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of 87 Infection Prevention and Control Annual Report 2017-18

2017-18

INFECTION PREVENTION AND CONTROL

ANNUAL REPORT 2017-18

AND ANNUAL SERVICE PLAN FOR 2018-19

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Infection Prevention and Control Annual Report 2017-18

CONTENTS PAGE

Index Page

1. Introduction 5

1.1 Purpose of the report 5 1.2 Link to National Directives and Corporate Objectives 2017-18 6 1.3 Key achievements for 2017-18 6

1.4 Key areas of focus for 2018-19 6 1.5 Reporting arrangements and structure 7

2. Infection Prevention and Control Service Plan – 10 Dashboard Rating for 2017/18 3. Summary of the Service Plan Audit Processes for 2017-18 11

3.1 Infection Prevention and Control Audit Programme 11 3.2 Service User/Carer/Involvement joint audits 11

3.3 Antimicrobial audit – Mental Health and Learning Difficulties 11

4. Community Specifications Audits Service Level Agreement 12 Knowsley

5. Healthcare Associated Infection Surveillance and Incident Monitoring 12

5.1 Patient Story from Mental Health Services 12 5.2 Patient Story from Mental Health Services 13 5.3 Methicillin Resistant Staphylococcus Aureus 15

5.4 Clostridium Difficile 16 5.5 In-patient Weekly Surveillance Data 16 5.6 Incident Monitoring 17 5.7 Diarrhoea & Vomiting (D&V) outbreaks April 2017-March 2018 20 5.8 Diarrhoea & Vomiting outbreaks as part of Community 20 Specifications Knowsley 5.9 Other outbreaks 20 5.10 Risks 21 5.11 Hand hygiene compliance 21

6. Influenza Immunisation programme 20 6.1 North West Boroughs Healthcare Staff Influenza Immunisation 21 Programme

6.2 Inpatient Influenza Immunisation Programme 21 7. Summary, recommendations and conclusion 22

8. References 22 9. Appendix 1: Infection Prevention and Control Quality Committee 23 Quarterly Reports 2017/18 Appendix 2: Infection Prevention and Control Service Plan 2018/19 79

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1. Introduction

Infections can develop either as a result of healthcare interventions such as medical or surgical procedures, or from being in contact with a healthcare setting either as an in-patient or within the community. National Institute for Health and Care Excellence has estimated that 300,000 patients a year in England develop an infection as a result of care in the NHS.

Healthcare associated infections are defined as an infection developed as a direct result of treatment in or contact with a health or social care setting, as a result of healthcare delivery in the community or as a result of an infection originally acquired outside a healthcare setting by patients, staff or visitors and then transmitted to others within that setting.

The incidence and management of healthcare associated infections continue to be monitored nationally via the Care Quality Commission, with standards based on The Health and Social Care Act - Code of Practice on the prevention and control of healthcare associated infections and related guidance 2008. Northwest Boroughs Healthcare NHS Foundation Trust (the Trust) has declared compliance with these standards.

Infection Prevention and Control remains high on the National Health Service agenda. The key priority areas for improvement in 2017-18 remained focused on the continued reduction and prevention of healthcare associated infection such as Methicillin Resistant Staphylococcus Aureus (MRSA), Methicillin Sensitive Staphylococcus Aureus (MSSA) Escherichia coli (E-Coli) blood stream infections and Clostridium difficile toxin associated disease.

In May 2017, The Secretary of State for Health announced a focus on reducing Escherichia coli blood stream infections with an ambition to reduce the number of cases by 10% in the first year. As approximately three-quarters of Escherichia coli blood stream infections occur before people are admitted to hospital, reduction requires a whole health economy approach. The Infection Prevention and Control team have been collaborating with the Clinical Commissioning Groups who are leading on achieving this target.

The organisation does not have any Trust-specific trajectories for the above infections.

Healthcare associated infection rates remain extremely low within the Trust. Surveillance for all infections continues within the Trust and data is reported to the Infection Prevention and Control Committee on a quarterly basis. The annual figures are presented within this report. It is important to note that the majority of infections that occur within the Trust are not healthcare associated.

1.1 Purpose of the Report

The purpose of this annual report is to:

Outline the accountability and management of Infection Prevention and Control within the Trust, and the reporting arrangements of the Director of Infection Prevention and Control and the Infection Prevention and Control Team.

Present the Infection Prevention and Control Annual Report 2017-18 and the projected Infection Prevention and Control Annual Service Plan for 2018-19.

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Provide assurance on the delivery and impact of the Infection Prevention and Control Service Plan for 2017-18.

Provide verification and assurance, of the progress made towards the directives within The Health and Social Care Act - Code of Practice on the prevention and control of healthcare associated infections and related guidance 2008. 1.2 Link to National Directives and Corporate Objectives 2017-18

The Care Quality Commission core objectives of The Health and Social Care Act - Code of Practice on the prevention and control of healthcare associated infections and related guidance 2008 The Infection Prevention and Control Service Plan also links to and reflects the Trust objectives. Delivery of the Infection Prevention and Control Service Plan is dependent on collaboration with operational services and other teams within the Trust such as estates and facilities, risk management, audit department, occupational health and the immunisation team. The Infection Prevention and Control Service Plan demonstrates the continuing progress made in all of these areas over 2017/18.

1.3 Key achievements for 2017-18

During the past year the Trust has maintained and achieved in the following areas:

Continuing compliance with Care Quality Commission regulations relating to Infection Prevention and Control.

Continuing overall improvement in audit results across the Trust which reflects both improvements in Infection Prevention and Control practices, but also the environment, due to close working with estates and facilities and community partners.

Achieving commissioners’ community specifications for Knowsley which are provided via a service level agreement.

Continuing compliance with the Antimicrobial Prescribing Guidelines within inpatient wards.

Overall incidence of Healthcare Associated Infection remains low with one case of Clostridium Difficile and zero Methicillin Resistant Staphylococcus Aureus bacteraemia cases attributable to the Trust.

Achieving the national target for staff influenza immunisations

1.4 Key areas of focus for 2018-19

To continue to maintain a very low incidence of Healthcare Associated Infection within the Trust through education, training and surveillance.

To continue to maintain improved national cleaning standards.

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To continue to monitor new and resistant infections that may occur around the Trust and focus on education regarding antimicrobial resistance, to all prescribers within the Trust including non-medical prescribers.

To continue to enhance the learning environment around Infection Prevention and Control as a productive and quality placement for student nurses.

To promote and embed the ‘Early recognition of Sepsis’ through infection control training across the Trust.

To continue to work with associated specialties of estates, domestic services, and pharmacists to monitor, manage and address any areas of concern.

1.5 Reporting arrangements/structure

The Infection Prevention and Control Assurance Framework and reporting structures which were established and operational throughout 2017-18 are illustrated overleaf on page eight. Detailed quarterly progress and exception reports are presented to and monitored on behalf of the Board via the Infection Prevention and Control Committee and Quality Committee. Infection Prevention and Control audit reports, based on national guidance are sent each month to Matrons and Quality Leads, the audit covers environmental cleanliness, hand hygiene, decontamination, safe disposal of sharps and clinical waste. The Quality Committee received a quarterly report which includes the results of the Infection Prevention and Control audit, along with fridge temperatures, and cleaning standards. The reports are available in appendix 1.

Quarterly reporting of Healthcare Associated Infection incidence and outbreaks was provided to the Clinical Commissioning Groups via the Infection Prevention and Control Assurance Framework report.

Monthly performance reports were provided to Knowsley Clinical Commissioning Group and Knowsley Metropolitan Borough Council for assurance around the delivery of the Knowsley community specification.

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Going forwards for 2018-19, the quarterly report will be further disseminated to local Assistant Clinical Directors and Assistant Directors for each borough for inclusion in the borough Quality and Safety agendas as a standing agenda item under Infection Prevention and Control. The minutes from local Quality and Safety meetings will be reviewed at the Infection Prevention and Control Committee to gain assurance that risks and issues which have been highlighted have been addressed or escalated as required.

2. Infection Prevention and Control Service Work-Plan and Dashboard Ratings for 2017-18 The Infection Prevention and Control service work-plan and dashboard for 2017-18 was set out in line with the Trust’s seven strategic objective headings; and comprised of a total of 20 sub objectives. During the year the dashboard should progress through red, amber and finally to green by the end of March 2018. Of the 20 objectives identified within the work-plan, 18 objectives were rated as “green” having been fully met and the work the Team have completed is described in this report. Two areas were rated as “amber” due to the Infection Prevention and Control Committee

Trust Board

Chief Nurse and Executive Director of Operational Clinical Services (Dip C)

Quality Committee

Infection Prevention and Control Committee

Infection Prevention and Control Team

Infection Control Personnel Link

Groups include: Trust Link Nurses, General Practice

Links, Survice user carer Links

Matron Oversight of Clinical

Operational Services

Trust Quality and Safety Meeting

Local Borough Quality and

Safety Meetings

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agreeing these as having been partially met at the end of quarter four for 2017-18. These “amber” objectives are described below and have been carried forward to the work-plan for 2018-19.

Objective 1.3 - Comply with Mandatory requirement to reduce E coli bacteraemia by 50% by 2021.

The Position at end of Quarter Year Periods for 2017-18

Q1 Action plan not yet agreed with the Commissioners

Q2 Received action plans from Knowsley and St Helens. Need to arrange access to Data Capturing System. Work now to be planned to commence in Q3 Action plans amended as not feasible. Awaiting access to EMIS system before work can commence

Q4 Still awaiting access to EMIS system. Has been escalated to Information Governance. The team has been attending regional Blood Stream Infection workshops and reviewing national guidance. This will continue into work plan for 2018-19.

Objective 1.6 - To extend current infection control agenda to newly acquired services

The Position at end of Quarter Year Periods for 2017-18

Q1 -

Q2 Sefton Borough - this work has now commenced and advice has been given to teams in the new services and they are part of Trust mandatory training. Need to complete scoping exercise.

Q4 Sefton Services are now integrated with IPC audit programme and education. St. Helens and Halton services will shortly follow. This will continue into the work-plan for 2018-19

The summary dashboard ratings for 2017-18 at year end are described in the table two which is overleaf on page 10.

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Table 2: 2017/18 Service Plan Objectives INFECTION PREVENTION AND CONTROL SERVICE PLAN – SUMMARY DASHBOARD/RAG RATINGS FOR 2017-2018

Trust High Level Objectives 2017-18

CQC – Regulation 12 – Safe Care and Treatment incorporated into Trust objectives and other DOH directives – e.g. NICE Guidance, NHSLA, 6 Cs NB: The delivery of services will take account of the need to safeguard and promote the welfare of children as service users of the Trust or as visitors to the premises This Service Plan is based on financial year and includes Knowsley Community Specifications SLA

Points for Discussion/Noting from

service plan delivery/ Exception reporting

Q1 Q1 Q1 Q2 Q2 Q2 Q3 Q3 Q3 Q4 Q4 Q4

Objective No: Issue

1. ARE WE DELIVERING OUR SERVICES SAFELY? – 6 objectives

2 4 2 4 4 4 2 4

2. DO WE HAVE SUFFICIENT, HIGHLY MOTIVATED, SKILLED STAFF? – 3 objectives

1 2 1 2 1 2 3

3. ARE WE DELIVERING TO OUR PATIENTS AND USERS? – 4 objectives

4 4 4 4

4. ARE WE FINANCIALLY VIABLE? -1 objectives

1 1 1 1

5. DO OUR STAKEHOLDERS SUPPORT WHAT WE DO? – 2 objectives

2 2 2 2

6. ARE WE DELIVERING OUR STRATEGY? - 1 objectives

1 1 1 1

7. IS THE ORGANISATION AND ITS SERVICES WELL LED? – 3 objectives

3 3 3 3

Total 20 objectives 3 17 3 17 2 18 2 18

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3. Summary of audit processes for 2017-18 Infection Prevention and Control Service Plan

The objectives of the Infection Prevention and Control Service Plan are based on The Health and Social Care Act - Code of Practice on the prevention and control of healthcare associated infections and related guidance 2008 criteria as monitored by the Care Quality Commission. Therefore, the objectives incorporate these and also are mapped against National Institute for Clinical Excellence (NICE) guidance.

3.1 Infection Prevention and Control Audit Programme

An on-going audit programme remains a key feature of performance management within the Trust and is in place to monitor compliance with Infection Prevention and Control policies and procedures. This is based on the Infection Prevention Society national audit tools.

The Infection Prevention and Control Team continue to work closely with key Trust teams such as medicines management, risk management, health and safety, estates and facilities and patient advocacy and liaison services.

This audit programme is related to audits undertaken by the link practitioner in each clinical area. Additional audits are also undertaken and include unannounced spot-checks by Service User and Infection Prevention and Control Team. One issue which has been raised by the Estates team was that of recording fridge temperatures. It is importance that fridges for patient’s food are cold enough to prevent any bacterial growth. Activities to raise awareness about the importance of recording fridge temperatures amongst staff has been undertaken during March with targeted communication to all ward managers and articles via Trust Communications - In view and a jointly developed managers briefing note with Estates.

3.2 Service User/Carer/Involvement Joint Infection Prevention and Control Audits

Active participation within Infection Prevention and Control from service user and carer representatives continues. Service users and carers continue representation on the Infection Prevention and Control Committee, Link Personnel Groups and training events, as shown in the diagram in page eight.

They remain an essential part of the Trust Infection Prevention and Control Team they undertake ‘spot checks’ to quality assure the current audit programme undertaken by the Link Personnel. The pass rate is 90% and any ward that has a score less than 90% is provided with an action plan to improve the results and then the area is re-audited until their score is over 90%.

3.3 Antimicrobial Audits - Mental Health and Learning Disabilities

Quarterly antimicrobial audits are undertaken to determine the level of compliance with prescribing and documentation against the relevant antimicrobial prescribing and documentation standards, such as antibiotic appropriateness, course length stop dates and culture and sensitivity reports. It is a requirement of the Care Quality Commission that all Trusts, including Mental Health Trusts, have such standards in place and ensure that they are monitored. The Care Quality Commission requires the Trust to collect data every three months. This was collected March, June, September and December 2017.

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The Trust Antimicrobial Prescribing Guidelines, depending on locality, are available on the Trust intranet. A laminated copy can also be found in all in-patient ward clinic rooms.

The doctor’s induction programme includes specific information on antimicrobial prescribing and draws attention to the guidelines which are to help reduce the incidence of bacterial resistance and rebound infections such as Methicillin Resistant Staphylococcus Aureus bacteraemia and Clostridium Difficile.

Each quarterly report is presented to, and approved by, the Infection Prevention and Control Committee and the Medicines Management Committee on behalf of the Board.

4. Community Specifications Audits Service Level Agreement in Knowsley

The Trust Infection Prevention and Control Team have provided services to the borough of Knowsley in accordance with contractual agreements. The team have been responsible for the delivery of infection control education sessions, completion of audits in a variety of settings inclusive of care homes and General Practice Surgeries and completed 30 Clostridium Difficile root cause analysis. The Infection Prevention and Control team continues to respond to all reports of infectious diseases and conditions in both community healthcare and local population. The team monitors local epidemiology and surveillance reports to predict areas of risk and level of responses required. The team works closely with Public Health England, Clinical Commissioning Groups and Social care to ensure that information, advice and support is readily available. The team met all the service specifications for this year.

5. Health Care Associated Infection Surveillance and Incident Monitoring

The Infection Prevention and Control Team care for patients in many different settings. The following patient stories hope to demonstrate the specialist nursing skills used to support our patients and staff.

5.1 Patient Story from Mental Health Services

In May 2017 the infection control team was asked to assist in arranging of an admission of a patient identified as having a pan-resistant organism to one of the mental health inpatient wards. Pan resistance means that the patient was carrying a bacteria that was highly resistant to many antibiotics and ensuring this bacteria was not transmitted to anyone else was of paramount importance. The patient was to be transferred from the acute trust and required admission for assessment and management of a number of underlying mental health issues that had been identified. It was anticipated that this admission would be transient step before the patient could be fully discharge back to their own home environment.

Such an admission of a patient isolated with carriage of a pan-resistant organism poses a significant infection control management issue within mental health settings, as unlike the acute inpatient setting of a general medical ward, mental health wards pose unique infection control management difficulties that need to be considered. Such issues within mental health can see patients having to be managed in a clinical environment where there are multiple unpredictable factors that can impede routine practices. An example would be that routinely in an acute medical environment, such patients would be isolated, and however in this case practices such as isolation can often exacerbate underlying mental health issues and potentially lead to aggression and conflict.

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The discharge of the patient from the acute trust to the inpatient mental health ward required a significant amount of strategic discharge planning and saw the infection control team play a pivotal role in ensure the admitting ward and staff were appropriately prepared and aware of the infection control measures that would need to be introduced into practice to ensure there was not cross infection or onward transmission risks posed to other service users and staff.

The planning saw the Infection Prevention and Control Team act as a liaison for the admitting area between the acute trust, Public Health England, Quality Matron and clinical microbiologists for both the acute and community trusts. The team in conjunction with the aforementioned professionals undertook and initiated the following to ensure the patient was safely and appropriately managed:

Identification of the most suitable inpatient area that would lend itself to appropriate infection control measures in relation to potential isolation/hygiene and environmental factors.

The undertaking of staff Infection Prevention and Control training in relation to the identified organism and how and what infection control measures should be introduced into practice to reduce any risks of cross contamination and onward transmission.

Bespoke Infection Prevention and Control training for domestic staff to ensure the environment was appropriately cleaned and disinfected and did not create any unintentional reservoirs where such an organisms could thrive and pose an onward transmission risk.

Risk assessment of other service users to ensure there was no potential cross infection risks posed to them by the patient to be admitted.

Following the planning stage the patient was successfully transferred to the mental health inpatient area from the acute trust and successfully managed by the ward staff in conjunction with the stipulated guidance and the continued Infection Prevention and Control Team support. The patient remained an inpatient within the ward for an approximately four week duration and on review the patient was appropriately and effectively managed by the ward team with no evidence of any apparent onward transmission of the organisms to any other service users or staff. This incident was an effective learning opportunity for both the Infection Prevention and Control Team and ward teams as the admission of patients identified with pan resistant organisms is something that will be seen more frequently across all Trust sites and inpatient facilities.

5.2 Patient Story from Community Services

Staphylococcus Aureus-Panton-Valentine Leukocidin Positive outcomes - a multi-agency approach.

This is the story of 32 year old gentleman with a diagnosis of Staphylococcus Aureus-Panton-Valentine Leukocidin (SA-PVL). He has given his permission for this story to be published however for the purpose of this case study he will be referred to as Mr P.

Staphylococcus Aureus-Panton-Valentine Leukocidin simply put, is Staphylococcus aureus (a bacteria which naturally lives on the skin), which is producing a toxin Panton-Valentine Leukocidin that destroys white blood cells. It predominantly cause skin and soft tissue Infections (SSTI), but can also cause invasive infections. The most serious of these is a necrotising haemorrhagic pneumonia with a high mortality, which often follows

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a “influenza-like” illness, and may affect otherwise healthy young people in the community. Unlike the classic Staphylococcus Aureus infections which affect the Elderly, debilitated and/or critically ill or chronically ill, Panton-Valentine Leukocidin affects young healthy people, students, athletes, military service personnel. It is often spontaneous and causes cellulitis and skin abscesses. It is almost always community-acquired and spreads easily in close community settings e.g. families and sports teams. Often the patient has no significant medical history.

Mr P was referred to the Infection control team by a consultant microbiologist from an acute trust as we deliver infection control under a service level agreement to the borough of Knowsley. He was known to have an unconfirmed diagnosis of Staphylococcus Aureus-Panton-Valentine Leukocidin, which he reported had been documented on his army discharge notes. He had presented at Accident and Emergency department multiple times with large skin abscesses which required drainage and systemic antibiotic treatment. His lesions were swabbed and a confirmed diagnosis given.

As part of the Infection Prevention and Control follow up, contact tracing is conducted due to virulent, transmissible strains of Staphylococcus Aureus often associated with Panton-Valentine Leukocidin which are easily spread in close community settings. This is often requested by Public health England, as it was on this occasion.

The Infection Prevention and Control Team made contact with Mr P and arranged a home visit. It was at this home visit that the story got a lot more complex. Mr P lives with his wife and his two small children; he attends a gym regularly and is a competitive mixed martial arts wrestler. He reports that other members of the gym have also presented to their own General Practitioners with similar symptoms to himself, and that this has been an on-going issue for a number of years. The gym he attends is not in Knowsley. Infection Prevention and Control Team identified that the gym could possibly be a reservoir for Staphylococcus Aureus-Panton-Valentine Leukocidin, which would explain the recurring skin and soft tissue Infections to Mr P and that of other gym members.

What did Infection Prevention and Control Team do next?

*Infection Prevention and Control nurse visited Mr P’s General Practitioner, gave a full explanation of Staphylococcus Aureus-Panton-Valentine Leukocidin and provided the relevant guidance on treatment. *Arranged for prescriptions for every member of the household to be commenced together.

*Gave full clear explanations to all members of house hold on the intensive treatment required to decolonise the skin, nose and throat.

*Contacted the Gym owner and got details of the other cases, these were then passed on to Public Health England for further investigation as this was now a potential outbreak. *Contacted our infection control colleagues in the locality of the gym and advised of the situation, arranged for them to visit the gym to provide training, and to complete an Infection Prevention and Control audit.

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Why was it so important to visit the gym?

Infections can spread from the infected skin of one person to another and via commonly shared items such as razors, towels, benches and other sporting equipment.

The risk of skin infections can be greatly reduced by:

• carrying out good personal hygiene • ensuring the environment in which you train is clean and well maintained.

Our colleagues visited the gym; they provided a comprehensive teaching session around Staphylococcus Aureus-Panton-Valentine Leukocidin, the risks and how to prevent infection. They made several recommendations to the gym owner to ensure that the members were training in a clean safe environment.

What changes did the gym make?

*Introduced alcohol hand gel throughout the gym *Introduced detergent wipes for cleaning the equipment before and after use *Updated shower areas to ensure adequate cleaning can take place and installed foot wash areas. * Display hand hygiene posters *Display clean your equipment posters *Establish routine cleaning schedules for all equipment and facilities * Make sure athletes follow all cleaning schedules.

The training session was evaluated positively:

“Very informative” “Thanks so much for all the support from both infection control teams” “This has helped me to understand why I keep getting skin infections, and how I can keep myself infection free in the future”

On-going care

The Infection Prevention and Control Team have recently followed up on Mr P, he is still training hard at the gym, and he has been Panton-Valentine Leukocidin free since our intervention. The gym has adopted excellent hygiene standards and all other members of the gym have also been Panton-Valentine Leukocidin free.

5.3 Methicillin-Resistant Staphylococcus Aureus Overall, the incidence of infections such as Methicillin-resistant Staphylococcus aureus

and Clostridium Difficile are low within the Trust. A weekly surveillance programme is undertaken to include all organisms and Methicillin-Resistant Staphylococcus Aureus screening on admission data is collected monthly.

Methicillin-Resistant Staphylococcus Aureus screening on admission includes patients in risk groups such as those:

admitted from acute Trusts, nursing or residential homes

known to have a previous history of Methicillin-Resistant Staphylococcus Aureus

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who use intravenous drugs and have wounds or lesions

with any self-harm wounds or lesions

with any indwelling devices or chronic wounds Compliance with screening is monitored monthly and reported to the Board via the Infection Prevention and Control Committee. Although some patients do decline to be screened on admission, overall compliance is very good.

5.4 Clostridium Difficile The incidence of Clostridium difficile infection is monitored as part of the ongoing surveillance program and one healthcare associated case was identified in 2016 within the Trust. There was one case of clostridium difficile associated diarrhoea identified in a patient on Rydal Ward. The findings of the route cause analysis which is a usual Infection Prevention and Control Team process undertaken in such incidents, was discussed with the clinical team in an attempt to learn lessons and highlight areas of good practice and areas where improvement could be made. Lessons learnt and recommendations for changes to practice –

The prescribing of antibiotics based solely on urinalysis test strips is not advised and recommended if the patient asymptomatic to await full microscopy results.

The ward manager will instigate a formal handover process including appropriate documentation to ensure communication around patient care is clear and consistent.

The pharmacist recommended any antibiotics prescribed for patients should have start and stop dates and the appropriateness of antibiotic prescriptions re-checked after 2-3 days.

The incident to be described and discussed at next ward meeting to make staff aware of areas of good practice and discuss the lessons learnt.

The Infection Prevention and Control Team did commend Rydal ward on their excellent nursing care of the patient during this physical illness and their infection control practices as there was zero further cases.

5.5 In-Patient Weekly Surveillance

As a trust we collect and collate weekly surveillance form all our inpatient wards, detailing infections and antibiotic treatments for urinary tract infections, Chest infections, wound infections and skin infections amongst others. From this data we can monitor infections and antibiotic usage to ensure prescribing is in line with current formulary and monitor multi resistance. The surveillance programme highlights potential issues and enables prompt feedback to the clinical areas for action. It also allows us to look for common trends and themes to further support targeted work plans. During 2018/19 the team will be taking the opportunity to review our surveillance processes to ensure we are consistent with the national definition. Table six presents the in-patient data 2017/18.

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Table six: Infection types by Borough April 2017 – March 2018

5.6 Incident Monitoring All incidents reported via DATIX system, enquiries from ward staff or laboratory surveillance that meet the incident recording criteria are monitored and followed up by the Infection Prevention and Control Team. Actions taken to address concerns may be in the form of recording an issue on the risk register or by issuing a Managers Briefing Note. This may be by the Infection Prevention and Control team or by wider Trust Services. For

Infection HAI CAI

Urine 43 8

CAUTI 1 0

Wound 9 1

Wound SH 14 1

Chest 28 0

Eye 2 0

Skin 39 5

ENT 9 0

Dental 2 0

Miscellaneos 1

43

1

914

28

2

39

92 1

8

0 1 1 0 05

0 00

10

20

30

40

50

Summary Results from Surveillance for Infection On Warrington Wards Annual Results - April 2017- March 2018

HAI

CAI

Infection HAI CAI

Urine 10 0

CAUTI 0 0

Wound 4 0

Wound SH 1 0

Chest 4 1

Eye 0 0

Skin 4 0

ENT 0 0

Dental 0 0

Miscellaneos

10

0

4

1

4

0

4

0 00 0 0 01

0 0 0 00

2

4

6

8

10

12

Summary Results from Surveillance for Infection On Halton Wards Annual Results - April 2017- March 2018

HAI

CAI

Infection HAI CAI

Urine 5 3

CAUTI 0 0

Wound 4 3

Wound SH 2 0

Chest 4 1

Eye 0 0

Skin 3 0

ENT 1 0

Dental 1 0

Miscellaneos 2

5

0

4

2

4

0

3

1 1

2

3

0

3

0

1

0 0 0 00

1

2

3

4

5

6

Urine CAUTI Wound Wound SH Chest Eye Skin ENT Dental Miscellaneos

Summary Results from Surveillance for Infection on Knowsley Wards Quarter 4 January - March 2018

HAI

CAI

Infection HAI CAI

Urine 17 0

CAUTI 0 0

Wound 1 1

Wound SH 0 0

Chest 4 2

Eye 2 0

Skin 5 4

ENT 0 0

Dental 6 0

Miscellaneos

17

01

0

42

5

0

6

0 01

02

0

4

0 002468

1012141618

Summary Results from Surveillance for Infection On St.Helens Wards Annual Results - April 2017- March 2018

HAI

CAI

Infection HAI CAI

Urine 51 7

CAUTI 0 0

Wound 9 1

Wound SH 3 0

Chest 24 3

Eye 2 2

Skin 15 5

ENT 5 1

Dental 10 0

Miscellaneos

51

09

3

24

2

155

1070 1 0 3 2 5 1 0

0102030405060

Summary Results from Surveillance for Infection On Wigan Wards Annual Results - April 2017- March 2018

HAI

CAI

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example Occupational Health Team issued Managers Briefing notes around hepatitis vaccination and the Infection Prevention and Control Team issues a note supporting patient’s influenza vaccinations.

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Table 7: Incidents April 2017 - March 2018

Patient Incident Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar

MRSA 1 1 1 1 1

Clostridium Difficile Toxin

Negative1 1 1 1

Clostridium Difficile- Toxin

Positive2 1

Inoculation injury 3 1 3 1 1 1 1 1 3

Outbreaks D&V 2 1 2 1

CPE 1

Adhoc Incidents

Strep A 1

MSSA 1

Pan resistant pseudomomas 1

Campylobacter 1

ESBL 1

Lymes disease 1

Increased incidence of diarrhoea.

No outbreak 1 1

Scarlet Fever 1

Salmonella 1

Shingles 1 1

Flu 3 2

Scabies 1 1

Environmental issues

Unsafe storage of sharps. 1 1 2

No Soap available in toilets 1

Vomit in communal area 1

Dirty Protest 1

Failed water supply 1

March - 1) sharps box knocked off clinical trolley, no injury sustained. Unsafe storage of sharps box, reported by datix.

2) Lid not secured correctly on sharps bin. No injuries sustained. Incident reported by datix.

February - isolated case.

March - Staff member (apprentice HCA) sample positive for salmonella. Staff member has diagnosis of IBS. Weekly samples being obtained. To remain of work until 48 hours

symptom free. OH department are aware.

February - Staff member been unwell for 2-3 days. GP confirmed scarlet fever. 6 other staff members c/o sore throat, cold like symptoms. Advised; increase hand hygiene, cough

etiquette. Increased environmental cleaning, alcohol gel. Arrange with Estates to have office deep cleaned.

January -

1) 7 pt's affected, 4 hospitalised, 1 died. Antivirals as per guidance. All infection control measures put into place.

2) 3 pt's and 3 staff members affected. Antivirals as per guidance. All infection control measures put into place.

3) Influenza type B. 9 pt's affected, 2 hospitalised. Antivirals as per guidance. All infection control measures carried out.

March -. Flu A. 2 pateints confirmed and two suspected, 1 staff member affected. Antivirals as per guidance. Ward closed 5 days.

2) Flu B, 2 confirmed 4 suspected and 2 staff affected. Antivirals as per guidance.Ward closed 5 days.

March - Pt undertaking dirty protest. Advice given re cleaning, standard precautions.

January - Needle stick injury during administratration of depot injection. Human error. Innoculation Injury procedure followed.

February - Needlestick injury obtained when finger struck used needle in sharps bin. Innoculation Injury procedure followed.

March - 1) student nurse obtained injury following administration of insulin injection. Did not use safety device. Innoculation injury procedure followed.

2) Sharps injury due to closing safety cover over used needle. Innoculation injury procedure followed and discussed in team meeting.

3) Injury sustained from uncovered insulin needle in box. Innoculation injury procedure followed.

March - 1 pt experiencing 1 episode of vomiting. 2 pt's experiencing diarrhoea & 1 staff member with diarrhoea. Infection prevention measures put in place.

February - Swab taken, MSSA present with no infection. Pt under TVN. No treatment with antibiotics required.

March - Strep A found in leg wound. Pt known drug user. Unable to isolate due to deteriorated mental health. Tissue Viability involved, enhanced cleaning put in place,

antibiotics reviewed and risk assessments carried out.

January - , C difficile toxin negative, GDH positive sample. Patient well in self, no known recent antibiotic use. No C difficile treatment required, advised to exercise caution if

antibiotics are prescribed in future.

Actual No. Actual No. Actual No. Actual No.Comments

January - , MRSA + in sputum, commenced on Doxycycline.

March - , MRSA + in self harm wound, antibiotics prescribed. Referered to tissue viability nurse.


5.7 Diarrhoea and Vomiting (D&V) outbreaks - April 2017- March 2018 The team support clinical teams when they report either single cases of diarrhoea and vomiting or potential outbreaks. There were eight outbreaks of diarrhoea and vomiting over the course of the year. This involved the Infection Prevent and Control Team temporarily closing the wards, face to face visits with clinical teams, implementation of increased Infection Prevention and Control precautions, and daily support and advice from Infection Prevention and Control Nurses in the team. This also involved sampling and liaison with microbiology and on one occasion joint working with Environmental Health Organisation.

5.8 Diarrhoea and Vomiting outbreaks as part of Community Specifications (Knowsley) The Infection Prevention and Control Team are also responsible for monitoring and advising on outbreaks within Knowsley as part of the Service Level Agreement for Knowsley. Any actions required are escalated to Knowsley Clinical Commissioning Group and Local Authority or Public Heath England as required. There have been several outbreaks of diarrhoea and vomiting managed by the team.

5.9 Other Outbreaks During Quarter Four there have been four outbreaks of influenza on the inpatient wards. There have been two outbreaks of Influenza A and two confirmed as Influenza B. Outbreaks of suspected influenza like illness on our inpatient wards have involved Infection Prevention and Control Team attending and swabbing the nose and throat of all suspected cases. Public Health England were informed. Outbreak incident numbers were allocated from the virology laboratories based in Manchester and we communicated between microbiology, virology and infection control colleagues in the acute trust when service users had been transferred. The Infection Prevention and Control Team ensured correct precautions were in place and provided all advice and precautions to the nursing teams involved. The team worked with pharmacy colleagues and ensured anti-virals for treatment and prophylaxis were prescribed in a timely manner. The Infection Prevention and Control Team continued to offer support and guidance to the wards on a daily basis as a minimum until the outbreaks were over.

Ward

Date

Closed D/V

Number of Service users

Symptomatic

Staff

Symptomatic

Date re

opened

Total days closed

to admissions

Parsonage 22.06.17 D&V 2 1 29.06.17 5

Tennyson 07.08.17 Campylobacter 2 1 10.08.17 3

Golbourne 29.08.17 D&V 5 0 03.09.17 6

Auden 20.10.17 D&V 2 1 25.10.17 5

Parsonage 06.11.17 D&V 4 2 11.11.17 6

Parsonage 22.11.17 D&V 3 2 29.11.17 7

Golbourne 27.12.17 D&V 1 2 29.12.17 3

Iris 05.01.18 D&V 6 6 12.01.18 8


There was twice daily communication with the Director of Infection Prevention and Control and the Assistant Director for Integrated Governance who has responsibility for Emergency Planning initiated daily conference calls to ensure business continuity and support for clinical teams.

5.10 Risks

A review of the work plan at year end 2017/18 showed there were no identified risks on the Trust Risk Register. This has highlighted a lessons learned in respect of the dynamic use of the Trust Risk Register for Infection Prevention and Control. A review will take place in quarter one to rectify this risks will be highlighted in respect of Bare Below the Elbow, Fridge Temperatures and capacity of the team to deliver the Infection Prevention and Control Agenda.

5.11 Hand hygiene compliance

Throughout 2017 the annual infection control audits were undertaken across all the Trust inpatient facilities and associated community sites and outpatient clinics. One of the practices these audits address is clinical staff compliance with national guidance in relation to clinical staff being Bare-Below-Elbows. This is within the clinical setting and whilst undertaking face-to-face patient contacts. This key principle is highlighted by the Department of Health and the World Health Organisation within their current guidance as one of the most effective ways in reducing the incidences of acquisitions of healthcare associated infections amongst patient groups, whilst also being a recognised practice demonstrated to reduce the potential onward transmission of pathogens within the healthcare environment to more susceptible patients. Repeatable throughout 2017 on both unannounced infection control audits and on self-audits undertaken by clinical staff, poor compliance with the Bare-Below-Elbows principle was noted repeatedly. The Infection Prevention and Control Team therefore undertook a review of practice and knowledge of ward staff to establish why compliance was not being achieved. This assessment identified a number of deficits in staff knowledge to what constitutes a clinical environment and a clinical undertaking. Through educational engagement with staff groups clarification was given to correct identified deficits and allow staff to express any other concerns they may have surround Bare-Below-Elbows. Subsequent Infection Prevention and Control audits, self-audits and Infection Prevention and Control Team presence within the clinical areas has positively identified that full compliance is improving and hand hygiene compliance will remain a high priority for the Infection Prevention and Control Team.

6. Influenza Immunisation Programme 6.1 Northwest Boroughs Healthcare Staff Influenza Immunisation Programme

Occupational Health and the Infection Prevention and Control Team have actively targeted staff groups during 2017/2018 aiming to achieve a higher Influenza immunisation uptake than previous years. The Trust achieved the national The Commissioning for Quality and Innovation for vaccinating front line staff which was 70%. The Trust achieved 71%. The Infection Prevention and Control Team supported the campaign by delivering vaccination training and managing vaccination clinics.


6.2 In-patient Influenza Immunisation Programme

Influenza immunisers have been trained across all Boroughs to help to ensure patients are offered Influenza vaccines whilst inpatients. Many patients within the trust fall in to the category of ‘at risk’ groups who require immunisation, as they may stay in hospital for some length of time and are sometimes reluctant to access Primary Care services for immunisation. The Trust has adopted a proactive approach to offer inpatient vaccination programme. This year in-patient ward teams and Medicines Management liaised with service users’ General Practices to clarify if the vaccine has already been administered. The doctor responsible for admitting a patient is also required to check and document this as part of their infection control assessment and document any relevant vaccination as part of the discharge letter. The Medicines Management Team supported this process during medicines reconciliation on admission.

7. Summary

Whilst it is recognised that patients in mental health care settings and community settings are at a lesser risk of Healthcare Associated Infection than those in acute care settings, it is important to remember they are often still at a risk of infection due to predisposing risk factors. The Trust has made significant achievements in year and continues to declare full compliance with quality standards in relation to Infection Prevention and Control. However the year-end review of the work plan and dashboard has highlighted that the risk register has not been used dynamically to capture any risks associated with Infection Prevention and Control and this has been amended in quarter one of 2018/19.

8. Recommendations It is recommended that the Quality Committee:

To approve this annual report.

To consider and agree the recommendations as detailed within the report.

To approve the report is shared with commissioners and stakeholders for the purposes of providing assurance of quality and safety.


Report prepared by: Karen Keighley Head of Nursing and Infection Prevention and Control Presented by: Gail Briers Chief Nurse/Director of Operational Clinical Services References

Care Quality Commission - Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12. (2008) http://www.cqc.org.uk/content/regulation-12-safe-care-and-treatment#full-regulation

Department of Health (2008) - Health & Social Care Act 2008: Code of Practice on the prevention and control of healthcare associated infections and related guidance. London.

National Health Service England /Public Health England: Patient Safety Alert (6/3/14) for ‘Addressing the rising trends and outbreaks in Carbapenemase- producing Enterobacteriaceae’.

Department of Health (2013) Decontamination: Health Technical Memorandum 01 05: Decontamination in primary care dental practices. HTM 01 05

Department of Health / Public Health England (2008) - Clostridium difficile infection: how to deal with the problem. Updated 2013. https://www.gov.uk/government/publications/clostridium-difficile-infection-how-to-deal-with-the-problem

NICE quality standard [QS113] 2016 https://www.nice.org.uk/guidance/qs113

http://www.cqc.org.uk/content/regulation-12-safe-care-and-treatment#full-regulation

http://www.cqc.org.uk/content/regulation-12-safe-care-and-treatment#full-regulation

https://www.gov.uk/government/publications/clostridium-difficile-infection-how-to-deal-with-the-problem

https://www.gov.uk/government/publications/clostridium-difficile-infection-how-to-deal-with-the-problem

https://www.nice.org.uk/guidance/qs113


Appendix 1: Please note for the purpoes of this Annual Report we have removed the appendix

from the quarterly reports to avoid confusion. The full summary of the workplan for 2017/18 is

detailed in the body of this report.

QUALITY COMMITTEE

_______________________________________________________ DATE OF COMMITTEE:

2 August 2017

TITLE OF REPORT:

Infection Prevention & Control Quality Report Quarter 1

SOURCE OF REPORT:


PURPOSE OF REPORT:

To inform the Committee of progress to date against the Trust’s Infection Prevention & Control Agenda

KEY POINTS:

The Trust has duties that must be met under The Health and Social Care Act 2008: Code of Practice for health and social care on the prevention and control of infections and related guidance This paper details progress of work against the Act and also provides an update for the Quality Committee.

REPORT AUTHOR:

Karen Keighley – Head of Nursing and Infection Prevention and Control July 2017

ACCOUNTABLE DIRECTOR:

Gail Briers - Chief Nurse/Director of Operational Clinical Services

RECOMMENDATION/S AND/OR ACTIONS TO THE COMMITTEE:

To note and comment on progress made against the Infection Prevention & Control work plan for Quarter 1.

RECOMMENDATIONS FOR None


AUDIT COMMITTEE (if applicable):

IMPLICATIONS AND LINKS FOR TRUST GOVERNANCE

Governance Areas (√ the areas the report supports, or to which it is linked)

√

1. Are we delivering our services safely? √

2. Do we have sufficient, highly motivated, skilled staff? √

3. Are we delivering to our patients and users? √

4. Is the organisation and its services well led? √

5. Are we delivering on our Quality Strategy? √

Does this paper address a risk on the Board Assurance Framework (BAF)?

Yes No √

If yes,

BAF entry No.

Trust High Level

Objective (as above)

Description from Board Assurance Framework


Infection Prevention & Control Quality Committee Report

Quarter 1: April to June 2017

1.0 Introduction

This paper provides the Quality Committee with the scheduled quarterly update of progress

against the Trust’s 2017/18 Infection Prevention and Control Service Plan (see appendix 1) and

to provide the committee with verification and assurance of progress during Quarter 1 covering

April to June 2017.

2.0 Key areas of Focus for 2017/18

2.1 To continue to maintain a very low incidence of healthcare associated infection within

the Trust through education, training and surveillance.

Progress: There have been no MRSA bacteraemia in this quarter. In the last report we

informed the committee of a recently diagnosed case of clostridium difficile infection.

This patient was admitted to the Trust during Q4 however they developed the infection

on 5th April 2017 Q1. The root cause analysis will be described in this report.

2.2 To continue to maintain improved national cleaning standards.

Progress: Cleaning standards continue to be maintained to a high standard within the

Trust and where issues are identified they are escalated.

2.3 To review enhanced surveillance of urinary tract infections on inpatient wards and

develop treatment and investigation pathways for all patients with recurrent urinary tract

infections, to help prevent repeat antibiotic prescribing.

Progress: Data has now been collected for 12 months and a report of findings and

recommendations will be produced for Q2 2017/18

2.4 To continue to monitor new and resistant infections that may occur around the Trust and

focus on education regarding antimicrobial resistance to all prescribers within the Trust,

including non-medical prescribers.

Progress: Weekly surveillance of ward infections continues and is reported quarterly

into the infection prevention and control committee. Antimicrobial resistance training and

awareness is included in all infection prevention and control training.


2.5 To continue to enhance the learning environment around infection prevention and

control as a productive and quality placement for student nurses.

Progress: Due to a reduction in staffing levels a decision has been made to temporarily

stop student nurse placements.

2.6 To continue to enhance knowledge and skills within the team.

Progress: Band 6 Nurse is due to complete infection prevention course at Manchester

University

2.7 To promote the ‘Early recognition of Sepsis’ through infection control training across the

Trust.

Progress: Sepsis awareness is now included in infection prevention and control training

3.0 Audit Progress for Q1

3.1 Audit Programme

The aim of the audit programme is to measure compliance against national and local standards

including 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. The annual audit

programme is determined by clinical need, observations and results (see Table 1), with

frequency subject to change at the discretion of the Infection Prevention and Control Team.

However the Hand Hygiene audit has to be completed quarterly as a minimum within non acute

settings as directed by the Health Act. Audits are undertaken by Link Personnel and

supplemented by unannounced spot-check audits by the Infection Prevention and Control

Team, accompanied by service user/carer representatives providing additional assurance (see

Table 2). In addition the Infection Prevention and Control Team, Matrons and Quality Leads

continue to monitor and address any issues identified.

Table 1: Audit Results

Matrons report including Q1 April – June 2017

Infection Control Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Hand Hygiene Observation Tool 97%

Hand Hygiene technique tool communiy

Mattress Audit 98%

Bare Below the Elbows Audit 93%

Combined Infection Control Audit


Table 2: Service User/Carer Audits Q1 April – June 2017

Service User Audit Results for Q1 April – June 2017

Ward Audit Date Result %

The Arch 04.05.17 94%

Priestners Ward 05.05.17 92%

Parsonage Ward 05.05.17 90%

Golbourne Ward 05.05.17 90%

Manor Farm HC 10.05.17 57%

Westleigh Ward 12.05.17 85%

Sovereign Ward 12.05.17 88%

Bluebell HC 15.05.17 58%

Kingsley Ward 02.06.17 97%

Sheridan Ward 02.06.17 97%

Stockbridge HC 02.06.17 95%

St Chads 07.06.17 77%

Towerhill HC 16.06.17 62%

Coniston Ward 16.06.17 97%

North Huyton HC 23.06.17 90%

Fairhaven 23.06.17 97%

The results for this quarter demonstrate high standards of infection control practice across the

inpatient services however in four health centres the standards have been poor, the IPC team

have escalated these concerns internally and with NHS Property Services who manage the


cleaning contract for these buildings. The IPC team will continue to closely monitor to ensure

standards remain consistently high.

3.2 National Cleaning Standards

Hotel Services follow the National Cleaning Standards (Department of Health) which require in-

patient areas to be audited monthly. Community areas are audited quarterly (Table 3).

Table 3: National Cleaning Standards

Key

Green 90 to 100

Amber 85 to 89

Red 0 to 84

Quarter 1 results are excellent, with average percentage scores across all business streams

achieving over 95 % (Green)

3.3 Kitchen Audits

All wards are monitored on a quarterly basis to ensure compliance with the Food Hygiene

(England) Regulations (2006) (Table 4). This is reported to IPC Committee.

Community National Health Stds Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Community Health Service 97%

Mental health Clinic 96%

In Patient National Cleaning Stds Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Domestics 98% 98% 97%

Nursing 97% 98% 96%

Estates 96% 97% 95%


Table 4: Kitchen Audits

Q4 Kitchen Audit Summary

Pass 90% - 100% Amber 85% - 89% Red less than 85

3.4 Service Level Agreement Audits

The Infection Prevention and Control Team are commissioned to provide infection prevention

and control advice, support, audit, and surveillance and management of healthcare associated

infection across care homes, general practitioners, dentists and schools in Knowsley.

0%

20%

40%

60%

80%

100%

120%

Overview - Trust Wide


Table 5 Service Level Agreement KPI achievement Quarter 1

Q1 Q2 Q3 Q4

Audit %age of residential/nursing care homes audited. Gold award homes

will self-audit for 2016/17 9%

%age of GP practices audited (30% sample) 0%

%age of dental practices audited (30% sample) 0%

%age of applicants under the AQP scheme audited nil req'd

Education and training

%age of GP practices with infection control champions 100%

%age of nursing/residential care homes with infection control champions 100%

%age of infection control champions to receive training 0%

Satisfaction rate for participants in learning events

Outbreak, incident and contact tracing Survey response rate for patients

Satisfaction rate for patients

Survey response rate for affected services

Satisfaction rate for affected services

Expert advice and support %age of patients diagnosed with community acquired C-difficile to

receive information and offer of support 100%

All audit programmes all key performance indicators were completed and achieved by the end

of March 2017. The IPCT have an agreed plan to deliver all key performance indicators in year.

The majority of the work is targeted at Q4 as agreed the local authority.

4.0 Carbapenemase- producing Enterobacteriaceae (CPE)

We have had zero cases of Carbapenemase- producing Enterobacteriaceae with the inpatient

services of the Trust at the time of writing this report but its incidence continues to increase

across Greater Manchester and also Cheshire and Merseyside.

Potential cases are monitored via the Infection Prevention and Control Team through the

weekly surveillance process when wards are asked if they have had any admissions from any of

the high risk hospitals from Manchester or Liverpool.

5.0 Antimicrobial Resistance

Quarterly audits undertaken by Medicines Management continue and these help to determine

the level of compliance with prescribing and documentation against the relevant antimicrobial

prescribing standards which is also part of an on-going programme to prevent antimicrobial

resistance. This continues to demonstrate good compliance with prescribing formulary.


Educational sessions continue to be delivered to healthcare staff both within the trust and

externally, via the service level agreement to General Practitioners, dentists and care homes, in

relation to Carbapenemase- producing Enterobacteriaceae and antimicrobial resistance.

The Infection Prevention and Control Team follow up any patient within the trust who has an

infection caused by a resistant organism.

6.0 Sepsis

The Trust Sepsis Group continues to meet facilitated by Interim Chair Beverley Tunstall – Nurse

Specialist IV Therapy until the new Resuscitation Officer commences in post in July. The group

have focused on training and the consideration of purchasing a different type thermometer to

ensure temperature readings are accurate.

7.0 Surveillance programme and incident monitoring

The Trust has an alert in-patient organism and conditions incidence surveillance programme

(see Table 6). This information is collected from the in-patient wards on a weekly basis and

reflects a more comprehensive picture of organisms in these settings including antibiotic usage.

The infection prevention and control team also document and record any incidents, outbreaks

and communicable diseases from all areas of the organisation.

Table 6: Incident Monitoring by Borough Q1 April – June 2017

HAI – Hospital Acquired Infection CAI – Community Acquired Infection

4

0 1

3 4

0

3

0 0 0

2

0 0 0 0 0 1 1

0 012345

Summary Results from Surveillance for Infection On Warrington Wards

Quarter 1 April-June 2017

HAI

CAI


1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0.20.40.60.8

11.2

Summary Results from Surveillance for Infection On Halton Wards


HAI

CAI

5

0 0 0 1

0 0 0 0 0

3

1 0 0 0 0 0 0 0

0123456

Summary Results from Surveillance for Infection on Knowsley Wards


HAI

CAI

3

0 0 0

1

0 0 0

1

0 0 0

1

0 0 0 0 0 0 0

0.51

1.52

2.53

3.5

Summary Results from Surveillance for Infection On St.Helens Wards


HAI

CAI


These graphs demonstrate the low levels of infection however surveillance is key as it provides

indication of increased levels of infections and allows the team the opportunity to respond early.

8.0 Clinical work

The team respond to frequent requests for advice and support around environemtal issues,

cleaning, hand hygiene, patients and staff with infections which are all responded to with

appropriate advice, support and clinical visits.

Dring this quarter the team facilitated a lessons learned meeting with Rydal ward. The findings

of the undertaken root cause analysis (RCA), was discussed with the team in an attempt to

learn lessons and highlight areas of good practice and areas were improvement could be made.

The RCA had highlighted a lapse in patient care around antimicrobial prescribing. A review of

the patients notes highlighted that the antibiotic was prescribed for an assumed urinary tract

infection, however apart from a positive urine dipstick result there was no other supporting

evidence to suggest the patient had a clinical UTI.

The patient, post antibiotics went onto develop unexplained diarrhoea which tested negative for

evidence of clostridium difficile infection; however a further stool specimen submitted two days

following the submission of the first sample did test positive for clostridium difficile toxin.

Additional RCA findings also highlighted that routine pharmacist review of prescribed antibiotics

had not been undertaken in accordance with local policy due to staffing issues/ pressures and

stop dates of prescribed antibiotics had also not been included on the drugs chart.

Recommendations have been made to the clinical team.

Report prepared by Karen Keighley – Head of Nursing and Infection Prevention and

Control

July 2017

6

0 1

0 0 0 0 1 1

0 1

0 0 0 0 0 1 1

0 0

2

4

6

8

Summary Results from Surveillance for Infection On Wigan Wards


HAI

CAI


QUALITY COMMITTEE


8 November 2017

TITLE OF REPORT:


SOURCE OF REPORT:


PURPOSE OF REPORT:

To inform the Committee of progress to date against the Trust’s Infection Prevention and Control Agenda

KEY POINTS:


REPORT AUTHOR:

Karen Keighley – Head of Nursing and Infection Prevention and Control October 2017




To note and comment on progress made against the Infection Prevention and Control work plan for Quarter 2.

RECOMMENDATIONS FOR AUDIT COMMITTEE (if applicable):

None




√







Yes No √

If yes,

BAF entry No.

Trust High Level




Infection Prevention & Control Quality Committee Report Quarter 2: July to September 2017

4.0 Introduction




July to September 2017.




Progress: There has been zero Methicillin Resistant Staphylococcus Aureus (MRSA)

bacteraemia cases in this quarter and zero patients diagnosed with clostridium difficile

toxin positive infection. Work has been undertaken this quarter to review Escherichia coli

bacteraemia following the publication in May 2017 of the new requirements for clinical

commissioning groups to reduce incidences of this infection by 50% by 2021.







Progress: Data has now been collected for twelve months and the team planned to

report on this issue in quarter two however due to staff sickness and an increase in

community infection prevention and control in Knowsley this will now be reviewed in

quarter 3.










Progress: Due to a reduction in staffing levels a decision had been made to temporarily

stop student nurse placements – however we are accepting student nurses for short

spoke placements


Progress: Band 6 Nurse has now successfully completed the infection prevention

course at Manchester University. Our other Band 6 nurse is completing his last module

for his degree. A skill mix review has taken place and we have identified funding for a

Band 7 secondment for twelve months and a Band 6 secondment for twelve months.

Recruitment for the Band 6 role has taken place and a start date is expected shortly. The

Band 7 post will be advertised internally.


Trust.


and the Sepsis project which was supported by Aqua has been completed and the team

will lead this work going forward.


3.1 Audit Programme

The aim of the audit programme is to measure compliance against national and local

standards including 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.

The annual audit programme is determined by clinical need, observations and results

(see Table 1), with frequency subject to change at the discretion of the Infection

Prevention and Control Team. However the Hand Hygiene audit has to be completed

quarterly as a minimum within non acute settings as directed by the Health Act. Audits

are undertaken by Link Personnel and supplemented by unannounced spot-check audits

by the Infection Prevention and Control Team, accompanied by service user/carer

representatives providing additional assurance (see Table 2). In addition the Infection


Prevention and Control Team and Matrons continue to monitor and address any issues

identified.


Matrons report including Q2 July-September 2017

Table 2: Service User/Carer Audits Q2 July-September 2017

90% above

85%-89%

84% below

Halewood walk in centre has fallen just below the standards we accept, an action plan and

advice and support has been provided. The issues were predominantly around environmental

cleanliness. The Infection Prevention and Control Team will continue to closely monitor to

ensure standards remain consistently high.




Table 3: National Cleaning Standards Q2

Summary of Cleanliness Audit 2017/18


Hand Hygiene Observation Tool 97% 97%

Hand Hygiene technique tool communiy 97%

Mattress Audit 98%

Bare Below the Elbows Audit 93% 90%



Key

Green 90 to 100

Amber 85 to 89

Red 0 to 84

Quarter 2 results are excellent; with average percentage scores across all business streams

achieving over 95 % (Green). This is similar to the high standards of results in quarter 1.

3.3 Kitchen Audits


(England) Regulations (2006) (Table 4). The following information is produced by the Catering

Team for Infection Prevention and Control Committee.

Each ward kitchen audit involves the use of a tool of 33 elements. It is a technical and visual

assessment of the cleanliness of the ward kitchen, including the monitoring and recording of

fridge temperatures, storage of open food and identification of patients’ personal food items.

The audit takes in to consideration the Trusts level of compliance with Food Safety legislation,

Trust policies and hygiene practices. Meeting with compliance of the ward kitchen is defined in

to 3 areas of responsibility, Nursing, Domestic Services and Estates. All ward managers receive

a full report clearly identifying any failures and corrective actions required

Outcome Required - Ward kitchen to score 90% (green) or above for a pass To ensure compliance with Food safety legislation, Catering and Cleanliness Policy.

To maintain high levels of food hygiene including preparation and service and to ensure that all

food and beverages are safe to consume.

To maintain level 5 food safety scores across all sites following EHO unannounced

assessments.

Community National Health Stds Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Community Health Service 97% 96%

Mental Health Clinic 96% 99%

In Patient National Cleaning StdDomestics 98% 98% 97% 97% 98% 99%

Nursing 97% 98% 96% 96% 97% 98%

Estates 96% 97% 95% 95% 95% 95%


Wards Achieving Amber

Ward Kitchen Audits 2017/18 Q2

Domestics

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Red 0 1 0 0

Amber 0 0 0 0

Green 22 21 22 22

Red 0 0 0 0

Amber 0 0 0 0

Green 22 22 22 22

Red 0 0 0 0

Amber 0 0 0 0

Green 22 22 22 22

Red 0 0 0 0

Amber 0 0 0 0

Green 22 22 22 22

Red 0 0 0 0

Amber 0 0 0 0

Green 22 22 22 22

Quarter 1 Quarter 2 Quarter 3 Quarter 4Red Total 0 1 0 0

Amber Total 0 0 0 0

Green Total 110 109 110 110

Percentage Green 100% 99% 100% 100%

Nursing


Red 3 3 0 0

Amber 2 2 0 0

Green 17 17 22 22

Red 1 1 0 0

Amber 0 0 0 0

Green 21 20 22 22

Red 1 4 0 0

Amber 1 0 0 0

Green 20 18 22 22

Red 1 1 0 0

Amber 0 0 0 0

Green 21 21 22 22

Red 1 1 0 0

Amber 0 0 0 0

Green 21 21 22 22


Amber Total 3 2 0 0

Green Total 100 97 110 110


Estates


Red 3 2 0 0

Amber 0 0 0 0

Green 19 20 22 22

Red 0 0 0 0

Amber 0 0 0 0

Green 22 22 22 22

Red 1 1 0 0

Amber 0 0 0 0

Green 21 21 22 22

Red 0 0 0 0

Amber 0 0 0 0

Green 22 22 22 22

Red 0 0 0 0

Amber 0 0 0 0

Green 22 22 22 22


Amber Total 0 0 0 0

Green Total 106 110 110 110


Children & Young

People

Adults

Learning Disabilities

Older Persons

Adults


Older Persons

Forensics

Forensics

Children & Young

People

Children & Young

People

Adults


Older Persons

Forensics

Issues across majorityof Nursing specifically adult servies


Pass 90% - 100% Amber 85% - 89% Red less than 85%

Key areas for improvement identified:

Austen – various fridge recordings missing and exceeding upper legal limit with no corrective

action.

Auden- excessive build-up of patient personal food and poor labelling

Marlowe- high risk food stored in fridge belonging to a patient and various open food items

Fairhaven- Out of date food, evidence of food kept back from previous meal service and poor

labelling of patient personal food.

Weaver- various fridge recordings missing on both fridges and patient personal food lacking of

any labelling and dates when opened.

Golborne- fridge recordings remains poor. Missing dates fall when the when the Housekeeper

is off. This action has been carried forward from all previous audits with no improvement.

Iris- High risk food items being stored in the ward kitchen belonging to patients. Poor labelling

of other personal food items. Evidence of poor stock control as excessive storage of patient

personal food items who have since been discharged.

Parsonage – missing fridge recordings and non-approved catering equipment stored in the

kitchen

Wards Achieving Red

84%

84%

85%

85%

86%

86%

87%

87%

88%

88%

89%

Austen Weaver Iris Auden Golborne Parsonage Fairhaven Marlowe


Key areas for improvement identified:

Kingsley- out of date food stored in the fridge. Staff food stored in fridge. Unlabelled patients

personal food items and incomplete fridge recordings.

Rydal- evidence of staff personal belongings, food and crockery stored in the kitchen. Irregular

fridge recordings consistent when the Housekeeper is off duty. Good Housekeeping Guide not

displayed.

0

10

20

30

40

50

60

70

80

90

Kingsley Rydal

Kingsley

Rydal


Wards Achieving Nursing Red

Wards Achieving Nursing Red

To date the poor scores attributed to nursing is concerning. Overall 9 wards failed to achieve

the expected standards.

Conclusion

Disappointing results for nursing responsibilities in general across the Trust for quarter 2.

In particular the higher risk inpatients on the LLAMS wards in relation to lack of fridge

recordings , decanting of open food products and lack of clear labelling of patients personal

food items will be difficult for the Trust to prove due diligence.

On a more positive note Atherleigh Park has shown significant improvement from quarter 1,

however Golborne still remains a concern.

Domestic services and Estates functions achieved high compliance with no issues.

This will be presented at Infection Prevention and Control Committee on 3rd November.

3.4 Knowsley Service Level Agreement Audits


and control advice, support, audit, and surveillance and management of healthcare associated

infection across care homes, General Practitioners, dentists and schools in Knowsley.

64

66

68

70

72

74

76

78

80

82

84

Nursing

Nursing



All audit programmes all key performance indicators were completed and achieved by the end

of March 2017. The Infection Prevention and Control Team have an agreed plan to deliver all

key performance indicators in year. The majority of the work is targeted at Q4 as agreed the

local authority.








Q1 Q2 Q3 Q4

Audit %age of residential/nursing care homes audited.

Gold award homes will self-audit for 2016/17 9% 14%

%age of GP practices audited (30% sample) 0% 30%

%age of dental practices audited (30% sample) 0% 0%

%age of applicants under the AQP scheme audited nil

req'd nil

req'd


%age of GP practices with infection control

champions 100% 100%

%age of nursing/residential care homes with infection control champions 100% 100%

%age of infection control champions to receive training 0%


Outbreak, incident and contact tracing Survey response rate for patients

Satisfaction rate for patients

Survey response rate for affected services

Satisfaction rate for affected services

Expert advice and support %age of patients diagnosed with community acquired

C-difficile to receive information and offer of support 100% 100%


Table 6: Incident Monitoring by Borough Q2 July-September 2017


13

1 1 1 4

0 3 3

0 0

5

0 0 0 2

0 0 0 0 0

5

10

15


Quarter 2 July-September 2017

HAI

CAI

2

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0.5

1

1.5

2

2.5



HAI

CAI

1

0

1

0

2

1

0 0 0 0 0 0 0 0

4

0 0 0

1

0

1

2

3

4

5


Quarter 2 July-Septemeber 2017

HAI

CAI


These graphs demonstrate the low levels of infection however surveillance is key as it provides

indication of increased levels of infections and allows the team the opportunity to respond early.

8.0 Clinical work

The team respond to frequent requests for advice and support around environemtal issues,


appropriate advice, support and clinical visits. Please see appendix 1 for a summary of the

patient and environmental incidents the team have responded to this quarter.

Report prepared by Karen Keighley – Head of Nursing and Infection Prevention and

ControlOctober 2017

4

0 0 0

1

0

1

0

2

0 0 0

1

0 0 0

1

0 0 0

1

2

3

4

5



HAI

CAI

11

0 0 0

5

0

3

0

4

0

5

0 2

0

3 2 1 0 0 02468

1012



HAI

CAI


Apendix 1

Q2 Incidents 2017/18


MRSA 1 1

Clostridium Difficile

Toxin Negative1 1 1

Clostridium Difficile-

Toxin Positive2 1

Inoculation injury 3 1 3 1

Outbreaks D&V 2

CPE 1

Pan resistant

pseudomomas1

Campylobacter 1

ESBL 1

Lymes disease 1

Increased

incidence of

diarrhoea. No

outbreak

1 1


Unsafe storage of

sharps.1 1

No Soap available

in toilets1

Vomit in

communal area1

Failed water

supply1

Both patients treated with Antibiotics as per treatment algorithm due to being symptomatic with diarrhoea, despite

no toxin evident. Both responded well to treatment. During treatment and for 48 hours after last symptom, patients

were nursed in isolation and all IPC precautions were in place. The team visited the ward regularly to provide

guidance and support.


Both cases MRSA colonisation, Supression treatment given. IPC standard precautions implemented.

This relates to a staff member. Guidance and support given to staff member and ward manager.

IPC policy followed. Refered to Occupational Health, blood tests and treatment given if required.

In August 1 ward closed with with outbreak of Diarrhoea. The ward staff quickly implemented IPC precautions and

cohorted symptomatic patients. The ward remained closed for a period of 5 days all patients made a full recovery

without issue.

In August 1 ward closed with an outbreak of Diarrhoea effecting 3 pateints initally, increasing to 7 patients over a 5

day period. The ward remained closed for a 5 days. All IPC precautions were in place and all patients made a full

recovery without issue.

Colonisation, education and guidance given.Isolated toilet facilities and standard IPC precautions implemented

Full training on specific organism delived to all clinical staff and domestic staff. Ongoing advice and support given to

team. Increased IPC precautions implemented as issued by PHE

Datix completed by staff member to report issue in health centre. Escalated with OCS. Issue resolved.

Datix completed by staff member to report a child had vomitted in a communal waiting room. Staff had followed IPC

policy. No issues to report.

Water supply failed at Peasley cross site. Wards had reserve tanks. Clinics had no reserve tanks. IPC advised clinics

be cancelled due to no provision for adequate hand hygiene, or toileting. IPC coordinated the supply of disposable

paper mashee urinals and bed pans from the acute trust in Whiston for wards. IPC guidance disseminated to all staff

on site. Issue resolved without further incident.

2 staff 2 patients spontenous onset of unexplained diarrhoea. Sample collected proved positive for campylobacter.

Ward remained closed until investigations completed. EHO informed. No Links attributed to NWBH, potentially

linked to local takeaway.

Urine infection. Treated following microscopy with appropriate antibiotics. Isolated single toilet facilities and

standard IPC precautions.

Positive identification prior to admission to NWBH. PHE informed and guidance issued for the medics form PHE.

Standard IPC precautions

In both incidences a thorough assesment of symptoms, onset of illness, past medical history, current medication

and physical health of the patients was undertaken. The wards remained open and staff observed the clinical

picture. Standard IPC precautions in place for those symptomatic. No new cases identified and all those

symptomatic resolved without issue.

In July a member of staff found a used sharps bin had not been assembled propery.

In August A member of staff found a scaple and blade left loose in drawer.

In both incidences the team Manager reviewed datix and IPC advised them to refer to the waste management

policy. There were No injuries sustained.


QUALITY COMMITTEE


14th February 2018

TITLE OF REPORT:


SOURCE OF REPORT:


PURPOSE OF REPORT:


KEY POINTS:


REPORT AUTHOR:

Louise Owens Lead Nurse Infection Prevention and Control January 2018






None


Governance Areas √


(√ the areas the report supports, or to which it is linked)







Yes No √

If yes,

BAF entry No.

Trust High Level



Infection Prevention & Control Quality Committee Report Quarter 3: October to December 2017


7.0 Introduction




October to December 2017.






toxin positive infection.







Progress: Data has been collected for 18 months and the team is now evaluating the

data, looking for themes to inform the work plan for the year ahead. A report will be

available when this work is complete in Quarter 4.









Progress: Due to a reduction in staffing levels a decision had been made to temporarily

stop student nurse placements – We intend to review this in Quarter 4.



Progress: The Band 7 IPC specialist Nurse has been seconded to the Lead Nurse post

to provide expert leadership and clinical guidance to the IPC team and Trust. One of the

band 6 IPC nurses has been seconded to the Band 7 post.

A secondment for the band 6 post has been recruited into internally and is due to start

with the team in February. This ensures the team has the full complement of staff

moving forward.


Trust.


and the Sepsis project which was supported by Aqua has been completed. The sepsis

group has been reconvened to review latest guidance, the current position and formulate

an action plan for the work required to ensure compliance with Sepsis guidance.


3.1Audit Programme












identified.

3.2 Audit Results for Q3


IPC Audit report including Q3 October – November 2017


Hand Hygiene Observation Tool 97% 97% 96%

Hand Hygiene technique tool communiy 97%

Mattress Audit 98% 98%

Bare Below the Elbows Audit 93% 90% 91%



month due

Audit Result Commentary October-

Mattress- The Trust achieved an overall score of 98%. Of the 180 mattresses audited only 5

were condemned.

The Mattress audit looks at compliance to minimum NHS standards for Mattresses, cleanliness

and condition.

November –

Hand hygiene- The trust achieved a 96% compliance with the Hand Hygiene observation audit.

Of 110 staff observed there were 477 appropriate opportunities for Hand decontamination

identified. Of these 477, only 20 opportunities were not taken by the staff audited.

Bare Below the Elbows- 110 staff were audited for compliance with the Bare Below the Elbow

Policy whilst in the care environment. 97 staff were recorded as compliant at the time of audit,

achieving an overall trust score of 91%.

Table 2: Service User/Carer Audits Q3 October – November 2017

90% above

85%-89% 84% below

0%

50%

100%

Lith

erla

nd

Wal

InCentre…

Au

den

War

d0

9.1

1.1

7

Au

sten

War

d0

9.1

1.1

7

Ch

est

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War

d1

5.1

1.1

7

Mar

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ard

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.17

Byr

on

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d0

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2.1

7

Ten

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2.1

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We

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.17

Gra

ssm

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War

d2

0.1

1.1

7

Iris

War

d1

4.1

2.1

7

Tayl

or

War

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4.1

2.1

7

89% 100%

84% 88% 94% 93% 99%

61%

94% 91% 94% 91%

Au

dit

Re

sult

%

Audit Dates

Service User Audit results Q3


Red - Bridge – 61% - Concerns noted; Clutter and limited availability of quality assurance such

as cleaning schedules and mattress audits. Actions have been taken to immediately resolve a

number of these issues and a re-audit will take place in Q4.




Information supplied by Soft FM manager.


Summary

Quarter 3 results are excellent; with average percentage scores across all boroughs achieving

over 95 % (Green). This is similar to the high standards of results in quarter 1 & 2.

This is particularly rewarding to report as the domestic service team has experienced

considerable sickness absence, much of which has been long term.

3.3 Kitchen Audits


(England) Regulations (2006) (Table 4).

The following information is produced by the Catering Team.

Purpose

To ensure compliance with Food safety legislation, Catering and Cleanliness Policies.

Summary of Cleanliness Audit 2017 /18 Quarter 3 (October - December )

Community National Health Stds Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18Community Health Service 97% 96% 97%

Mental Health Clinic 96% 99% 99%

In Patient National Cleaning Std

Domestics 98% 98% 97% 97% 98% 99% 99% 99% 98%

Nursing 97% 98% 96% 96% 97% 98% 99% 98% 97%

Estates 96% 97% 95% 95% 95% 95% 96% 94% 98%

Key

Green 90 to 100

Amber 85 to 89

Red 0 to 84


To maintain high levels of food hygiene including preparation, service and to ensure that

all food and beverages are safe to consume.

To maintain level 5 food safety scores across all sites following EHO unannounced.





Trust policies and hygiene practices.

Outcome Required - Ward kitchen to score 90% (green) or above for a pass

All ward managers and Matrons receive a full report clearly identifying any failures and

corrective actions required.

Immediate remedies of issues that may pose a risk are undertaken at time of audit.

A separate report is provided at the quarterly IPC meetings and also discussed at the locality

catering focus meetings.

The ward kitchen audit is defined in to 3 areas of responsibility, Nursing, Domestic Services and

Estates. Functional is the overall score achieved.


Pass 90% - 100% Amber 85% - 89% Red less than 85%

Key Areas for Improvement

Auden - incomplete fridge recordings

Austen - incomplete fridge recordings

Functional Domestic Nursing Estates

Auden 94% 100% 88% 100%

Austen 91% 100% 82% 100%

Byron 91% 100% 82% 100%

Chesterton 91% 100% 82% 100%

Fairhaven 85% 100% 76% 80%

Kingsley 88% 100% 82% 80%

Marlowe 88% 100% 76% 100%

Sheridan 97% 90% 94% 100%

Totals / Average 91% 99% 83% 95%


Bridge 88% 91% 82% 100%

Weaver 73% 91% 59% 100%

Totals / Average 81% 91% 71% 100%


Grasmere 100% 100% 100% 100%

Coniston 100% 100% 100% 100%

Rydal 82% 100% 71% 80%

Willow 91% 100% 83% 100%Totals / Average 93% 100% 89% 95%


Iris 88% 100% 82% 80%

Taylor 91% 100% 94% 60%

Totals / Average 90% 100% 88% 70%


Sovereign 100% 100% 100% 100%

Pasonage 88% 91% 82% 100%

Preistner 97% 100% 94% 100%

Golborne 85% 100% 71% 100%

Westleigh 91% 100% 82% 100%

Totals / Average92% 98% 86% 100%

Warrington Hotel Services Monitoring

Halton Hotel Services Monitoring

WiganHotel Services Monitoring

Knowsley Hotel Services Monitoring

St Helens Hotel Services Monitoring


Byron- incomplete fridge recordings, no corrective action completed on recordings over 8°C and

incorrect sheet

Chesterton- incomplete fridge recordings

Fairhaven- incomplete fridge recordings. Clutter on window ledge and large storage box

collecting empty bottles for activities

Kingsley - incomplete fridge recordings.

Marlowe – incomplete fridge recordings and only one thermometer for 2 fridges.

Weaver – staff food stored in the ward kitchen, incomplete fridge recordings, excessive stock of

patients personal food items in the fridge, many being high risk and out of date and lack of

patient identification labelling.

Rydal – out of date food items and staff food being stores in the fridge. Lack of labelling on

some food items.

Iris – opened food items not covered, patient’s personal food items not labelled and Member of

staff assisting a patient with eating was not wearing a green apron and had a long sleeved

cardigan on.

Parsonage - incomplete fridge recordings.

Golborne - incomplete fridge recordings and gluten free cereal not in airtight container.

Westleigh- incomplete fridge recordings

Conclusion

Disappointing results for nursing responsibilities in general across the Trust for quarter 3.

Weaver ward in particular is causing concern mainly due to high risk out of date food in the

patient fridge.

Continued inconsistent fridge recordings on Parsonage which coincides with when the

Housekeeper is off duty.

Domestic services and Estates functions achieved high compliance with any issues already

logged awaiting action.

The Infection Prevention Control Team has discussed concerns with the individual wards and

will increase Trust communications and awareness of the importance of fridge temperature

recordings and storage of patient’s food.



and control advice, support, audit, education and surveillance and management of healthcare

associated infection across care homes, General Ppractitioners, dentists and schools in

Knowsley.



Q1 Q2 Q3 Q4

Audit %age of residential/nursing care homes audited. Gold award homes

will self-audit for 2017/18 9% 14% 68%

%age of General Practices audited (30% sample) 0% 30% 30%

%age of dental practices audited (30% sample) nil required

%age of applicants under the AQP scheme audited nil req'd


%age of General Practices with infection control champions 100% 100% 100%

%age of nursing/residential care homes with infection control champions 100% 100% 100%

%age of infection control champions to be offered training 0% 100% 100%


Expert advice and support %age of patients diagnosed with community acquired C-difficile to

receive information and offer of support 100% 100% 100%

All audit programmes and all key performance indicators are to be completed and achieved by

the end of March 2017. The Infection Prevention and Control Team have an agreed plan to

deliver all key performance indicators within the year. The majority of the work is targeted at Q4

as agreed by the local authority.

























Table 6: Incidence Monitoring by Borough Q3 October-December 2017


11

0 2 3

11

2

8

1 2 0 0 0 0 0 0 0 1 0 0 05

1015


Quarter 3 October - December 2017

HAI

CAI


1 0

1 1

3

0 1

0 0 0 0 0 0 0 0 0 0 0 0 0

2

4



HAI

CAI

2 0

1 0

5

0

3

0 0 0 2

0 0 0 0 0 0 0 0 0246



HAI

CAI

4

0 0 0 1 1 1

0

2

0 0 0 0 0 0 0 0 0 0 0

2

4

6



HAI

CAI

16

0 3 3 6 2

6 3 1 0 0 0 0 0 0 0 0 0 0 0

10

20



HAI

CAI


These graphs demonstrate the low levels of infection reported however surveillance is key as it

provides indication of increased levels of infections and allows the team the opportunity to

respond early.

8.0 Clinical work

The team respond to frequent requests for advice and support around environmental issues,




Report prepared by Louise Owens–Lead Nurse Infection Prevention and Control January

2018


Q3 Incidents 2017/18


MRSA 1 1 1

Clostridium Difficile

Toxin Negative1 1 1

Clostridium Difficile-

Toxin Positive2 1

Inoculation injury 3 1 3 1 1 1

Outbreaks D&V 2 1 2

CPE 1

Adhoc Incidents

Pan resistant

pseudomomas1

Campylobacter 1

ESBL 1

Lymes disease 1

Increased

incidence of

diarrhoea. No

outbreak

1 1

Shingles 1 1

Scabies 1


Unsafe storage of

sharps.1 1

No Soap available

in toilets1

Vomit in

communal area1

Failed water

supply1

In October an inpatient was diagnosed with Shingles, appropriatte IPC management advice and suport given to the clinical staff

for the ward in relation to onward transmission of the virus and risks.

December also saw a case of confirmed shingles in a staff member, again appropriate IPC support and management advice given.

One patient in inpatient servces confirmed positive for carriage of scabies, ward staff adviced in relation to management of

confirmed case

Two accidental innoculation injuries occurred by NWBH staff whilst administering insulin to patients, in both cases IPC policy

was followed and affected staff referred to Occupational Health for blood tests and treatment.

In October 2017 one ward closed due to an unexplained outbreak of diarhoea and vomiting. 2 Patients and 1 staff member

presented with symptoms of unexplained diarrhoea and vomiting. The ward was closed with enhanced IPC enteric precaution put

in place for four days. No causative organism identified. In December 2017 one ward suffered two outbreaks of unexplained

diarhoea which led to the ward closing an implementing enhanced IPC measures, one outbreak early December which led to the

ward being closed for six days and with the second outbreak late December, with the ward being closed for five days. In both cases

a number of staff and patients were symptomatic and again no causative organisms were identified.


MRSA wound infection reported on an ward. Patients microbiology analysis reviewed by clinical microbiologist and appropriatte

antimicrobial therapy prescribed with Tissue Viability Support. Supression treatment given. IPC standard precautions

implemented.


QUALITY COMMITTEE


May 2018

TITLE OF REPORT:


SOURCE OF REPORT:


PURPOSE OF REPORT:


KEY POINTS:


REPORT AUTHOR:

Louise Owens Lead Nurse Infection Prevention and Control April 2018






None




√







Yes No √

If yes,

BAF entry No.

Trust High Level




Infection Prevention & Control Quality Committee Report Quarter 4: January to March 2018

10.0 Introduction




January to March 2018.






toxin positive infection.







Progress: Data has been collected for 18 months and the team continues to evaluate

the data, identifying themes to inform the work plan for the year ahead. Early indications

identify a need for more sampling for sensitivities to antibiotics and an over reliance on

dipstick urinalysis testing as opposed to clinical examination findings. Targeted

education and awareness raising activities will be included in the IPC work plan for

18/19.










Progress: Student Nurses can now access short spoke placements with the Infection

Prevention & Control team. We hope to be able to offer longer placements later in the

year when the skill mix in the team has developed.


Progress: The Band 7 IPC specialist Nurse has been seconded to the Lead Nurse post

to provide expert leadership and clinical guidance to the IPC team and Trust. One of the

band 6 IPC nurses has been seconded to the Band 7 post.

A secondment for the band 6 post has been recruited into internally and has started with

the team in February. This ensures the team has the full complement of staff moving

forward.


Trust.

Progress: Sepsis awareness is now included in Infection Prevention and Control

training and the Sepsis project which was supported by Aqua has been completed. The

sepsis group has been reconvened to review latest guidance, the current position and

formulate an action plan for the work required to ensure compliance with Sepsis

guidance for the whole of NWBH.

3.0 Audit Progress for Q4 3.1 Audit Programme












identified.


3.3 Audit Results for Q4

Table 1: IPC Audit report including Q4 January – March 2018

month due

Audit Result Commentary Jan 2018 - Community Hand Hygiene and Bare Below the Elbows

The Community Hand Hygiene results, incorporating both community health and mental Health

Teams, were very promising with 100% of staff able to demonstrate good hand hygiene

technique with 95% of staff able to describe all ‘5 moments’ for Hand Hygiene.15 teams were

audited with a total of 83 staff.

99% of staff demonstrated knowledge of Bare below the elbows policy and when it must be

adhered to.

Feb 2018 -

Hand hygiene- The trust achieved a 95% compliance with the Hand Hygiene observation audit.

Of 114 staff observed there were 424 appropriate opportunities for Hand decontamination

identified. Of these 424, only 14 opportunities were not taken by the staff audited.

Inpatient Bare Below the Elbows - 114 staff were audited for compliance with the Bare Below

the Elbow Policy whilst in the care environment. 94 staff were recorded as compliant at the time

of audit, achieving an overall trust score of 97%.

March 2018 - Combined Audit

The Combined Infection Prevention and Control Audit comprises of areas highlighted from a

number of different IPC audits were high compliance is essential.

An overall Trust score of 92% has been achieved. Areas noted for improvement were damaged

furniture and staff knowledge particularly around awareness of IPC Link Worker and audit

results.


Hand Hygiene Observation Tool 97% 97% 96% 95%

Hand Hygiene technique tool communiy 97% 93%

Mattress Audit 98% 98%

Bare Below the Elbows Audit 93% 90% 91% 99% 97%

Combined Infection Control Audit 92%


Table 2: Service User/Carer Audits Q4 January – March 2018

Formby Health Centre –

Overall impression is that Formby clinic is well maintained, clean and clear of clutter. There was

some slight damage to plaster around sink in Clinic Room 1 this presumably occurred when

soap dispensers were changed. The Domestics room was overly cluttered with equipment

stored on the floor.




Information supplied by Soft FM manager.

90% above

85%-89%

84% below



REPORTS FOR VARIOUS SITES;

WARRINGTON

Performance across the Warrington sites (Hollins Park & Fairhaven) remains very high with

average scores across the service at 98%.

HALTON

Performance at Halton, includes Bridge and Weaver Units, with average scores of 91%. On

analysis, the scores recorded for ‘Estates’ was 88%. Investigation reveals that this score

reflects issues in regards to poor wall and ceiling finishes in a number of audited areas. This

facility is owned by Warrington & Halton General Hospital (WHGH) under a Service Level

Agreement. The Trust’s Estates Team are liaising with WHGH Estates team on the matter.

WIGAN & LEIGH (Atherleigh Park)

Performance at Atherleigh Park is very high with average scores across the service at 100%.

ST HELENS (Peasley Cross)

Performance at Peasley Cross, includes Iris and Taylor Units and scoring remains very high,

with an average cleanliness score of 98%

KNOWSLEY R&R

Performance at Knowsley R&R includes Coniston, Grasmere, and Rydal is very high, with an

average score of 99%.

Community Health Services

Community National Health Stds

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Community Health Service 95%

Mental Health Clinic (Non In Patient) 98%

In Patient National Cleaning Std

Domestics 98% 97% 98%

Nursing 99% 98% 97%

Estates 96% 96% 96%


Overall the clinics /centres scored well with an overall average score of 95%

Summary

Audits scores for Quarter 4 remain very good and should provide a solid base for the impending

PLACE Inspection regime which is due in the forthcoming months.

3.3 Kitchen Audits


(England) Regulations (2006) (Table 4).

The following information is produced by the Catering Team.

Purpose

To ensure compliance with Food safety legislation, Catering and Cleanliness Policies.

To maintain high levels of food hygiene including preparation, service and to ensure that

all food and beverages are safe to consume.

To maintain level 5 food safety scores across all sites following EHO unannounced.





Trust policies and hygiene practices.

Outcome Required - Ward kitchen to score 90% (green) or above for a pass

All ward managers and Matrons receive a full report clearly identifying any failures and

corrective actions required.

Immediate remedies of issues that may pose a risk are undertaken at time of audit.

A separate report is provided at the quarterly IPC meetings and also discussed at the locality

catering focus meetings. The ward kitchen audit is defined in to 3 areas of responsibility,

Nursing, Domestic Services and Estates. Functional is the overall score achieved.


Key Areas for Improvement for Nursing Function

Warrington

Austen – missed fridge temperature recording on one occasion.

Chesterton- incomplete fridge recordings.

Marlowe – incomplete fridge recordings for both fridges.

Halton

Q4 2017


Auden 91% 91% 94% 80%

Austen 91% 100% 82% 100%

Byron 94% 100% 88% 100%

Chesterton 91% 100% 82% 100%

Fairhaven 85% 91% 88% 80%

Kingsley 100% 100% 100% 60%

Marlowe 85% 82% 82% 100%

Sheridan 100% 90% 100% 100%



Bridge 88% 100% 76% 100%

Weaver 100% 100% 100% 100%

Totals / Average 94% 100% 88% 100%


Grasmere 100% 100% 100% 100%

Coniston 94% 100% 100% 60%

Rydal 91% 100% 82% 100%

Willow 91% 100% 83% 100%Totals / Average 94% 100% 91% 90%


Iris 76% 91% 71% 60%

Taylor 97% 100% 100% 80%



Sovereign 97% 100% 94% 100%

Pasonage 85% 100% 71% 100%

Preistner 94% 100% 88% 100%

Golborne 88% 100% 76% 100%

Westleigh 100% 100% 100% 100%

Totals / Average93% 100% 86% 100%

Red = Less than 85%, Amber = 85 - 89%

Warrington Hotel Services Monitoring

Halton Hotel Services Monitoring

WiganHotel Services Monitoring

Knowsley Hotel Services Monitoring

St Helens Hotel Services Monitoring


Bridge – staff preparing breakfasts not wearing green aprons and not Bare below Elbow.

Patient’s personal food items not labelled.

Knowsley

Rydal – reception staff using patient’s fridge for storage of personal food. Patients personal high

risk food stored in ward kitchen fridge was unlabelled.

St Helens

Iris – patient’s personal food items in fridge not labelled, various food items stored in cupboard

unlabelled.

Wigan

Parsonage – incomplete/ missing fridge temperature recording on one occasion. Patient

personal food not dated when opened. Butter left out of the fridge.

Golborne - incomplete fridge recordings. OT sorting out equipment in the kitchen.

Key Areas for Improvement for Estates Function

Estates achieved over 90% however St Helens (Iris ward) achieved 70% because celling light

out, damage to wall behind the door and flooring torn in areas under the counter where the

freezer has been removed.

Conclusion

Disappointing results for nursing responsibilities in general across the Trust for quarter 4,

however only 5 related to lack of fridge recordings compared to Q3 which had 11.

IPC will continue to monitor these results. During April the results have been escalated to

Borough ADs for discussion at local Q&S meetings. Activities to raise awareness about the

importance of recording Fridge temperatures amongst staff has been undertaken during

March/April with targeted communication to all ward managers and articles in In-view. IPC has

also suggested exploring alternative arrangements to resolve incomplete Fridge temperature

monitoring if issues continue.




and control advice, support, audit, education and surveillance and management of healthcare

associated infection across care homes, general practitioners, dentists and schools in

Knowsley.


The Infection Prevention and Control Team have an agreed plan to deliver all key performance

indicators within the year. The majority of the work is targeted at Q4 as agreed by the local

authority.

All audit programmes and all key performance indicators have been completed and achieved by

the end of March 2018.









Q1 Q2 Q3 Q4

Audit

%age of residential/nursing care homes audited. 9% 14% 68% 100%

%age of General practices audited (30% sample) 0% 30% 30% 30%


%age of General practices with infection control champions 100% 100% 100% 100%

%age of nursing/residential care homes with infection control champions 100% 100% 100% 100%

%age of infection control champions to be offered training 100% 100% 100% 100%

Satisfaction rate for participants in learning events Analysis pending

Expert advice and support %age of patients diagnosed with community acquired C-Difficile to

receive information and offer of support 100% 100% 100% 100%







externally, via the service level agreement to general practitioners, dentists and care homes, in










Table 6: Incidence Monitoring by Borough Q4 January-March 2018



These graphs demonstrate the low levels of infection reported however surveillance is key as it

provides indication of increased levels of infections and allows the team the opportunity to

respond early.

8.0 Clinical work

The team respond to frequent requests for advice and support around environmental issues,




Report prepared by Louise Owens – Lead Nurse Infection Prevention and Control April

2018


Appendix 1 – Q4 Incidents resulting in action from IPCT Q4 Incidents 2017/18


MRSA 1 1 1 1 1

Clostridium Difficile Toxin Negative 1 1 1 1

Clostridium Difficile- Toxin Positive 2 1

Inoculation injury 3 1 3 1 1 1 1 1 3

Outbreaks D&V 2 1 2 1

CPE 1

Adhoc Incidents

Strep A 1

MSSA 1

Pan resistant pseudomomas 1

Campylobacter 1

ESBL 1

Lymes disease 1

Increased incidence of diarrhoea. No

outbreak 1 1

Scarlet Fever 1

Salmonella 1

Shingles 1 1

Flu 3 2

Scabies 1 1


Unsafe storage of sharps. 1 1 2

No Soap available in toilets 1

Vomit in communal area 1

Dirty Protest 1

Failed water supply 1

January - Parsonage, C difficile toxin negative, GDH positive sample. Patient well in self, no known recent antibiotic use. No C difficile treatment

required, advised to exercise caution if antibiotics are prescribed in future.


January - Kingsley, MRSA + in sputum, commenced on Doxycycline.

March - Coniston, MRSA + in self harm wound, antibiotics prescribed. Referered to tissue viability nurse.

January - Pennington unit, Recovery team. Needle stick injury during administratration of depot injection. Human error. Innoculation Injury procedure

followed.

February - St Helens OOH District Nurses. Needlestick injury obtained when finger struck used needle in sharps bin. Innoculation Injury procedure

followed.

March - 1) Taylor ward, student nurse obtained injury following administration of insulin injection. Did not use safety device. Innoculation injury

procedure followed.

2) Phlebotomy services, Manor Farm MC. Sharps injury due to closing safety cover over used needle. Innoculation injury procedure followed and

discussed in team meeting.

3) St Helens District Nurses. Injury sustained from uncovered insulin needle in box. Innoculation injury procedure followed.

March - Fairhaven unit. 1 pt experiencing 1 episode of vomiting. 2 pt's experiencing diarrhoea & 1 staff member with diarrhoea. Infection prevention

measures put in place.

February - Kingsley ward. Swab taken, MSSA present with no infection. Pt under TVN. No treatment with antibiotics required.

March - Priestner unit. Strep A found in leg wound. Pt known drug user. Unable to isolate due to deteriorated mental health. Tissue Viability involved,

enhanced cleaning put in place, antibiotics reviewed and risk assessments carried out.

March - 1) Parsonage unit, sharps box knocked off clinical trolley, no injury sustained. Unsafe storage of sharps box, reported by datix.

2) Golbourne unit. Lid not secured correctly on sharps bin. No injuries sustained. Incident reported by datix.

February - Iris ward, isolated case.

March - Auden, Staff member (apprentice HCA) sample positive for salmonella. Staff member has diagnosis of IBS. Weekly samples being obtained. To

remain of work until 48 hours symptom free. OH department are aware.

February - Information governance Hollins Park. Staff member been unwell for 2-3 days. GP confirmed scarlet fever. 6 other staff members c/o sore

throat, cold l ike symptoms. Advised; increase hand hygiene, cough etiquette. Increased environmental cleaning, alcohol gel. Arrange with Estates to

have office deep cleaned.

January -

1) Kingsley ward. 7 pt's affected, 4 hospitalised, 1 died. Antivirals as per guidance. All infection control measures put into place.

2) Austen ward. 3 pt's and 3 staff members affected. Antivirals as per guidance. All infection control measures put into place.

3) Rydal, influenza type B. 9 pt's affected, 2 hospitalised. Antivirals as per guidance. All infection control measures carried out.

March-

1) Austen Ward. Flu A. 2 pateints confirmed and two suspected, 1 staff member affected. Antivirals as per guidance. Ward closed 5 days.

2) Coniston - Flu B, 2 confirmed 4 suspected and 2 staff affected. Antivirals as per guidance.Ward closed 5 days.

March - Priestner unit. Pt undertaking dirty protest. Advice given re cleaning, standard precautions.


Appendix 2: Infection Prevention and Control Service Plan 2018/2019

Trust High Level Objectives 2018-19

1. We will deliver quality, safe & efficient services with a highly skilled and motivated workforce 2. We will deliver whole person care through targeted growth 3. We will retain our values and culture 4. We will engage with our communities and staff to deliver services differently 5. We will play an active role in local place based care systems to maintain a whole person care focus and high clinical standards 6. We will grow and develop at scale being seen as an equal partner in any system-wide collaboration

IPC core agenda will be delivered under Trust High level objective number one. CQC – Regulation 12 – Safe Care and Treatment, DOH directives – e.g. NICE Guidance, NHSLA, 6 Cs This Service Plan is based on financial year and includes Knowsley Specifications Service Level Agreement.

NB: The delivery of services will take account of the need to safeguard and promote the welfare of children as service users of the Trust or as visitors to the premises


We will deliver quality, safe & efficient services with a highly skilled and

motivated workforce 13 Objectives

Points for Discussion/Noting from service plan delivery/

Exception reporting

RAG Q1

RAG Q2

RAG Q3

RAG Q4

Issue

1. To have a robust audit programme in place to monitor compliance with the Health and Social Care Act.

2. To have a robust surveillance programme in place to identify any HCAI/ Outbreaks and ensure prompt delivery of a quality service.

3. Improve the knowledge and understanding of antimicrobial resistance. Conserve and steward the effectiveness of existing treatments

4. Comply with Mandatory requirement to reduce all Gram negative Blood Stream Infections by 50% by 2021.

5. To ensure the Trust and CCG continues to comply with the Health and Social Care Act 2008 and CQC Regulation 12 Safe care and treatment.

6. To provide the Trust Board and CCG with assurance of compliance with the Health and Social Care Act 2008 and other national and local directives via Quality Committee

7 To extend current infection control agenda to newly acquired services ensure integrations and inclusion

8 To provide a quality infection prevention and control team and support systems to deliver service to Trust and community specifications SLA

9 To develop a workforce that is knowledgeable and skilled in IP&C and develops workforce capacity to deliver high quality service to improve both staff and patient experience.

10 Progress and develop links with other agencies to improve service delivery

11 To continue to develop service user engagement and empowerment

12 To ensure that the Trust is not adversely affected by HCAI/IPC

13 To ensure engagement at all levels within the organisation from Board to Ward including external Community Specification SLA To provide regular communication to Trust Board, staff and service users

Total


ABBREVIATIONS

CN Chief Nurse (Director of Nursing and Executive Director of Operational Services)

RCA Root Cause Analysis

DD Deputy Director of Nursing and Safeguarding OH Occupational Health

CCG Clinical Commissioning Group IPCC Infection Prevention and Control Committee

CM Consultant Microbiologist PIR Post Incident Review

DIPC Director Infection Prevention & Control HR Human Resources

CQC Care Quality Commission HE Head of Estates

AM Antimicrobial Pharmacist SB Chief Executive Officer

IPCT Infection Prevention and Control team HF Head of Facilities

PHE Public Health England LG Assistant Director of Nursing and Quality

IPC Infection Prevention and Control Q&S Quality and Safety

PH Public Health PM Procurement Manager

CDI Clostridium Difficile Infection HN Head of Nursing

BBE Bare below the elbows AMR Antimicrobial Resistance

MRSA Methicillin Resistant Staphylococcus Aureus BSI Blood stream infection

UTI Urinary tract infection FM Facilities Management

SLA Service level agreement CPE Carbapenemase Producing Enterobacteriaceae

WIC Walk in Centre LD Learning disability

HC Health Centre CHS Community Health Service

DOH Department of Health ESR Electronic service record

HCAI Health Care Associated Infection DSR Desk top Service review

SU Service User PH Public Health

PDR Personal Development Review NHSI National Health Service Improvement

MH Mental Health KPI Key Performance indicator


1. WE WILL DELIVER QUALITY, SAFE & EFFICIENT SERVICES WITH A HIGHLY SKILLED AND MOTIVATED WORKFORCE

No Objective Method of assurance Timescale for delivery

Ap

r -

Ju

n

17

Ju

l -S

ep

17

Oct -

Dec

17

Dec 0

9

Jan

-

Ma

r 18

Update/notes

1

To have a robust audit programme in place to monitor compliance with the Health and Social Care Act.

Planned programme of IPC audits in accordance with Annual Work Programme and Community Specifications agreed by Trust Board and CCG / PH

Programme to include cleanliness, environment, clinical practices, antimicrobial prescribing,

KPI – 100% of areas to be audited where applicable

KPI – >90% of areas to achieve >90%

Clinical leads / matrons to work with IPCT to action any issues identified in audits. Audit results and action plans to be disseminated and discussed at IPCC & Quality Committee

Escalation to Borough Management teams were compliance not achieved

To feedback audit reports to commissioners / Council (SLA) and escalate any untoward concerns within agreed timescale

Continue to monitor hand hygiene and BBE results across the Trust including community teams.

Monthly Annual work plan - Knowsley SLA

Q1:

Q2:

Q3:

Q4:

2 To have a robust surveillance programme in place to identify any HCAI/ Outbreaks and ensure prompt delivery of a quality service.

mandatory surveillance of HCAI

To ensure on-going effective surveillance programme which highlights issues of concern promptly providing feedback to clinical areas for action

KPI – investigation of 100% of notified IPC related incidents/reports to IPCC

KPI - 100% of wards included in weekly surveillance

KPI – No avoidable MRSA bacteraemia

KPI – To achieve CDI target as agreed by CCG

KPI- All CDI RCA to be commenced within 72 hours and completed within 2/52

KPI – IPCT to respond to 100% of notified outbreaks

All HCAIs reported to PHE and Commissioners as per protocol/contract

Q1

Q2

Q3

Q4


3 Improve the knowledge and understanding of antimicrobial resistance. Conserve and steward the effectiveness of existing treatments

Complete baseline assessment for NICE guidance NG63 (Meds Management)

Ensure AMR is included in all IPC training

Involvement with medicines management and other external partners to deliver antimicrobial resistance messages across the boroughs

Explore use of eLearning packages for staff provided by NHS England & PHE

To respond to new guidance as released

To engage with PH messages and campaigns re AMR

To complete enhanced surveillance on UTIs looking for themes and trends to support targeted work plans To complete local surveillance to monitor infections and antibiotic usage.

Current antibiotic formulary in line with local surveillance for multi resistant organisms

On going Q1

Q2

Q3

Q4

4 Comply with Mandatory requirement to reduce all Gram negative Blood Stream Infections by 50% by 2021.

Undertake enhanced surveillance of a selection of community acquired Ecoli bacteraemia.

Consider the use of local and national PH messages and projects to help reduce the risks associated with development of Bacteraemia.

Attendance at meetings supporting BSI reduction strategy

Work with external stakeholders to support NHSI Gram negative Blood stream Infections across whole health economy and Trust

On-going Q1:

Q2

Q3

Q4

5

To ensure the Trust and CCG continues to comply with the Health and Social Care Act 2008 and CQC Regulation 12 Safe care and

Policies and procedures in place and up dated

Audit of compliance with policies and procedures

IPC embedded in job descriptions within Trust.

To ensure all national directives reviewed and embedded in work plan

Ensure oversight of Cleanliness audits and issues via IPCC

Annual high level clean by FM

Ensure oversight of Food hygiene issue via IPCC

Ensure inclusion of IPC by Estates in building projects/ refurbishments within the Trust

Quarterly

Q1:

Q2:

Q3:


treatment. IPCC overview of annual Legionella control plans

To ensure IPCT are involved in relevant work streams to improve care delivery

Q4:

6

To provide the Trust Board and CCG with assurance of compliance with the Health and Social Care Act 2008 and other national and local directives via Quality Committee

To ensure robust assurance frameworks in place

Quarterly Performance Report to Board

Quarterly report to IPCC and Quality Committee

Quarterly SLA monitoring report to Knowsley Commissioners and CCG

Quarterly Quality monitoring Report to all CCG commissioners

Quarterly Assurance Framework reports to Commissioners and escalation reports as required according to contract specifications

IPC Annual Report for Board

IPC annual report for SLA

Ad hoc updates and reports when required

clear guidelines on reporting corporate risk from the IPC

Monthly Quarterly Annually

Q1:

Q2:

Q3:

Q4:


7 To extend current infection control agenda to newly acquired services ensure integrations and inclusion

Scoping exercise to determine relevant services, buildings and staff.

Redesign current audit calendar

Work with Education and Training department to provide IPC training as required.

Ensure new services have IPCT contact details

Identify appropriate escalation procedures for IPC in new services.

Prevention and control of infection is considered as part of all new service provision.

Service Reviews and New business development: the IPCT will have engaged with, participated and supported the trust in preparing tenders and bids for new services/ renewals and changes to existing clinical services.

Complete DSR were required and within set time scales Scoping exercise to determine relevant services, buildings and staff.

Q1

Q2

Q3

Q4

8

To provide a quality infection prevention and control team and support systems to deliver service to Trust and community specifications SLA

Reassessment of workload vs. capacity once new services integrated.

Appropriate skill mix in place

Provide/seek education opportunities for IPCT

Appropriate job descriptions

KPI – 100% of IPCT PDR up to date by June 2018

Regular service review

To review terms of reference of IPCC annually in Aug 2018

To ensure prompt and efficient laboratory services

IPCT to receive timely reports from all laboratory services

Effective and committed Link Practitioner Group and champions at all level of the organisation including Knowsley Community SLA

KPI - Link Practitioner meetings to be held a minimum of quarterly

Provide expert IPC advice/ support and work closely with all levels of the Trust and community specifications SLA. e.g. clinical, medical devices/decontamination/ Modern Matrons/Facilities/Procurement.

Attendance at meetings requiring IPC input as required.

Monthly Quarterly On-going

Q1:

Q2

Q3


To update expert knowledge of the Infection Prevention and Control Team via PDR process

Continue with professional development and up skilling of IPCT

Network with other MH and community areas/teams locally and nationally

To ensure all IPCT undertake Trust ‘Coaching Culture’ Course

Timely and effective specialist microbiological support is provided to the Trust.

Q4

9

To develop a workforce that is knowledgeable and skilled in IP&C and develops workforce capacity to deliver high quality service to improve both staff and patient experience.

DDN DIPC

Continue to work with Training and Development and HEI to review current provision

Ensure all Link Personnel up skilled and increased attendance at meetings.

Work with clinical areas/audit and research department to continually review and improve practice.

Expand Student Placement Programme

Review and report ESR training records and attendance

Continue to develop Service User Involvement strategy

Continue training programme for MH/LD, CHS and Community Specifications SLA staff

To support OH in the delivery of the flu vaccine, working towards staff influenza immunisation target.

To ensure all at risk patients in MH / LD are offered flu vaccine and staff are trained to increase uptake To continue compliance with EU Sharps safety directive2013 and to ensure safety devices are in use

To ensure that the curriculum content of the Trusts Infection Control induction and statutory courses is evidence based, and report and monitor attendance.

On-going

Q1:

Q2

Q3

Q4

10 Progress and develop links with other agencies to

Work with partner organisations including CCG to continue to reduce HCAI across the whole health economy such as MRSA, Clostridium difficile, UTI, E coli, CPE and other emerging organisms

Q1


improve service delivery

Work with community service & other organisations to promote uptake of vaccination for inpatients, targeting at risk groups

Work with partner organisations including CCG to continue to reduce HCAI across health economy and raise awareness of AMR.

Work with PHE, report infection control adverse incidents e.g. outbreaks

Work with community service & other organisations to promote uptake of vaccination for inpatients, targeting at risk groups

Work with PHE, report infection control adverse incidents e.g. outbreaks

Q2

Q3

Q4

11

To continue to develop service user engagement and empowerment

DIPC DDN

SU actively engaged in agenda, attending IPCC, undertaking joint audits including WIC and HC.

KPI – SU to be involved in >50% of unannounced spot-checks

To inform users and carers of how they can participate in good infection prevention

To ensure good communication via various channels

On going

Q1

Q2

Q3

Q4

12

To ensure that the Trust is not adversely affected by HCAI/IPC

DDN DIPC

•To provide an infection prevention and control budget that reflects requirements of the service plan including resources are allocated in the annual budget •Estates Business Plans for required infection control improvements 2018/2019 •To ensure that the Trust and CCG is not adversely affected by DOH Zero Tolerance MRSA directive

Ensure DIPC/ Trust is aware of any risks to delivery of IPC service including requirements under SLA

There is a programme to manage and monitor the potential and actual risks of Health Care Associated Infections (HCAI’s).

On-going

Q1

Q2

Q3

Q4


NOTES

NB: Further in depth evidence including minutes of relevant meetings/committees is provided on: 1) Trust ‘G’ drive Internal and External Assurance for CQC Regulation 12: 2) ¼ Assurance Framework progress/exception reports to Quality Committee 3) Annual Board and Performance reports 4) CCG Monthly Assurance Framework 5) Quarterly Quality Contract Monitoring

Title STATUS Review Date Comments

13

To ensure engagement at all levels within the organisation from Board to Ward including external Community Specification SLA To provide regular communication to Trust Board, staff and service users

DIPC DDN

Executive level representation at IPCC

Board level awareness and support of IPC issues and challenges

IPC discussed at Borough Q&S meetings

Infection Prevention and control will be granted the appropriate priority and attention both within the organisation and external Community Specification SLA reflected within outcome / performance data

CCG/Council to action any issues raised within external Community Specification SLA

Board level responsibility for IPC is clearly defined

To ensure robust systems of communication of NHS guidance/directives / HCAI information in place

To keep updated on new directives

To review reports to ensure relevance

To ensure easily accessible audit results for all areas

Review information on Trust Intranet and Internet page

On-going

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4


CPE (Carbapenemase Producing Enterobacteraciae)

July 2018

MRSA Aug 2020

Blood borne Virus (Sharps Policy

Feb 2020

Infection Control Policy

Feb 2020

Immunisation Policy

April 2019

Infectious Disease Outbreak (pandemic) Policy

April 2021

Animals in Healthcare

June 2018

Blood Borne Virus Procedure

Feb 2020

Clostridium difficile procedure

April 2021

CPE - Carbapenemase producing Enterobacteraciae procedure

July 2018

Decontamination of Environment Procedure

Feb 2020

Hand Hygiene procedure

Feb 2020

Infectious diseases Procedure

April 2020

Infectious Disease Outbreak (Pandemic) Procedure

April 2021

Inoculation incident

February 2020

Inoculation Procedure

February 2020

IPC Standard precautions procedure

August 2020

IPC Surveillance procedure

August 2020

Multi- Resistant Gram Negative Bacteria; including CPE

N/A

Outbreak procedure

August 2020

Sepsis Procedure December 2018


RISK REGISTER

ID Description Progress

Init

ial R

ati

ng

Cu

rren

t

rati

ng

Ad

eq

uacy o

f

Co

ntr

ol

Last Review Date

Responsible Owner

No risks as of 1.4.18

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