infection prevention and control cleaning policy cleaning... · infection prevention & control...
TRANSCRIPT
Infection Prevention & Control Cleaning Policy Feb 15 Page 2
Policy Title:
Cleaning Policy
Executive Summary:
The health and Social Care Act 2008 (DH2015) required healthcare premises to “provide and maintain a clean and appropriate environment and have systems in place to ensure all care workers including contractors and volunteers are aware of and discharge their responsibilities in the process of preventing and controlling infections”. To reduce the risk of infection it is essential to have systems and process in place to reduce the transmission of pathogens in the health care environment by ensuring appropriate environmental cleaning and the decontamination of patient equipment.
Supersedes: Cleaning, Sterilisation and Disinfection Policy 2012
Description of Amendment(s):
New policy to reflect national guidance and control mechanisms required to reduce the risk of Health Care Associated Infection.
This policy will impact on: Clinical Staff, Domestic Contractors, Estates and clinical practice
Financial Implications: Increased Screening due to identification of new cases
Policy Area: Infection Prevention and Control Trust Wide
Document Reference:
ECT002453
Version Number: V1 Effective Date: February 2016
Issued By: Infection Prevention and Control Group
Review Date: May 2018
Authors: Anita Swaine Lead Nurse Infection Prevention and Control
Impact Assessment Date:
February 2016
APPROVAL RECORD
Committees / Group Date
Consultation: Infection Prevention and Control Group
January 2016
Approved by: Date
Director Nursing Quality and Performance, Director of Infection and Control
January 2016
Infection Prevention & Control Cleaning Policy Feb 15 Page 3
Contents
Page
1 Introduction
4
2 Purpose
4
3 Responsibilities
5
4 Cleaning Process and Definitions
7
5 Community premises
11
6 Blood and Bodily fluid spillages
11
7 Training
13
8 Monitoring compliance
13
Legislation, Guidance and References
14
Appendix 1 - levels of cleaning required for specific microorganisms
15
Appendix 2 - commonly used equipment and the level of cleaning required
17
Appendix 3 – Post infection clean process
24
Appendix 4 – Post infection clean signoff check list
30
Appendix 5 – General points about the use of disinfectants
32
Equality and Human Rights Policy Screening Tool
33
Infection Prevention & Control Cleaning Policy Feb 15 Page 4
1 Introduction The Health and Social Care Act 2008 (DH2015) requires healthcare premises to
“provide and maintain a clean and appropriate environment and have systems in place to ensure all care workers including contractors and volunteers are aware of and discharge their responsibilities in the process of preventing and controlling infections”.
To reduce the risk of infection it is essential to have systems and processes in
place to reduce the transmission of pathogens in the healthcare environment by ensuring appropriate environmental cleaning and the decontamination of patient equipment.
Cleanliness standards in health care premises are a key element of quality
performance which is monitored externally by the Care Quality Commission (CQC) and is part of the established registration requirement. This is to ensure Organisations are fit for purpose in relation to environmental cleanliness and that infection prevention and control is embedded and effective.
Organisations are required to comply with the Hygiene Code of Practice (part of
the Health & Social Care Act, 2008) in order for registration to be granted to healthcare (and social care) organisations. Outcomes from this monitoring process can result in enforcement notices on behalf of service users if services are identified as poor.
2 Purpose The purpose of this policy is to ensure that all East Cheshire NHS Trust staff
(including contractors) working in hospital (Macclesfield District General Hospital, Congleton War Memorial Hospital, Knutsford Cottage Hospital and community settings (which East Cheshire NHS Trust has responsibility for) understand their responsibilities towards ensuring that patients receive treatment in a safe and clean environment.
This policy does not cover community premises where the Trust is not
responsible for the cleaning (e.g. GP practices) as these areas will have their own policy for environmental cleaning in accordance with the requirements of the Health and Social Care Act 2008 (DH 2015). However clinical equipment used by staff in both hospital and community settings must be clean and fit for purpose as per the standards outlined in this policy.
Staff must be aware of the different process for cleaning and decontaminating
both equipment and the environment to ensure that patients/service users are protected from the risks of Health Care Associated infections (HCAI). This awareness includes the products that should be used when dealing with a blood or body fluid spillage.
All Clinical areas are responsible for ensuring that a clean and safe environment
is provided which:
Is suitable in purpose
Is maintained in a good physical repair and condition
Minimises and reduces the risk of healthcare associated infection transmission.
Effective arrangements must be in place to ensure that the environment and patient equipment are cleaned and decontaminated effectively; therefore minimal
Infection Prevention & Control Cleaning Policy Feb 15 Page 5
equipment must be kept in the patient environment. In addition to cleaning equipment and environment all single use items within the area need to be disposed of as part of the cleaning process. This policy provides up to date information on the selection of appropriate cleaning methods for the environment and patient equipment.
3 Responsibilities
The Chief Executive has ultimate responsibility for the implementation and monitoring of the policies in use in the Trust, and ensuring sufficient resources are made available to ensure the provision of a clean and appropriate environment which facilitates the prevention and control of HCAI. This responsibility may be delegated.
The Director of Nursing, Performance and Quality, Director of Infection Prevention and Control (DIPC) will take the lead responsibility for the development and implementation of this policy with support of the Lead Nurse Infection Prevention and Control and the Consultant Microbiologist/Infection Prevention and Control Doctor. In addition to challenging poor standards and holding to account as appropriate, this role will provide assurance to the Trust Board that systems and process are in place to ensure compliance with agreed standards
The Infection Prevention and Control Lead Nurse will have responsibility for ensuring the policy is implemented and monitored across the Trust and that the policy is updated to reflect any changes to the national or local guidelines. The policy will be readily accessible via the Trust infonet system.
In addition the Infection Prevention and Control Team (IPCT) will: - Provide education and support to clinical staff on the links between Infection
Prevention and Control and cleaning of the environment and equipment. - Ensure that a robust audit programme is in place to support clinical areas in
maintaining standards of cleanliness and identifying appropriate actions required.
- Provide support to the Cleaning service Provider to ensure effective standards of cleanliness are maintained, and that any remedial action undertaken is reflective of Trust standards.
The Head of Facilities is accountable for a clean, safe environment and is responsible for:
- Implementation and management of the Cleaning Service Provider throughout the Trust.
- Ensuring that contract negotiations and service planning identified through the SLA’s and service specification are in place and adhered to. Changes to the specifications are made in conjunction with the Infection Prevention and Control Lead Nurse, Consultant Microbiologist and Matrons.
The Head of Estates is responsible for ensuring that the fabric, fixtures and fittings of Trust premises are maintained to reduce the risk of HCAI and that appropriate systems and processes are in place for the effective decontamination of equipment.
Matrons have responsibility for ensuring that a clean and safe environment is provided. This includes making sure that the clinical areas levels of cleanliness
Infection Prevention & Control Cleaning Policy Feb 15 Page 6
are reflective of Trust standards, and that staff are supported in identifying and resolving any areas of concern.
This role will be undertaken in conjunction with the ICT and the Healthcare Cleaning contracts manager, escalating concerns as required. Effective systems and process need to be in place for the appropriate cleaning of equipment that is used at the point of care (e.g commodes, hoists, mattresses), and that there is a system in place to identify that items of equipment have been decontaminated (indicator tape, notices) and that the clean equipment is stored appropriately.
Ward Senior Sister / Departmental Managers are responsible for ensuring that all staff:
- Are aware of, and comply with, this policy - Understand the link between cleaning and the transmission of HCAI - Are aware of their roles and responsibilities with regard to cleaning and
decontamination of patient environment and equipment, and that they are aware of the process identified within this policy.
- Are responsible for ensuring that the importance of cleaning and cleanliness is embedded into the clinical area. As a process of ensuring patient confidence that they are cared for in a clean, safe environment.
- Monitor the levels of cleanliness in both the environment and patient equipment (this may be delegated to other team members as appropriate)
- That clean equipment is suitably labelled.
Healthcare Cleaning Manager is responsible for the operational delivery of the cleaning contract in accordance with the agreed contract specifications. This includes the provision of products, and ensuring that all healthcare cleaning staff are suitably trained as per the National Specifications for Cleanliness in the NHS (NPSA 2007) and the NHS Cleaning Manual (NPSA 2009). They must provide:
- Appropriate standards of cleanliness in line with the cleaning schedules. Cleaning Schedules are to be agreed as part of the Trust specification for cleanliness.
- Assurance that environmental cleaning is carried out within this schedule. - Cleanliness standards are monitored and feedback is given to the Senior
Sister/Manager with any remedial actions clearly identified within a specific timeframe.
- Cleaning schedules that are available on request and are displayed in clinical areas.
- Assurance that any concerns raised are actioned promptly whoever they are raised by i.e. Senior Sister, Matron, ICT, housekeepers, visitors, or patients.
- Appropriate training for Healthcare cleaning staff, and ensure that they understand the relationship between cleaning and infection prevention and control.
All Employees are responsible for: - Ensuring standards of cleanliness are maintained to protect patients and others. - Understanding their individual responsibilities in relation to environmental
cleaning and decontamination of equipment. - Understanding the process for raising concerns in relation to failures in cleaning
processes. - Attending Infection Prevention and Control training as required within their role
which will be identified via the Trust appraisal process.
Infection Prevention & Control Cleaning Policy Feb 15 Page 7
4 Cleaning Process and Definitions
Cleaning Definitions and Process
All surfaces should be visibly clean with no blood and body spillages, dust, dirt, debris, adhesive tape (National Specifications of Cleanliness 2007). Cleaning visibly removes grease, soil and approximately 80% of micro-organisms
Routine/ Discharge clean including patients who have been reverse barrier nursed e.g. Neutropenic (Neutral detergent/ Tristal)
This is undertaken when a patient not in Isolation is discharged this includes patients who have been cared for in isolation for their own protection This is a routine coordinated response by Nursing staff and Healthcare Cleaning staff.
Infection Clean for example patients isolated for MRSA, CDI, Norovirus, VRE (Tristal this is a sporicidal agent)
This is undertaken when a patient is isolated in a side room or cohort nursed due to the identification of a specific infection. This is a twice daily clean of the patients side room/ bay and associated equipment
Post infection Clean for example following MRSA, CDI patient, Norovirus Outbreak (Tristal this is a sporicidal agent, Steam)
This is undertaken when a patient is moved out of isolation and may occur when the patient is
Discharged or transferred
No longer requires isolation
Following a risk assessment by the Infection Prevention and Control Nurse
Post Infection Cleans will be undertaken by the Ward Staff and the Specialist cleaning team. This is a coordinated response by IPCT, Ward Senior Sister, Matron and ISS Specialist Cleaning team.
Curtains must be changed as part of a post infection clean as the last action once the room has been signed as cleaned to the correct standard.
Deep Clean -for example VRE, annual programme of work or after a specific Outbreak as requested by the IPCT(triple clean) Steam/ Tristal ( this is a sporicidal agent)/Steam
These occur as part of a planned programme of work, following a specific micro-organism and or following an outbreak. Requests for a deep clean will be made by the IPCT/Clinical Matron. Out of hours this will be via the site manager. Deep cleans are undertaken by the Ward Staff, Estates, Specialist Cleaning team.
Infection Prevention & Control Cleaning Policy Feb 15 Page 8
4.1 Cleaning Process (MDGH, CWMH, KCH, and East Cheshire Trust Community Clinics/ Equipment).
In all instances clean in accordance with the prescribed method statement. To identify the level of cleaning required for specific microorganisms refer to Appendix 1. The list is not exhaustive therefore for further advice and support contact the Infection Prevention and Control team; out of hours contact the Consultant Microbiologist on Call.
Prior to cleaning, all equipment must be inspected for any signs of damage which may render cleaning ineffectual. Any concerns about the integrity of the equipment replacement or repair must be escalated to the Senior Sister / Manager. In their absence this must be reported to their nominated deputy.
Cleaning wipes approved by the IPCT are available in clinical areas to routinely clean equipment. If a specific level of cleaning is required then alternatives to the wipes may be required. A list of commonly used equipment and the level of cleaning required is included in Appendix 2
Equipment requiring repair must be cleaned and labelled appropriately as per the Cleaning Sterilisation and Disinfection Policy.
Any damage to surfaces, flooring, and seals must be escalated to the Senior Sister or Nurse in Charge, and also to Estates for assessment of repair or replacement. In community settings this may be the building manager as Estates do not cover all the community clinical areas, for example GP practices (District Nurses may work out of these areas).
Staff involved in the cleaning process must ensure they wear correct Personal Protective Equipment (PPE) in accordance with Trust Policy including Standard Precautions Policy, Isolation Policy, and Outbreak Policy.
Disposable paper roll/disposable cleaning cloths must be used once and then discarded into the appropriate waste stream.
Healthcare Cleaning staff work to specific agreed cleaning schedules these must be clearly available in the clinical area
Healthcare cleaning is undertaken with the use of a micro-fibre system (cloths are laundered daily at temperatures reaching 65c). In addition they may use mops in particular during specific infection control restrictions, these heads are changed as a minimum on a daily basis.
Containers containing cleaning agents must be clearly labelled with the date of activation and must be stored and disposed of as per COSHH requirements.
Ventilation is an important part of the cleaning process therefore as far as practicable windows must be opened, however to prevent the transmission of organisms the doors to the areas must be kept closed during the cleaning process.
Equipment must be clearly labelled following decontamination; this must include the date of cleaning, time of cleaning and a signature. This should be removed at the patient’s bedside when the equipment is put back into use.
Infection Prevention & Control Cleaning Policy Feb 15 Page 9
4.2 Routine Cleaning (MDGH, CWMH, KCH, and East Cheshire Trust
Community Clinics/ Equipment). The aim of environmental cleaning is to remove visible dirt, dust and organic
matter e.g. blood and faeces which may contain bacteria. This is undertaken using a mix of detergent and specific chemicals requested by the IPCT e.g. sporicidal, Chlorine releasing agents.
In all instances clean in accordance with the prescribed method statement.
Healthcare cleaning staff undertake cleaning within agreed cleaning schedules which list the areas to be cleaned and the frequencies required. The Senior Sister or Manager may request a variation in this process dependent on clinical needs of the patient.
Healthcare cleaning equipment is implemented using a colour coding system (NPSA 2007)
Miro-fibre is used with a suitable detergent or disinfectant (as per COSHH) dependent on the task.
Equipment must be kept clean and cloths changed on a minimum of a daily basis.
Cleaning trolleys when not in use must be stored in the domestic cupboard and not on the corridors.
A process of working from clean to dirty areas must be followed.
Corners, edges, curtain rails and underneath surfaces must be checked as part of the routine cleaning process.
Clean mops and buckets must be available for clinical staff in the sluice to undertake spillage cleans as required.
The Healthcare cleaner must liaise with the Nurse in Charge/Manager or appropriate deputy to establish any specialist cleaning requirements. Any concerns must be raised with the Healthcare cleaning Supervisor.
Although a range of staff are required to ensure effective cleaning of the environment and equipment, some specific equipment which is a nursing responsibility (Cleaning Disinfection and Sterilisation Policy). Listed below is an example of areas of responsibility
Nursing Responsibility Healthcare Cleaning Responsibility
All clinical equipment Horizontal Surfaces, fixtures and fittings high and low
IV Stands and Pumps Floor including corners and edges
Monitoring equipment, oxygen and suction etc
Bed Frame underneath
Upper part of bed frame including the mattress check
Locker including Patient medicine box upon discharge
Trolleys Bed Pan washers
Cots/Cot Mattress Table
Pillows Water jugs and glasses
Clipboards, files, holders Removal of Waste
Vases En suite facilities/ Bathrooms/ toilets
Remove all disposable products Hand Wash basins
Toys Curtains
Blood and bodily fluid spillage Shower Curtains
Commodes Wall washing
Infection Prevention & Control Cleaning Policy Feb 15 Page 10
4.3 Infection Cleaning – (this section particularly relates to inpatient areas in the hospital setting).
In all instances clean in accordance with the prescribed method statement.
Patients with specific isolation requirements will require a higher level of cleaning this MUST be undertaken using appropriate sporicidal agent.
Frequent touch points e.g. door handles, taps, must be cleaned TWICE daily, during outbreaks, or for specific isolation increased frequency may be required. The IPCT/Matron will advise when this is necessary
Equipment must be kept to a minimum, and as far as possible kept in the room for that specific patient. This must be cleaned following use with the appropriate cleaning agent.
4.4 Post Infection Cleaning (this section particularly relates to inpatient areas
in the hospital setting - Appendix 3)
In all instances clean in accordance with the prescribed method statement.
Following the patient discharge the Cleaning service provider must be contacted via extension1999 and notified that the area requires a Post Infection Clean, ideally they should be provided with the time the room will be vacated.
The room must be cleared and prepared for cleaning including the removal of curtains. Nursing staff must remove all personal equipment, linen, and ensure that disposable/opened items are discarded.
Cutlery and Crockery should be returned to the main kitchen as normal for machine washing. However, items normally washed at ward level should be washed separately in the ward kitchen in hot soapy water and then in the dishwasher.
Wall Washing is not required unless there is visible staining on the walls or specifically requested by the IPCT
Cleaning MUST be undertaken using Tristal / Steam in addition to the appropriate micro fibre system (which MUST be discarded and laundered immediately after use).
Once completed the room MUST be signed of as clean by the Nurse in Charge and Healthcare Cleaning supervisor (Appendix 4)
Any curtains can then be rehung.
The bed manager should then be notified the room is available. 4.5 Deep Clean/ Triple Clean (Appendix 3)
The decision of when to deep clean a ward, side room or bay after a specific infection or outbreak will be made by the Infection Prevention and Control team and or Clinical Matron. Out of Hours this must be done in conjunction with the Site Manager and Senior Nurse. During periods of increased operational pressures and the Trust reporting “Black” a risk assessment by the DIPC, Infection Control Lead Nurse, Consultant Microbiologist may be undertaken to open a bay before the ward deep clean has been completed, this risk assessment will be clearly documented as part of the outbreak documentation.
During working hours a member of the Infection Prevention and Control Team will liaise with the Healthcare Cleaning Manager, Estates and brief them on the requirements and time frame available. Out of hours, a request for a Deep clean will be made after consultation with the on call microbiologist and co-ordinated via the site manager.
The room must be cleared and prepared for cleaning including the removal of curtains. Nursing staff must remove all personal equipment, linen, and that disposable/opened items are discarded.
Cutlery and Crockery should be returned to the main kitchen as normal for machine washing. However, items normally washed at ward level should be
Infection Prevention & Control Cleaning Policy Feb 15 Page 11
washed separately in the ward kitchen in hot soapy water and then in the dishwasher
Estates must be asked to start the process by cleaning light fittings, vents and removal of radiator covers.
Wall washing will be requirement to be undertaken by the Specialist clean team.
Deep cleaning of a ward department may take a number of days to complete to ensure all areas including equipment are thoroughly decontaminated effectively.
5 Community Premises
If a patient is known to have an infection they should be seen at the end of a clinic session as far as practicable and providing it is not detrimental to the patient’s clinical care. Surfaces, trolleys, couches, chairs and any equipment used must be cleaned with a universal sanitising wipe by community staff, for example green clinell wipes (as per manufacturer’s instructions).
Dependent on the community premises e.g. GP practice they may have their own healthcare cleaning provider who will follow their specific cleaning schedules and not East Cheshire NHS Trusts.
Non-critical multi use equipment/devices used in the community such as syringe drivers, Doppler’s, bladder scanners, ear care machines and suction machines must be decontaminated as soon as possible after patient use and or on return to clinical base.
Any equipment requiring return for repair must be cleaned prior to return with the appropriate wipe
Personal protective equipment including gloves and aprons must be worn when cleaning spillages (as per Standard Precautions Policy). All waste must be disposed of in the clinical waste stream. N.B cleaning products containing chlorine must not be used on patient’s furniture or carpets. Any blood/body fluid on these items must be cleaned using soapy water and disposable paper towel/roll.
Curtains should be on a planned programme of laundry and replacement (quarterly) and or when visibly soiled. Disposable curtains must be changed every 6 months or when visibly soiled.
6 Blood and Bodily fluid spillages (as per Standard Precautions Policy) Any blood and body fluid spillages are to be cleaned with a hypochlorite based
solution e.g. Haz TAB/HAZ TAB granules (NaDCC) Sodium Dichloroisocyanurate, This is because blood and bodily fluids can contain harmful pathogenic micro-organisms. Haz-Tabs must be stored as per COSHH guidelines.
Protective clothing, e.g. gloves and apron, must be worn when dealing with
blood/body fluid spillage. The area must be made safe to prevent further contamination and protect staff and patients.
Make up the chlorine solution as per manufactures instructions using the Haz tab
dilution bottle to mix the solution. The solution must be made up fresh every 24 hours; unused solution must be discarded after 24 hours.
Blood/body fluid spillage can be divided into groups:
Soiling of equipment or where it is not practicable to use a hypochlorite powder e.g. splashes and drips.
Spillage on the floor or large surface areas.
Infection Prevention & Control Cleaning Policy Feb 15 Page 12
Actions to take following Blood Bodily Fluids Spillage. Please note it is not appropriate to use hypochlorite on carpet or soft furnishings as this may damage the fabric.
Blood and bodily fluid spillage (no matter how small).
Use PPE this must include gloves and aprons to prevent contamination of clothing. Face Protection may be required if it is suspected that splashes may occur to the eyes, nose or mouth. Mop up excess fluid with paper towels, leave towels on spillage. Gently pour the HAZ-TAB solution over the spillage (ensure all the blood spillage is covered) and leave for a minimum contact period of 2 minutes (to kill blood borne viruses) ensure that the area is well ventilated and cordoned off if necessary to prevent slips/falls. After a minimum of 2 minutes wipe up/mop up the area (dependent on the size of the spillage). Clear away towels / disinfectant / granules from the area, place immediately into a lined and lidded waste bin. Wash the area with water and allow drying. Dispose of used equipment and PPE in appropriate clinical waste bin. Decontaminate hands using soap and water.
Body Fluids, eg vomit, urine, faeces
Use PPE this must include gloves and aprons. Wipe up the fluid with absorbent paper soaked in freshly prepared chlorine solution (1,000 ppm available chlorine solution) Clear away spillage with paper roll Wash area with detergent and water using paper roll Dispose of used paper roll in an orange clinical waste bin Dispose of PPE in Clinical waste bin Decontaminate hands using soap and water
Infection Prevention & Control Cleaning Policy Feb 15 Page 13
7 Training Managers must ensure that all staff are appropriately trained in relation to complying with all Infection Prevention and Control policies, and that this compliance is monitored as part of the staff appraisal process. The basic requirements for Infection Prevention and Control are:
Induction for all new staff to the Trust
Mandatory training incorporating Infection Prevention and Control
Specific medical device training relating to equipment identified for individual practice
In addition the IPCT will support clinical areas by providing bespoke training incorporating standards of cleanliness and the transmission of microorganisms and the delivery of dedicated Infection Prevention and Control Study days.
8 Monitoring compliance
Monitoring standards of cleanliness is undertaken via:
Infection Prevention and Control Environmental audit peer review.
Post infection/ Incident review meetings
Matron clinical audits
Housekeeper audits
IPCT audit verification process
Contract Monitoring by the Trust.
Contractors audit and monitoring process
Non-compliance with the policy will be managed via the staff disciplinary route; this will be supported by the Director of Nursing, Quality, Performance, DIPC, and the Medical Director. This policy should be read in conjunction with as a minimum but not exclusively
Decontamination of Medical Devices requiring high grade disinfection and sterilisation’
Standard Precautions Policy
Specific Microorganisms policy e.g. Clostridium difficile
Isolation Policy.
Outbreak Policy.
Hand Hygiene Policy.
Infection Prevention & Control Cleaning Policy Feb 15 Page 14
Legislation, Guidance and References Association of Healthcare Cleaning Professionals (2013) Revised Healthcare Cleaning Manual available from http://www.ahcp.co.uk Ayliffe, Bradley (Ed) (2009) Control of Hospital Infection – a practical handbook (5th
Edition) Arnold: London British Standards Institution (BSI) (2011) PAS 5748:2011 Specification for the planning, application and measurement of cleanliness in hospitals. BSI: London Control of Substances Hazardous to Health (Amendment) Regulations (COSHH) 2004 Department of Health (2004) A Matron’s Charter: An Action Plan for Cleaner Hospitals DOH: London Department of Health (2004) Towards Cleaner Hospitals and Lower Rates of Infection DOH: London Department of Health (2006) Safe Management of Healthcare Waste. DOH: London Department of Health (2008) From Deep Clean to Keep Clean. Learning form the Deep Clean Programme DOH: London Department of Health (2008) Clean, safe care. Reducing Infections and saving lives DOH: London Department of Health (2015) The Health and Social Care Act 2008, Code of Practice on the prevention and control of infection and related guidance Available at: https://www.gov.uk/dh Loveday HP et al. (2014) Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection January 2014: 86S7 S1-S70. National Patient Safety Agency (2007) The National Specifications for Cleanliness in the NHS: a Framework for Setting and Measuring Performance Outcomes NPSA: London National Patient Safety Agency (2009) The NHS Cleaning Manual NPSA: London NHS Litigation Authority (2010) Risk Management Standards 2010/11 Available at : http://www.nhsla.com/NR/rdonlyres/E974091E-036C-4D5E-A28F-229687E08461/0/201011AcuteISPCTStandardsFINAL.doc WHO (2006) Your 5 moments of hand hygiene [pdf] Available at: http://www.who.int/gpsc/tools/Five_moments/en/
Infection
Daily Cleaning Schedule
Cleaning agent (ISS)
Nursing cleaning agent
Nursing equipment to be cleaned by ward
Discharge Cleaning
Clostridium difficile
Infection clean 2 x daily (Including dedicated bathroom / toilet)
Sporacidal e.g. Tristel,
Sporacidal agent e.g. Tristel
All equipment used in the room must be cleaned after every use with sporicidal agent e.g. Tristel None dedicated items e.g. hoist must be cleaned with Tristel after each use.
Post infection clean – Steam and Tristel
Including dedicated bathroom – if appropriate Curtain change. On discharge ensure that disposable/opened items are
discarded. CPE
Infection clean 2 x daily (Including dedicated bathroom / toilet)
Sporacidal agent e.g. Tristel
Sporacidal agent e.g. Tristel
All equipment used in the room must be cleaned after every use with sporicidal agent e.g. Tristel None dedicated items e.g. hoist must be cleaned with Tristel after each use.
Post infection clean – Steam and Tristel.
Including dedicated bathroom – if appropriate Curtain change. On discharge ensure that disposable/opened items are discarded
Diarrhoea and / or vomiting
Infection clean 2 x daily (Including dedicated bathroom / toilet)
Sporacidal agent e.g. Tristel
Sporacidal agent e.g. Tristel
All equipment used in the room must be cleaned after every use with sporicidal agent e.g. Tristel None dedicated items e.g. hoist must be cleaned with Tristel after each use.
Post infection clean – Steam and Tristel.
Including dedicated bathroom – if appropriate Curtain change. On discharge ensure that disposable/opened items are discarded
Respiratory illness e.g. FLU
X1 daily routine clean General purpose detergent
Detergent / disinfectant wipes (Clinell Green packet)
Detergent / disinfectant wipes (Clinell Green packet)
Post infection clean – Tristel.
On discharge ensure that disposable/opened items are discarded
Norovirus Infection clean 2 x daily. (Including dedicated bathroom / toilet)
Sporacidal agent e.g. Tristel
Sporacidal agent e.g. Tristel
All equipment used in the room must be cleaned after every use with sporicidal agent e.g. Tristel None dedicated items e.g. hoist must be cleaned with Tristel after each use.
Post infection clean – Steam and Tristel.
Including dedicated bathroom – if appropriate Curtain change. On discharge ensure that disposable/opened items are discarded
MRSA Infection clean X1 daily (Including dedicated bathroom / toilet)
General purpose detergent
Detergent / disinfectant wipes (Clinell Green packet)
Detergent / disinfectant wipes (Clinell Green packet)
Post infection clean – Tristel.
Including dedicated bathroom – if appropriate Curtain change.
Appendix 1: levels of cleaning required for specific microorganisms
15
16
Infection
Daily Cleaning Schedule
Cleaning agent (ISS)
Nursing cleaning agent
Nursing equipment to be cleaned by ward
Discharge Cleaning
On discharge ensure that disposable/opened items are discarded
VRE Infection clean 2 x daily (Including dedicated bathroom / toilet)
Sporacidal agent e.g. Tristel
Sporacidal agent e.g. Tristel
All equipment used in the room must be cleaned after every use with sporicidal agent e.g. Tristel None dedicated items e.g. hoist must be cleaned with Tristel after each use.
Deep Clean– Steam, Tristel, Steam.
Including dedicated bathroom – if appropriate Curtain change. On discharge ensure that disposable/opened items are discarded
17
ITEM ROUTINE ADDITIONAL RECOMMENDATIONS
Airways Single use
Ambubags Detergent and hot water or appropriate detergent wipe. Dry thoroughly.
Ambulift Detergent and hot water or appropriate detergent wipe. Dry thoroughly.
Hypochlorite if contaminated with bodily fluids, or after potentially infected patients.
Ampoules and Vials Wipe neck with alcohol impregnated swab.
Aseptic non touch technique trays
Detergent and hot water if visibly soiled or appropriate disinfectant & detergent wipe followed by 70% v/v Isopropyl alcohol in 2% w/v chlorhexidine impregnated alcohol wipe. Dry thoroughly
ANTT policy – clean aseptic surface i.e. plastic tray/dressing trolley with 70% alcohol unless visibly soiled then wash with detergent and water or appropriate disinfectant wipe.
Auroscopes single use
Babies bottles (a) Use pre-packed sterile feeds.
.
Parent who bring in own equipment must be provided with individual sterilisation equipment
Baths Clean at least daily, and between patients, with detergent and hot water and rinse and dry.
After use by known or a potentially infected patient, clean with Chlorine releasing agent or sporicidal rinse and dry.
Bath Mats Disposable single patient use
Bed Frames (a) Routine Use.
Wash with disinfectant & detergent wipes (Universal sanitising wipes) between patients and at regular intervals. Allow to air dry.
(b) If contaminated with blood use10.000ppm chlorine
Use chlorine releasing agent/ Sporicidall for post infection cleans e.g. Clostridium difficile, Norovirus
Appendix 2: commonly used equipment and the level of cleaning required
18
ITEM ROUTINE ADDITIONAL RECOMMENDATIONS
releasing agent (Haztabs), Rinse with water and dry.
Other body fluid or faeces wash with haztabs 10.000 ppm available chlorine solution, air dry.
Bed Pans Washer Disinfector
(Remove bodily fluids prior to placing in machine
Bed/slipper pans, place directly into washer/disinfector e.g. DEKOMED 190
Bed Pan Washer/Disinfectors DEKOMED 190
Wash outside Tristal or appropriate sporicidal wipe. Report any leakage’s to Nurse in Charge who will report to Estates.
Blood Glucose Meters Wipe clean between each patient with disinfectant wipe. If any blood contamination with 10,000ppm chlorine releasing agent (Haztabs).
BP cuffs Disinfectant & detergent wipe between each patient Clinell disinfectant wipes
Breast pumps As per Maternity SOP
Carpets Carpets should not be used in areas where spillage of blood and body fluids is a possibility. If a carpets must be used e.g. audiology dept. purchase carpets which can tolerate hypochlorite
(a) Routine use: Vacuum clean according to agreed frequencies. Clean periodically by hot water extraction.
(b) For known contaminated spillage, e.g. blood & bodily fluids. Wear disposable gloves and plastic apron.
Note that chlorine solutions may bleach carpet.
Faeces & Vomit – Remove as much organic matter as possible using paper towels, discard directly into appropriate clinical waste bag. Clean area using a Hypochlorite solution and rinse with water. Blood - Hypochlorite, rinse well. As per section 6
19
ITEM ROUTINE ADDITIONAL RECOMMENDATIONS
Cleaning Cloths Disposable single use
Microfibre must be washed at 65c
Use different cloths in different areas, i.e. Green - Kitchens Red - Bathrooms & Toilets Blue - General Areas
Commodes (and Sanichairs) After each use dismantle the frame and fully clean all surfaces using Sporicidal eg. Tristel Attach a “I am Clean” sticker.
Crockery and Cutlery
(Ward Use)
Wash in ward dishwashing machine or return to main kitchen.
Alternatively, wash by hand in hot water and detergent and leave to air dry.
Disposable crockery and cutlery are unnecessary provided adequate washing up facilities are available.
Curtains Washable, flame resistant material must be used. The curtains must be laundered as per the ward cleaning schedule, or when dirty, for aesthetic reasons or when advised by the Infection Prevention & Control Team. Sufficient spare curtains must be available to allow this.
The metal frames/rails must be cleaned with disinfectant / detergent wipes (Universal sanitising wipes) wipes at least weekly.
If disposable curtains are used they must be dated and changed in accordance with the manufacturers guidance, following a ward outbreak or when soiled,
Dressing Trolley Clean with detergent and hot water or / after use disinfectant & detergent wipe then let to dry appropriate detergent wipe before commencing dressings.
20
ITEM ROUTINE ADDITIONAL RECOMMENDATIONS
Drip stands Minimum daily disinfectant & detergent wipes
Between patients
If soiled with bodily fluids 10.000pm hypochlorite
Pay particular attention to the underside of the drip stand
During a deep clean these must be steamed
Endoscope See local guidelines.
Feeding Bottles Single patient use If parents bring in patients own they must be given a single patient use sterilising kit as per Maternity SOP .
Floors Detergent or hypochlorite For blood / bodily fluids contaminated spillages use hypochlorite 10,000 p.p.m, or granules For other known or potentially infected spillage use hypochlorite solution 1,000 p.p.m.
Furniture Detergent in hot water or appropriate detergent wipe. Following discharge of patient with known infection this will be cleaned as part of the Post infection cleaning process
Hand basins
Healthcare cleaning contractors SOP
Humidifiers Wash daily with soap and water, then rinse and dry before refilling with sterile water.
In between patient use send to HSDU.
Ice Making Machine (blood gasses and physio/trauma pateints.
Defrost, wash inside with detergent and hot water, rinse and dry, weekly.
Infant Incubator Detergent and hot water or appropriate detergent wipe, then Hypochlorite solution, 125 p.p.m available chlorine (dilute to manufacturer’s instructions)
Important to wipe dry, especially metal parts.
Injection Trays/Kidney Dishes Disposable or detergent and hot water or appropriate disinfectant wipe – minimum daily.
21
ITEM ROUTINE ADDITIONAL RECOMMENDATIONS
Laryngoscope Blades Single use
Lavatory Brush Rinse at last flush and store dry.
Mattress Refer to Appendix ?? Specific mattress cleaning process.
Measuring Jug (for use in dirty utility room only)
Disposable single patient use
Medicine Pots Disposable single patient use.
Manual Handling Aids: Machinery Fabric Slings belts & Slides
Detergent in hot water or appropriate detergent wipe and dry. Launder unless single patient use.
These are single patient use and must be clearly identified with the patients details.
t
Mops – Isolation For Healthcare cleaners Yellow- Isolation Nursing
Mops – Spillage After use with disinfectants, rinse well and store dry. White
Nailbrushes Not recommended. Theatres only, single use only.
Nappies Disposable single use.
Nebulisers & Volumatics Wash daily with detergent in hot water or appropriate disinfectant & detergent wipe, rinse and dry. For single patient use only.
Must be stored dry when not in use.
Razor – Electric Patients own razor only.
Razor – Wet Single patient disposable only , Store dry. Dispose of used blades and disposable razors in sharps disposal box immediately after use.
Resuscitation bagging Mask Single patient use only
22
ITEM ROUTINE ADDITIONAL RECOMMENDATIONS
Resuscitation pocket mask Single patient use only
Shaving Brushes Use not recommended unless patient’s own
Shower Chairs Wash with detergent in hot water or appropriate disinfectant & detergent wipe, between patients.
After potentially or known infected patient use chlorine releasing agent or sporicidal rinse and allow to dry.
Spirometer
Use a bacterial filter for any spirometry tests. The filters are single use.
Please note that a mouth piece with a one way valve is not a bacterial filter; bacterial filters offer a much higher level of protection.
Wash any parts that come in to contact with the filter or the patient with detergent and water, rinse and dry.
After each session - the spirometer should be disinfected with an appropriate disinfectant according to the manufacturer’s instructions.
If you do not use a bacterial filter it is recommend that the machine is disinfected between patients with an appropriate disinfectant according to manufacturer’s instructions
Stethoscope Heads Wipe with disinfectant Check with manufacturer the product can withstand the cleaning agent
Suction Jars Single use or send to HSDU. Store dry.
Thermometer - Electronic single patient use
Tables Minimum daily with disinfectant and detergent wipe Pay particular attention to the underside of the table
Tonometer Prisms Single Use .
Toys Vinyl/plastic toys decontaminate minimum of daily with disinfectant & detergent wipe, rinse and dry
Wash weekly with hot soapy water, or when visibly
Hospital toys must be washed with detergent and hot water, rinsed and dried on removal from the room of an infectious child who has been isolated.
Change toy box at the end of the day following clinics and replace
23
ITEM ROUTINE ADDITIONAL RECOMMENDATIONS
soiled.
Soft toys are not recommended for general use unless single patient use e.g. child’s own / dedicated for child.
with clean toys for the next session.
Urinals Place in Bed Pan Washer/Disinfector e.g. DEKOMED 190.
Ventilators As per ITU SOP
Ventstream Wash daily with detergent in hot water or appropriate detergent wipe, rinse and dry.
Must be returned to HSDU between patients.
Wash Bowls
Detergent in hot water or appropriate disinfectant & detergent wipe.
Dry thoroughly inside and outside and store inverted.
Each patient should have an individual wash bowl.
Wash bowls must be disposed of if any damage/ scratches are visible.
This list is not exhaustive advice can be found as necessary from the Infection Prevention and Control Team
Appendix 3 Post Infection Clean/ Deep Clean Process Required outcome: When notified by Infection Prevention and Control that a “Post Infection Clean or a Deep Clean/Triple Clean” is to occur the following procedures must be followed. Post infection / Specialist cleaning prior to a ward re-opening will only occur on recommendation of the Infection Prevention and Control Team and be based on risk assessment. On completion of the clean the checklist at the end of the document must must be completed by the Senior Sister / Deputy, Health Care Cleaning supervisor, out of hours Site Manager. This documentation will provide evidence it has occurred to a satisfactory standard.
Key Contacts:
Infection Prevention and Control Nurse (IPCN)
Senior Sister / deputy (as appropriate)
Matron
Facilities Soft FM
Healthcare cleaning team
Estates
Healthcare cleaning manager / supervisor
Catering Department
Bed Managers
Ward Manager Responsibilities:
To liaise with Infection Prevention and Control and all appropriate departments / teams involved in the Post Infecction Clean/ Deep clean process to ensure timely completion
To organise sufficient staffing levels to complete deep clean without affecting patient care.
To identifiy a lead person each shift to work in liason with ISS to assist with the co-ordination of the deep clean
To identify a responsible qualified staff member each shift to take responsibility for signing off compled cleaning elements on behalf of the ward / ward manager in their absence.
To ensure appropriate PPE is available for staff
To contact ISS portering services to assist in the removal of condemned furniture / equipment (de-clutter)
To liaise with linen department to ensure sufficient supply of fresh linen for ward.
To organise replacement mattresses as required To condem rusty / faulty patient related equipment Ensure food / beverages e.g. bread, coffee etc are stored in sealed
containers.
Nursing Responsibilites:
To organise the movement of patients within the ward area to facilitate cleaning of empty bays / siderooms
To remove patient belongings / medicines from area being cleaned
To order replacement specialist mattresses in anticpation of patient needs
24
25
To dispose of opened clinical supplies e.g. pads, patient wipes stored in bays / single rooms
To remove and dispose of none laminated notices, organising replacements where necessary
To complete cleaning tasks without affecting patient care.
Healthcare Cleaning Management / Deputy Responsibilities:
To liaise with Infection Prevention and Control and Senior Sister to co-ordinate the smooth running of the post infection / deep clean and be present from start to finish.
To sign off the completed cleaning elements on behalf of ISS
To remove and replace all curtains on the ward / dept as appropriate.
To clean all mattresses including specialist mattresses.
To empty and clean all dispensers and replace stock when cleaning completed.
To wash all walls in the ward / dept.
To fully steam clean all areas and equipment followed by a thorough sporacidal (Tristel) wipe down of all surfaces.
To scrub all hard flooring
To liaise with estates to clean equipment thoroughly e.g. estates remove radiator covers and ISS clean inside
To fully steam clean and wipe down all bathrooms, toilets, shower/wet rooms using sporacidal (Tristel)
To Replace all shower curtains
To damp dust high and low level surfaces with sporacidal e.g.Tristel
To wipe down beverage trolley with with sporacidal e.g.Tristel
To wipe down all window blinds with with sporacidal e.g.Tristel
To clean domestic cleaning trolley with sporacidal e.g.Tristel
To complete sign off checklist with Senior Sister or the Nurse in Charge
To liaise with Senior Sister / allocated responsible person prior to condeming equipment
Estates Responsibilities:
To liaise with ISS to organise removal of radiator covers, clean vents, wall-mounted fans, light fittings etc required for cleaning to occur
To replace radiator covers, light fittings etc on completion of cleaning
To plan for extended hours to assist with co-ordination and completion of clean
To clean and maintain smoke detectors
To clean vents
Ceilings in liaison with Healthcare Cleaning team e.g. removal of ceiling tiles
26
POST INFECTION/ DEEP CLEAN CLEANING PROCESS
ESTATES REPONSIBILITY
To remove all radiator covers throughout the ward / dept. in preparation for cleaning and replace when cleaning completed
To clean all fans
To clean all ceiling vents
To clean all lights and fittings throughout the ward
To remedy small repairs on the ward including damage sealant in bathrooms
HEALTHCARE CLEANING (SUPERVISOR CHECKLIST )
Bathrooms / toilets
Clean toilet, pipework and sanitory fittings
Descale toilets, showers and baths
Clean all dispensers (inside and outside) and refill
Wash sinks and tiles in line with standard operating procedure
Clean bins inside and out
Clean any wall mounted fittings
Clean floor
Remove and replace shower curtain
Replenish consumables
Clinic room / clean utility room
Clean stacking systems inside and outside
Clean shelving and fixtures
Clean high level and walls
Clean hand hygiene dispensers (inside and outside) and replenish
Clean sink and fittings as per standard operating procedure
Clean floor
27
Wipe outside of medication lockers
General ward area
Clean buffer bars, picture frames, fixtures and fittings
Complete high and low level cleans and wall washes using sporacidal e.g. Tristel
Clean sink as per standard operating procedure
Clean dispensers inside and out and replenish consumables
Clean around nurses station once staff have removed stationary etc
Clean floor and behind stand alone units e.g. drawers
Clean all door vents, fittings and hand contact areas
Machine scrub, prepare and polish floors and edging
Entrance corridor to clinical area
Complete high and low level cleans and wall washes using sporacidal e.g. Tristel
Clean floor
Clean beverage machine
Clean notice boards
Bays and Side rooms
All furniture, fixtures and fittings must be steam cleaned and then cleaned with sporacidal e.g. Tristel
Take down and replace with clean curtains
Clean bed tables, uncluding underside and wheels
Dispose of consumables left by ward staff – discuss with ward staff prior to disposal of consumables
Clean bins inside and out
Clean curtain rails using sporacidal e.g. Tristel
Clean sink as per standard operating practice
Clean external light fittings
Clean notice boards
Clean window sills
Clean buffer bars
28
Clean dispensers inside and out and replenish
Clean bed lockers inside and out
Clean floor
Clean bed & bed frames
Wash chairs and foot stools, including legs and under seat. Advise ward staff of any torn / broken equipment to discuss condeming the item.
Clean patient buzzers, bed lights, switches etc
Kitchens Clean inside and outside of bins, cupboards, fridge, dishwasher, microwave, Toaster,
Ensure food is within expirary date
Clean high and low level shelving,
High and low level clean walls and floors
Clean sinks as per standard operating practice
Ward Staff responsibilities
29
Nurses station / office
Clear desk, remove and sort all stationary, dispose of none laminated posters and replace as appropriate
Clean computer equipment, phones, IPADs, COWS,
Empty and clean patient notes trolleys (inside and out)
Clinical room: Empty room in preparation for ISS to clean
Remove patient medication / equipment from drawers/ shelves / drawers /boxs in preparation for ISS to clean. Replace items following clean.
Clean patient associated equipment e.g. glucometer machines
Clean inside of medications cupboard
Remove stationary in preperation for ISS to clean surfaces
Patient equipment
Remove all patient equipment from bay / single room in preparation for cleaning
Remove suction pots, clean and replace when bay / single room ready for patient occupation.
Clean all patient related equipment and label with green “I am clean” tape on completion of cleaning item. This list is not exhaustable but includes:
Resus Trolley, ECG machines, hoists, patient scales, drip stands, commodes, dynamaps, bed pan holders, thermometers, cardiac monitoring equipment, walking aids, sharps / ANNTT trays, drip stands, stacker units, wheelchairs, walking frames
Strip bed in preparation for clean and remake beds prior to re-occupation by patients
Checks mattresses and pressure relieving devices for signs of damage allowing bodily fluids to be absorbed. Condem if cover torn or damaged.
Replace patient related equipment in bays / single rooms following cleaning
Sluice/dirty utility
Clean commodes in preparation for steam cleaning by ISS
Dispose and replace broken / cracked patient wash bowls
Condem any rusty equipment and organise replacment if required
Ward office: Ward staff to prepare room ready for ISS to clean
30
POST INFECTION CLEAN – SIGN OFF CHECKLIST
DATE …………………………
WARD …………………………
Element Responsible people
Element completed by (only sign on completion of element) Date & signature (Print name)
Kitchen
Ward entrance / link corridor entrance
Bay No …..
Bay No …..
Bay No …..
Bay No …..
Single Room …..
Single Room …..
Single Room …..
Single Room …..
Bathroom / toilet 1 – room number…..
Bathroom / toilet 2 - room number …..
Bathroom / toilet 3 - room number…..
Bathroom / toilet 4 - room number …..
Shower Room – room number …..
Shower Room 1 – room number…..
Shower room 2- room number…..
Sluice
Appendix 4 – post infection signoff checklist
31
Element Responsible people
Element completed by (only sign on completion of element) Date & signature (Print name)
Nurse’s Station
Ward /Healthcare cleaning team
Meeting Room
Healthcare Cleaning team
Store Room
Healthcare cleaning team
Ward office
Ward staff / Healthcare cleaning team
To be signed off as a minimum by a member of staff representing the ward andHealthcare Cleaning Supervisor
Date Designation Signature
Senior Sister / Nurse in Charge
Healthcare cleaning supervisor
32
Appendix 4 - General Points about the use of disinfectants Anyone using disinfectants must first receive appropriate training in their safe and effective use. Disinfectants, particularly concentrated solutions can be highly corrosive, therefore avoid contact with skin and splashing onto the skin, mouth, eyes or clothing and always wear the appropriate protective equipment e.g. gloves, apron, goggles or visor. Familiarise yourself with the Controls of Substances Hazardous to Health (COSHH) assessment for every disinfectant used Disinfectant products should be kept in a locked cupboard away from access by the general public/patients.
Only use disinfectants approved by the Trust
Always check the expiry dates before use
Always replace the container cap securely after use
A sterile solution once opened should be regarded as non-sterile.
Disinfectants must be used at their correct concentration or dilution (refer to instructions).
Disinfection solutions must be made up in the appropriately labelled container using fresh water.
Diluted disinfectants may rapidly become inactivated over time, therefore always use freshly prepared solutions.
Some disinfectants can be inactivated by other chemicals including detergents, therefore never mix disinfectants with other products unless you know it is safe to do so.
Partially used containers of disinfectant should never be topped-up.
33
Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed?
Infection Prevention and Control Cleaning Policy
Details of person responsible for completing the assessment:
Name: Anita Swaine
Position: Lead Nurse Infection Prevention and Control
Team/service: Infection Prevention and Control
State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document)
Cleanliness standards in health care premises are a key element of quality performance which is monitored externally by the Care Quality Commission (CQC) and is part of the established registration requirement. This is to ensure Organisations are fit for purpose in relation to environmental cleanliness and that infection prevention and control is embedded and effective.
2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below – how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC.
Age: East Cheshire and South Cheshire CCG’s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally.
34
Race:
In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British
5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK – Poland and India being the most common
3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language.
Gypsies & travellers – estimated 18,600 in England in 2011. Gender:
In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area.
Disability:
In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability
In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia
Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness.
C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted.
In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC.
Mental health – 1 in 4 will have mental health problems at some time in their lives.
Sexual Orientation:
CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation).
CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC.
Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%.
Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester
Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester
Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester
Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester
Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester
35
Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester
None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester
Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester
Carers:
In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC.
2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?)
None
2.3 Does the information gathered from 2.1 – 2.3 indicate any negative impact
as a result of this document?
None
3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No √ Explain your response: If there is a patient whose first language is not English, then staff need to be aware of how to access interpretation facilities, in case there are queries about cleaning regimes. ___________________________________________________________________ GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No√ Explain your response: No impacts identified – policy applies equally to all ___________________________________________________________________ DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes √ No Explain your response: Information given needs to be tailored to individual’s needs. Eg BSL interpreter for deaf people, leaflets are pictorial for patients with limited
36
understanding, large print for low vision etc, in case there are queries about disinfection/sterility of instruments. ___________________________________________________________________ AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No √ Explain your response: No impact identified – policy applies equally ___________________________________________________________________ LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently?
Yes No √ Explain your response: No impacts identified – policy applies equally __________________________________________________________________ RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently?
Yes No √ Explain your response: Staff need to be naked below the elbows when giving clinical care regardless of religious belief as per dress code policy ___________________________________________________________________ CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes √ No Explain your response: Clinical staff need to discuss the appropriate requirements for carers as these will vary dependent on the environment and level of care undertaken ___________________________________________________________________ OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No √ Explain your response: No other impacts identified. _________________________________________________________________ 4. Safeguarding Assessment - CHILDREN
a. Is there a direct or indirect impact upon children? Yes No
37
b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people:
c. If no please describe why there is considered to be no impact / significant impact on children. This is a cleaning policy for staff
5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc?
This policy has been ratified by the ICG which includes a member of the public. As with the majority of IC policies it is acknowledged that staff need to support individuals who require Isolation , any variance to this must be clearly documented in the patients notes as part of their clinical care
6. Date completed: 7/1/2016 Review Date: 7.5.2018
7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact?
Action Lead Date to be Achieved
8. Approval : At this point, you should forward the template to the Trust Equality and Diversity Lead [email protected]
Approved by Trust Equality and Diversity Lead: Date: 17/02/16