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This document describes the roles and responsibilities for the provision and management of Infection

Prevention and Control Services for Leicestershire Partnership NHS Trust

Key Words: Infection Prevention & Control

Version: 8

Adopted by: Quality Assurance Committee

Date adopted 19 September 2017

Name of author: Amanda Hemsley

Name of responsible committee:

Infection Prevention and Control Committee

Date issued for publication:

September 2017

Review date: July 2018

Expiry date: 1 January 2019

Target audience:

All LPT Staff

Type of Policy: Clinical

Non Clinical

Which Relevant CQC Fundamental Standards?

Infection Prevention and Control

Overarching Policy

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Contents Version Control…………………………………………………………………… 3 Equality Statement………………………………………………………………... 3 Due Regard………………………………………………………………………… 4 Definitions that apply to this Policy………………………………………………. 4 1.0 Purpose of the Policy………………………………………………………. 5

2.0 Summary of the Policy ……………………………………………………. 5 3.0 Introduction ………………………………………………………………… 5

4.0 Infection Prevention and Control ………………………………………… 6

4.1 Assurance…………………..…………………………………………. 6 4.2 Infection prevention incidents……………………………………….. 6 4.3 Information available to public, patients and staff ……………….. 7

5.0 Duties within the Organisation…………………………………………. 7 6.0 Training ……………………………………………………………………… 11

7.0 Monitoring Compliance and Effectiveness …………………………… 11 8.0 Links to Standards/Performance Indicators.…………………………. 16

9.0 References and Bibliography …………….……………………………. 16

Appendices

Appendix 1: Training Needs Analysis……………………………………………….. 18 Appendix 2: The NHS Constitution…………………………………………………... 19 Appendix 3: IPC Committee Terms of Reference……………………................... 20 Appendix 4: Governance reporting ……………………………………................... 25 Appendix 5: Contribution list…………………………………………………………. 26 Appendix 6: Outcome 8; Key Performance Indicators…………………………….. 27 Appendix 7: Due regard screening template………………………………………… 28

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Version Control and Summary of Changes

Version Date

Comment

1 February 2008 New Policy

2 November 2008

Reviewed by Infection Control Project Manager (Seconded)

2 Draft 2

February 2009 Minor amendments following Consultation process.

3 April 2009 Further amendments following consultation with Assistant Directors and NHS Leicester City Commissioning and Governance Committee

4 December 20010

Revisions to incorporate requirements of NHSLA Standards

5 November 11 Harmonised from 3 legacy organisation and processes reviewed

6 December 2014 Review of document in line with new policy layout and review date

7 July 2015 Review of documented in line with LPT policy requirements together with Due regard process

8 June 2017 Policy review in line with policy timetable, inclusion of new layout for policies

For further information contact: Infection Prevention and Control Team

Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, (sex) gender, gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development and review. Due Regard

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LPT must have due regard to the aims of eliminating discrimination and promoting equality when policies are being developed. Information about due regard can be found on the Equality page on e-source and/or by contacting the LPT Equalities Team. The due regard assessment template is Appendix 7 of this document.

Definitions that apply to this policy CD

A bacterium that normally lives in the large intestine and can cause inflammation of the bowel with associated symptoms of diarrhoea if it increases in numbers

CDT The toxins produced by clostridium which cause the symptoms of the disease.

Consultant in Health Protection

A consultant for Public Health England who is knowledgeable in Infectious Diseases

Care Quality Commission (CQC)

Independent health and adult social care regulator.

Extended Spectrum Beta Lactamases (ESBL’s)

Bacteria that produce enzymes called ESBLs, which are resistant to many penicillin and cephalosporin antibiotics and often to other types of antibiotic.

Health Care Associated Infection

Any infection by any pathogen acquired as a consequence of a healthcare intervention or which is acquired by a healthcare worker in the course of his or her duties

Health Care Premises

Where care or services are delivered to a person related to the health of that individual

Meticillin Resistant Staphylococcus Aureus (MRSA)

A type of Staphylococcus aureus bacteria resistant to certain antibiotics, including methicillin and many other commonly prescribed antibiotics

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1. Purpose of the Policy This document provides and promotes robust infection and prevention control systems to ensure clean environments and good evidence based practices to minimise the risk of health care associated infection (HCAI) to patients, staff and visitors. It aims to assist Leicestershire Partnership Trust (LPT) managers, staff and other healthcare workers to understand LPT infection prevention and control plans and recommended practices so they can work toward implementing good practice. It supports the implementation of the Health and Social Care Act 2010 in ensuring LPT meets statutory and mandatory requirements as identified by the Care Quality Commission (CQC). 2. Summary and Key Points

This policy sets out arrangements for the roles and responsibilities and accountabilities of staff for infection prevention and control within LPT and provides assurance that these arrangements meet the requirements of the Health and Social Care Act 2008 (updated 2015). This policy confirms LPT’s commitment to the prevention and control of infection. It is supported by documents at a local and national level and outlines key processes and procedures in relation to diseases and care provided to patients and service users by staff working within the remit of LPT. It outlines the requirements for all clinical staff in regard to attending mandatory infection prevention and control training which is appropriate to their role. The policy support the development of systems to ensure that surveillance of HCAIs meets local, regional and national requirements. Further guidance for healthcare workers and other staff who work in Prisons and places of detention can be found in ‘Prevention of infection and communicable disease control in prisons and places of detention – A manual for healthcare workers and other staff’

3. Introduction Prevention and control of healthcare associated infection is part of the overall clinical governance and risk management strategy within the healthcare setting. LPT is committed to providing high quality patient services and promoting high standards of infection prevention and control practice thus the rationale for this policy. Basic hygiene and infection prevention and control are important in protecting the health of the public. Evidence suggests that up to 30% of healthcare associated infections are preventable through adherence to good infection control procedures. The Health and Social Care Act 2008 (updated 2015) Code of Practice for the Prevention and Control of Health Care Associated Infections sets out key activities that should be undertaken by all NHS organisations with respect to good practice. Furthermore, the Department of Health (DH) has produced the Essential Steps to

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Safe, Clean Care: reducing healthcare-associated infections in Primary Care Trusts (DoH 2007).

This document and its associated policies within the remit of infection prevention and control provide a framework to assist organisations in embedding good infection prevention and control throughout the health and social care settings. These systems need to be at the heart of all clinical and management practice. Consideration should be given to the range and types of environment within LPT where infection can occur, and the systems in place to support prevention and control of infection/ decontamination. All staff must possess an appropriate awareness of their role in the prevention and control of infection in their area of work. Not only is this part of their professional duty of care to the patients with whom they are involved, but also their responsibility to themselves, to other patients and members of staff under the Health & Safety at Work Act (1974). The Control of Substances Hazardous to Health (COSHH) Regulations (2002) requires actions to be taken to control the risk of hazardous substances, including biological agents. LPT has a Service Level Agreement with University Hospitals of Leicester (UHL) Microbiology Department. UHL Microbiology Department and Public Health England (PHE) provide expert advice on management of incidents and infection control outbreaks. LPT recognise the need for infection prevention and control to form an integral part of all service planning and development, including induction, on-going training, clinical audit and surveillance. 4. Infection Prevention and control Policy 4.1 Assurance The Infection Prevention and Control Committee receive assurance on the progress of the annual programme of work and annual audit programme. The Terms of Reference outline the responsibilities of the directorates to ensure compliance is monitored, this is reflected in the Terms of Reference (Appendix 3). Reporting mechanisms regarding governance and assurance to the committee from the directorates is identified in Appendix 4. 4.2 Infection prevention and control incidents Staff must report all incidents pertaining to infection prevention and control in accordance with LPT reporting procedures. This will include non-adherence with infection prevention and control procedures. Habitual non-adherence to the policy may result in disciplinary action being taken. Root cause analysis will be used to investigate serious incidents to determine system failure or care delivery problems. Criteria for defining an infection control incident include but are not limited to:

• Adverse effect on the activity of Inpatient Beds • Closure of beds

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• Cancellation of procedures • Failure to comply with infection prevention and control policies and

guidelines • Increased incidence/outbreak of infection • Death associated with Clostridium difficile • Death associated with MRSA • Bowel surgery associated with Clostridium difficile • MRSA Bacteraemia • Water management issues • Legionella • Sharps injuries •

An e-IRF incident report form must be completed for each of the above through the safeguard system. Serious Incident report (SI)/Root Cause Analysis (RCA) must be commenced for the following identified as community acquired infections:

• Toxin positive Clostridium difficile • Death associated with Clostridium difficile • Death associated with MRSA • Bowel surgery associated with Clostridium difficile • MRSA Bacteraemia • Increased incidence/outbreak of infection resulting in closure of a

ward 4.3 Information available to the public, patients and staff LPT has established its own website and makes information available to the public on a variety of infection control issues. The website has an area dedicated to Infection Prevention and Control, with information which includes:

• Policies • Patient leaflets • Contact details • Relevant websites • IPC documents i.e. annual report • Newsletters • Learning and Development information • Videos and short films • Statutory and Mandatory documents

The website can be accessed at http://www.leicspart.nhs.uk/ . 5.0 Duties within the Organisation The Trust Board has a legal responsibility for Trust policies and for ensuring that they are carried out effectively. Trust Board Sub-committees have the responsibility for ratifying policies and protocols.

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Chief Executive Officer The Chief Executive Officer (CE) of Leicester Partnership Trust is responsible for ensuring that there are effective arrangements for infection prevention and control within the organisation. The CE devolves responsibility for infection prevention and control (IPC) to the Trust’s Director of Infection Prevention and Control (DIPaC) Director of Infection Prevention and Control (DIPaC) (Chief Nurse/Deputy Chief Executive) The DIPaC is responsible for LPT’s Infection prevention and control strategy, implementation of the annual IPC programme and for providing assurance on IPC to the Trust board, Quality Assurance Committee and the general public. The DIPaC delegates the duties, in so far as they are applicable to the Deputy DIPaC. Deputy DIPaC (Head of Professional Practice and Education) The Deputy DIPaC is responsible the integration of IPC into the organisation Clinical Governance Systems and for ensuring the safety of patients from infection is a priority. Directorate Directors and Heads of Service are responsible for: Ensuring that comprehensive arrangements are in place regarding adherence to this policy and how policies and procedures are managed within their own department or Service in line with the guidelines in this policy. Ensure that team managers and other management staff are given clear instructions about policy arrangements; to enable them to instruct staff under their direction. Distribute information about this policy and associated procedures in a timely manner throughout the directorate. Ensure that all staff have access to this policy, either through the intranet or if policy manuals are maintained all the policies are the most up to date policies and are replaced as required. Maintain a system for recording that this policy has been distributed to and received by staff within the directorate and these records are available for inspection upon request for audit purposes. Managers and Team leaders are responsible for: Ensuring this policy is followed and understood as appropriate to each staff member’s role and function. The information in this policy must be given to all new staff on induction. It is the responsibility of managers and team leaders to have in place a local induction that includes this policy.

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Ensuring that staff new to the Trust attends Occupational Health (OH) to ensure that they have been screened and their immunisations are up to date (as applicable). Ensure that their staff know how and where to access current policies and procedures via the intranet. Ensuring that a system is in place for their area of responsibility that keeps staff up to date with new polices and policy changes and any recommended training related to policies. All staff All employees of the Trust have a responsibility to be aware at all times of their responsibility in ensuring Infection Prevention and Control requirements are met. Staff should ensure they are aware of how to access all policies and information pertaining to their role in the remit of Infection Prevention and Control. It is the responsibility of each individual member of staff to ensure they are appropriately trained and competent in the subject of Infection Prevention and Control and specific relation to their role. Any member of staff not feeling competent in the subject of Infection Prevention and Control must seek further training/advice from their manager. Where the adherence to Infection Prevention and Control procedures is comprised and causes or harm or presents a risk of harm to patients, this should be reported on the Trusts incident reporting system ‘Safeguard’ and in line with the Incident Reporting Policy. Infection Prevention and Control Team The Infection Prevention and Control Team work city and county wide across the health care economy of Leicester, Leicestershire and Rutland, working in partnership with primary care services, acute hospital trusts and statutory and independent care agencies to prevent and reduce communicable disease, healthcare associated infections and vaccine preventable disease. The key roles and responsibilities are summarised:

• Support and provide evidence of compliance with the Health and Social Care Act 2010, Care Quality Commission etc.

• Provision of clinical advice to health care professionals in the prevention, reduction and control of healthcare associated infections, communicable diseases and decontamination.

• Develop, review and maintain effective infection prevention and control policies and guidelines

• Advise on the implementation of national infection control initiatives • Support the provision of an infection control training programme • Develop, support and monitor the implementation of the infection prevention

and control annual programme of work

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• Develop, support and monitor the implementation of the infection prevention and control annual audit programme

• Provide clinical advice on the design/refurbishment of clinical premises • Advise on the procurement of products • Advise on the development of new services in line with national directives

or local requirements • Support staff and provide advice in relation to risk management and root

cause analysis processes in the remit of infection prevention and control • Support research programmes • Investigate incidents and support organisational lessons learnt and provide

reports and training as indicated Medical Devices Asset Manager (MDAM) It is the responsibility of the MDAM to:

• Lead a Medical Devices Group (MDG) that includes representation from Divisions including clinical, management, infection control, risk management, training, procurement and finance staff

• Ensure the MDG monitors medical device related incidents and supports investigations where necessary

Health and Safety Team/Advisors:

• Provide competent advice and guidance on health and safety related issues that relate to infection prevention and control issues.

• Support the IP&C and Health and Safety agenda , by seeking assurance from within LPT to demonstrate that management arrangements are in place and effective in particular relation to waste, water management and sharps incidents

• Review health and safety related incidents, including those involving waste, and may identify individual incidents for further investigation or follow up.

Procurement Team Procurement of products and medical devices is currently carried out by the Leicestershire and Rutland NHS Procurement Partnership. The Procurement Partnership’s main responsibilities are:-

• To purchase healthcare products and medical device goods or services on behalf of LPT, ensuring they meet the required quality standards and indemnities

• To comply with the Trusts Standing Financial Instructions (SFI) and Standing Orders (SO) and relevant EU and UK legislation

• Provide value for money • Add value to non-stock requisitions • Make savings

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• Negotiate contracts for healthcare products and medical device goods and services

• Provide advice and support in obtaining competitive quotations and ensuring Occupational Health OH Services are currently provided to staff within LPT by an OH Physician and a team of Nurse Advisors. This service provides OH to all LPT employees. It is the responsibility of the team to:

• Develop policies and procedures which are consistent across the NHS in Leicester.

• Provide advice on OH quality standards for both medical and nursing staff. • Support the delivery immunisation and vaccination services for staff. • Receive and support referrals of ill-health, sickness management, return to

work, fitness to practice and utilise the teams experience of complex health 6.0 Training

There is a need for training identified within this policy. In accordance with the classification of training outlined in the Trust Learning and Development Strategy this training has been identified as mandatory training and role development training The course directory e-source link below will identify: who the training applies to, delivery method, the update frequency, leaning outcomes and a list of available dates to access the training. http://www.leicspart.nhs.uk/Library/AcademyCourseDirectory.pdf A record of the event will be recorded on ULearn. The governance group responsible for monitoring the training is the Quality Assurance Committee (QAC) 7.0 Monitoring Compliance and Effectiveness The infection prevention and control committee has a responsibility to review and support the development of this policy. Appropriate stakeholders will also be involved in the policy development and includes the Health Protection Team for Public Health England. This policy has been developed in line with the health and Social Care Act (2008) Code of Practice on the prevention and control of infections and related guidance. DH recommendations have also been incorporated into the development of this policy.

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Policy Monitoring Section Criteria Number & Name: 4.3 Infection Prevention and Control Policies Duties outlined in this Policy will be evidenced through monitoring of the other minimum requirements Where monitoring identifies any shortfall in compliance the group responsible for the Policy (as identified on the policy cover) shall be responsible for developing and monitoring any action plans to ensure future compliance. Reference Minimum

Requirements Self-assessment evidence Process for Monitoring Responsible

Individual/Group Frequency of Monitoring

4.3 The trust must have policies in place to inform and support staff in clinical practice, and other practices that are relevant to the infection prevention and control agenda

Policies required as stipulated by the Health and Social Care Act 2008, updated 2015. Management of animals and pets in healthcare. Aseptic Non-touch technique and clean technique Management of chickenpox and shingles Management of infectious events and exclusion from childcare and school for childhood infections Cleaning and

Policy status timetable Policies reviewed and accepted through the IPC committee and confirmed through Quality Assurance Committee Incidents reported on Safeguard, reviewed on a monthly basis Reports are produced and discussed at the Health and Safety and Infection Prevention and Control Committee’s

Infection Prevention and Control Team

Policy timetable included in the annual report Policy timetable reviewed through the bi-monthly IPC committee Polices formally reviewed Bi-annually (or as required If sooner)

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decontamination of equipment, medical devices and the environment, (including the management of blood and body fluid spillages) Collection, handling and transportation of specimens Management of extended spectrum beta-lactamase producing organisms Management of patients with suspected or confirmed diarrhoea and/or vomiting Food hygiene for ward kitchens Hand hygiene Management of head lice Management of an increased incidence or outbreak of infection – strategic

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Management of an increased incidence or outbreak of infection at ward level Linen and laundry Management of meningitis Management of Meticillin Resistant Staphylococcus Aureas (MRSA) Notifying known or suspected infectious diseases Personal protective equipment for use in healthcare Management of patients with scabies Management of sharps and exposure to blood borne viruses Management of a patient requiring source isolation precautions

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Staff health relating to communicable disease Transmissible spongiform encephalopathy (TSR) including Creutzfeldt-Jacob Disease (CJD) variant CJD (vCJD) Management of patients with Tuberculosis

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8. Links to Standards/Performance Indicators

This policy links to the Care Quality Commission Outcome 8 - Appendix 6 LPT Infection Prevention and Control Committee will monitor the need for the development of new guidance and the review of existing policies. These will be included in the LPT Infection Prevention and Control Annual Programme, which will set priorities and timescales for implementation. LPT Infection Prevention and Control Policy will be subject to a review every three years (unless new guidance or evidence is available prior to this). Associated will be subject to a review every three years and be amended in line with newly published evidence or national guidance.

9. References and Bibliography The following associated documents to support the Infection Prevention and Control agenda are available on the LPT trust intranet: http://www.leicspart.nhs.uk/_SupportServices-

• Overarching Infection Prevention and Control Policy • Hand Hygiene • Personal Protective Equipment • Aseptic Non Touch Technique • Management of a Patient who has died (Cadaver) • Childhood Infections • Animals in Healthcare • Cleaning and Decontamination • Collection, Handling and Transport of Specimens • Staff Health relating to communicable Infections • Management of Head Lice • Management and Treatment of Chickenpox and Shingles • Management of Scabies • Management of Sharps and Exposure to Blood Borne Viruses • Meningitis • Notifying Known or Suspected Infectious Diseases • Source Isolation • Management of Tuberculosis • Management of Meticillin Resistant Staphylococcus aureus • Management of Increased Incidence or Outbreak of Infection • Management of Known or suspected Diarrhoea and Vomiting • Food Hygiene in Ward Kitchens • Linen and Laundry • Management of ESBL’s • Transmissible Spongiform Encephalopathy (TSE) including Creutzfeldt-Jacob

Disease (CJD) Variant CJD (vCJD

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This policy was drafted with reference to the following: Department of Health (2006). Standards for Better Health. DH: London

Department of Health, (2007). Essential steps to safe, clean care: Reducing healthcare-associated infections. DH: London Department of Health (2008). The Health Act 2008 – Code of Practice for the Prevention and Control of Healthcare Associated Infections. DH: London

Health and Safety at Work Act (1974). London: The Stationary Office.

NHS Litigation Authority, 2009/10. Risk management Standards for Acute Trusts, Primary Care Trusts and Independent Sector Providers of NHS Care.

The Control of Substances Hazardous to Health (COSHH) Regulations, (2002). Statutory Instrument No. 2677 (online). London: The Stationary Office.

NICE Clinical Guideline 2 - Prevention of Healthcare Associated Infection in Primary and Community Care (2010) Prevention of Infection & Communicable Disease Control in Prisons & Places of Detention – A manual for Healthcare Workers and other Staff. August 2011. © Health Protection Agency. HPA Gateway Reference: HPA11-02.DH Gateway reference: 16314.

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Training Needs Analysis

Training topic: Infection Prevention and Control Training Hand Hygiene training

Type of training: Mandatory (must be on mandatory training register) Role specific

Division(s) to which the training is applicable:

√ Adult Learning Disability Services √ Adult Mental Health Services √ Community Health Services √ Enabling Services √ Families Young People Children √ Hosted Services

Staff groups who require the training:

All staff for Induction and mandatory training Clinical staff will undertake role specific training

Update requirement: Hand hygiene and clinical mandatory training is required every two years General mandatory training is every 3 years

Who is responsible for delivery of this training?

Clinical mandatory training will be delivered by the IP&C team. The Learning and Development department will provide training for induction and other associated sessions Training for issues picked up in regards to IPC incidents will be provided as required by the IP&C team

Have resources been identified?

All sessions are available either via the learning and development department or via eLearning.

Has a training plan been agreed?

The core components of the policy are supported in mandatory training

Where will completion of this training be recorded?

√Trust learning management system

How is this training going to be monitored?

Learning and Development - ULearn IPC Committee where required QAC receive training figures

Appendix 1

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The NHS Constitution

NHS Core Principles – Checklist

Please tick below those principles that apply to this policy The NHS will provide a universal service for all based on clinical need, not ability to pay. The NHS will provide a comprehensive range of services

Shape its services around the needs and preferences of individual patients, their families and their carers

Respond to different needs of different sectors of the population

Work continuously to improve quality services and to minimise errors

Support and value its staff

Work together with others to ensure a seamless service for patients

Help keep people healthy and work to reduce health inequalities

Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

Appendix 2

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Infection Prevention and Control Committee Terms of Reference

References to “the Committee” shall mean the Infection Prevention and Control (IPC) Committee 1.0 Purpose of Committee 1.1 The purpose of the committee is to maintain an overview of Infection

Prevention and Control priorities within the Trust. The Committee provides assurance to Trust Board through direct reporting to the Quality Assurance committee on IPC activity across the trust.

1.2 The committee will:

I. Identify key standards of IPC as part of the trusts clinical governance programme and disseminate as agreed actions.

II. Ensure that the IPC annual programme is developed and disseminated to the directorates with actions monitored through this group.

III. Ensure that appropriate IPC policies and guidelines are in place and monitored in line with the Health and Social Care Act and CQC compliance.

IV. Ensure monitoring of compliance for training and development in relation to IPC and receive assurance on content and quality of training provided.

V. Report on trends identified by IPC surveillance and provide the appropriate support, advice and information, ensuring it is disseminated to clinicians, managers and others as deemed necessary.

VI. Agree the annual infection control audit programme and disseminate the information to the directorates to ensure its implementation.

VII. Receive and monitor action plans following increased incidences, outbreaks and Serious Incidents in relation to IPC

VIII. Ensure compliance with antimicrobial stewardship arrangements and monitor antimicrobial consumption.

IX. Present the annual infection prevention report to Trust board X. Provide relevant information and monitor the delivery of agreed local

and national IPC targets for divisions and the organisation

Appendix 3

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2.0 Clinical Focus and Engagement 2.1 The Trust considers clinical engagement and involvement in Board decisions

to be an essential element of its governance arrangements and as such the

Trust’s integrated governance approach aims to mainstream clinical governance into all planning, decision-making and monitoring activity undertaken by the board.

3.0 Authority 3.1 The committee is authorised by the Quality Assurance Committee to conduct

its activities in accordance with its terms of reference. 3.2 The committee is authorised by the Quality Assurance Committee to seek

any information it requires from any employee of the Trust in order to perform its duties.

4.0 Membership 4.1 The Infection Prevention and Control Committee is chaired by the Chief

Nurse/Deputy Chief Executive. 4.2 Deputy Chair will be the Head of Professional Practice and Education. 4.3 The membership of the committee is listed in the Annex 4.4 The membership of the committee will comprise of the necessary persons to

ensure that operational practices across the trust comply with the Health and Social Care Act 2008 (updated 2015) and all other pertinent NHS best practice standards e.g. CQC, NICE.

4.5 The committee will be made up of members who must attend regularly and

meet the 75% attendance criteria and attendees who will need to attend when they have papers to present as per the reporting schedule when requested to do so for specific agenda items.

4.6 Only members of the committee have the right to attend committee meetings.

However, other individuals and officers of the Trust may be invited to attend for all or part of any meeting as deemed appropriate.

4.7 Membership of the committee will be reviewed and agreed annually with the

Quality Assurance Committee. 5.0 Secretary 5.1 Secretarial support will be provided from the Professional Standards Team 6.0 Quorum 6.1 The quorum necessary for the transaction of business shall be six members;

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representation of this group must include; Chair/Deputy Chair, Lead Nurse from each directorate (or designated other), and an IPC nurse. A duly convened meeting of the Committee at which a quorum is present shall be

Competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee.

6.2 Any meetings that are not quorate will continue and any decisions made will

be ratified by those absent within 10 days of the meeting. A record of these agreements made to be held by the secretary of the meeting.

7.0 Frequency of Meetings 7.1 The Committee shall normally meet bi-monthly and at such other times as

the Chair of the Committee shall require at the exigency of the business.

7.2 Members will be expected to attend at least three-quarters (75%) of all meetings. (Attendance will be reported in the annual report)

8.0 Agenda/Notice of Meetings 8.1 Unless otherwise agreed, notice of each meeting confirming the venue, time

and date together with an agenda of items to be discussed, shall be forwarded to each member of the Committee, and any other person required to attend, no later than 5 working days before the date of the meeting. Supporting papers shall be sent to Committee members and to other attendees as appropriate, at the same time.

9.0 Minutes of Meetings 9.1 The secretary shall minute the proceedings and resolutions of all Committee

meetings, including the names of those present and in attendance. 9.2 Minutes of Committee meetings shall be circulated promptly to all members

of the Committee and, once agreed, to the secretary of the Quality Assurance Committee. The Committee’s minutes will be open to scrutiny by the Trust’s auditors.

10.0 Duties The Committee shall: 10.1 Receive summaries and action points from the directorates to seek

compliance in line with local and nationally agreed priorities, and provide support to these groups where necessary.

10.2 Maintain and provide updated summaries from all directorates regarding

assurance of the annual work programme for infection prevention and control.

10.3 Maintain and provide updated summaries from all directorates regarding

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assurance of the annual audit programme for infection prevention and control.

10.4 Communicate exceptions and risks to the Quality Assurance Committee 11.0 Reporting Responsibilities: 11.1 The Committee shall make whatever recommendations to the Quality

Assurance Committee it deems appropriate on any area within its remit where action or improvement is needed.

11.2 The Committee shall produce for the Quality Assurance Committee an

annual report on the work it has undertaken during the course of the year. 12.0 Annual Review 12.1 The Committee shall, at least once a year, review its own performance,

constitution and terms of reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the Quality Assurance Committee for approval.

13.0 Risk Responsibility 13.1 The risk areas the Committee has special responsibility for will be those that

fall within the remit of this Committee, and that require monitoring as identified by external verifiers or assessors of the service including the CQC.

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Annex – Membership of the Committee

Chief Nurse/ Deputy Chief Executive

Head of Professional Practice and Education

Senior Nurse Advisor – Infection Prevention and Control

Infection Prevention and Control Nurse(s)

Estates and Facilities shared service representative

Consultant Microbiologist

Occupational Health Practitioner

Directorate Lead Nurse (or delegated deputy) for:

o Community Health Service

o Families, Young People and Children

o Adult Learning Disabilities/Adult Mental Health

Property Manager, LPT estates and facilities

Head of Health and Safety Compliance

Podiatry Manager

Antimicrobial Prescribing Lead

Adhoc representation

Public Health England East Midlands

Emergency Planning Lead

Tissue Viability Lead

Training Delivery Manager

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Appendix 4

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Contribution List Key individuals involved in developing the document

Name Designation Amanda Hemsley Senior Nurse Advisor, Infection Prevention and Control Antonia Garfoot, Mel Hutchings, Annette Powell, Andy Knock, Julie Williams

Infection Prevention and Control Team

Circulated to the following individuals for consultation

Name Designation Adrian Childs Chief Nurse/Deputy Chief Executive Vic Peach Head of Professional Practice and Education Joanne Wilson Lead Nurse, FYPC Emma Wallis Lead Nurse, Physical Health – CHS Division Kam Palin Occupational Health Nurse

Kathy Feltham Lead Nurse, MHSOP, CHS Division Claire Armitage Lead Nurse, AMH&LD community Michelle Churchard Smith Head of Nursing, AMH&LD, Inpatient Tracey Yole Lead Nurse, Community, CHS Bernadette Keavney Head of Trust Health and Safety Compliance Liz Tebbutt Performance and Quality Assurance Manager Gregory Payne Training Delivery Manager Amin Pabani Podiatry Manager Anita Patel Project Administrator Jane Capes Senior Matron, AMH/LD Liz Compton Senior Matron AMH/LD Katie Willets Senior Nurse, FYPC Tejas Khatau Lead Pharmacist, FYPC Zoe Gilbert Senior Matron for Prisons

Appendix 5

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Outcome 8: Cleanliness and infection control

People should be cared for in a clean environment and protected from the risk of infection.

Cleanliness and infection control providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. Outcome 8 Compliance Criterion

Key Performance Indicator

1 Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them.

2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections

3 Provide suitable accurate information on infections to service users and their visitors

4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion

5 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people

6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection

7 Provide or secure adequate isolation facilities 8 Secure adequate access to laboratory support as

appropriate 9 Have and adhere to policies, designed for the

individual’s care and provider organisation’s, that will help to prevent and control infections

10 Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care

Appendix 6

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Due Regard Screening Template

Section 1 Name of activity/proposal Infection Prevention and Control Overarching

Policy Date Screening commenced 7 June 2017

Directorate / Service carrying out the assessment

Infection Prevention and Control Team

Name and role of person undertaking this Due Regard (Equality Analysis)

Amanda Hemsley, Senior Nurse Advisor, Infection Prevention and Control

Give an overview of the aims, objectives and purpose of the proposal: AIMS: To provide clear guidance to Trust staff on their responsibilities in relation to infection prevention and control. OBJECTIVES: Infection Prevention and control safety is a legal requirement under the Health and Safety at Work Act 1974. This document provides information on the processes required for the cleaning and decontamination of equipment and the environment for patients receiving healthcare. This will support the prevention of cross infection within the organisation and ensure staff are aware of the process and roles and responsibilities of individuals within LPT in the remit of infection prevention and control. Section 2 Protected Characteristic If the proposal/s have a positive or negative impact

please give brief details Age

This document provides guidance on the roles and responsibilities of all staff working within the trust in relation to the prevention and control of infection. Therefore the correct implementation of this policy will help reduce any adverse effect irrespective of any protected characteristic and is therefore equality neutral

Disability Gender reassignment Marriage & Civil Partnership Pregnancy & Maternity Race Religion and Belief Sex Sexual Orientation Other equality groups?

Section 3 Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below.

Yes No High risk: Complete a full EIA starting click here to proceed to Part B

Low risk: Go to Section 4. √ Section 4 If this proposal is low risk please give evidence or justification for how you

Appendix 7

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reached this decision: This policy is the overarching policy for all subsequent infection prevention and control policies. The policies take into consideration the needs of patients and staff and the safeguarding of same. It follows government legislation and relevant bodies have been consulted prior to the development of any policies prior to having them agreed at trust board level. Signed by reviewer/assessor Amanda Hemsley Date Sign off that this proposal is low risk and does not require a full Equality Analysis Head of Service Signed Date