff working directly with service users;
(e) Administrative staff who work directly with service users.
2.2
The acute Trusts require the following staff to attend annual infection control
mandatory training. These staff provide services to MMHSCT via SLA arrangements
with the acute trusts:
(a) Estates and facilities staff employed through PFI / other providers;
(b) Laboratory staff.
2.3
The Localities / Services will be responsible for ensuring attendance at infection
control training. Records of attendance must be collated by the infection control team
and forwarded to MMHSCT Training Department for inclusion on the data base;
2.4
Numbers of attendees at infection control mandatory training are monitored and
reported to MMHSCT Infection Control Group. Training figures (which include
infection control figures) are collected by the Training and Education Services at
Chorlton House and reported to the Operational Risk and Governance Committee on
a bi monthly basis and to Board quarterly. The Training and Education Services at
Chorlton House produce two reports: A compliance report which is run for a year’s
period as updates are required yearly and a monthly attendance report which is just
the total of staff who have attended training for that month. Numbers of staff attending
training are collated on a monthly basis;
2.5
Non attendance at mandatory infection control training sessions is followed up by the
training department and the Locality management teams;
2.6
Evidence of completion of infection control mandatory training is checked at
appraisal. All inpatient trained nursing and medical staff who have been identified as
requiring ANTT skills are also updated and competency tested in Aseptic Non Touch
technique;
2.7
Members of the Infection Control Team will have their personal and professional
development plans agreed through their host Trust;
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2.8
The Infection Control Team will produce information in the form of posters and
leaflets;
2.9
The Infection Control Team will undertake infection control training of all Trust staff at
induction and on an ongoing basis.
3 Policy
Implementation
3.1
The Policy will be launched via members of the Infection Control Group and
cascaded to multi-professional staff across the organisation;
3.2
The Policy will be available on MMHSCT Intranet.
4
Monitoring, evaluation, review and assurance
4.1
This policy will be subject to review every two years or more frequently if legislation
or authoritative guidance changes;
4.2
The Infection Control team will review and evaluate its activities and performance in
line with the Code of Practice.
5 Strategy
5.1
The NHS Executive Definition of risk management is as follows:
“Identifying all risks which have potentially adverse effects on the quality of care
and the safety of patients, staff and visitors; assessing and evaluating these risks;
and taking positive action to eliminate or reduce them.”
5.2
Incident Management underpins a basic part of the Risk Management Framework for
Manchester Mental Health and Social Care Trust. It is important as part of the
incident reporting process that incidents and serious untoward incidents are
investigated in a consistent way. Additionally, where untoward events have been
managed satisfactorily, lessons need to be shared within the organisation to ensure
that the same kinds of errors are not a recurring feature in our services. The Trust (as
part of its investigation process for Serious Untoward Incidents) will use Root Cause
Analysis (RCA) techniques to identify key areas of learning for the organisation, and
will identify systems failures, key events and human error where apparent;
5.3 The management of the risk of infection will follow this pattern.
5.4
Appendix 1 provides an overview of the strategy for infection prevention and control.
6 Risk
Assessment
6.1
Manchester Mental Health and Social Care Trust has implemented a comprehensive
integrated process of incident and serious incident reporting. The DATIX system is
the electronic system that all incidents are reported on, and it is in turn linked to the
NPSA. The electronic system is managed through the Governance Team all incidents
are recorded and reported on one Trust wide electronic incident reporting form. The
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form is used to report all incidents, serious untoward incidents, near misses, major
incidents and identified risks to safety
.
6.2
The Trust has a standard approach to clinical risk assessment and risk management,
described in The Policy for Clinical Risk Management and Assessment on the Trust
intranet.
6.3
Clinical risks associated with HCAI will be identified through this process.
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Appendix 1
[meeting map to be inserted]
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Appendix 2
Infection Control Strategy
Policy
• All staff are aware of
the Trust Infection Control
Policy Manual
• Any local specific policies
Organisation
are identified and
documented
• Identify
infection
hazards
• Assess their potential
for harm
• Implement
control
measures
Audit
• Participate in Trust wide
and local (where
applicable) audit
•
Share learning and good
Application
practice
• Ensure all staff are
trained in infection
control
• Lead by example
• Correct bad practice
Inspection
Are standards being maintained,
for example, prevention of
needlestick injury/universal
precautions
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Document Outline