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					                                                                                       BoD: 24.11.10
                        OPEN BOARD OF DIRECTORS’ MEETING                               Item: For Info
                                24 November 2010

TITLE OF PAPER        Infection Control Q2 Report - July to September 2010

TO BE PRESENTED BY    Liz Lightbown, Executive Director of Nursing and Quality

ACTION REQUIRED       To provide information, which will ensure the Board of Directors’ is aware of
                      the team’s progress on the infection control agenda

                      To provide the Board of Directors’ with an opportunity to discuss the action
                      plans and to register opinions against salient points highlighted

OUTCOME               For the Board of Directors’ to approve the progress made by the Infection
                      Prevention and Control Team (IPCT) against the Infection Control Programme

TIMETABLE FOR         November Board of Directors’ meeting

LINKS TO OTHER KEY    Infection Control Programme 2010/2011
REPORTS / DECISIONS   Safety and Risk Strategy

LINKS TO OTHER        Board Assurance Framework
RELEVANT              Care Quality Commission (CQC) monitoring of compliance with The Health
FRAMEWORKS            and Social Care Act 2008
BAF, RISK, OUTCOMES   NHS Litigation Authority (NHSLA)

IMPLICATIONS FOR      Possibility of capital and revenue costs incurred by Directorates, as a result of
SERVICE DELIVERY      recommendations by the IPCT

CONSIDERATION OF      Legal Requirement to comply with The Health and Social Care Act 2008

Author of Report      Rosie Dixon
Designation           Senior Nurse – Infection Prevention and Control
Date of Report        November 2010
                                                SUMMARY REPORT

Report to:    Board of Directors’
Date:         24 November 2010
Subject:     Infection Prevention and Control Q2 Report - July to September 2010
Author:      Rosie Dixon, Senior Nurse – Infection Prevention and Control (SN IPC)
Approved by: Liz Lightbown, Executive Director of Quality and Nursing

1.       Purpose
A written quarterly report is submitted to the Board of Directors’ to monitor progression of the infection control
programme for 2010-2011, and therefore the Trust’s adherence to The Health and Social Care Act 2008. The report
covers infectious incidents within the Trust, actions taken and out-comes, if known, to provide reassurance that the
Trust is taking the appropriate actions in relation to infection prevention and control.

2.       Summary
The Trust declared compliance with The Health and Social Care Act 2008, in order to register with the Care Quality
Commission (CQC). The points below identify progress against the strategic objectives identified in the infection
control programme.

 Improved attendance from clinical directorates and senior managers required at the Infection Control Committee
   to ensure robust decisions are made.
 All training provided includes hand hygiene as a minimum element therefore 469 members of staff have received
   training equating to 15% of workforce.
 1 Trust attributable clostridium difficile infection identified in a patient from the FMI directorate.
 Infection Prevention Audits have been completed in 4 of the 6 directorates; overall most areas are achieving the
   minimum compliance requirements, where there are weaknesses action plans are in place.
 All job descriptions now reiterate staff members responsibility to infection prevention and control

No       2010 -2011 Infection Control Programme Strategic Objectives
1    To ensure that we comply with all elements of the Health Act 2008
     The annual programme for the coming year has been completed and agreed by the Board of Directors. The
     actions documented below and within objectives 2 - 8 demonstrate measures taken to ensure compliance
     with all 10 criterion contained within the Act.
       Closer working relations have been established between the infection prevention and control team
          (IPCT) and the senior management teams from dementia, functional mental illness, learning disabilities
          directorates during the last quarter. Work to improve and formalise relations with the other directorates is
       The Infection Control Committee has met twice during this quarter, attendance from clinical directorates
          would benefit from being more consistent and the individuals attending should be at an appropriate level.
       Together with Human Resources all job descriptions are to include a statement to reinforce the trusts
          commitment to reducing infections from September 2010.
       Liaison and communication between all healthcare organisations both locally and regionally are being
          strengthened in relation to infection prevention and control.
       The trust has access to a consultant microbiologist, Dr Rob Townsend, as well as the previous links with
          the Consultant in Communicable Disease Control (CCDC), Dr Rosy McNaught.
       Maintenance and improving the Infection Control Teams specialist knowledge has been achieved
          through attendance at the Infection Prevention Society National Conference and networking with
          members of the Infection Prevention Society, specifically those working in other Mental Health/Learning
          Disability Trusts.
2    Promoting the importance of Hand Hygiene in preventing cross infection
     The IPCT continue to promote the importance of hand hygiene around the trust.
       ‘Cleanyourhands’ champions continue to be provided with the skills to cascade hand hygiene training
          including the World Health Organisation 5 moments for hand hygiene.
No         2010 -2011 Infection Control Programme Strategic Objectives
       The adequacy of appropriate hand hygiene facilities across the Trust continues to be evaluated and
            specific risks are considered prior to advise being given.
       Areas that have inadequate hand hygiene facilities or are not promoting the importance of hand hygiene
            adequately have been identified and issues are addressed together with supplies. Additional training
            provided and management teams informed. If deemed by the area that provision of adequate facilities is
            a risk, then the area is expected to add it to their risk register.
3    To provide education, training and development to all staff involved in the care of service users.
      It is a requirement for all staff working for the Trust to have received appropriate infection prevention training
      annually. The following quantifies* the provision of training by the link champions and the infection control
      team during the last quarter. All training includes hand hygiene as a core element.
      The relocation of the training department to Fulwood has prevented the SN-IPC being able to provide a link
      champion study day it is hoped that this will soon be rectified.
       There have been 2 infection control study days provided this quarter with 26 (42) members of staff
       Corporate induction continues to include infection control on the program 40 (94) have received this
       Essential training provision to older adults continues to incorporate infection control and the programme
            is adjusted annually to incorporate key issues, 38 (87) members of staff attended.
       Specific cleanyourhands training provided by the infection control assistant and the link champions has
            been re-launched in the directorates. 105(155) have reported completing specific training.
       The infection control e-learning program continues to be promoted however uptake is generally poor and
            reports from staff having difficulties accessing the program has resulted in the SN-IPC providing a
            number of sessions to groups of staff. E- Learning uptake since the last report suggests only 27 (39)
            individuals have accessed the programme and have managed to complete certain elements.
       Ad-hoc sessions have been provided where possible on request often to manage a specific issue
            relevant to the area; during this quarter 32 (52) were able to have training in this way. This training
            includes specific training for the administration of immunisations and vaccinations.
     In total from April to September 469 members of staff have had training in IPC.
     * The new Oracle Learning Management (OLM) system for monitoring training provides inconsistent results
     therefore the above figures cannot be considered absolutes.
4    To monitor rates of infection through surveillance, the direct management of all infections including
     alert organisms identified within the trust.
       Prevalence survey monitoring of in-patients continue and has been promoted more during this quarter
            and compliance is good in most areas. Maple ward has not provided data regularly which will skew their
            directorate’s figures. The overall results for the last quarter within the Trust are illustrated in Appendix 1.
       Mandatory reporting shows that there has been zero incidence of MRSA bacteraemia and 1 episode of
            clostridium difficile infection during the last quarter.
       Improved liaison with the other health providers in Sheffield has meant more prompt recognition and
            management of confirmed incidence of infections.
5    To monitor the practices and quality of care through audit and review of Infection, prevention and
     Control practices.
       The annual IPC audits have been completed by the IPCT in Acute Community and Rehabilitation and
            Recovery directorates using an adapted tool. Minimum compliance 2010/2011 has been set at 80%.The
            overall scores as applied to inpatient areas equate to 88% for Acute, Community and 84% for Rehab
            and Recovery. Main issues were poor cleanliness and condition of the environment including specific
            problems in the kitchens and adherence to hand hygiene policy was poor. The results have been fed
            back to the main areas and senior managers.
       Observational hand hygiene audits have continued to be performed in a number of areas and it is
            expected that these will continue for the rest of the year.
6    To provide expert advice, strategy formation and development of policies.
       Decontamination policy has been ratified in this quarter
       The main Infection Prevention and control policy commenced review during this quarter.
       SN-IPC has provided expert advice to all clinical and corporate directorates relating to multiple issues,
            examples below.

          o   Estates with refurbishments, new builds, water management and hotel services
          o   Supplies regards product standardisation and systems
          o   Clinical staff re specific infection issues in service users and staff, treatment and staff
          o   Contributes to a number of Trust wide meetings discussing and advising on practice issues.
No      2010 -2011 Infection Control Programme Strategic Objectives
7    Ensuring that the trust maintains a clean and safe environment and has effective decontamination
     processes in place.
       IPC environmental audits have continued to be carried out in FMI, Rehabilitation and Recovery and the
         Acute and Community directorates and any identified issues are being addressed by senior
         management teams.
       Cleaning schedules are displayed in all areas of the trust; however facilities, at present, are not
         monitoring compliance against these schedules.
       Legionella positives continue to be identified in the Michael Carlisle Centre. Discussions have been held
         with pro-economy to explore why this continues to occur and actions are being progressed by estates.
8    To provide Infection Prevention and Control communications and information to service users/carers
     and staff
       The infection control page of the intranet is actively being updated to include more information for staff
         and information relevant for service users.

3.     Next Steps
The SN - IPC will continue to provide and monitor the service.

4.      Required Actions
For the Board of Directors’ to receive and approve the report, to note the on-going activity of the Infection Control
Team and to promote a proactive approach to infection control.

5.     Monitoring Arrangements
Bi-monthly reporting at Infection Control Committee. Monthly verbal and quarterly written reporting to Quality and
Risk Group, Data included onto the Dashboard, with quarterly written reports to the Board of Directors’.

6.       Contact Details
For further information, please contact:

Rosie Dixon, Senior Nurse – Infection Prevention and Control
0114 2716720

Tony Flatley
Lead Nurse
Appendix 1 – Prevalence Survey Data July – September 2010

                             D&V/       MRSA
                                                               SCABIES/              Chest            SHINGLES/     Soft tissue    Oral/   therapies
                           Norovirus/    (Col       TB   UTI              C.DIFF                BBV
                                                               HEADLICE            Infections         Chicken pox   infections    dental
                           Rotavirus     /inf)

               Clients         0          6         1     41       0        1         39          3       1             45          1             134

Trust Totals



D&V – diarrhoea and vomiting
MRSA – meticillin resistant staphylococcus aureus
TB – tuberculosis
UTI – urinary tract infection
C.Diff –clostridium difficile infection
BBV – blood borne virus

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