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SOMERSET PARTNERSHIP NHS FOUNDATION TRUST

INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2016/17

Sponsoring Director: Director of Nursing and Patient Safety

Author: Head of Infection Prevention and Control/Decontamination Lead.

Purpose of the report: To advise the Trust Board with regards to the Infection Prevention and Control activity for the year 2016/17 as per the requirements of the Health and Social Care Act.

Key Issues and Recommendations:

The Trust has robust systems and processes in place to manage the risk associated with the prevention and management of infections within our services. Commissioner set trajectory of five cases of Clostridium difficile infection (with identified lapses in care) was attributed to the Trust for 2015/16. The out-turn figure reported as of 31 March, 2017, was zero cases. Commissioner set trajectory of zero MRSA Blood Stream Infection (BSI). The out-turn figure for 2016/17 is reported as zero cases, with the last attributable case being reported in 2009, pre-acquisition. There were six gastro-intestinal illness related outbreaks impacting on the Trust’s inpatient activity. This equals the previous year. All affected wards were fully supported by the Infection Prevention and Control Team, and are to be commended for their robust management of the outbreaks The increasing prevalence of antibiotic resistant micro-organisms, especially those with multiple resistances, is causing international and local concern. The Trust has investigated one cases of blood stream infections associated with these organisms and learning has been disseminated trust wide Audits of compliance with Trust policy to include hand hygiene, isolation, cleanliness and management of sharps have continued to be undertaken and the Trust Board can take a high level of assurance of compliance with CQC Outcome 8.

Infection Prevention and Control Annual Report 2016/17 July 2017 Public Board - 1 -

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A lack of interface between RiO and IC Net was identified at the close of 2014/15, and this has continued to be problematic during 2016/17. This means that the IPC Team are no longer automatically being notified of patients, with identified infections, being transferred to our inpatient wards. Despite this IT based issue the Team have safely managed this ongoing situation. During 2016/17 PWC (Trust Internal Auditors) reviewed the Trust internal processes in place for managing infection prevention and control and for monitoring compliance with key regulations. The audit confirmed that the Trust had a robust infection internal audit plan that was in line with the Hygiene Code of Practice. The Trust policy has been updated to ensure that all staff are aware of the escalation and governance process.

Actions required by the Board:

The Board is asked to discuss and note the report.


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INFECTION PREVENTION AND CONTROL ANNUAL REPORT

2016/17 SOMERSET PARTNERSHIP FOUNDATION TRUST


CONTENTS

Page

CONTENTS 1 Introduction ......................................................................................... 4 2 Surveillance ......................................................................................... 5 3 Outbreaks ............................................................................................ 11 4 Infection Prevention and Control Audit Activity ............................... 18 5 Decontamination ................................................................................. 21 6 National Initiatives .............................................................................. 22 7 Training ................................................................................................ 26 8 Legionella and Water Quality ............................................................. 28 9 New Build Initiatives ........................................................................... 29 11 Compliance with CQC: Relevant CQC Standard .............................. 30 APPENDICES

APPENDIX A INFECTION PREVENTION AND CONTROL TEAM

WORK PROGRAMME 2016/17 ............................................ 31


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1. INTRODUCTION

1.1 This report details Infection Prevention and Control activity from 1 April

2016 to 31 March 2017, with an assessment of performance against national targets for the year. The report provides assurance to the Board of Directors and the public on compliance with the Health & Social Care Act 2008 (updated July 2015): Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance (commonly known as The Hygiene Code) and also in relation to National Institute for Health and Clinical Excellence (NICE) guidance.

1.2 This Annual Report is indicative of Somerset Partnership NHS

Foundation Trust’s continued pledge to deliver excellent community and mental health service to the population it serves by demonstrating ongoing commitment to reducing health care associated infections, and provides an overview of the progress made and the processes in place for the prevention and control of health care associated infections during the reporting period of 1 April 2016 to 31 March 2017.

1.3 Infection Prevention and Control continues to be a fundamental

component of the Quality and Patient Safety agenda. Despite the continued challenging financial climate during 2016/17, the Trust has continued to provide a service that meets the needs of our patients and service users.

1.4 Healthcare-associated infections are generally related to multiple factors. Prevention of these infections depends on daily vigilance and implementation Infection Prevention and Control practices. These practices are outlined in Trust infection prevention and control guidelines, policies, and procedures.

1.5 To reduce healthcare associated infections Somerset Partnership NHS

Foundation Trust ensures that effective systems are in place for the prevention and control of infection. These systems incorporate national guidance and good practice, engage staff and make infection prevention and control ‘everyone’s business’. All staff (clinical and non-clinical) employed by Somerset Partnership NHS Foundation Trust are responsible for understanding, maintaining and implementing these principles and practices within their respective service areas.

1.6 Microbiology and Infection Prevention and Control Medical support

continues to be provided by the Taunton and Somerset NHS Foundation Trust’s Consultant Microbiologist Team. The role of the


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Somerset Partnership’s Infection Prevention and Control Doctor is provided by Dr. Mike Smith.

1.7 The Somerset Partnership Infection Prevention and Control Team has

maintained an effective service this year and has delivered on all of the Infection Prevention and Control activities outlined in the 2016/17 programmes of work across all services( for further details please refer to Appendix A).

2. SURVEILLANCE

2.1. Mandatory surveillance is carried out for all Meticillin Resistant Staphylococcus aureus bacteraemia (bloodstream infections), Meticillin Sensitive Staphylococcus aureus bacteraemia (bloodstream infections) and for all cases of Clostridium difficile notifications, using the national Healthcare Associated Infections Database system. Confirmed isolates are reported by the responsible laboratory, which for Somerset Partnership NHS Foundation Trust is via Taunton and Somerset NHS Foundation Trust.

2.2 Monthly isolate rates of Meticillin Resistant Staphylococcus aureus

bacteraemia and Clostridium difficile are reported locally throughout the organisation via the Somerset Partnership NHS Foundation Trust local performance management structure.

2.3 Root cause analysis investigations are undertaken on all cases of

Meticillin Resistant Staphylococcus aureus bacteraemia bloodstream infections and Toxin positive Clostridium difficile. This process is undertaken in collaboration with local care teams. The resulting actions plans are reviewed at strategic and operational level Infection Prevention and Control meetings, together with a review of routine surveillance data, to inform clinical practice.

2.4 In all appropriate clinical settings, the Somerset Partnership NHS

Foundation Trust Infection Prevention and Control Team routinely collate, review and compare data on all alert organisms, conditions and infections in order to monitor infection rates and assess any increasing risks of infection. Data is fed back in a timely fashion, either routinely through the Infection Prevention and Control Implementation Group or locally when a problem occurs in order to ensure actions are taken.

2.5 IC Net is the database surveillance system used by both of the

Somerset Acute NHS Foundation Trusts, Somerset Clinical Commissioning Group (in relation to primary care cases) and Somerset Partnership NHS Foundation Trust Infection Prevention and Control Teams. The system has been responsible for improving the


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communication of patient details and clinical intervention between teams and healthcare settings across the county.

2.5.1 The system works by collating information in relation to patient

admissions and discharges via the PAS and Cerner systems, linking them to the Acute Trust managed Laboratory interface. The information is then integrated into the system through pre-set filters to provide the Somerset Infection Prevention and Control Teams with relevant patient specific information.

2.5.2 A lack of interface between RiO and IC Net was intially identified at the

close of 2014/15. Due to this lack of interface the Infection Prevention and Control Team were no longer automatically being notified of patients (with identified infections) being transferred to a Somerset Partnership NHS Foundation Trust inpatient setting.

2.5.3 The main concerns regarding the lack of interface between IC

Net/RIO/PAS and Cerner have been raised and highlighted via the Directorate and Trust Risk Register due to the following;

• patients may not be isolated in a timely/robust manner resulting

in the spread of infection within an inpatient area; • patients may not commence timely/appropriate treatment due to

staff being unaware of current infection status; • incorrect IPC figures may be reported to the Trust Board and via

national reporting due to inaccuracies within the system.

2.5.4 The system remains fully compliant with the Information Governance Toolkit.

2.5.5 The Infection Prevention and Control Team have continued to work

with the Trust Information Management and Technology Team to endeavour to resolve all IC Net related issues, but at the close of Quarter Four, 2016/17 the lack of interface between IC Net/RIO/PAS and Cerner remains problematic.

2.6 Immediate feedback to Locality/Service Managers and Matrons of ‘hot

spots’ or problem areas occurs as necessary. Routine and regular sharing of surveillance data is via the Somerset Clinical Commissioning Group Infection Prevention and Control Assurance Committee and Somerset Partnership NHS Foundation Trust Infection Prevention & Control Assurance Group.

2.7 Clostridium difficile

2.7.1 Clostridium difficile infection (CDI) remains an unpleasant, and

potentially severe or fatal infection that occurs mainly in elderly and other vulnerable patient groups, especially those who have been exposed to antibiotic treatment. 17% of patients who are diagnosed


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with Clostridium difficile have died by day 30 after diagnosis. After controlling for risk of death in non-CDI patients (9%), the Clostridium difficile attributable death rate is 8% i.e. one in 12 patients, (Planche et al. Lancet Infect Dis, 2013).

2.7.2 Reporting of all Clostridium difficile cases is part of the Mandatory

Enhanced Surveillance System which is managed via Public Health England.

2.7.3 The NHS has made great strides in reducing the numbers of CDIs,

however, the rate of improvement for CDI has slowed over recent years and some infections are a consequence of factors outside the control of the NHS organisation that detected the infection. Further improvement on the current position is likely to require a greater understanding of the individual causes of CDI cases, in order to understand if there were any lapses in the quality of care provided in each case, and if so, to take appropriate steps to address any problems identified.

2.7.4 For 2016/17, organisations have continued to be encouraged to

assess each CDI case to determine whether the case was linked to ‘a lapse in the quality of care provided to patients’ Somerset Clinical Commissioning Group has considered the results of these assessments and exercise discretion in deciding whether any individual case of CDI affecting a patient under its contract should count towards the aggregate number of cases on the basis of which contractual sanctions are calculated.

2.7.5 As per the previous year, Commissioners have been advised by NHS

England to apply exactly the same principles as outlined for infections identified as acute related infections to those identified from within the community, in order to encourage learning and improvement. This includes cases associated with community providers. Following identification of a sample positive for C. difficile obtained within 72 hours of admission to an acute setting or from a community setting or independent provider, providers are required to assess the care provided to determine if there were lapses in care. Any learning should support the development of an action plan and subsequent improvement in care as well as forming part of the relevant contract management processes.

2.7.6 As was the case in 2015/16, during 2016/17 there were no national CDI objectives attributed for community services providers, and no financial sanctions related to CDI mandated in the NHS Standard Contract for community services providers.

In an effort to continually drive healthcare improvement, Somerset Partnership NHS Foundation Trust was allocated a Commissioner set


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trajectory of 5 ‘avoidable’ toxin positive CDI cases (due to identified lapses in care).

2.7.7 The out-turn figure for 2016/17 is zero toxin positive CDI cases. For

2015/16 the Trust reported 8 cases (nil of which were attributable to the Trust).This is an outstanding result, and evidence of the robust assessment processes being implemented locally, with support from the IPC team members.

2.7.8 The objectives for all organisations during 2017/18 remain as per

2016/17 & Somerset Clinical Commissioning Group has therefore set the 2017/18 Clostridium difficile infection objective trajectory at 5 toxin positive cases

(assessed as ‘avoidable’ due to identified lapses in care).

2.7.9 Local guidance on management of patients identified with the organism is available via the Somerset Partnership NHS Foundation Trust Clostridium difficile Policy. This may be accessed via the Somerset Partnership NHS Foundation Trust Intranet site.

2.8 Meticillin Resistant Staphylococcus Aureus (MRSA)

2.8.1 Staphylococcus aureus is a bacterium that is present on the skin and

in the nose and throat of approximately 30% of the healthy population. On intact skin its presence is harmless. It is the most common cause of localised wound and skin infections.

2.8.2 Mandatory surveillance of blood stream infections due to Meticillin

Resistant Staphylococcus aureus has continued during 2016/17. As of April, 2014, nil nationally set trajectories had been attributed to Somerset Partnership NHS Foundation Trust; therefore a Commissioner trajectory for 2016/17 was set at zero.

2.8.3 During 2016/17 all admissions to Somerset Partnership NHS

Foundation Trust Community Services managed community hospitals, all ‘high risk’ admissions to Mental Health inpatient units and all pre- operative podiatric surgery patients have been routinely screened for Meticillin Resistant Staphylococcus aureus colonisation.

2.8.4 Mental Health Inpatient units screen the following high risk individuals

only;

• those who have any indwelling device;

• those who have a break in the skin, which would include acute, chronic and ‘slow to heal’ wounds regardless of cause;

• history of admission (excluding A&E attendance) to any other hospital or residential setting within one month (a residential


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setting includes residential care/nursing care homes/ prison/young offenders institutions);

• history of surgery (including Minor and Day surgery) within one month.

2.8.5 Patients with Meticillin Resistant Staphylococcus aureus colonisation

identified following admission screening are routinely decolonised to reduce the risk of Meticillin Resistant Staphylococcus aureus bacteraemia, as per local Policy.

2.8.6 Nil cases were reported as attributable to this Trust during 2016/17,

and the out-turn figure reported remains at zero cases. 2.9 Meticillin Sensitive Staphylococcus Aureus (MSSA)

2.9.1 Most strains of Staphylococcus aureus are sensitive to the more

commonly used antibiotics, and infections can be effectively treated. Some Staphylococcus aureus bacteria are more resistant. Those resistant to the antibiotic meticillin are termed meticillin-resistant Staphylococcus aureus and often require different types of antibiotic to treat them. Those that are sensitive to meticillin are termed meticillin-sensitive Staphylococcus aureus.

2.9.2 During 2016/17 there was no requirement for community care organisations to provide this as mandatory data. The Somerset Partnership Infection Prevention and Control team has continued to undertake root cause analysis investigations into any reported case of MSSA blood stream infection.

2.9.3 During Quarter 3, a patient was admitted under Section 136 of the Mental Health Act (MHA) and detained to Rydon (Ward 1) under Section 2 MHA with mixed affective state or manic episode. This was possibly due to poor concordance with medication.

2.9.3.1 During Q4 the patient’s medical and physical condition deteriorated &

as sepsis was considered the patient was transferred to an Acute NHS Trust setting for further review. The patient was treated for sepsis/MSSA bacteraemia and Bacterial Endocarditis, in Musgrove Park Hospital but deteriorated further and sadly passed away on 1 March, 2017, whilst being cared for within the intensive care unit. HM Coroner assessed this case a death by natural causes.

2.9.3.2 Infection was considered at several times throughout the patient’s Sompar inpatient stay, however, no focal site was identified and no symptoms consistent with systemic infection were evident. The patient had several wounds, but all were small, superficial and appeared to be healing well, there was no evidence to support infection of the respiratory or urinary tracts and although there was pain, swelling and


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intermittent redness associated with the feet, the underlying deformity/arthritic changes would also account for these symptoms. Bacterial endocarditis can be related to oral infections however, endocarditis associated with oral cause would result in a Streptococcal rather than a Staphylococcal infection.

2.9.3.3 The RCA undertaken by the Trust IPC Team was reviewed by the Trust Infection Control Doctor, who advised that the bacteraemia appeared unavoidable. Learning identified during the RCA investigation has been disseminated locally.

2.10 Gram Negative Organisms

2.10.1 The increasing prevalence of antibiotic resistant micro-organisms,

especially those with multiple resistances, is causing international concern. Antibiotic resistance makes infections difficult to treat. It may also increase the length of severity of illness, the period of infection, adverse reactions (due to the need to use less safe alternative drugs), length of hospital admission and overall costs.

2.10.2 Many bacteria are normally found in the bowel. Not all are resistant to

antibiotics and not all will cause serious illness. Species of bacteria commonly found include the Enterobacteriaceae (e.g. Escherichia coli or E. coli, Klebsiella, Proteus and Enterobacter). These bacteria are also referred to as Gram-negative bacilli (thus called because of their appearance in the staining methodology used by the laboratory). Other clinically important Gram-negative bacilli include Pseudomonas and Acinetobacter.

2.10.3 These Gram-negative bacteria, under certain circumstances can become resistant to antibiotics and may require infection control management. These may be introduced into the gut via the faecal-oral route and establish in small numbers (colonisation). Problems can occur when the organism has the opportunity to migrate to areas such as the bladder (manifesting as a urinary tract infection), a wound (wound infection) or the blood stream (blood stream infection).

2.10.4 Secondary spread in health care settings can readily occur via the hands of healthcare personnel. Endemic strains may persist in health care settings for years because of patient colonisation, environmental contamination, and hand transmission. Correct infection prevention and control practices are essential to prevent spread and outbreaks of Gram-negative bacteria.

2.10.5 There is nil local trajectory set for monitoring these organisms, despite this, the Somerset Partnership Infection Prevention and Control team undertake Root Cause Analysis investigations on all bloodstream infections, in an effort to identify any learning which may be disseminated.


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2.10.6 During 2016/17 there has been one reported blood stream infections

associated with Gram-negative bacteria (E Coli, Enterococcus faecium and Enterobacter cloacae).

2.10.6.1 This case was reported at the end of Quarter 4, and the patient was residing at that time on Luke Ward, Dene Barton Community Hospital. The patient was in receipt of End of Life Care due to diagnosis of cholangiocarcinoma. The patient was known to IPC team following admission, due to loose stools on admission, a previous history of MRGNO Grade C & previous E coli BSI in, 2016.

2.10.6.2 The RCA was reviewed by the Trust Infection Control Doctor who advised that the root cause was possible biliary stent involvement, previous recent history of E Coli BSI & Septicaemia secondary to underlying Ca; this case was assessed as unavoidable. Learning identified during the RCA investigation has been disseminated locally.

2.10.7 Somerset Partnership NHS Foundation Trust Infection Prevention and

Control Team have continued to provide training to clinically based staff on gram-negative organism colonisations and provide regular advice when undertaking Infection Prevention and Control visits.

2.11 For the 2017/18 financial year a Quality Premium has been assigned to a required 10% reduction of blood stream infections caused by gram negative organisms, across the whole health community. A particular emphasis has been placed (in the first two years) on those as a result of E Coli infection. These account for the majority of all recorded Gram Negative cases. As part of this premium, additional expectations have been placed on primary care in relation to appropriate antibiotic prescribing.

3. OUTBREAKS

3.1 Norovirus

3.1.1 Norovirus is the most common cause of infectious gastroenteritis

(diarrhoea and vomiting) in England. The Illness is generally mild and people usually recover fully within 2-3 days. Infections can occur at any age because immunity does not last. Historically known as 'winter vomiting disease', the disease is more prominent during the winter months, but can occur at any time of year. It is also known as small round structured virus (SRSV) or Norwalk-like virus.

3.1.2 Approximately 3,000 people a year are admitted to hospital with

norovirus in England and the incidence in the community is thought to be about 16.5% of the 17 million cases of infectious intestinal disease


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in England per year, and there is evidence that this burden has increased over the past decade.

3.1.3 The symptoms usually start between 24 - 48 hours after the initial

norovirus infection, although they can start after as little as 12 hours. The first symptom is usually a sudden onset of nausea, which is followed by projectile vomiting and watery diarrhoea. Some people may also have: • a mild fever;

• headaches;

• stomach cramps;

• aching limbs.

Symptoms normally last between 12 – 60 hours, although most people make a full recovery within one to two days.

3.1.4 Norovirus related outbreaks impacting on the Trust’s inpatient activity may be viewed at Table 1.

3.1.5 National guidance in relation to norovirus outbreak management is based on a principle of minimising the disruption to important and essential services and maximising the ability of organisation to deliver appropriate care to patients safely and effectively. There has been a shift of focus towards a balance between the prevention of spread of infection and maintaining organisational activity. In effect, this means a move away from the traditional approach of complete ward closure and an adoption of a pragmatic, escalatory system of isolation using single rooms and cohort nursing without compromising patient care both for norovirus itself and other essential healthcare. This approach has been utilised across numerous Trust managed inpatient areas during the 2016/17 winter period, which has seen ongoing unprecedented pressures impacting on all health care services.

3.1.6 All affected areas were fully supported by the Infection Prevention and

Control Team, and are all to be commended for their robust management of the outbreaks.

3.1.7 A Norovirus Outbreak Review Meeting for 2015/16 has previously

been held on 26th May, 2016, where 6 outbreaks were reviewed, of which 1 had been confirmed as attributable to norovirus.

At the close of Q4, 2017, of the 6 cases reported by the Trust, 4 have

been confirmed as attributable to norovirus. The 2016/17 Norovirus Outbreak Review Meeting will be convened in May, 2017. These


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findings will be considered during the 2016/17 Norovirus Outbreak Review Meeting (May, 2017).

3.1.8 On the 19th September, 2017, a Somerset Provider ‘Conference Call’

was convened. This enabled Somerset NHS healthcare providers to review and agree the processes to ensure continued, effective manage of outbreaks prior to the onset of the winter season, thus supporting patient flow across all services.

3.1.8.1 It had been in excess of 5/6 years since the Somerset Countywide

Norovirus Plan had been agreed, which still promoted a 72 hour exclusion time scale. The outcome of the meeting was cross county agreement to introduce a 48 hour exclusion time (post cessation of symptoms), with Consultant Microbiologist support.

3.8.1.2 This change in practice has worked well during the 2016/17 winter

season, and all Provider teams have endeavoured to ensure that patient flow has been managed safely during outbreak incidents.

TABLE 1 Trust-wide Norovirus Activity: 2016/17

INPATIENT AREA AFFECTED

DATE OF RETRICTIONS

NUMBER OF PATIENTS

AFFECTED/ CAUSATIVE ORGANISM

1. Chard 03/04/16 – 25/04/16 13 patients affected Norovirus confirmed

2. Minehead

24/04/16 – 30/04/16 4 patients affected Norovirus confirmed

3. Crewkerne 27/04/16 – 05/05/16 7 patients affected Norovirus confirmed

4. Crewkerne 26/05/16 – 31/05/16 3 patients affected Nil causative organism

confirmed 5. Williton 22/11/16 – 28/11/16 9 patients affected

Norovirus confirmed 6. Dene Barton 20/02/17 – 23/02/17 17 patients affected

Nil causative organism confirmed

3.2 Influenza 3.2.1 The Influenza Vaccination programme is a coordinated and evidence

based approach to planning for the demands of Influenza across England. Each year the NHS prepares for the unpredictability of flu. For most healthy people, Influenza is an unpleasant but usually self-limiting disease with recovery generally within a week. However, the following people are at particular risk of severe illness if they catch Influenza:


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• older people;

• the very young;

• pregnant women;

• those with underlying disease, particularly chronic respiratory or

cardiac disease;

• those who are immunosuppressed.

3.2.2 All NHS healthcare workers have a duty of care to protect their patients and service users from infection. This includes getting vaccinated to provide protection against acquisition/cross infection of Influenza.

3.2.2 For the 2016/17 Influenza Vaccination Season, a Commissioning for

Quality and innovation (CQUIN) was achievable which focused on improving the health and wellbeing of NHS staff in England as part of its Healthy Workplaces effort. As part of the health and wellbeing CQUIN indicator there was an aim to increase staff flu vaccination rates from around 50 per cent to nearer 75 per cent.

3.2.3 The Trust Executive lead for the Programme was the Director of

Human Resources, with the Vaccination Programme being managed via the Well @ Work Team in collaboration with the Trust Occupational Health Service, Optima.

3.2.4 Vaccination sessions were available to frontline staff across a variety

of inpatient settings, and delivered via Optima. For 2016/17 Peer Vaccination Teams were established in an effort to increase the uptake of frontline staff. These teams included representation from frontline workers ( Ward Sisters/ Staff Nurses), District Nursing Team members and Specialist Nurse Teams, (IPC and Clinical Practice Team).

3.2.5 National, provisional data from the fifth monthly collection of influenza

vaccine uptake by frontline healthcare workers (PHE Weekly National Influenza Report Summary of UK surveillance of influenza and other seasonal respiratory illnesses) show 63.4% were vaccinated by 28 February 2017, compared to 50.8% vaccinated in the previous season by 29 February 2016.

3.2.6 The overall uptake for Somerset Partnership NHS Foundation Trust

was 43.92% which is a 2.02% increase in uptake on the 2014/15 figure. As part of the health and wellbeing CQUIN indicator for 2016/2017, the Trust therefore received a percentage of the overall available CQUIN fund, which was linked to the percentage of frontline healthcare workers vaccinated.


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3.2.7 For the 2017/18 season the percentage required to achieve the

CQUIN payment will be increased to 50% uptake and over. The IPC Team will again be supporting the implementation of this programme.

Please see Table 2, for further details regarding Somerset

Partnership’s frontline staff uptake. TABLE 2: UPTAKE OF FLU VACCINATION: DATA FROM 1ST SEPT 2016 - 31ST DEC 2016 2015/16 Figures 2016/17 Figures Trust Name Somerset Partnership

No of HCW involved with Direct patient care 2,837

Flu doses given 1,190

Vaccine uptake % 41.9

No of HCW involved with Direct patient care 2,803

Flu doses given 1,231

Vaccine uptake % 43.9%

3.3 Influenza (Group A) Outbreak: Wincanton Community Hospital

3.3.1 On Thursday 16th December, 2016, the Somerset Partnership NHS

Foundation Trust Infection Prevention and Control Team were made aware of four inpatients residing at Wincanton Community Hospital who, within the preceding week, had all presented with respiratory symptoms. The emerging clinical picture was discussed with the Trust Infection Control Doctor, who advised for nasopharyngeal swabs to be taken. Three members of care staff had been symptomatic with respiratory symptoms (unknown aetiology) during the previous week.

3.3.2 Three of the four swabs obtained, tested positive to Influenza A, (this

strain was included within the 2015/16 seasonal Influenza Vaccine). Appropriate outbreak/isolation precautions were instigated with support from the IPC Team.

3.3.3 Influenza Antiviral therapy was not prescribed as the recommended 48

hours post onset of symptoms period had passed. Nil other patients or staff reported any further respiratory symptoms.


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3.3.4 An Outbreak Control Meeting was convened as per Trust Policy. It was noted that one of the inpatients diagnosed with Influenza A had previously received Influenza vaccine via the General Practitioner prior to admission. This information was escalated to the Public Health England (South/South West) Health Protection Team via the Head of the Infection Prevention and Control Team. Of the 16 inpatients who were residing on Hadspen Ward, 8 had not received vaccination via the Primary Care route. This information was raised with Somerset CCG, and it was suggested that this information be escalated via the five Primary Care Practices located within the Wincanton area.

3.3.5 Additional Influenza Vaccination sessions were offered to any frontline

care staff within the Hospital and were delivered via the ‘Peer’ Vaccination route. It is noted that 28% of the Wincanton staff received vaccine as part of the Somerset Partnership NHS Foundation Trust Vaccination Programme.

3.3.7 Post this outbreak it has been reported that outbreaks of Influenza A

have been experienced across the Somerset based Care Home sector. These were managed via the PHE South /Southwest Health Protection Teams.

4. INFECTION PREVENTION AND CONTROL AUDIT ACTIVITY 2016/17

4.1 Infection Prevention and Control audit enables the organisation to

assess actual practice against defined standards as identified within the Code of Practice for the Prevention and Control of Health Care Associated Infections (2010); it should also permit reporting of non-compliance or issues of concern by either healthcare workers or the Infection Prevention and Control Team.

4.2 The Infection Prevention and Control audit programme promotes

continual improvement as it enables a blame-free mechanism for changes in practice, if indicated. The results of audit, when provided back to staff, can turn defects into improvements after appropriate changes are completed.

4.3 All audit results have been shared at the relevant Trust Best Practice

Groups, the Trust Infection Prevention and Control Assurance Group, and are also reported quarterly via the Trust Clinical Governance Group.

4.4 A mixed methodology approach is applied by the Infection Prevention

and Control Team when undertaking the audit programme, and includes;


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• documentation review;

• staff interview;

• observational review.

4.5 Some fundamental requirements for preventing infection in healthcare environments are;

• cleanliness of hands and the environment;

• isolation of patients known or suspected of having easily

transmissible or epidemiologically important pathogens;

• uUse of personal protective equipment (PPE);

• targeted screening (MRSA);

• decontamination of Medical Devices. These are areas which have been subject to the Somerset Partnership Trust Infection Prevention and Control team undertaking audits of compliance.

4.6 Infection Prevention and Control Audit results have also been

complimented by observational reviews undertaken via Patient Led Assessment of the Clinical Environment (PLACE).

4.7 Commercially led audits of compliance have also been undertaken

during 2016/17 as follows;

• Daniels Healthcare: Review of sharps bin usage within Mental health Services;

• Becton Dickinson: Review of compliance with EU Safer Sharps Legislation;

4.8 A member of the IPC Team has undertaken a Regulation Governance related audit to assess the Infection Prevention and Control Team’s compliance with regards appropriate use of the county-wide Laboratory database system known as IC net.

4.9 A stand-alone survey was undertaken during 2016/17 to assess staff

knowledge relating to MRSA screening within the Mental Health inpatient services

4.10 A detailed Audit Report for 2016/17 has been submitted to the

Infection Prevention and Control Assurance Group.


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4.11 Recommendations and resulting action plan, arising from the Infection Prevention and Control audits have been agreed and monitored by the following Trust Groups;

• Hand Hygiene/Cleanliness= Infection Prevention and Control

Assurance Group;

• Community Infection Prevention Society Audit = Infection Prevention and Control Assurance Group;

• Environmental Cleanliness = Infection Prevention and Control

Assurance Group, Facilities Management Governance Group; • Isolation Audit = Infection Prevention and Control Assurance

Group; • MRSA Screening Audit = Infection Prevention and Control

Assurance Group; • Sharps Safety = Health and Safety Committee and Infection

Prevention and Control Assurance Group; • Medical Devices = Health and Safety Committee and Infection

Prevention and Control Assurance Group; • HTM 01/05 Compliance ( PCDAC) Audit = Infection Prevention

and Control Assurance Group; • Internal Audit undertaken by PWC = Infection Control: Infection

Prevention and Control Assurance Group; • Legionella: Compliance with flushing of little used outlets = Water

Safety Group; Infection Prevention and Control Assurance Group.

4.12 The IPC team seconded an Assistant Practitioner (AP) from May,

2016, for a one year period. The staff member (who currently works as an AP within the South Somerset District Nursing Services), worked with the team (0.20 whole time equivalent), devising and implementing a Hand Hygiene Audit Tool for use across the Trust managed District Nursing Services

The work programme (devised by the AP in conjunction with the IPC Nurse Specialist), consisted of development of an audit tool specific for self-audit within each team/hub/spoke; the work programme undertaken included;


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• hand hygiene refresher training, particularly relating to the World Health Organisation Programme, ‘Five moments for hand hygiene’;

• direct support and training for any member of staff allocated to undertake the audit;

• collection of audit results;

• feedback to District Nurse leads where appropriate, were undertaken by the secondee.

The monthly audit will now become compulsory (as per the Community Services inpatient units) and the data will continue to be collected and reported back to the Trust board as part of the 2017/2018 IPC work programme.

Table 4: Somerset Partnership Infection Prevention and Control Team Hand Hygiene Results 2016/17 Mental Health Hand Hygiene Audits

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

100.0% 100.0% 80.0% 80.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%100.0% 90.0% 100.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 90.0% 100.0%100.0% 100.0% 100.0% 94.0% 100.0% 90.0% 96.0% 100.0% 100.0% 92.0% 98.0% 100.0%

Pyrland 2 76.0% 88.0% 96.0% 98.0% 100.0% 90.0% 90.0% 88.0% 100.0% 100.0% 100.0% 100.0%100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%90.0% 90.0% 96.0% 86.0% 100.0% 98.0% 100.0% 84.0% 100.0% 100.0% 100.0% 100.0%98.0% 100.0% 98.0% 95.0% 98.0% 80.0% 90.0% 96.0% 100.0% 100.0% 100.0% 100.0%

100.0% 100.0% 60.0% 100.0% 100.0% 66.0% 100.0% 10.0% 98.0% 90.0% 100.0% 100.0%100.0% 100.0% 100.0% 100.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%60.0% 90.0% 60.0% 88.0% 100.0% 100.0% 90.0% 100.0% 100.0% 90.0% 100.0% 100.0%94.8% 97.0% 89.4% 93.3% 98.8% 93.4% 97.6% 89.0% 99.8% 97.5% 98.9% 100.0%

Community Hand Hygiene Audit

Hospital Ward Apr - 16 May - 16 Jun - 16 Jul - 16 Aug - 16 Sep - 16 Oct - 16 Nov - 16 Dec - 16 Jan - 17 Feb - 17 Mar - 17

Bridgwater Waverley 100.0% 96.0% 100.0% 90.0% 100.0% 94.0% 90.0% 98.0% 100.0% 100.0% 100.0% 100.0%Burnham Ward 100.0% 100.0% 70.0% 100.0% 100.0% 100.0% 100.0% 92.0% 100.0% 100.0% 100.0% 100.0%Chard Swinbanks 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 90.0% 100.0% 100.0%Crewkerne Ward 100.0% 100.0% 100.0% 90.0% 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Dene Barton Luke 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 86.0% 100.0% 100.0% 100.0% 100.0%Frome Marshfield Ward 100.0% 70.0% 100.0% 100.0% 100.0% 100.0% 98.0% 100.0% 100.0% 98.0% 100.0% 60.0%Minehead Exmoor Ward 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% CLOSED CLOSEDShepton Mallet One ward 100.0% 100.0% 100.0% 90.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%South Petherton Mary Robertson Ward 76.0% 78.0% 100.0% 90.0% 98.0% 94.0% 88.0% 98.0% 100.0% 98.0% 100.0% 100.0%Wellington Ward 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.0% 100.0% 100.0%West Mendip 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Willtion Exmoor Ward 100.0% 100.0%

Williton Meadow Ward 100.0%not

submitted 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%Wincanton Hadspen 100.0% closed CLOSED 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Athlone 100.0% 100.0% 100.0% CLOSED CLOSED CLOSED CLOSED CLOSED CLOSED CLOSED CLOSED CLOSED98.3% 95.3% 97.7% 96.9% 99.7% 99.1% 98.2% 98.0% 100.0% 98.8% 100.0% 96.9%

Wessex House

Rydon 1

St Andrew'sWillow

Hospital

AshHolfordMagnoliaPyrland 1

Rowan

Rydon 2


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Table 5: Somerset Partnership Of Infection Prevention and Control Team Quarterly Hand Hygiene Validation Results 2016/17

2016/17

INPATIENT (LINK PRACTITIONER)

REPORTED SCORE

IPC TEAM VALIDATED SCORE

Q1 95.2%

90.32% Q2 97.0%

92.8%

Q3

97.1% 94.06% Q4 98.6%

93.6%

TOTAL = 96.9% 92.6% Table 6: Somerset Partnership Cleanliness Results 2016/17 Mental Health Cleanliness 2016/17Hospital Apr - 16 May - 16 Jun - 16 Jul - 16 Aug - 16 Sep - 16 Oct - 16 Nov - 16 Dec - 16 Jan - 17 Feb - 17 Mar - 17Ash 99.0% 97.0% 99.0% 98.0% 99.3% 99.0% 99.0% 100.0% 99.0% 99.0% 99.0% 99.0%Holford 96.0% 100.0% 100.0% 99.0% 94.0% 99.0% 95.0% 100.0% 98.0% 100.0% 100.0% 98.0%Magnolia 100.0% 100.0% 99.0% 100.0% 98.0% 99.0% 99.0% 99.0% 99.0% 99.0% 100.0% 98.0%Pyrland 95.0% 95.0% 96.5% 94.0% 97.0% 94.4% 94.0% 94.0% 98.0% 100.0% 98.0% 98.0%Rowan 99.0% 98.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 100.0% 99.0%Rydon 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.0% 100.0% 99.5% 100.0% 99.0% 99.5%St Andrew's 98.0% 100.0% 99.0% 99.0% 100.0% 99.0% 97.0% 98.0% 99.0% 99.0% 99.0% 99.0%Willow 98.0% 99.0% 99.0% 98.0% 98.0% 99.0% 98.0% 100.0% 99.0% 99.0% 99.0% 99.0%Wessex House 99.0% 99.0% 99.0% 98.0% 99.3% 99.0% 98.0% 100.0% 99.0% 99.0% 99.0% 99.0%Mental Health Ward Total 98.2% 98.6% 99.0% 98.4% 98.2% 98.6% 97.5% 98.8% 98.8% 99.4% 99.3% 98.7%

Community Health Cleanliness Audits 2016/2017

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

Bridgwater Overall) 99.4% 99.7% 98.9% 99.4% 97.3% 97.0% 99.3% 98.6% 98.8% 98.4% 99.2% 98.5%Mary Stanley Ward 99.0% 100.0% 99.0% 99.0% 99.0% 98.0% 100.0% 98.0% 98.0% 100.0% 100.0% 100.0%Waverly Ward 99.6% 99.2% 99.5% 99.7% 99.2% 99.3% 98.8% 98.7% 99.0% 97.5% 99.4% 99.2%Burnham (Overall) 99.1% 99.0% 99.3% 99.5% 99.5% 99.0% 99.5% 99.5% 99.5% 99.5% 99.5% 99.5%Wards 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0%Chard (Overall) 99.0% 99.0% 100.0% 98.0% 98.8% 98.0% 98.0% 98.0% 98.0% 98.7% 98.3% 99.0%Wards 100.0% 99.0% 100.0% 98.0% 97.5% 97.0% 98.0% 97.0% 97.0% 98.0% 97.5% 98.5%Crewkerne (Overall) 97.0% 96.8% 98.8% 99.0% 97.8% 99.2% 98.8% 98.5% 97.3% 98.0% 98.0% 99.0%Ward 97.0% 96.8% 98.8% 99.0% 97.8% 99.0% 98.8% 98.5% 97.3% 98.0% 97.7% 99.0%Dene Barton (Overall) 98.0% 98.3% 96.8% 97.7% 96.6% 96.7% 97.7% 97.8% 97.2% 97.0% 95.5% 95.6%Luke Ward 98.0% 97.8% 97.5% 97.5% 97.8% 97.0% 97.5% 98.0% 97.3% 96.5% 96.3% 95.0%Lydeard Ward 98.0% 99.0% 98.0% 98.0% 97.5% 97.6% 98.0% 98.5% 97.5% 98.0% 95.5% 96.5%Frome (Overall) 98.4% 96.0% 97.0% 94.8% 97.7% 98.4% 97.0% 99.3% 98.3% 96.3% 98.8% 98.8%Marshfield Ward 97.8% 95.0% 96.0% 97.0% 99.0% 99.0% 99.7% 99.7% 97.7% 93.3% 99.0% 98.7%Minehead Overall) 98.0% 99.0% 98.8% 99.8% 99.4% 99.5% 99.9% 97.3% 99.7% 99.8% 99.9% 100.0%Exmoor Ward 98.0% 98.0% 97.7% 99.7% 99.7% 99.0% 99.5% 98.3% Closed Closed Closed closedShepton Mallet 97.3% 100.0% 100.0% 99.0% 99.3% 99.3% 99.2% 98.8% 98.6% 98.5% 99.0% 98.4%Fosse Ward 98.0% 99.0% 100.0% 99.0% 100.0% 98.0% 98.2% 97.0% 98.0% 98.0% 99.0% 99.0%Kearton Ward 95.0% 100.0% 100.0% 100.0% 99.0% 99.0% 98.2% 100.0% 99.0% Closed Closed ClosedSouth Petherton (Overall) 100.0% 99.8% 99.3% 99.5% 100.0% 99.5% 100.0% 100.0% 99.6% 100.0% 99.5% 99.5%Mary Robertson Ward 100.0% 98.8% 99.9% 99.4% 100.0% 99.4% 99.5% 99.5% 99.8% 100.0% 99.5% 100.0%Wellington (Overall) 97.0% 97.0% 97.0% 97.0% 97.0% 98.0% 98.0% 98.0% 98.0% 97.0% 98.0% 98.0%Ward 96.0% 96.0% 96.0% 97.1% 96.1% 97.0% 95.3% 97.5% 95.4% 96.8% 96.2% 95.7%West Mendip (Overall) 97.6% 98.2% 97.6% 98.4% 96.9% 99.1% 98.3% 98.7% 99.3% 98.3% 98.3% 98.3%Cathedral Ward 97.0% 98.0% 97.0% 98.0% 98.0% 96.0% 99.0% 98.0% 99.0% 98.0% 98.0% 98.0%Abbey Ward 98.0% 98.0% 97.0% 98.0% 98.0% 98.0% 96.0% 99.0% 99.0% 98.0% 98.0% 97.0%Williton (Overall) 97.0% 97.0% 97.6% 97.5% 98.3% 98.1% 97.5% 97.0% 97.3% 98.0% 97.7% 97.5%Meadow Ward 97.0% 97.0% 98.0% 97.5% 98.5% 98.0% 97.5% 97.0% 97.5% 97.5% 97.5% 97.5%Wincanton (Overall) 97.3% 98.0% 99.0% 99.0% 99.0% 99.0% 98.1% 99.0% 98.3% 98.0% 97.5% 97.5%Hadspen Ward 97.0% Closed closed 99.0% 99.0% 99.0% 99.3% 98.3% 98.3% 98.0% 97.5% 99.3%Athlone Ward 97.6% 99.0% 99.0% Closed closed closed Closed 100.0% closed Closed Closed 99.0%Community Hospital Total 98.0% 98.3% 98.5% 98.3% 98.3% 98.5% 98.5% 98.5% 98.4% 98.0% 98.4% 99.0%


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5. DECONTAMINATION

5.1 The Head of Infection Prevention and Control provides Decontamination advice for the Trust.

5.2 Written procedures, protocols and policy for effective decontamination

of equipment are available via the Trust Intranet site.

5.3 Outpatient & Day Case Surgery: Decontamination Processes

5.3.1 The Trust Theatre and Endoscopy User Group meet on a quarterly basis. This group is chaired by the Head of Infection Prevention and Control and its purpose is to provide assurance that decontamination processes undertaken across the Trust meet the required national guidance/standards/ recommendations. This group reports to the Trust of Infection Prevention and Control Assurance Group.

5.3.2 Automated Endoscopy Reprocessing Units used for the

decontamination of Endoscopes at Minehead Community Hospital

5.3.2.1 The Getinge ED-FLOW AER (automated endoscope reprocessing)

has been decommissioned. The only endoscopy activity currently carried out at Minehead Day case Unit is Cystoscopies, using the Endosheath system. Decontamination of the scopes is via the use of Tristel 123 (Chlorine Dioxide triple wipe system).

5.3.3 Cystoscopy Service; Bridgwater Community Hospital OPD

5.3.3.1 Responsibility for the decontamination of cystoscopes utilised during the delivery of the Urology Service, delivered via the Out Patient Department, based within Bridgwater Community Hospital, transferred to Taunton and Somerset NHS Foundation Trust from 1 April, 2015. This Trust took the decision to not decontaminate this equipment utilising the onsite Automated Endoscopy Reprocessing unit, due to capacity issues triggered by the National Bowel Screening Programme.

5.3.3.2 Taunton and Somerset NHS Foundation Trust have chosen to utilise a

‘sheathed’ Cystoscope system. Trust staff working within the Out Patient Department, at Bridgwater Community Hospital were trained prior to this service commencing in went live in September, 2015.The service is now operating at the intended capacity, with nil issues being escalated as of 31 March 2016.


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5.4 HTM 01- 05 Compliance: Primary Care Dental Services

5.4.1 Specialist Dental Services are delivered via Sompar Salaried Dentists across a variety of clinical sites. The IPC Lead for Dental Services undertakes environmental audits within all clinics. Action plans arising from these are monitored via the Trust IPC Assurance Group.

5.4.2. The Somerset Partnership Infection Prevention and Control Team

were also requested to undertake Infection Prevention and Control Audits of the following specialist Dental Practices , based on the Isle of Wight and Dorset:

• Cowes Medical Centre, West Cowes;

• Arthur Webster Clinic, Shanklin; • Brookside Health Centre, Freshwater; • Carisbrooke Health Centre, Carisbrooke; • Browning Centre, Boscombe, Bournemouth • Canford Health Clinic, Canford Heath, Poole.

5.4.3 Somerset Partnership are required to ensure that infection prevention

and control standards are robust and consistent with the requirements of national legislation and guidelines as detailed within section 1.1-1.3 of the Health Technical Memorandum (HTM) 01-05 − Decontamination in primary care dental practices.

5.4.4 Audits have been undertaken during 2016/2017 across all of the Isle of Wight and Dorset based specialist Dental services. Action plans have been assimilated/disseminated locally and are being monitored via the Trust IPC Assurance Group.

5.4.5 HTM 01-05 service specific compliance scores (with 2015/16

comparison in brackets) are as follows:

• Somerset based Primary Care Dental Access Clinics = 99.32% compliance (> 99% 2015/16);

• IOW based Primary Care Dental Access Clinics = 97.71 %

compliance (> 96% 2015/16); • Dorset based Primary Care Dental Access Clinics = 99.82%

compliance (>99% 2015/16);


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6. NATIONAL INITIATIVES

6.1 European Union Directive to Prevent Injuries and Infections to Healthcare Workers from Sharp Objects such as Needle Sticks

6.1.1 On 10 May 2010, a European Union Directive was introduced to

prevent injuries and blood-borne infections to hospital and healthcare workers from sharp instruments such as needles.

In summary the aims of the above legislation are:

• to achieve the safest possible working environment;

• to prevent workers’ injuries caused by medical sharps;

• to protect workers at risk;

• to set up an integrated approach establishing policies in risk, assessment, risk prevention, training, information, awareness raising and monitoring;

• to put in place response and follow up procedures.

6.1.2 The Directive was established due to the accidents sustained by Healthcare Workers. Most of these injuries are sustained post use of a sharp, but prior to disposal (approximately 75%).

6.1.3 Work has been undertaken Trust wide to ensure compliance with the

Directive, and also across specialist services such as Dentistry, Podiatry and Day Case Theatres.

6.1.4 The Trust ‘approved’ cannulae, phlebotomy, subcutaneous and

intramuscular devices are now in use across the Trust, and training has been provided. Training has also been provided by the manufacturer of a safer insulin syringe and insulin pen.

6.1.5 Becton Dickinson have undertaken an audit to assess Trust

compliance with EU Legislation in relation to sharp safe equipment in April, 2016. Actions identified post these audits have been managed locally.

6.2 Exceptions

6.2.1 A potential safer sharps solution for the two inch needle used in Mental

Health (used for delivery of Depo [intra muscular] injections) was being piloted at the close of Q4.

6.2.2 There has been a rise in the amount of injuries attributable to ‘dirty’

sharps incidents, from the 18 incidents reported in 2015/16 to 32


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reported in 2016/17. The reason for this rise is not known, however the Trust has continued to promote a culture of positive incident reporting during the last financial year and as the overall number of reported incidents relating to all sharps categories has risen from 28 (2015/16) to 54 (2016/17) this may account for the increase.

TABLE 7: Reported Needle Stick Incidents 2016/17

6.3 Catheter Associated Urinary Tract Infections (CAUTI)

6.3.1 Evidence demonstrates that 2.5% of hospital inpatients acquire a urinary tract infection (UTI) during an admission. This can lead to an increased length of hospitalisation (average 5-6 days) and additional pain and discomfort experienced by patient. It can also be factor in complicated upper urinary tract infections and bacteraemia. The major predisposing factor is the presence of an indwelling urinary catheter. Evidence suggests that an average of 26% patients are catheterised and the risk of acquiring a catheter associated urinary tract infection (CAUTI) is 1-2% per procedure.

6.3.2 The 2012/13 NHS Operating Framework announced the extension to

the collection of data using the NHS Patient Safety Thermometer. This included the prevalence of catheter associated infections .These nationally driven initiatives tasked all healthcare providers to critically analyse and risk assess their clinical management of urinary catheterised patients, in an effort to reduce the risk associated with urinary tract infection acquisition.

6.3.3 In view of the above, a urinary catheter ‘free’ inpatient service has

been implemented across the 13 Community Services inpatient areas. A final report, detailing the outcomes of this initiative, has been completed and is to be distributed and shared across all departments.

It is to be noted that there has been a successful implementation programme. A total of 182 patients, with an indwelling urinary device, were assessed within 48 hours of admission to the inpatient services. A total of 88 (48%) patients fitted the criteria for TWOC (trial without catheter) resulting in 70 (79%) patients who had successful TWOC’s.

DATIX REPORTS 12/13 13/14 14/15 15/16 2016/2017 Injury from dirty sharps 24 29 > 31 > 18< 32> Sharps or needles found 6 5 < 4 < 3< 4> Injury from clean sharps 5 8 > 2 < 4> 5> Accident of some other type or cause

2 9 > 7 < 3< 13>

Total 37 51> 44< 28< 54>


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A reaudit of ongoing compliance with this programme was completed at the close of 2016/2017 and the final report of this audit is pending.

6.3.4 Associated work has highlighted the positive impact a ‘urinary catheter

passport’ can have on the overall management of indwelling urinary catheters and the reduction of inappropriate use.

This finding has been raised by Trust IPC staff, via the County Wide

Infection Prevention and Control Assurance Group (hosted by Somerset CCG) as the use of this tool this would impact well as part of a whole health economy approach.

The IPC Team will continue to promote the establishment of a urinary

catheter Passport, in collaboration with the county wide Continence and IPC teams.

6.4 World Antibiotic Awareness Week (14 – 20 November 2016)

6.4.1 This was supported across England by the Department of Health and

its Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI).

6.4.2 World Antibiotic Awareness Week was locally marked by an article in

‘What’s on Sompar’ which invited staff to sign up as antibiotic guardians and to investigate the resources on the website. Posters and additional national information was also distributed, trust wide.

7. TRAINING

7.1 Infection Prevention and Control training has continued to be delivered (as part of the Induction and Mandatory Training Programme) via the provision of face to face sessions, completion of an e-learning module via the Intranet site.

7.2 The development of the Infection Prevention and Control webpage, on

the Somerset Partnership intranet and public website, has continued to be undertaken.

7.3 The Trust monitors and manages staff training via an electronic

Learning Management System.

7.3.1 The total number of staff in receipt of Infection Prevention and Control Training = 3395 staff (excluding bank staff, new starts staff on maternity leave and long term sick. Percentage staff in receipt of


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Infection Prevention and Control Training = 96.4% (> 1.9% on 2015/16 figures).

7.4 Additional Infection Prevention and Control training has been delivered

by the Team as follows;

• Trust based Assistant Practitioner Course;

• Trust Induction Programme;

• Link Practitioner Training Updates;

• Local Medical Committee IPC training ( for Practice Nurses);

• HTM 01/05 update for Dental Services;

• ad hoc local training as requested by individual team Managers.

7.5 Development of the Infection Prevention and Control Link Practitioner role has continued during 2016/17. The purpose of the role is to assist in raising the profile of the prevention and control of infection across all Trust managed areas.

7.6 Infection Prevention and Control learning points and news articles are

delivered in a written format, and distributed via the ‘What’s on’ Trust Newsletter.

7.7 The Somerset Partnership Infection Prevention and Control Team (in

collaboration with the other members of the Somerset Infection Control Forum) assisted in the organisation and delivery of an Infection Prevention and Control study day held at the Taunton Conference Centre , Somerset College, Taunton , 7th July 2016.

7.7.1 The day provided an opportunity for staff to be appraised of current,

evidence based information to enable the implementation of robust practices across all of the Somerset care settings. Evaluations of the day were extremely positive. This is an annual event and enables the Somerset Infection Prevention and Control forum to generate income. This income has been used to fund attendance for staff at the annual Infection Prevention Society Conference.

8. LEGIONELLA AND WATER QUALITY

8.1 Somerset Partnership NHS Foundation Trust has a responsibility to ensure the risk of transmission of Legionella to patients/staff/visitors accessing and utilising health care services is minimised. In response to this requirement the Trust has an established Water Hygiene Group.


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8.2 The Somerset Partnership Trust Estates Lead has been identified as the Trust Responsible Person in relation to Legionella control.

8.3 The Taunton and Somerset NHS Foundation Trust Consultant

Microbiologist acts as the Somerset Partnership Trust Infection Prevention and Control Doctor in relation to Legionella control.

8.4 The function of the Water Hygiene Group is:

• to focus on Legionella and water quality management;

• to identify potential areas of risk, including changes to clinical

activity and location of high risk groups;

• to advise on the recommended procedures for the prevention of Legionella;

• to carry out the necessary action if an outbreak of Legionnaires disease is suspected in accordance with the Trust Legionella Operational Policy.

8.5 The Head of Infection Prevention and Control/Decontamination Lead is

a member of the Somerset Partnership Water Hygiene Group.

8.6 Flushing of little used outlets three times per week continues to be complied with and documented across all inpatient and other clinical sites as per the requirements of the Trust Legionella Policy. The Trust Infection Prevention and Control team validate compliance with this requirement on a quarterly basis.

8.7 The Water Hygiene Group has met twice during 2016/17. The external

advisors, who are also the Trust’s appointed Authorizing Engineers, have carried out an audit of the management of the water services with particular reference to Legionella risks, and presented the results to the Water Hygiene Group. The Water Safety Policy has been updated during this period and, in line with the policy, the programme for carrying out risk assessments has continued.

8.7.1 The Audit Action Plan is monitored via the Water Hygiene Group and

reported on via the Infection Prevention and Control Assurance Group.

9. NEW BUILD INITIATIVES

9.1 As per the requirements of Health Building Note 00-09: Infection control in the built environment (March 2013), it is imperative that of Infection Prevention and Control measures are "designed-in" at the very outset of the planning and design stages of a healthcare facility and that input continues up to, into and beyond the final building stage.


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The IPC Team have provided specialist input for the planning processes in relation to the following, during 2016/17;

• Shepton Mallet Healthcare Campus (ongoing); • Chard Community Hospital Refurbishment Programme

(pending).

10. COMPLIANCE WITH CQC: RELEVANT CQC STANDARD

10.1 Outcome 8: Cleanliness and Infection Control:

10.1.1 The organisation is fully compliant with this standard;

10.2 Code of Practice for health and adult social care on the prevention and control of infections and related guidance:

Criterion detailed within the Hygiene Code of Practice

11. CONCLUSION

11.1 Over the past year the Trust has:

• achieved zero cases of MRSA bacteraemia; • achieved zero cases of Trust attributable Toxin Positive

Clostridium difficile; • reported and managed 6 outbreaks of gastrointestinal infection,

four of which were attributable to Norovirus; • reported and managed an outbreak of Influenza A; • continued to work towards ensuring compliance with the Health

and Social Care Act 2008 (2010); • maintained & improved CAUTI care pathways; • continued to monitor and train staff in hand hygiene performance; • continued to embed optimal antibiotic stewardship;

11.2 This report effectively demonstrates the work that has been carried out regarding monitoring and achievement of quality and reduced infection rate targets. The Trust has again been able to report full compliance

10.2.1 The organisation is able to demonstrate full compliance with the 10 compliance


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with Commissioner set trajectories in relation to of Infection Prevention and Control objectives.

11.3 The Trust IPC work programme has continued to enable ongoing

delivery of safe care, in relation to infection prevention and control, across both Community and Mental Health services by increasing staff and public awareness of this important agenda.

11.4 Continuous improvement is the aim of the Infection Prevention &

Control Team, with ‘zero’ tolerance of infection and avoidable harm and this Annual Report recognises the success and achievements of the past 12 months.

11.5 It is however acknowledged that improvements must be continuous

and there remain many challenges ahead, and these are reflected in the IPC Team’s 2017/18 Work Programme.


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Links to Strategic Themes:

Identify to which of the Somerset Partnership NHS Foundation Trust strategic themes this report relates by including a cross behind the relevant theme(s)

Quality and Safety Sustainability and Transformation

Service Delivery Culture and People

Links to the Assurance Framework:

The Trust fails to implement its Quality Improvement Plan and fails to achieve improvement in harm free care and patient and carer involvement leading to poorer patient experience and patient safety

Links to the Trust Values:

Identify to which values this report relates:

Working together

Making a Difference

Everyone counts

Links to CQC Domains:

[Identify which of the CQC domains are covered by this report by including a cross behind the relevant domain(s)]

Is it safe? Is it caring?

Is it well-led? Is it effective?

Is it responsive to people’s needs?

Equality:

Identify whether the report has an impact on the protected characteristics set out below, including risks, and if so, say how these risks are to be managed. Only tick the relevant box for which there is an impact. Age Disability Gender re-assignment Marriage and

Civil Partnership

Pregnancy and maternity

Race


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Religion or Belief Sex Sexual Orientation Learning

Disabilities

Legal or statutory implications/ requirements:

The report provides assurance to the Board of Directors and the public on compliance with the Health & Social Care Act 2008 (updated July 2015): Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance - The Hygiene Code.

Public/Staff Involvement History:

All operational divisions are represented at the Trust infection Prevention and Control meeting. There are established team based staff champions.

Previous Consideration:

The Trust Board last considered the annual report in June 2016.


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APPENDIX A

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

Source Expected Outcomes Progress Completion Date

Health and Social Care Act 2012 Clostridium difficile ‘How to deal with the problem’ 2009 and updated Chapter 3 issued in May 2013 Clostridium difficile infection objectives for NHS organisations in 2015/16 and guidance on sanction implementation February 2015 Infection: Prevention and control of healthcare-associated infections in primary and community care (CG 139: NICE 2012)

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1.1

1.2

1.3

1.4

1.5

The Trust can demonstrate an understanding of their specific responsibilities in relation to Infection Prevention and Control (IP&C)

The Trust will ensure that there is continuous improvement in IP&C demonstrated by adherence to MRSA Bacteraemia and Clostridium Difficile trajectories

The IPC Team will ensure that nationally led initiatives will be implemented and monitored across all care environments

The IPC Team will undertake and/or assist with IPC audits as per the Trust’s Audit Programme

The IPC team will assist clinical staff to implement actions identified during RCA investigations which will result in practice improvement and safer patient outcomes

The Infection Prevention and Control team will liaise with the Senior Clinical Pharmacist, Medicines Management regarding antibiotic prescribing on

each RCA

The Infection Prevention and Control team

1 2 3 4 5 6

All areas will be able to demonstrate: - Infection prevention and control is part of all KSF appraisals - All Job Descriptions have IP&C responsibilities and accountabilities Monitor all mandatory surveillance data with evidence of supporting policies and robust internal reporting mechanisms

Monitor & report mandatory Surveillance including MRSA/Cdiff Clostridium difficile - trajectory = 5 (Avoidable Toxin +ve) MRSA BSI trajectory = 0 ( this remains as per 15/16 trajectory) Community CPE guidance. IPC team continue to assist in undertaking routine post infection review with clinical staff / investigation of alert organisms ensuring shared learning is achieved across the healthcare community. These will be reported via the IPC Implementation Group/Somerset CCG Assurance Group/ Somerset C. diff Group/SMAICAL. All toxin positive cases will be reviewed during a locally held review meeting where lapses of care will be reviewed as per the NHS England C. diff Objective document. All Toxin + ve cases will be reviewed in collaboration with the Somerset CCG IPC lead to provide assurance of avoidablilty/non avoidability, and actions taken post identification of lapses in care. Annual Infection Prevention and Control audits are being undertaken as per audit programme

Ongoing Ongoing For Completion by March 31st 2017 Compliance as required Quarterly Quarterly Review at IPC Assurance Committee. Quarterly Report via SMAICL March 31st 2017 March 31st 2017


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‘5 Moments for Hand Hygiene’ WHO hand hygiene initiative epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2014) Start Smart - Then Focus Antimicrobial Stewardship Toolkit for English Hospitals

1.6

will support the requirement for a medicines management antimicrobial lead review of Antimicrobial Stewardship within the organisation.

Monthly Infection Prevention and Control audits continue to be supported as follows:

• Hand Hygiene compliance: undertaken by Link Practitioners

• Isolation; • Cannula care; • Commode cleanliness. • Microbiology locally held Specimen Logbooks

Quarterly Infection Prevention and Control audits continue to be supported as follows:

• Hand Hygiene Validation; • Isolation; • Cannula care; • Legionella; Flushing of little used outlets; Validation;

Annual Infection Prevention and Control audits continue to be supported as follows

• MRSA Screening Validation; • Decontamination of Medical Devices; • Compliance with EU Legislation in relation to Sharp safe Equipment; • CAUTI;

Commercial Audits for 2016/17: 1) Daniels: Sharps disposal Compliance Audit; Community Matrons/Community Nursing Team (car boot sharps compliance); 2) Hand Hygiene: Externally led Audit of Trust Hand Hygiene compliance ( ECOLAB) 3) BD: Compliance with sharp safe legislation across inpatient services.

monthly Undertaken by IPC team during surveillance ALL BY MARCH 31ST 2017 Quarterly ALL BY MARCH 31ST , 2017 August 2016 TBC May 2016


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


Health and Social Care Act 2012 Choice Framework for local Policy and Procedures 01-06 – Decontamination of flexible endoscopes: Policy and management (2012) HTM 01-05 Dental

Health Building Note 00-09: Infection control in the built environment epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2014)

1 2 3

The IPC Team will ensure that programmes of surveillance are in place Relevant services will demonstrate compliance with European standards for the decontamination of reusable medical devices Performance monitoring measures relating to IPC will demonstrate sustained improvement across all units

1 2

3 4 5 6

IPC team will visit each Community Hospital on a weekly basis, review those pts identified with lab reported infections and act as a local resource during the visit Mental Health inpatient units will be visited for surveillance purposes. IC net is maintained and monitored across inpatient services and is compatible with the RiO/PAS system whilst also ensuring IG compliance. Quarterly surveillance reports to IPC Assurance Group and Somerset CCG Assurance IPC Committee /Trust Board/SMAICL IPC Team continues to assist Sompar Dental Access Lead Managers to ensure ongoing compliance with requirements of HTM01-05. Head of IPC continues to provide advice and support to Minehead community hospital in relation to on site Automated Endoscopy Reprocessing Units, ensuring full compliance with CPP01 06 Endoscopy Head of IPC to provide advice and support to Bridgwater community hospital in relation to proposed Endoscopy Sheathing solution, ensuring full compliance with CPP01 06 Endoscopy

ALL WEEKLY : RECORDED VIA RIO AND ICNET; Ongoing interface issues continue in to 16/17; manual review undertaken by IPC Nurses Quarterly report Quarterly report Monitored via IPC Assurance Group Monitored via IPC Assurance Group


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Head of IPC/Deputy attends meetings, as requested, where performance monitoring reports relating to IPC are monitored/discussed, as follows;

• Hotel Supervisors Assurance Group; • Facilities Management Gov Group • Cleaning Contract Review Meetings • Somerset Microbiology and Infection Control+

Leads (SMAICL) • Winter and Capacity Planning; • Clinical Governance Group; • Somerset Infection Prevention and Control

Assurance Group (SIPAC); • Health and Safety; • Medical Devices; • Community Hospital Best Practice Group; • Legionella and Water Safety Group; • New Build Groups; • TUG and EUG; • Point of Care testing;

Quarterly attendance


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


Health and Social Care Act 2012

Health Building Note 00-09: Infection control in the built environment

National Specifications for Cleanliness (2007)

Chief Nurse HIA: CAUTI (2010) • • Infection: Prevention and control of healthcare-associated infections in primary and community care (NICE 2012)

Five Moments for Hand Hygiene

1 2

3 4 5

Assurance will be provided for patient/public and the Commissioners that Infection Prevention and Control National Cleaning Standards are implemented and adhered to. Inter healthcare transfer forms will be utilised The organisation’s website will have an IPC site allowing for public to access relevant information Provide representation at the county wide Somerset Infection Prevention and Control Forum Chief Nurse High Impact Actions in relation to the reduction of Catheter Associated Infections

1 2

3

4

Cleaning specifications and Operational Guidelines are monitored via the Hotel Services Assurance Group and reported via the IPC Assurance Group. Performance scorecard reviewed at Senior Managers Operational Group. IPC Incidents pertaining to healthcare transfers will be investigated by the Head of IPC and reported via the IPC Assurance Group and the Somerset CCG IPC Assurance Committee and SMAICL The IPC team maintain this site with relevant information pertaining to IPC which includes;

• General principles pertaining to IPC and control of HCAI;

• Relevant surveillance data; • Information pertaining to alert organisms

(MRSA/MRGNO/ C.diff); • Hand washing information; • ANTT Guidance; • Team contact details. • Outbreak info • Sharps info • Infection Prevention and Control Leaflets • Policy Links

The IPC team continue to participate in the Somerset Infection Prevention and Control forum

QUARTERLY As required Updated as required QUARTERLY


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epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2014)

6 7

will be locally implemented Safety Thermometer Provision of patient/relative information

5 6

The IPC team will participate in ensuring assurance is provided in relation to ANTT. This will include;

• ANTT to be standing agenda item on IPC Assurance Group;

• Review of eLearning solution in relation to ANTT training and compliance

CAUTI program audit will continue to be supported by the Infection Prevention and Control Team/ Continence Team The CAUTI Working Group will meet quarterly to monitor Safety Thermometer data pertaining to CAUTI. The Group will also review;

• the catheter free inpatient services ; • Pilot of the catheter free inpatient services to be

considered for one of the District Nursing Service. The IPC team will Validate Patient Safety Thermometer CAUTI data on a quarterly basis; CAUTI data collection will be undertaken locally but support from the Infection Prevention and Control Team will be provided when required

Quarterly Annual Quarterly Quarterly As required


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


Health and Social Care Act 2012 epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2014) Internal Trust IPC Audit Programme • Infection: Prevention and control of healthcare-associated infections in primary and community care (NICE 2012) Saving Lives Campaign, 2007 Chief Nurse HIA: CAUTI (2010)

1 2

All services are able to demonstrate compliance with Infection Prevention and Control Policies and protocols which reflect National Standards and Guidance for best practice. Compliance with policies and protocols are evidenced through audit.

1 2 3 4

The organisation’s website will provide access for all staff to relevant IPC policies/protocols and procedures. Policies will be reviewed on a bi annual basis or sooner if national policy dictates. MRSA Policy compliance reaudit to be undertaken in July 2016 Medical Devices Decontamination Audit to be completed by the close of Q1 ICNet Database will be maintained and compliance with Trust Information Gov compliance assured Outbreaks will be reported in a timely manner to CCG/Trust Board.

Bi annual August 2016 May 2016 March 2017 Monthly


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

Source Expected Outcomes Progress Completion date Clinical Negligence Scheme for Trusts Health and Social Care Act 2009 • Infection: Prevention and control of healthcare-associated infections in primary and community care (NICE 2012) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2014) Start Smart - Then Focus Antimicrobial Stewardship Toolkit

1 2 3

The Trust is able to provide evidence of Infection Prevention and Control training and ensures attendance for all employees All contractors operating on Trust managed property will receive IPC information in leaflet format Within the Antimicrobial Stewardship Strategy the Trust will have in place appropriate antimicrobial prescribing guidelines appropriate to each care setting. Where treatment is initiated by an external organisation, principles of antimicrobial stewardship will be applied to the section of the patient care pathway provided by our Trust. Adherence to the guidelines and stewardship principles will apply to all staff

1 2 3 4 5 6

The Trust will demonstrate that ALL staff have completed mandatory annual infection prevention and control training. The IPC Team will continue to support the provision of mandatory Infection Prevention and Control training. The IPC Team Lead will continue to review and assist the Learning and Development Team with the implementation of a ‘blended e-leaning’ training programme to compliment the current programme All services will be able to demonstrate: - Infection prevention and control is part of all KSF appraisals -All Job Descriptions have IP&C responsibilities and accountabilities Outbreaks reported to PHE / CCG database Cross county communication with fellow Infection Prevention and Control Teams via SIC Forum

ANNUAL; REVIEWED BY LINE MANAGERS AT APPRAISAL As required As required Annual As required Quarterly


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for English Hospitals (UPDATED 2015)

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Medicine Management representation at IPC Assurance Group delivering audit information is relation to antimicrobial prescribing practices ( including high risk prescribing data)

Quarterly


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

Source Expected Outcomes Progress Completion Date Health and Social Care Act 2008 • Infection: Prevention and control of healthcare-associated infections in primary and community care (NICE 2012) Health Building Note 00-09: Infection control in the built environment Saving Lives Campaign, 2007 epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2014)

1 2 3

4

The Trust Board and the Infection Prevention and Control Assurance Group will receive assurances that Infection prevention and Control is being managed effectively across all Trust managed services The Trust will provide assurance of adequate provision and use of isolation facilities. The Trust will designate sufficient resources to ensure that infections are managed and facilities are fit for purpose New build (Healthcare) facilities require IPC team involvement to ensure compliance with HBN 00-09.

1 2 3 4 5

The IPC team monitor compliance with Commissioner set Trajectories (MRSA and C. diff) Staff are made aware of their responsibilities in relation to IPC via attendance at Induction/Mandatory and ad hoc IPC training sessions. Assurance gained via triangulation of data Isolation Policy: Audit of compliance IPC team to be included with all new builds/refurbishment as required. IPC Link Practitioner system established and maintained Trust wide

• Bi annual ½ day update session for all LP staff

- May 2016 - October 2016

March 2017 March 2017 Monthly ( during surveillance). As required Bi- Annual


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Criterion 7: Provide or secure adequate isolation facilities Source Expected Outcomes Progress Completion Date

Health and Social Care Act 2008 Saving Lives Campaign, 2007

Health Building Note 00-09: Infection control in the built environment epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2014)

1 2 3 4

The Trust Board and the Infection Prevention and Control Assurance Group will receive assurances that Infection prevention and Control is being managed effectively across all Trust managed services The Trust will provide assurance of adequate provision and use of isolation facilities. The Trust will designate sufficient resources to ensure that infections are managed and facilities are fit for purpose New build Healthcare facilities are suggested for Bridgwater Community Hospital

1 2 3 4

All outbreaks of infection will be reviewed for compliance with Policy. Any period of increased incidence (PII) will be investigated by the IPC team with support sourced via the Trust Infection Control Doctor Maintain side room compliment/effective use through the identification of risk in collaboration with all relevant areas. Isolation Audit Compliance monthly for 2016/17 Sompar Infection Prevention and Control Lead will continue to provide expert Infection Prevention and Control advice provision for all Trust new build facilities, thus ensuring that IPC needs have been designed, planned for and met as per the requirement of HBN 00-09 (Infection Prevention and Control in the Built Environment) IPC Team will support ANY new build process in relation to IPC requirements. Those known for 2016/17 are

• Millstream Gardens • Bartec 10b • Chard CH

As required March 2017 Monthly audit


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Criterion 8: Secure adequate access to laboratory support as appropriate

Criterion 9 Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections

Source Expected Outcomes Progress Completion Date Health and Social Care Act 2008 Saving Lives Campaign, 2007

1 2

3

Taunton and Somerset NHS Foundation Trust are fully accredited via Clinical Pathology Accreditation Taunton and Somerset NHS Foundation Trust Consultant Microbiologist provides sessions thus ensuring provision of expert Microbiological advice Trust’s Service Level Agreement with Microbiology Services

1 2. 3. 4.

Evidence of Certification. Monthly meeting with ICD/IPC team ICD attends IPC Assurance Group SLA includes reference to Microbiology Laboratory support

FULLY ACCREDITED MONTHLY QUARTERLY ANNUAL


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Source Expected Outcomes Progress Completion Date Health and Social Care Act 2008 Internal Audit Essential Steps to safe, clean Care, 2006 Saving Lives Campaign, 2007

Health Building Note 00-09: Infection control in the built environment • • Infection: Prevention and control of healthcare-associated infections in primary and community care (NICE 2012) Start Smart - Then Focus Antimicrobial Stewardship Toolkit

1 2

All Trust managed services are able to demonstrate awareness/implementation of Infection Prevention and Control core Policies and protocols which reflect National Standards and Guidance for best practice The Antimicrobial Prescribing Policy will be adhered to by all staff prescribing and administering antimicrobials.

1 2 3 4 5 5 6 7

All staff are advised of the location of all IPC policies during IPC Induction/mandatory training. Infection Prevention and Control policies will be reviewed and updated as required Compliance with policies and protocols is evidenced through audit (monthly, quarterly and annual). The Trust’s Medicines Management Lead/Senior Clinical Pharmacist attends the quarterly Trust IPC Assurance Group to provide Antimicrobial advice/support. An Outbreak Control Group would be convened as per policy as required with particular reference to MRSA/Cdiff/MRGNO/ Norovirus. These incidents will be reported via the Trust IPC Assurance Group, CCG IPC Assurance Group and the Trust Board. An annual ‘wash up’ review meeting will be held to review all GI outbreaks which have impacted across inpatient services during 15/16. All mandatory surveillance will be reported to the PH England via Taunton and Somerset NHS Foundation Trust Microbiology Laboratory and also via the Trust IPC Assurance Group, CCG IPC Assurance Group and the Trust Board Clinical audits and Medicines Management monitoring of

March 2017 March 2017 March 2017 March 2017 As required April 2016 As required Quarterly


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for English Hospitals (UPDATED 2015)

prescribing will be reported via the Trust IPC Assurance Group and the Drug and Therapeutics Group.


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

Source Expected Outcomes Progress Completion Date Health and Social Care Act 2009 WHO ‘5 Moments’ for Hand Hygiene. Saving Lives Campaign, 2007 • Infection: Prevention and control of healthcare-associated infections in primary and community care (NICE 2012)

1 2 3 4 5 6 7

Sompar will continue to implement the requirements of the WHO ‘5 Moments’ for Hand Hygiene across all Trust managed services Hand hygiene is seen as the single most important method for preventing the spread of healthcare associated infection All Trust staff will have access to Well @ Work Service. Well@ Work Service policies are accessible to all staff IPC induction training is available for all Trust staff IPC responsibilities are reflected in job descriptions/PDP’s/appraisals Winter Planning includes Annual Influenza Vaccination Campaign for staff

1 2 3 4 5 6

The IP &C Team will continue to audit the effective compliance of WHO ‘5 Moments’ for Hand Hygiene in collaboration with all Heads of Service/Locality Managers/Matrons/Link Practitioners. Link Practitioners and Hand Hygiene Champions will receive bi annual training on the East and West of the County. The monthly audit programme will be reviewed and amended to reflect validation audit results. The Trust will maintain a zero tolerance policy with regards compliance with the Sompar Hand Hygiene Policy. Monitoring of compliance with effective hand hygiene will continue to be through internal performance monitoring systems. All areas will be able to demonstrate: - Infection prevention and control is part of all KSF appraisals -All Trust Job Descriptions will include IP&C responsibilities and accountabilities Sharps:- Assurance of ongoing compliance with EU

Quarterly Bi annual Monthly March 2017


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legislation

• Audit of compliance to be undertaken in Mental health services collaboration with Commercial partner

Staff compliance with Trust Immunisation Programme to be managed in collaboration with the Trust HR Team. This includes Influenza Vaccination uptake.

March 2017 March 2017


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