Get documents about "BRADFORD DISTRICT CARE TRUST Urinary Tract Infection
Document Sample
BRADFORD DISTRICT CARE TRUST
Report from the Director of Infection Prevention and Control
Annual Infection Prevention Report
April 2009 – End March 2010
Authors:
Nick Morris
Director of Infection Prevention and Control
Samantha Moorehouse
Lead Nurse Infection Prevention and Control
Date: April 2010
Executive Summary
The aim of this report is to inform the Trust Board of the systems, processes and activity
in place within the Trust to reduce the risks of Health Care Acquired infection between
1st April 2009 and 31st March 2010. The infection prevention and control team has
completed the majority of actions in a challenging year with the H1N1 pandemic. In
addition, the following were key elements of the infection prevention and control team
activity and performance:
The Trust has had no MRSA bacteraemia cases during the year
There was two Clostridium difficile case compared to four the previous year
The Trust achieved 52.6% of front line staff vaccinated against H1N1
The Trust achieved its target of 65% of staff up to date with infection prevention
training
A rolling programme of infection prevention and control audits using the
Department of Health/ Infection Prevention Society Quality Improvement tools for
Mental Health has been conducted.
Standards of environmental cleanliness remain high in areas cleaned by hotel
services other sites have made significant improvements.
This year has seen a decrease in outbreaks of diarrhoea and vomiting
MRSA targeted screening has now been rolled out to include Ashbrook,
Maplebeck and Oakburn wards.
The number of inoculation contamination injuries remains low with scratches
accounting for the majority of incidents.
1. Introduction
Infection prevention and control is a requirement of all NHS Organisations and the Trust
is required to comply with the „Code of Practice for health and adult social care on the
prevention and control of infections and related guidance‟. The criterion within the code
reflects a need to assure the public that appropriate quality of care is applied in public
service settings where people receive care and are not in a position to control the
standards of hygiene etc themselves they ultimately rely on the service provider to
maintain high standards of care on their behalf.
The Trust puts infection prevention and control at the heart of good management and
clinical practice and is committed to ensuring that appropriate resources are allocated
for effective protection of patients, their relatives, staff and visiting members of the
public. The implementation of appropriate infection prevention practices is a key way to
reduce avoidable healthcare associated infections (HCAI) to both patients and staff. In
addition ensuring infection prevention and control policies are in place and implemented
is an essential component in ensuring a safe environment for patients and staff.
The annual infection prevention and control report is a requirement under the „Code of
Practice‟ of which Criterion 1 states that „the nominated Director for Infection Prevention
and Control (DIPC) is to prepare an annual report on the state of HCAI in the
organisation for which he or she is responsible and release it publicly.‟ This report has
been produced by the lead nurse for infection prevention and control on behalf of the
DIPC. The annual report summaries the initiatives and activities carried out during
2009-2010 within Bradford District Care Trust. It explains the Trust management
arrangements for infection prevention and incidences of infection. The report aims to
assure the public that the minimisation and prevention of infection is given the highest
priority by the Trust.
2. Infection Prevention and Control Management Arrangements
The Infection Control Committee has met on three occasions this past year. The
Service Governance Committee has received quarterly reports on infection prevention.
The DIPC has produced and submitted quarterly reports to the Trust Board on progress
with implementation of the „Code of Practice‟ and any infection control matters arising,
including quarterly breakdown of Infection control cases, alerts and any „outbreaks‟.
The work undertaken during this period has reflected the Trust priorities and the
infection prevention annual programme. The first half of the year saw a significant
amount of time dedicated to pandemic flu preparation, leading on the vaccination
programme and the second half of the year on achieving the training target set by the
Trust.
2.1 The Infection Prevention and Control Team:
The infection prevention team has increased in size this year and now consist of the
following:
Nick Morris, Director of Strategy and Nursing and is also the Trust‟s Director of Infection
Prevention and Control and is the responsible Director for the Infection Prevention
Team.
Dr Paul Godwin, Consultant Microbiologist is the Trust‟s Infection Control Doctor
Samantha Moorehouse Lead Nurse Infection Prevention and Control
Yvonne Hanson Infection Prevention and Control Matron
3. Infection Prevention Policy Development
Each NHS body is expected to have systems in place that are sufficient for it to apply
evidence based protocols and to comply with the relevant provisions of the Health and
Social Care Act in order to minimise the risk of Health Care Acquired Infection to
patients, staff and visitors. Compliance with policies/protocols is audited as per the
annual programme, appendix 2. The following new policies and protocols were written
and approved by the Infection Control committee:
New protocol developed: Urinary Catheter Care
Policies/protocols reviewed and updated:
Infection Prevention and Control
Hand Hygiene
Clostridium Difficile
Meticillin Resistant Staphylococcus Aureus
Prevention and management of Inoculation Contamination Injuries
Blood-Borne Viruses
Management of CJD
Contributions were made to: Food hygiene policy
4. Surveillance
The Trust is set a performance target regarding the reporting of MRSA reportable
bacteraemia. There have been no such cases reported in this financial year. [See table
below] A Root Cause Analysis investigation was undertaken on the one Clostridium
difficile case and the findings presented to the Infection Control Committee. Information
on other infections has improved and work will continue this coming year to have an
accurate record.
Confirmed positive isolates April 2009 – March 2010
Clostridium difficile 2
ESBL 3
MRSA reportable bacteraemia 0
MRSA Colonisation/Infection 7
MRSA Screening positive 9
Other Infections April 2009 – March 2010
Campylobacter 2 (1 staff member)
Chicken Pox 1
Conjunctivitis 1
Head lice 5
Hepatitis C 1
Scabies 2
Shingles 2
Ringworm 1
The Clostridium Difficile cases appear to be associated with multiple acute hospital
admissions and the comorbidities of the patients. Infection prevention precautions were
implemented and the patient started on a course of Metronidazole.
The two campylobacter cases were at Wainfleet House, these were investigated by the
infection prevention team and environmental health, no source was identified. The
kitchen has since been audited by the Trust‟s food services department and an action
plan produced; all the actions have now been implemented.
The Trust has had its first three cases of ESBL (Extended-Spectrum Beta-Lactamase)
producing E. coli, which is an antibiotic resistant strain of E.coli. In many instances, only
two oral antibiotics and a very limited group of intravenous antibiotics remain effective.
Both these cases were urinary tract infection; both of the patients have made a full
recovery. This type of infection tends to occur in people with other underlying medical
conditions, patients who have been taking antibiotics or who have been previously
hospitalised. This is an emerging national problem and surveillance is currently being
developed by the HPA.
5. Outbreaks
5.1 Outbreak of H1N1 influenza
There was one confirmed outbreak of H1N1 influenza; the outbreak involved 8 service
users and 10 staff at Shipley Resource Centre. Infection control precautions were
implemented and day care services were cancelled for service users living in care
homes. The outbreak was well managed by the unit and the spread of infection was
minimised as far as possible. The outbreak gave the opportunity to test plans and
procedures to ensure that we have robust systems in place for future outbreaks.
5.2 Outbreaks of diarrhoea and vomiting
This year has seen the number of Health Protection Agency nationally recorded
outbreaks of viral gastroenteritis increase, where as the Trust has seen a decrease.
This could be attributed to the increase in staff training and the strict implementation of
precautions and disinfection procedures when an outbreak is suspected. When
outbreaks do occur improvements still need to be made in the sending of specimens to
identify the causative organism.
Viral gastroenteritis episodes April 2009 – end March 2010
Health Care Month Service Staff Other organism
Facility Users
Moorfield Place April 6 0 0 None
confirmed
Heather Grove June 2 2 0 Sapovirus
Reevy Road August 5 2 0 None
confirmed
Ashbrook December 1 5 0 Norovirus
Ilkley January 4 1 0 None
confirmed
Heather Grove January 2 1 None
confirmed
Dale view Grove February 2 5 0 None
confirmed
Ian Clough Hall February 7 1 0 None
confirmed
Ward 24 February 7 9 0 Norovirus
Duchy Court February 6 6 0 Norovirus
Rix House February 11 10 0 Norovirus
Thomas Court March 3 3 0 None
confirmed
Assessment & March 3 10 0 None
treatment unit confirmed
Listonshiels March 7 1 0
Total 66 56 0
6. MRSA Screening
Patients on admission to ward 24, Duchy and Chellow continue to be screened for
MRSA colonisation. This is essential as these three wards contain high risk and
vulnerable patients. Early detection is vital as it ensures that individual patients are
given appropriate de-colonisation treatment where necessary and additionally
transmission to other patients is prevented.
The number of patients colonised with MRSA remains small, containment measures
are implemented by the nursing teams when necessary and supported by the infection
prevention nurse. These measures appear to have been effective in preventing the
spread of infection.
The Department of Health has now issued guidance for mental health trusts on targeted
screening for all admissions, the specified criteria being:
Patients who are admitted following surgical procedures.
Patients that are admitted following admission to an acute Trust
Intravenous drug users
Patients who self harm
Patients with a possible diagnosis of delirium
Patients with chronic wounds e.g. leg ulcers
Patients with an indwelling device e.g. catheter
A pilot of targeted screening was initially commenced on Heather and Fern ward at the
Airedale Centre for Mental Health. Following the pilot evaluation targeted screening has
now been rolled out to include Ashbrook, Maplebeck and Oakburn.
7. Inoculation Contamination Injuries
Month Sharps Sharps Bites Bites Scratches Scratches Spitting Spitting
Injury injures IR1 followed IR1 form followed incident incident
IR1 followed form up Occ up Occ IR1 form followed
form up Occ Health Health up Occ
Health Health
Apr 0 0 0 0 4 2 2 3
May 1 1 0 0 15 2 1 1
Jun 1 2 2 1 15 6 3 1
Jul 0 1 2 1 15 6 2 0
Aug 0 0 1 0 13 2 2 1
Sep 0 0 0 0 10 2 1 2
Oct 1 0 2 1 11 3 3 2
Nov 0 0 3 2 10 2 0 0
Dec 1 2 1 1 3 0 0 0
Jan 0 1 1 1 10 0 1 0
Feb 1 1 1 1 12 2 1 0
Mar 0 1 0 0 10 0 1 0
Total 5 6 13 6 128 25 17 10
Figures of inoculation contamination injuries remain low with scratches accounting for
the majority of incidents. This year has seen a decrease in all types of injuries from the
previous year when there were 9 sharps injuries, 29 bites and 220 scratches. Work still
needs to be done on improving staff attendance at occupational health following an
injury. To support this cards have been produced which explains the procedure for staff
to follow and posters are currently being produced.
8. Pandemic Influenza H1N1
The World Health Organisation (WHO), declared a global flu Pandemic on the 11 th June
2009. This meant the H1N1 virus had spread to at least two regions of the world. The
following months were spent in preparation for the pandemic ensuring that the Trust had
robust contingency plans in place. A pandemic incidence control team was convened.
The team initially met daily and then twice a week. Regular updates and information was
provided to staff and key information was disseminated to each area. Additional
personal protective equipment was purchased and stock piled. Educational sessions
were held for all Trust staff which covered information on influenza, how it is spread,
PPE, and what precautions to take. Clinical skills training for qualified inpatient staff was
also, and they the cascaded this information to their colleagues.
The age group most affected was the under 20‟s with the majority of symptoms
being mild and people affected recovering quickly.
The Trust saw the highest number of staff and service users affected by H1N1 influenza
in July. Figures continued to fall in the preceding months. With the continued fall in
numbers, the pandemic incidence control team has now been disbanded, should figures
increase, the team will reform. All infection prevention training sessions continue to
include all essential. H1N1 Swine Flu pandemic still remains a significant infection
control and human resource threat to the organisation at this time.
Month Staff Service Users
July 79 12
August 26 5
September 2 1
October 6 1
November 3 0
December 2 0
January 0 0
February 0 0
March 0 0
8.2 Influenza/seasonal vaccination programme
In October 2009 the seasonal and H1N1 Trust vaccination programme commenced.
The first phase was to vaccinate vulnerable service users and frontline healthcare
workers. This year has seen a major change in the Trust vaccine programme instead of
staff having to attend a session in Occupational Health the vaccines have been
administered at a variety of sites throughout the Trust, in total 70 sites were visited. The
vaccine programme was led by the lead nurse for infection prevention and control,
consequently this has meant that some of the infection prevention programme is behind
schedule. The approach was taken to maximise the availability of the vaccine to staff in
their workplace, the effectiveness of the programme can be seen in table 1.
In previous years the Trust has had a poor seasonal flu vaccine uptake with less than
150 seasonal influenza vaccines administered. This year the Trust ordered 600
vaccines and all were administered to front line staff in the first few weeks of the
vaccination programme.
Regionally the Trust is in fifth place for vaccine uptake of frontline staff, 52.6% for H1N1
and 35.6% for seasonal. Two sites have achieved 100% vaccination of their staff, this
has been achieved by the managers being proactive and supporting their staff.
Vulnerable inpatients were also offered the seasonal and H1N1 vaccine, uptake can be
seen in table 2.
Table 1: Vaccine uptake per site
Site Percentage of Percentage of staff
staff vaccinated vaccinated with H1N1
with seasonal
Ashbrook 96% 100%
Ashfield House 67% 67%
Assessment & treatment 54% 58%
Baildon ward 68% 84%
Branwell Lodge 37% 41%
Chellow Lodge 63% 60%
Clover ward 30% 37%
Copwood 30% 40%
Duchy Court 33% 30%
FieldHead n/a 46%
Fern Ward 48% 52%
Grove RC 100% 100%
Halifax Rd 42% 42%
Heather ward 31% 42%
Hillbrook n/a 34%
HouseKeepers 34% 44%
Ingrow Centre n/a 53%
Keighley Day Services 47% 66%
Ilkley Ward 28% 53%
Listonsheils 58% 67%
Low Moor RC 78% 86%
Maplebeck 42% 71%
Melville House n/a 83%
New Ridge 76% 76%
Oakburn 24% 36%
Reevy Rd 48% 48%
Rix House 39% 61%
Sheldon Ridge 74% 74%
Shipley RC 60% 63%
Stoney Ridge 65% 76%
Thornton Ward 37% 44%
Ward 24 53% 63%
Weaver Court 50% 50%
Whiteoaks 48% 54%
Table 2: Vaccine uptake of Vulnerable Service Users
Site Number of Service Number of Service
Users vaccinated Users vaccinated with
with seasonal H1N1
Ashbrook 16 16
Assessment & treatment 3 3
Baildon ward 4 4
Chellow Lodge 8 8
Clover ward 3 3
Duchy Court 8 8
Fern Ward 2
Heather ward 3
Ilkley Ward 1 2
Maplebeck 8 8
Oakburn 14 14
Thornton 1 1
Ward 24 5 5
9. Education and Training
The Health and Social Care Act (2009) identifies the importance of effective education,
training, information and communication for all. The Trust is committed to ensuring that
all staff receives regular infection prevention and control (IPC) mandatory training; in
order to ensure that staff have the knowledge to prevent and manage the spread of
infection and, ultimately improve patient and staff safety.
Effective prevention and control of health care associated infections (HCAI) has to be
embedded into everyday practice and applied consistently by everyone; it is particularly
important to have a high awareness of the possibility of HCAI in both patients and
healthcare workers to ensure early and correct management is implemented and where
applicable a rapid and accurate diagnosis is made, thus resulting in effective treatment
and containment of an infection.
Education forms part of every staff member‟s job description and evidence of
attendance is included in all staff appraisals.
One of the key objectives for the infection prevention team this year was to increase the
number of staff who attended mandatory training. On the 31st March 2010 the team
achieved the target of 65%.
9.1 Induction
Infection prevention and control is part of the Trust induction. The Trust induction
training incorporates everyone who is new to the Trust, this happens bi-monthly. The
session includes basic principals of infection prevention, hand hygiene,
decontamination, inoculation contamination injuries and a practical session with the light
box, a tool designed to establish and reinforce good hand washing skills.
9.2 Mandatory Training
Clinical staff must attend infection prevention and control mandatory training annually,
non clinical (administration) staff bi-annually. All sessions are presented by the infection
prevention team. The sessions last approximately 1.5 hours, human resources record
all attendance. Staff who do not attend are followed up by human resources.
The mandatory training sessions have been designed to encompass the following
Infection Prevention issues:
Who‟s who within the infection prevention team
The environment – including decontamination and management of spillages
Hand hygiene – including use of the light box
Chain of infection
Healthcare Associated Infections and the cost implication
The use of personal protective clothing
Sharps management – including management of injuries
Waste management – including segregation
MRSA/Clostridium difficile/norovirus and Influenza
Packaging, handling and delivery of laboratory specimens
Measures to avoid exposure to blood-borne viruses, including immunisation
against hepatitis B
9.3 Ad hoc sessions
The main focus for additional infection prevention training this year has been pandemic
influenza with sessions held at a variety of locations throughout the Trust.
9.4 Learning Disability
A number of basic hygiene sessions have been done throughout the trust for Learning
disability service users. These have evaluated very well and more sessions are planned
for the coming year.
9.5 E-learning Package
The Trust is due to launch an e-learning package in April which will allow staff to
undertake their annual training on line one year and face to face the following year.
9.6 Summary of Training Figures
Directorate Actual %
Mar-10 453 CAMHS Directorate (Level 4) 60 78.9%
Mar-10 453 Facilities & Informatics - All (Level 4) 298 73.0%
Mar-10 453 LD Health Care Directorate (Level 4) 554 61.9%
Mar-10 453 Older People MH Directorate (Level 4) 113 74.3%
Mar-10 453 Adult Mental Health Directorate (Level 4) 295 63.9%
Mar-10 453 Forensic Services (Level 4) 44 55.0%
453 Social Care & Inclusion Directorate (Level
Mar-10 4) 65 65.3%
Mar-10 453 Substance Misuse (Level 4) 18 69.2%
Mar-10 453 HQ - Human Resources (Level 5) 49 75.4%
Mar-10 453 HQ - Trust Management (Level 5) 53 76.8%
Mar-10 453 HQ - Finance 17 85.0%
Mar-10 453 HQ - Payroll 36 100.0%
Total 1602 66.4%
10. Infection Prevention Link Workers
The infection prevention link workers are recruited from any discipline within the
unit/ward, the criteria being that they have an interest in infection prevention and
control. Their role is to act as a resource in their clinical area and liaise with the infection
prevention team. They act under the supervision of the infection prevention team as a
resource and role model for colleagues.
The link worker group is run by the infection prevention team, meetings are held
quarterly and agenda and minutes produced. The meetings offer an opportunity to
provide educational sessions, disseminate new/updated infection prevention policies,
hand-out information and audit tools that can then be taken directly back to each
healthcare setting within the Trust. The group provides a forum for staff to discuss
infection control issues and share best practice.
A successful training day for the link workers was held in October produced
collaboratively with the two acute trusts, PCT and HPA. The day updated staff on issues
such as emerging infections, Board to ward, improving hand hygiene compliance,
occupational immunisations, outbreaks in food premises and pandemic influenza.
11. Audit Programme
11.1 Infection Prevention Audits
A rolling programme of infection prevention and control audits using the Department of
Health/Infection Control Nurses Association audit tools has been conducted. This year
the Trust has been a pilot site for the new Department of Health/Infection Prevention
Society Quality Improvement tools in Mental Health.
The objectives of the audits are to inform services of their level of compliance to
infection prevention standards, policies and procedures and allow improvements to be
made based upon the findings.
Wards/departments and health care facilities are audited under the categories listed
below:
Management of Infection Prevention and Control
General environment
Kitchen
Sharps handling and disposal
Management of patient equipment
Handling and disposal of linen
Personal Protective Equipment
11.2 Overall Score and Compliance Rating
The Quality improvement tools include compliance categorisation in the scoring method
to provide a clear indication of compliance. The categories are allocated as follows:
Compliant >90%
Partial Compliance 76 - 89%
Minimal Compliance <75%
11.3 Reporting and Monitoring
At the time of audit the infection prevention nurse verbally reports any areas of concern
and of good practice to the member of staff accompanying them. A written summary
report and detailed recommendations in the form of an action plan is developed by the
infection prevention nurse and given to the area manager for action. A copy is also
shared with the DIPC, general manager, matron, hotel services and estates. Support
from the infection prevention team is offered to implement changes required to improve
practice.
The area is requested to return the completed action plan within six weeks to the
infection prevention team, detailing the actions taken and a timeline for completing any
outstanding. The Infection Control Committee monitors the reports and action plans.
11.4 Results
The following infection prevention audits were under taken prior to the quality improvement trial commencing.
Weaver Court
Ian Clough Hall
Rix House
Wainfleet House
The following table illustrates quality improvement audits carried out by the infection prevention team and the compliance
scores.
Health care Overall Management General Ward Therapeutic Patient Management Sharps Personal
facility score of infection Environment kitchen Kitchen equipment of linen handling protective
prevention equipment
Clover 90.95% 100% 93.80% 70.33% n/a 100% 86.67% 92.31% 100%
Communal 87.53% n/a 87.53% n/a n/a n/a n/a n/a n/a
area ACMH
Fern 89.73% 95% 89.62% 100% n/a 65% 93.33% 100% 81.82%
Heather 87.72% 85% 88.05% 95.93% n/a 65.38% 93.33% 91.67% 100%
Helios 83.78% 100% 79.72% n/a 79.37% n/a n/a n/a 100%
Maplebeck 87.65% 95.34% 84.25% 95.24% 89.74% 95% 80% 92.31% 100%
Moors Suite 87.60% n/a 87.22% n/a 88.89% n/a n/a n/a n/a
Oakburn 89.93% 100% 86.67% 99.22% 90.08% 86.67% 85.71% 100% 100%
OPD 84.35% 76.47 83.05% n/a n/a 84.62% n/a 100% 100%
Reevy Rd 90.51% 95.24% 89.34% 90.52% n/a 100% 91.30% 100% 90%
Key issues:
Inadequate storage
Patient equipment visibly contaminated
Cleanliness issues due to lack of storage
11.5 Mattress Audit
An audit of all the inpatient and care home bed mattresses has been conducted. This
identified a number that needed replacing; these have now been ordered and will be
replaced once they arrive.
11.6 Sharps Management audit
The annual sharps management audit which is carried out by Daniels Healthcare Ltd.
on behalf of the Trust took place in March 2010. The aim of the audit is to establish
whether or not sharps are disposed of in a safe manner.
Recommendations:
Check colour coding to ensure all area‟s are following the same guideline
regarding sharps disposal and segregation
Posters required in some area
11.7 Management of inoculation contamination injuries audit
The aim of the audit was to establish the level of awareness of staff on the actions to be
taken in the event of an inoculation contamination injury. The level of awareness of the
location of the infection prevention and control policy and the actions to be taken in the
event of an inoculation contamination injury were high.
Recommendation:
Area‟s to be provided with a „Flow Chart‟ of actions to be taken in the event of sharps
/needle stick / bite injury including splashes to eyes and wearing of contact lenses.
11.8 Compliance to Hand Hygiene Policy Audit
Infection poses a significant risk in the healthcare setting and effective hand hygiene is
one of the most important procedures for preventing the spread of infection. Over the
years various national initiatives have been developed aimed at improving compliance
with effective hand hygiene; most notably the National Patient Safety Agency –
„Cleanyourhands‟ Campaign. The „Code of Practice‟ stresses the importance and need
for all healthcare workers to have good hand hygiene and the importance of audit in
monitoring compliance to the hand hygiene policy.
The aim of the audit was to look at various aspects of compliance to the hand hygiene
policy. There was an increase, overall, in compliance from 26% in 2007 to 31% in 2009.
Recommendations:
Develop education and training to raise awareness of hand hygiene principals
16
Introduce an annual hand hygiene road show for staff, patients and public
Infection prevention nurses to work closely with the matrons to improve
compliance with hand hygiene standards and to monitor these standards
Introduce monthly audits
11.9 Availability and use of Decontamination Products Audit
The aim of the audit was to establish the range of decontamination products available
and the awareness of staff of the purpose/use of the different products. The extent of
training and assurance provided by the cleaning service staff was impressive. There
was however, a lack of understanding that the Sanitizer powder has disinfectant
properties. The knowledge and awareness of clinical staff is low with the majority of
areas automatically suggesting getting the information from the domestic staff.
Recommendations:
Infection Prevention training to include how disinfectants work
Each ward/home to keep a Biohazard spill kit
11.10 Audit Report of the Cleaning and Management of Equipment
The aim of the audit was to ascertain the cleaning/decontamination standards of all
patient equipment within the inpatient areas. The decontamination of this equipment is
the responsibility of ward staff, not the house keeping staff. Many staff was not aware
that the responsibility for the decontaminating patient equipment was within their remit.
Recommendation:
Cleaning schedules to be developed for patient equipment
Verna care tape to be used as the system to identity equipment has been
cleaned
Poster to be developed showing how to decontaminate commodes
12 Kitchen Audits
The annual kitchen audits were conducted in July with the catering manager ward
kitchens are included in infection prevention environmental audits.
The following areas were audited:
Airedale Centre Mental Health Main kitchen
Lynfield Mount main kitchen
Lynfield Mount Dining room
Daisy Hill House main kitchen
Daisy Bank main kitchen
Moorlands View main kitchen
17
12.1 Generic Issues
Issues that were observed were the cleaning of spillages as they occurred with staff not
following the “Clean as you go” policy rigidly, this has been reinforced through team
brief and local training. In addition attention to detail as part of the cleaning process was
observed with trolley and mobile table wheels requiring attention as did floor/wall
junction corners behind tables and work-surfaces.
The storage of paperwork was also observed as a possible contamination risk although
it is a legal requirement (The Food Hygiene (England) Regulations 2006) to hold written
records for six months,
The extraction and ventilation systems in all areas had been cleaned and are deep
cleaned on a six monthly contractual basis as is all fixed equipment, walls and floors.
The raw meat fridge at Daisy Bank was in disrepair, this has been disposed of an
alternate storage unit for raw meat made available.
12.2 Maintenance Issues
Some areas required maintenance work, these have been reported and in many cases
the actions have now been completed.
12.3 Completed Actions
Waste bins have been replaced in all kitchens with foot operated units which
incorporate a recessed lid to prevent hand opening.
Food Services have reviewed the storage methodology and have moved to using plastic
coated binders.
The deep cleans are carried out by Robinsons Hygiene, Manchester following a
Procurement tendering exercise.
The Food Hygiene Policy has been reviewed during the past year and has recently
been ratified and can be accessed on the Trust Intranet.
13. Cleanliness Standards
In 2007, the National Patients Safety Agency (NPSA) published the NHS National
Specifications for Cleanliness providing a framework for setting and measuring performance
outcomes. This framework also supports compliance with the Health & Social Care Act
(2009): Code of Practice for NHS on the Prevention and Control of Healthcare Associated
Infections. All Trusts are now required to review current cleanliness related policies, review
cleaning responsibilities and conduct a review into existing practice against best practice
following the publication of the revised Healthcare Cleaning Manual (NPSA 2009).
18
The hotel services department implement an audit process in line with the national
specifications for cleanliness to demonstrate assurance of the standards. The results have
been maintained above the 87% average pass rate during the year for the Trust locations
where cleaning services are provided by Hotel Services. There are 8 Learning Disability
locations which are cleaned by other agencies, of which 3 are above the pass rate and 5
are below the pass rate of 87% for the year. Recent audits, completed in March 2010, show
continuing improvements whereby 5 sites now meet cleanliness standards. The 3 sites failing
to meet standards have implemented an action plan to rectify this issue.
13.1 Audit results – Trust cleaned sites
Reviewing the twelve month period all sites are above the overall average required pass
rate of 87%. Each site achieved a monthly average above 87%; the only exception being
Oakburn Ward, achieving 78.99% in May 2009, an action plan was developed and
the actions implemented.
19
13.2 Audit results – other agency cleaned sites
Due to recent changes in legislation, care homes are now governed by the same cleanliness
legislation as hospitals and as such, should be cleaned to the same high standards. In March
2009, the lead nurse for infection prevention and control requested the scope of the cleanliness
audit programme broaden to include both Trust and Yorkshire Housing Learning Disability
locations. Cleaning services are provided by other agencies and not by the Hotel Services
department in these care homes.
The following chart displays the annual average area performance for Trust care homes.
The following chart displays the annual average area performance for Yorkshire Housing care
homes.
(Cleaning services are provided by other agencies).
20
Old Park Road, Ashfield House and Branwell Lodge cleanliness standards were above the
average pass rate of 87%. Although the annual average area performance of Rix House and
Sheldon Ridge were below the average pass rate of 87%, recent audits have met required
standards and have exceeded 87%.
Reevy Road, Weaver Court and Halifax Road have not met standards; all three sites have
implemented an action plan to improve cleanliness standards and systems. Since the
introduction of the action plans all sites have seen improvements in cleanliness standards.
The „Code of Practice‟ sets out criteria by which managers of NHS organisations are to
ensure service users are cared for in a clean environment, where the risk of HCAI is kept
as low as possible. The implementation of the British Institute of Cleaning Science (BICSc)
Cleaning Operators Proficiency Certificate Scheme (COPCS) provides the Trust with an
assurance of staff training and competence within the Hotel Services Department.
All Hotel Services staff are to be BIC‟s trained in chemical competence, single solution
mopping, suction cleaning, damp dusting and cleaning toilets/washroom furniture. Training
and assessment takes place „on the job‟. After verification of competence the candidates are
issued with a certificate as proof of completion. There are currently 145 people trained in these
tasks, it is expected that all 232 Hotel Services staff will be trained by December 2010.
13.3 Patient Environment Action Team (PEAT)
PEAT is an annual assessment, established in 2000, of inpatient healthcare sites in
England with more than ten beds. Each inspection is carried out by a Patient Environment
Action Team which consists of local NHS staff including the infection prevention nurse,
matron or senior nurse, food service, hotel service, and estates manager, service user/carer.
The team inspects standards across a range of patient services including food, cleanliness,
infection prevention, privacy and dignity and the patient environment (including bathrooms,
21
lighting, floors and patient access to give the hospital an overall rating.
13.4 Bradford District Care Trust: PEAT-09 Assessment Results
Environment Privacy
Food Score
Site Name Score & Dignity
Daisy Bank Good Excellent Good
Lynfield Mount Hospital Good Excellent Excellent
Airedale General Hospital Good Excellent Good
Daisy Hill House Good Excellent Good
The 2009/10 Lynfield Mount Assessment was accompanied and scores verified by an
independent NPSA PEAT assessor.
A PEAT action plan is currently being developed; progress to the plan will be monitored
through the Patient Environment Action Group.
The Trust supports the PEAT annual assessment programme by conducting 6 monthly
PEAT walkabouts. The PEAT team accompanied by a non-executive Director visit
wards or sites to carry out an assessment using the PEAT criteria. A file note of
observations and actions required is sent to the relevant managers and teams. The
PEAT walkabouts have recently been extended to cover non inpatient areas such as
resource centres and other day services. PEAT Walkabouts were conducted in June
2009 visiting Chellow Lodge and Duchy Court and in November 2009 visiting Stoney
Ridge, New Ridge and Shipley Resource Centre. A summary of findings and resultant
planned actions was submitted to the Resources Committee.
14. CleanYourHands Campaign
October 2009 marked the launch of the second year of the “cleanyourhands” campaign.
This annual initiative, run by the National Patient Safety Agency (NPSA), aims to keep
the importance of hand hygiene high on the agenda. The focus this year has been the
World Health Organisation‟s „Five moments‟ for hand hygiene.
14. NPSA Patient Safety Alert Clean Hands Save Lives
This alert required all providers of NHS care in England and Wales to undertake an
audit in order to monitor compliance with the alert and to review current risk
management strategies by examining current hand hygiene facilities. The audit looks at
the placement, accessibility and suitability of hand hygiene products including hand
wash basins and hand wash dispensers.
Update on actions
The Hand hygiene policy has been updated to include the „5‟ moments and
approved by the Infection Control Committee
22
The infection prevention training programme has been updated to reflect the
policy changes
All plugs have been removed from hand wash basins
Hand wash posters have been re-displayed at all hand wash basins following
removal for deep clean
Damaged hand wash basins have been replaced/repaired
An estates plan has been developed for replacing none compliant sinks this plan
also includes providing additional sinks in the areas identified.
Alternative products to alcohol gel have been sourced and are currently being
trialled in a variety of locations
15. Infection Prevention Annual Programme
The Infection Control programme (appendix 2) has been monitored by the
infection control committee throughout the year with quarterly reports to the
Service Governance Committee. Good progress has been made towards
completion of the objectives those not completed have been carried over to this
year‟s programme (appendix 3).
23
UPDATED POSITION ON PLANNED ACTIONS RELATING TO HCAI DECLARATION - MARCH 2010 Appendix 1
CRITERION ACTION IDENTIFIED CURRENT STATUS / PROGRESS
Criterion 1: The trust has in place and Whilst the Trust now has a Infection prevention and control is now
operates effective management standardised job description which part of the staff appraisal system and
Systems for the prevention and control ensures that infection prevention & included in all job descriptions
of HCAI that are informed by risk control responsibilities are identified for
assessments and analysis of infection all staff, there remains a requirement
incidents partly meets for infection prevention & control
responsibilities to be included as part
of the formal appraisal system. This
action will be completed by the 31st
March 2009.
The current transfer policy does not Infection control risks have now been
include information on infection control included in the transfer policy
risks and plans to manage these risks.
The policy is currently under review
and will be updated to include these
issues by the 30th April 2009.
Criterion 2: The trust provides and The trust does not have a dress code This policy has now been ratified.
maintains a clean and appropriate policy in place which addresses the
environment that facilitates the issue of clothing worn by staff when
prevention and control of HCAI partly carrying out duties being clean and fit
meets for purpose. This policy will be in place
by 31st May 2009.
Criterion 9: The trust ensures, so far as The occupational health service This policy has now been approved by
is reasonably practicable, that utilised by the Trust does not currently the Infection Control Committee and is
healthcare workers are free of and are have a complete set of policies in to go to the next Resource Committee
protected from exposure to place. These are currently being for ratification.
communicable infections during the developed and will be in place by the
course of their work, and that all staff 28th February 2009.
are
suitably educated in the prevention and
control of HCAI partly meets
24
Appendix 2
Infection Control Programme 2009-2010
Objectives Action Review/Progress Evidence Timetable
To ensure the provision of Review & revise existing policies The policy is now Policies & guidelines October
evidence based, up to & guidelines complete and has available on the intranet 2009
date infection prevention been ratified by SGC ICC minutes
and control policies Enteral feeding To go to next ICC SGC minutes Jan 2010
Head lice Approved by ICC Sept 2009
Infection control for new builds & Due to the updated March
refurbishments version of the DH 2010
guidance being out
for consultation – this
has been deferred till
the guidance is
published
Catheterisation & catheter care Approved by ICC Jan 2010
Implement infection Evaluate pilot of risk assessment This is now complete ICC minutes September
control risk assessment and work now needs SCG minutes 2009
for patients to commence to Quarterly SGC report
include the risk
assessment on RIO
Implement risk assessment tool As above March
2010
Develop Infection Control Increase number of Link workers Numbers have been ICC minutes December
link workers throughout throughout the Trust increased and this is SGC minutes 2009
the trust on-going Quarterly SGC report
Develop & facilitate Link worker The day was held in Dec 2009
study day October and
evaluated very
positively
To undertake infection Environmental audits using the 14 audits completed Audit report March
25
control audits IPS audit tool Audit action plan 2010
Hand Hygiene – compliance to Audit complete – ICC minutes March
policy actions commenced SGC minutes 2010
Aseptic technique Assessment tool Quarterly SGC report March
complete – audit to Matrons meeting 2010
be done 2010/11 minutes
Compliance to inoculation Audit complete – Health Act meeting December
contamination injury policy actions commenced minutes 2009
Safe Handling and disposal of Audit complete – Nov 2010
sharps actions commenced
Universal Precautions audit to be done March
2010/11 2010
Compliance to disinfection policy Audit complete – Jan 2010
actions commenced
To ensure that all staff Deliver Induction for all trust staff. On going Training records Continuous
receive infection control Increase number of mandatory Additional sessions ICC minutes Continuous
training on training and additional ad hoc were arranged and Quarterly SGC report
induction/mandatory and sessions the target of 65% Appraisal records
essential training achieved
Run Infection control road shows Pandemic influenza March
at a variety of sites sessions held at a 2010
variety of sites
Continue and develop sessions for Sessions held in Annual report Continuous
service users July‟09
Develop competency training for Competency tool Training records March
aseptic technique developed training to ICC minutes 2010
be commenced in Quarterly SGC report
2010
Develop & facilitate a study day The day was held in Training records December
for matrons & ward managers October and ICC minutes 2010
evaluated very Quarterly SGC report
positively
To implement „Essential Pilot implementation of the hand To Trial new QIT in Matrons meeting November
26
Steps for cleaner safer hygiene part of „preventing the March minutes 2009
care‟ spread of infection‟ Compliance score charts
Following evaluation of pilot sites Pilot not complete and action points. March
launch trust wide Link worker minutes 2010
ICC minutes
To meet mandatory Provide advice and support in the ongoing Surveillance reports to Continuous
surveillance of Infections event of an outbreak, producing a Infection Control
requirements, monitor report on close of outbreak Committee
trends in infection and Follow up confirmed cases of ongoing Continuous
identify potential MRSA & C Diff Root cause analysis
outbreaks reports
Summary outbreak
reports.
Compliance with Core Ensure that all government ongoing ICC minutes Continuous
standards, NHSLA, guidance is analysed and applied Quarterly SGC report
Health Act and other to Trust practice Annual report
government guidance
27
Appendix 3
Infection Prevention and Control (IPC) Annual Programme 2010/11
Introduction
This year‟s annual programme is mapped to the criterion of the Health and Social care
Act 2008 Code of Practice for health and adult social care on the prevention and control
of infections and related guidance (DH December 2009). Compliance with the Act is
enforceable by the Care Quality Commission and a declaration of compliance with the
Code by the Trust, is a statutory requirement for registration under the Health & Social
Care Act 2008.
The Act provides information on how Trust staff can prevent and control healthcare
associated infections (HCAI) and how the Trust can meet the registration requirements.
Infection prevention and control is an integral part of quality healthcare. Not all HCAI are
preventable therefore swift reaction to problems such as cross infection and outbreaks
of infection will always be a necessary element of the work of the infection prevention
and control team (IPCT), however a proactive approach is vital to help avoid HCAI.
Within the Trust provision of a comprehensive education programme, the development,
implementation and review of policies and guidelines in conjunction with infection
surveillance are all components of the IPCT proactive approach to infection prevention
and form the basis of this programme.
28
Programme
Compliance criterion Programme of work 2010/11 By whom (lead) Evidence Date to be
point achieved
1. Systems to manage Attend Infection Control Committee Infection Minutes Quarterly
and monitor the meetings Prevention and
prevention and control Control Team
of infection. These (IPCT)
systems use risk Review ICC TOR annually IPCT Minutes Annually
assessments and Provide HCAI mandatory surveillance and IPCT SGC report/Minutes Quarterly
consider how statistics on alert organism and alert
susceptible service condition surveillance e.g. new MRSA
users are and any risks isolates and Clostridium Difficile infection
that there environment Undertake root cause analysis for serious IPCT SGC report/Minutes As required
and other users may incidents of HCAI (MRSA bacteraemia,
pose to them.
Clostridium Difficile)
Review all outbreaks of HCAI at the IPCT Reports/ Quarterly
Infection Control Committee Minutes
Provide expert advice to all service IPCT Minutes/ As required
developments to ensure infection risks are Emails/plans
considered and good infection prevention
facilities/practices are included in the
development. In particular, ensure that
infection control is considered in the built
environment through
involvement of infection control expertise
to capital projects from concept stages to
commissioning, together with minor
refurbishment projects
Develop and deliver a training programme IPCT SGC Quarterly
of education (Induction and mandatory) for report/minutes/training
29
all staff as per TNA records
Develop a workbook as an alternative to IPCT workbook October 2010
attending mandatory training
Develop infection prevention road shows IPCT minutes March 2011
at a variety of sites
Develop and facilitate a study day for IPCT Minutes/evaluations November
matrons, ward managers and link workers 2010
Educate and support infection prevention IPCT/IPLW Minutes/audit reports Continuous
link workers (IPLW) to undertake hand
hygiene compliance audits, urinary
catheter care and environmental RIT‟s
using the Quality Improvement tools.
Hand hygiene audits and
environmental RIT‟s should be
undertaken on a monthly basis.
The urinary catheter care audits
should be undertaken twice a year
in appropriate areas.
Feedback will be provided to
IPLWs, managers and matrons on
a monthly basis with regard to
progress and any
recommendations.
Educate and support Matrons to IPCT/Matrons Minutes/audit reports Quarterly
undertake environmental RIT‟s quarterly
Undertake audits using the Quality IPCT Minutes/audit March 2011
Improvement tools. Audits will include: reports/SGC quarterly
The environment report
Hand hygiene
Decontamination of patient
30
equipment
Ward kitchens/therapeutic kitchens
Sharps management
Management of body
fluids/spillages
Use of Personal protective
equipment
Management of laundry/linen
Feedback and action plans will be
provided to Matrons/managers and re-
audit of any element scoring 75% or less
will be done within 6 months.
Audit the compliance to the hand hygiene IPCT Audit report/SGC December
policy quarterly report 2010
2. Provide and maintain Ensure that there is infection prevention IPCT/Hotel Audit Continuous
a clean and appropriate input into environmental monitoring services manager reports/minutes/PEAT
environment in systems scores
managed premises that
facilitates the Cleanliness Standards validation
prevention and control audits
of infections. PEAT assessments
Provide specialist input at PEAG
meetings
Continue with Year 2 „Cleanyourhands‟ IPCT/IPLW Hand hygiene audits Continuous
campaign which includes:
Patient involvement
31
Poster campaign
Alcohol gel at the point of care
Hand hygiene training based on the
5 moments
Observational audits with feedback
charts
Undertake annual infection prevention IPCT Audit reports March 2010
environmental audits (criterion 1) and
report poor compliance via ICC and
Matrons meeting
Undertake an audit of patient equipment IPCT Audit report January 2010
decontamination and report compliance
via ICC and Matrons meeting
Provide expert advice in the reviewing of
the following policies
Cleaning services
Building and refurbishment,
including air-handling systems
Planned preventive maintenance
Management of drinkable and non-
drinkable water supplies
3. Provide suitable Develop a specific Infection Prevention IPCT/Intranet Intranet page Jan 2011
accurate information on and Control page on the Trust Lead
infections to service intranet/internet. Page to include general
users and their visitors. information on infection prevention,
current policies and guidelines, annual
plan and SGC reports. Include links to
other Trust Wide policies, such as
Occupational Health and Waste IPCT Leaflets February 2011
management.
32
Review and update information leaflets on:
hand hygiene for staff
Reducing Infection Risks for
Patients IPCT Leaflets October 2011
Information leaflet on MRSA,
Norovirius, C. Diff
Develop „MRSA Screening‟ Leaflet
4. Provide suitable Review and update information leaflets as
accurate information on per criterion 3
infections to any person Audit use of the transfer/discharge IPCT Audit report March 2011
concerned with infection prevention form
providing further
support or
nursing/medical care in
a timely fashion.
5. Ensure that people Develop the infection risk assessment and IPCT/RIO lead Completed risk September
who have or develop an care plans on to RIO. assessment/care 2010
infection are identified plans
promptly and receive Audit the use of the infection risk IPCT Audit report March 2011
the appropriate assessment tool
treatment and care to Continue alert organism and condition IPCT Reports/ Continuous
reduce the risk of surveillance e.g. scabies, influenza, Minutes
passing on the infection Norovirus and MRSA as per criterion 1.
to other people.
Provide advice and support in the event of IPCT Reports/ Continuous
outbreaks or infection control incident. Minutes
Provide education to IPLW‟s on risk IPCT Lesson November
assessment and prompt identification of plan/presentation 2010
infection at IPLW meeting.
33
Include education on risk assessment and IPCT Lesson December
prompt identification of infection during plan/presentation 2010
mandatory training sessions
6. Ensure that all staff As per criterion 1 develop programme of
and those employed to education, audit and monitoring of practice
provide care in all
settings are fully
involved in the process Ensure that all approved policies and IPCT Web page June 2010
of preventing and guidelines are available to all staff on the
controlling infection. Trust intranet/internet.
Provide opportunities for IPLW‟s to IPCT/IPLW Minutes March 2010
feedback infection prevention issues in
their area to the IPCT to allow action
plans to be formulated as necessary
Work with the estates department to IPCT/Estates Records of provision
ensure that a robust system is in place for of information to
provision of information to contractors contractors and others
Develop information leaflet for contractors IPCT Leaflet September
2010
7. Provide or secure Provide specialist infection control advice IPCT Minutes Continuous
adequate isolation to new build or refurbishment projects as
facilities. per criterion 1
Ensure that the isolation policy is available IPCT/Intranet Intranet May 2010
on the trust intranet Lead
34
8. Secure adequate Ensure that staff is aware of MRSA IPCT Screening numbers/ March 2011
access to laboratory screening guidelines and are trained on Training records
support as appropriate. how to take appropriate specimens when
required.
Review the need for revision of the SLA‟s Microbiology/DIPC Screening numbers September
with the microbiology labs in light of 2010
Department of Health‟s guidance on
elective screening
9. Have and adhere to Review and update infection prevention IPCT Policies/ICC Minutes Continuous
policies, designed for and control policies and guidance as per
the individual‟s care and schedule/review dates and/or following the
provider organisations publication of new evidence/guidance.
that will help to prevent Policies/guidelines to be updated: IPCT Policies/guidelines March 2011
and control infections. Standard Infection Control
Precautions
Major Outbreak Plan
Decontamination, cleaning and
disinfection
Ward Closure due to a
Suspected or Confirmed
Outbreak of Infection IPCT Policies/guidelines March 2011
Staff Immunisation and
Vaccination
Policies to be developed
MRSA screening
Extended Spectrum Beta
Lactamases (ESBL‟s)
Immunisation of service users
Closure of rooms, wards,
departments and premises to
35
new admissions
Use and care of invasive
devices
Guidance on Animals and Pets
in Healthcare Facilities
Undertake compliance audits of the IPCT Audit reports March 2011
following infection prevention and control
policies/guidelines standard precautions,
hand hygiene and aseptic technique.
10. Ensure, so far as is Deliver induction and mandatory training IPCT Training records Continuous
reasonably practicable, as per training needs analysis see
that care workers are criterion 1
free of and are
protected from Provide specialist infection prevention and IPCT Policies/ As required
exposure to infections control input into Occupational Health records
that can be caught at policies and/or situations as required
work and that all staff Work with Occupational Health on the IPCT/Occ health Vaccination records November
are suitably educated in annual influenza vaccination programme nurse 2010
the prevention and Audit compliance to the inoculation IPCT Audit report March 2010
control of infection contamination injury policy
associated with the
provision of health and
social care.
Monitoring Delivery
Progress against the programme will be monitored by the Infection Control Committee. Significant lapses will be immediately
brought to the attention of the Chief Executive and the Board of Directors by the DIPC, as appropriate.
36
References
DH (2003) Winning ways. Working together to reduce Healthcare Associated Infection in England. Report from the Chief Medical
officer. London. DH. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4064682
DH (2008) MRSA Screening - Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_086687
http://www.clean-safe-care.nhs.uk/ArticleFiles/Files/Screening-for-Mental-Health-patients_Final-Guidance.pdf
DH (2009) The Health and Social Care Act 2008 (Code of Practice for the prevention and control of healthcare associated
infections and related guidance) Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110288
NPSA (2008) Cleanyourhands campaign (community). Further information available at:
http://www.npsa.nhs.uk/cleanyourhands/
