TRUST BOARD

SEPTEMBER 2012
ANNUAL INFECTION CONTROL PLAN
Purpose:

For Ratification

Author:

Mary Ayton, Lead infection control Nurse

Lead Director:

Christopher Tibbs, Medical Director

EXECUTIVE SUMMARY
The plan lays out the framework and objectives of the Trusts infection control strategy for the
current year
1.

INTRODUCTION
For compliance with The Health and Social Care Act 2008, the Trust needs to meet Outcome 8
of the Care Quality Commission (CQC) registration requirement for cleanliness and infection
control: People should be cared for in a clean environment and protected from the risk of
infection.

2.

MAIN CONSIDERATIONS
2.1. Surveillance: To undertake surveillance which is compliant with national requirements
and designed to achieve reduction in HCAI Audit of compliance with infection control
measures and establishments of tolerance limits for 2012-13
2.2. Audit: Monitor compliance with IC Policies/Guidance through the IC Audit Programme
2.3. Training: Providing educational IC framework for all HCWs through adherence to the
statutory and mandatory training policy
2.4. Policies and Guidelines: To maintain and enhance IC Policy and Guidance to include
national standards and local results with audit and monitoring reports Maintaining a
contemporary and up to date set of infection control policies
2.5. Decontamination: To comply with National and EU regulations
2.6. Cleanliness: To comply with national guidance on cleanliness standards and provide
patients and visitors with a clean hospital environment
2.7. Antibiotic prescribing: To promote prudent antimicrobial prescribing for the
management of antibiotic resistance and reducing antibiotic related CDI and other HCAI
2.8. Estates: To ensure hospital premises are designed and built to facilitate the prevention
and control of infection

3.

RISK MANAGEMENT IMPLICATIONS RELATIONSHIP WITH ASSURANCE FRAMEWORK

Integral requirement of CQC and NHSLA standards and compliance with legislation

4.

CONCLUSIONS and RECOMMENDATIONS

The Infection control plan sets out the appropriate actions to maintain a clean and safe
environment in the Trust and to minimise the risk of infection to patients and staff
The Trust Board is recommended to ratify this plan.

RSCH Infection Control Plan 2012-13

For compliance with The Health and Social Care Act 2008 The Trust needs to meet Outcome 8 of the Care Quality Commission (CQC) registration
requirement for cleanliness and infection control: People should be cared for in a clean environment and protected from the risk of infection.
Objective

Action

Timescale

Lead

Surveillance -

MRSA bacteraemia (MRSAB)

April 2012- March 2013

Mary Ayton

To undertake surveillance
which is compliant with
national requirements and
designed
to
achieve
reduction in HCAI

DH Objective for 2012-13 = 1

Reported monthly to HPA via the HCAI
data capture system (DCS)
RCA for all cases
Christopher Tibbs

MSSA bacteraemia (MSSAB)

April 2012- March 2013

Mary Ayton

No objective set
Reported monthly to HPA via the HCAI
DCS
RCA for RSCH apportioned cases
Christopher Tibbs

Clostridium difficile (CDI)

April 2012- March 2013

DH Objective 2012-13 = 22
RSCH Internal Objective 2012-13 = 15
Reported monthly to HPA via HCAI DCS
RCA for RSCH apportioned case or death

Mary Ayton

Christopher Tibbs

Progress

Objective

Action

Timescale

Lead

E-coli bacteraemia

April 2012- March 2013

Mary Ayton

January June 2012

Mary Ayton

Ongoing

Marian Hunt

April 2012- March 2013

Christopher Tibbs

No objective set
Reported monthly to HPA via the HCAI
DCS

GRE positive blood cultures

Progress

No objective set
Reported quarterly to HPA via HCAI DCS

Monthly provision of HCAI data

Feedback and communication via TrustNet and
G:\Shared\TrustWide\INFECTION
CONTROL
TEAM FOLDER (Managed by ICT)\HCAI Monthly
Surveillance Data

Outbreaks/Incidents
Convene and minute Outbreak/Incident Outbreak
Meeting in liaison with Head of Patient Safety &
Quality, providing reports to commissioning and
monitoring groups as required

Objective

Action

Audit

Saving Lives

Monitor compliance with

IC
Policies/Guidance
through the IC Audit
Programme

Minimum
Compliance

Hand Hygiene

89%

Bare Below the Elbows (BBE)

88

Environment

80

Central VAD Insertion

93

Central VAD Care

90

Peripheral VAD Insertion

73

Peripheral VAD Care

83

Uretheral Catheter Insertion

72

Uretheral Catheter Care

82

Clostridium difficile (CDI)

74

SSI

92

VAP

90

Timescale

Lead

April 2012- March 2013

Helen Collins

Progress

Objective

Action

Timescale

Lead

April 2012- March 2013

Gill Hickman

Ongoing

Mary Ayton

Providing educational IC Infection Control Team will support a single

framework for all HCWs Infection Control Programme (100% compliance)
through adherence to the
statutory and mandatory
training policy
Update
Ongoing

Mary Ayton

ICNA

Compliance %

PPE

85

Isolation Rooms

85

Patient Equipment 85
Training

Induction

Infection Control Team will support all clinical

and non-clinical staff working in clinical areas to
receive an annual Infection Control Update via
planned training sessions or e-learning modules
(85% compliance)

Doctors

Ongoing

All new junior doctors to receive local

competency assessments (LCAs) in Infection
Control at time of Induction as well as completing
IC e-learning training tracker.

Louise Duffield

Progress

Objective

Action

Timescale

Lead

Hand Decontamination

Ongoing

Mary Ayton

All staff including contractors and volunteers to

receive hand decontamination training

Adopt a zero tolerance approach through

challenging non compliance and use of DIPC zero
Ongoing
tolerance letters

Policy/Guidelines

Planned programme of review/updating with March 2013

adherence to the policy on policies

To maintain and enhance

IC Policy and Guidance to
include national standards
Hand Decontamination Policy to NHSLA level 2
November 2012
and local results with audit
standard
and monitoring reports

Decontamination

Opening of new compliant Endoscopy Unit

To comply with National Review/updating

and EU regulations
Policy/Guidance

of

October 2012

Decontamination

Christopher Tibbs

Gill Hickman

Mary Ayton

Robin Jago
TBC

November 2012

Progress

Objective

Action

Timescale

Lead

Cleanliness

Ensure compliance with

Ongoing

Janet Carr

March 2013

Janet Carr

Ongoing

Maria Rana

Ongoing

Dr Papu De

Ongoing

Graham Maynard

To comply with national

National monitoring of standards
guidance on cleanliness
Education of Housekeeping staff
standards and provide
Peer and Public review of service
patients and visitors with a
Support of peer and public reviewers
clean
hospital
Compliance with annual PEAT Inspection
environment

Monthly patient environment audits (MEAT)

Antibiotic Prescribing

Use of IC data in relation to HCAI to

promote antimicrobial policies

To
promote
prudent
antimicrobial prescribing
for the management of
antibiotic resistance and
reducing antibiotic related
CDI and other HCAI

Audit

Continual review of antibiotic use as part

of the Stewardship Programme

Estates

Monthly Estate Meetings to review all

new builds and refurbishments. Sign off
of plans and pre-opening build by ICT in
line with National guidance and practice

To
ensure
hospital
premises are designed and
built to facilitate the
prevention and control of
infection

Progress