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Consultation Checklist
Name of Policy
Infection Prevention and Control Policy
Named person developing Policy
Sarah Turner
Senior Infection Prevention & Control Nurse
Timescale for completion
September 2007
Consultation Date Agreed
Document previously ratified July 06, needed to be updated re Sept 07
Health Act 2006
Approval
Yes/No Date Assessed
Infection Prevention & Control Committee YES 12th Sept 2007
Approved Yes
Signed______Dr James Catania_______________________
Designation__Director of Infection prevention & Control__
IC/05/01/JC/ST review July 06 1 of 9
Stepping Hill (Infection Control Policy)
TRUST POLICY
Infection Prevention & Control Policy
APPROVAL/ADOPTED Infection Prevention & Control Committee
September 2007
DATE OF APPROVAL / ADOPTION
September 2008
REVIEW
Available on the Intranet
DISTRIBUTION
All other Infection Prevention & Control Policies
RELATED POLICIES / DOCUMENTS
Sarah Turner
AUTHOR/FURTHER Senior Infection Prevention & Control Nurse
INFORMATION
Previous Infection Prevention & Control Policies
THIS DOCUMENT REPLACES
IC/05/01/JC/ST review July 06 2 of 9
Stepping Hill (Infection Control Policy)
INFECTION PREVENTION AND CONTROL POLICY MISSION STATEMENT
The Trust will ensure a managed environment, which minimises the risk of infection to
patients, staff and visitors.
INTRODUCTION
i The Infection Prevention and Control Policy describes the relationships and
responsibilities that form the framework for Infection Prevention and Control within the
Trust.
ii Prevention and control of infection is part of the overall risk management strategy
within the Trust and an integral part of the management of antibiotic resistance (see
Appendix II).
Iii The introduction of the NHSLA Standards and the Health Act 2006 requires NHS
organizations to ensure that their arrangements for IP&C conform to the standards, and
that the standards are incorporated into everyday infection prevention and control practice.
1. Principles of Infection Prevention and Control provision within the Trust
1.1 There is an Infection Prevention and Control Team comprising of Director of Infection
Prevention and Control (Medical Director), Infection Prevention and Control Doctor
(designated Consultant Microbiologist), Consultant Microbiologists, Consultant in
Communicable Disease Control, Senior Infection Prevention and Control Nurse, Infection
Prevention and Control Nurses (Trust and Community) and Biomedical Scientist. They
work closely together to provide advice on all infection issues. They liaise with all
departments including occupational health, estates, sterile services, catering, and hotel
services to maintain a safe environment which minimises the risks of infection for patients,
staff and visitors to the Trust. This advice is available 24 hours a day.
1.2 The Trust will ensure access to a CPA accredited microbiology laboratory, which will
support the Infection Prevention and Control service via processing, data provision
surveillance and specialist testing. Microbiology services will be available on a 24-hour
basis. Funding of investigations during outbreaks will be met through the financial
management of the Division of Laboratory Medicine. Staffing and other costs will be met
through the divisional financial management of the affected division/s.
1.3 Surveillance of infection is carried out using defined methods in accordance with agreed
objectives and priorities. Key indicators capable of providing early warning of risk and
improvements will be used by the Trust and action plans are developed from this
surveillance.
1.4 The Infection Prevention and Control Team will oversee policies, procedures and guidance
for the prevention and control of infection are commissioned and implemented. The
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Stepping Hill (Infection Control Policy)
infection prevention & control documentation will reflect relevant legislation and published
professional guidance and will assist with the implementation of this Policy. This
documentation will be approved by the Infection Prevention and Control Committee before
ratification by the Clinical Effectiveness Committee and the Trust Board.
1.5 The Chief Executive or an appropriate deputy is informed of any unforeseen emergencies
or serious problems or issues relating to Infection Prevention and Control.
1.6 Out of hours Senior Management support is provided to cover urgent Infection Prevention
and Control issues.
1.7 Prevention and control of infection is considered as part of all service development activity.
This includes the development of policies and planning pertaining to engineering and
building services and involvement in the purchase of all medical devices/ equipment.
1.8 The Infection Prevention and Control Team should be involved in the contracting process
for hotel and other services which have implications for Infection Prevention and Control
e.g. cleaning, laundry, clinical waste and decontamination.
1.9 The Infection Prevention and Control Team liaises with the local Consultant in
Communicable Disease Control when dealing with outbreaks of infection within the acute
and community setting.
1.10 The Infection Prevention and Control Committee meets bi monthly, endorses all infection
prevention and control guidelines, provides advice and support on the implementation of
said guidelines and monitors the progress of the annual infection prevention and control
programme.
1.11 The MRSA / CDT Performance Management Group meet monthly to review the Infection
Prevention & Control Quality Dashboard, Saving Lives and Hand Hygiene compliance and
will review and update action plans in response to these areas.
1.12 Membership of the Infection Prevention and Control Committee is as laid down in the
Terms of Reference (Appendix I).
1.12 The Prevention of Infection Practitioners Group chaired by the Senior Infection Prevention
and Control Nurse will provide a direct link to clinical staff. This group reports to the
Infection Prevention and Control Committee.
1.13 Arrangements are in place for reporting on Infection Prevention and Control issues raised
at Infection Prevention & Control Committee Meetings to the Clinical Effectiveness
Committee. From this committee reports will be sent to the Trust Board.
1.14 In line with the requirements of the Health Act 2006, liaison between the Bed Management
Team (including the Discharge Coordinators) and the Infection Prevention & Control Team
will include where practicable information pertaining to admissions, transfers, discharge and
movement of patients between departments & within & between health care facilities.
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2. Management Responsibilities for Infection Prevention & Control within the Trust
2.1 The Prevention and Control of Infection is part of the overall risk management strategy
within the Trust.
2.2 Overall and final responsibility for ensuring systems are in place for the prevention of
infection to patients, staff and visitors is the responsibility of the Chief Executive.
2.3 The Executive Director of Nursing is the delegated nominated Board Member, Executive
Director of the Trust with responsibility for the management of risk within the Trust.
2.4 The Medical Director is the Director of Infection Prevention and Control and will provide
leadership at Executive level to address issues in relation to Infection Prevention and
Control.
2.6 Clinical Directors, Divisional General Managers, Ward Sisters and Clinical Heads of Service
are responsible for ensuring various Infection Prevention and Control policies, procedures
and guidelines are implemented by all Health Care Workers in their Divisions.
2.7 The day-to-day implementation of the Infection Prevention and Control is the responsibility
of all Health Care Workers, with support from the Infection Prevention and Control Team.
2.8 The Infection Prevention and Control Team reports to the Infection Prevention and Control
Committee.
2.9 The Infection Prevention and Control Committee is accountable to the Chief Executive and
Trust Board.
3. Structural Organisation of Infection Prevention and Control within the Trust
3.1 Every individual in the Trust has a responsibility for ensuring Infection Prevention & Control
practices are adhered to.
3.2 Every individual in the Trust should seek advice from the Infection Prevention & Control
Team regarding Infection Prevention & Control issues and report to the Infection Prevention
& Control Team any issues perceived as an Infection Control risk
3.3 The day-to-day implementation of the Infection Prevention and Control Service is the
responsibility of the Infection Prevention and Control Team.
3.4 Prevention of Infection Practitioners receive training by the Infection Prevention & Control
Team and assist with the provision of a safe environment regarding infection prevention &
control in the departments in which they work.
4. Infection Prevention and Control Training within the Trust
4.1 The aim of the Infection Prevention and Control Team is to provide education in Infection
Prevention and Control to all health care staff including those employed in support services.
Infection prevention and control is included in the induction programme for new staff and a
mandatory bi annual update is given to all staff.
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4.2 Infection Prevention & Control eLearning is also available to all staff members. This
package must be completed by new starters within 2 months, and for existing members of
staff on a yearly basis in addition to the mandatory training offered.
5. Monitoring and Review of Infection Prevention & Control Services within the Trust
5.1 The annual Infection Prevention and Control Programme will be developed by the Infection
Prevention and Control Team, discussed, ratified and submitted to the Clinical
Effectiveness Committee and Risk Management Committee and forwarded to the Trust
Board and Chief Executive.
5.2 The Trust (Divisional General Managers, Heads of Nursing and Technical Clinical Heads of
Departments) will work towards an annual audit programme to monitor compliance with
Infection Prevention and Control Policies such as Saving Lives.
5.3 The Trust’s performance as regards the Infection Prevention and Control Programme will
be reported in the Annual Report which will be presented to the Infection Prevention and
Control Committee Meetings, Clinical Effectiveness Committee and Risk Management
Committee and forwarded to the Trust Board and Chief Executive.
5.4 Compliance with the Infection Prevention and Control NHSLA Standards is monitored
annually by the Infection Prevention and Control Team and by the Internal Audit
Department within the Trust and its progress is in turn monitored by the Risk Management
group, which reports to the Trust Board.
5.5 Compliance with the Health Act 2006, is monitored on quarterly basis through the IPCC.
Each division has been made responsible fro drawing together an action plan for their own
division and for cascading this information to all their staff members.
6. Definition of Roles
6.1 Infection Prevention and Control Committee (refer to Terms of Reference Appendix I).
6.2 Infection Prevention & Control Team (refer to 1.1 of Infection Prevention and Control
Policy).
6.3 Director of Infection Prevention and Control: Role will be fulfilled by the Medical Director
who will provide leadership at Executive level to address issues in relation to infection
prevention and control.
6.4 Infection Prevention and Control Doctor: Role fulfilled by Consultant Microbiologist who
through professional advice, will support the Director of Prevention and Control to produce
an annual report on the state of healthcare associated infection in the organisation, to
oversee local control of infection policies and their implementation, to assess the impact of
all existing and new policies and plans on infection and make recommendations of change.
6.5 Senior Infection Prevention and Control Nurse: To manage and develop the Trust’s
Infection Prevention and Control Nursing Service, and in conjunction with the Director of
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Infection Prevention and Control and the Infection Control Doctor to develop, plan and
implement strategies to reduce the risk of infection to patients, staff and visitors.
6.6 Infection Prevention and Control Nurse: In conjunction with other members of the Infection
Prevention and Control Team will develop, plan and implement strategies to reduce risk of
infection to patients, staff and visitors.
6.7 Biomedical Scientist: To carry out duties in relation to prevention, surveillance and control
of infection as a member of the Infection Prevention and Control team reporting to the
Infection Prevention and Control Doctor and in accordance with the Trust, District National
guidelines. To maintain an advisory input to the laboratory with respect to infection
prevention and control issues.
IC/05/01/JC/ST review July 06 7 of 9
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Appendix I
Infection Prevention and Control Committee
Terms of Reference
Membership
Chair: Director of Infection Prevention and Control (Medical Director)
Infection Prevention and Control Doctor (designated Consultant Microbiologist)
Consultant Microbiologists
Consultant in Communicable Disease Control
Senior Infection Prevention and Control Nurse
Infection Prevention and Control Nurses (Trust and Community)
BMS Infection Prevention and Control
(The above form the Infection Prevention and Control Team)
Director of Nursing Services
Director of Occupational Health Services
Lead Person Division of Women and Children Services
Lead Person Division of Surgery (A&E, Orthopaedics, General Surgery, Urology)
Lead Person Division of Medicine
Lead Person Division of Critical Care
Lead Person Division of Clinical Support
Lead Person Division of Radiology
Lead Person Division of Laboratory Medicine
Matron Representative
Director of Estates
Director of Facilities
Senior Antibiotic Pharmacist
Senior Risk Manager
Assistant Director of Nursing (Risk)
Lead Person Occupational Health Medicine
Primary Care Group (Trust representative)
Pennine Care Trust representative
Other stakeholders will be invited as appropriate
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1 In the absence of the Director of Infection Prevention and Control, the Infection Prevention
and Control Doctor will chair the meeting.
2 Reports to
The Infection Prevention and Control Committee reports to the Clinical Effectiveness Committee
and to the Risk Management Committee.
3. Meetings
Bi monthly
4. Responsibilities
To advise the Trust in all aspects of infection prevention and control as outlined in the Infection
prevention and Control Policy.
3 Functions
3.1 The functions of the committee are: To formulate, implement and monitor progress of the
Annual Action Plan (ratified by this committee) based on an Annual Report.
3.2 To ratify the Annual Report, submitted by the Director of Prevention and Control with the
support of the Infection Prevention and Control Doctor.
3.3 Commission and approve policies, procedures and protocols, local rules and guidelines in
relation to infection prevention and control. The committee will provide assurances to the
Clinical Effectiveness Committee and the Risk Management Committee that they are
compliant with the NHSLA Standards, Standards for Better Health & the Health Act 2006.
3.4 To review and audit their implementation i.e. Saving Lives Compliance Tools. Any changes
to practice will be highlighted (from feedback, action plans etc) to the committee.
3.5 To advise the Divisions and Management Board of any resources required for
implementation
3.6 Consider and implement where necessary any National Reports / Guidance that is relevant
to the area of infection prevention & control
3.7 To advise on the most effective use of resources.
3.8 To encourage education of all grades of staff and facilitate liaison between the different
disciplines involved.
3.9 The Infection Prevention and Control Doctor will make a résumé of the issues raised at the
Infection Prevention & Control Committee and present this on a regular basis to the Clinical
Effectiveness Committee.
3.10 The key issues from the committee will also be reported to the Risk Management
Committee, quarterly, by a designated member of the Infection Prevention and Control
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Team. The committee will be informed regarding the numbers of mandatory reported
infections including MRSA bacteraemia, and Clostridium difficile infections etc. Identification
of trends, analysis of incidents and any feedback from these will be highlighted at the
committee.
3.11 The Prevention of Infection Practitioners group, chaired by Senior Infection Control Nurse,
will meet regularly and feed into this committee (see this group’s own individual Terms of
Reference and Membership).
3.12 The terms of reference for the Infection Prevention & Control Committee will be reviewed
annually.
3.13 The committee will develop any risk assessments identified by the Infection Prevention &
Control Team, and inform the committee regarding such.
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Risk Management Organisational Chart Board of Directors
Assurance Board
Clinical Audit
Effectiveness Committee
Committee
Risk Management
Committee
Infection
Prevention
and Control
Health and Medicines
Committee Moving Management
Safety
Group and Group
Handling
Group
COSHH Blood
Medical Transfusion
Devices Committee
Group
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INFECTION PREVENTION & CONTROL TEAM - ORGANIZATIONAL CHART
Chief Executive
Executive Director of
Nursing
Clinical Director Laboratory
Medicine
Director of Infection Prevention &
Control
Assistant Director of
Nursing - Quality
Biomedical Scientist Consultant Microbiologist, Infection
Prevention & Control Doctor
Senior Infection
Prevention & Control
Consultant Microbiologists, Nurse
Infection Prevention &
Control Nurses
IC/05/01/JC/ST review July 06 12 of 9
Stepping Hill (Infection Control Policy)
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