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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
 
 

SECTION A:  MANAGEMENT ARRANGEMENTS FOR PREVENTION AND 
5
CONTROL OF INFECTION 
 
 

Management arrangements overview 
6
 
 

Roles and responsibilities of named Individuals within MMHSCT. 
6
 
 

The Executive Director of Nursing on behalf of the Chief Executive  
6
 
 

The Lead Nurse for Infection Prevention and Control 
7
 
 

The Infection Control Team  
7
 
 
5.5  Key Responsibilities of the Infection Control Team 
8
 
 
5.6  MMHSCT Infection Control Team  
8
 
 

Locality Directors, Clinical Directors and Service Managers  
9
 
 

Modern Matrons  
9
 
 

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
 
 

SECTION B:  CLINICAL CARE PROTOCOLS 
11
 
 

Policies and Procedures 
11
 
 

12 Core Protocols  
11
 
 
Trust Board Paper 
 
Page 3 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 


Infection Control Audit 
13
 
 
4 Surveillance 
14
 
 

Saving Lives Framework             
14
 
 

SECTION C:  HEALTH / SOCIAL CARE WORKERS 
14
 
 

Occupational Health Services 
14
 
 

Training & Education for Trust Employees 
14
 
 
3 Policy 
Implementation 
15
 
 

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 
 
Page 5 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 


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. 
 
 

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. 
 
 

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. 
 
 
Trust Board Paper 
 
Page 6 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
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. 
 
 
 

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. 
Trust Board Paper 
 
Page 7 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

 
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. 
 
 
 
Trust Board Paper 
 
Page 8 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 


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. 
 
 

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. 
 
 

Pharmacists will:     
 
9.1 
Monitor the use of and adherence to the host trust antibiotic policies; 
 
 
Trust Board Paper 
 
Page 9 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
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; 
 
Trust Board Paper 
 
Page 10 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

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; 
Trust Board Paper 
 
Page 11 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

 
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. 
 
 

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. 
 
 
 
 
Trust Board Paper 
 
Page 12 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 


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. 
 
 

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; 
 
 
Trust Board Paper 
 
Page 13 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

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. 
 
 

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 
 

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; 
Trust Board Paper 
 
Page 14 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

(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. 
 
 

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;  
 
 
Trust Board Paper 
 
Page 15 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

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.  
 
 

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 
Trust Board Paper 
 
Page 16 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

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. 
Trust Board Paper 
 
Page 17 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

Appendix 1 
 
 
[meeting map to be inserted]
Trust Board Paper 
 
Page 18 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

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 
 
 
 
Trust Board Paper 
 
Page 19 of 19 
Date of Board 26th February 2009  
Agenda Item: 18 
 
DRAFT POLICY  
Operational Risk & Governance Committee 10/02/09 
 

Document Outline