Infection Prevention & Control Management

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Version: V[X]

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[job title & dept]

Reviewed by Committee or Expert Group [expert group, virtual panel or sub-committee]

Equality Impact Assessed by: [job title & dept]

Related procedural documents [show all related document]

Review date: [2 years from date of ratification]

It is the responsibility of users to ensure that you are using the most up to date document template – ie obtained via the intranet.

In developing/reviewing this policy Provide Community has had regard to the principles of the NHS Constitution.

Version Control Sheet

Version Date Author Status Comment

1. Introduction

The purpose of infection prevention and control is to limit the acquisition and spread of micro-organisms, by using evidence-based knowledge as part of the overall policy of delivering safe and high-quality health and care for all service users.

The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (2015) requires organisations providing any commissioned service to ensure specialist advice on infection prevention and control is available to staff and that Infection Prevention and Control (IPC) is embedded throughout the organisation. A nominated IPC lead should be identified by the organisation and this individual should seek support and guidance from an external specialist IPC provider or local commissioners inc. the local authority and/or UK Health Security Agency (UKHSA) previously known as Public Health England.

https://www.gov.uk/government/publications/the-health-and-social-care-act2008-code-of-practice-on-the-prevention-and-control-of-infections-andrelated-guidance

All providers of a regulated service are required to be registered with the Care Quality Commission (CQC) https://www.cqc.org.uk/. A service must be regulated if it appears in a list of activities, which includes the delivery of care to service users in their own homes.

The CQC will measure organisations against the Code of Practice for the Prevention and Control of Healthcare Associated Infections (2015) and other relevant guidance and codes of practice as an integral component of the registration and inspection process.

The organisation supports the principle that infections should be prevented wherever possible and that effective arrangements for the prevention and control of infection are provided throughout the organisation.

It is the organisation’s policy to encourage the individual responsibility of every member of staff to participate in the prevention and control of infection and to comply with Health & Safety, COSHH and other legislation and regulations applying to the safe provision of health and care.

2. Purpose

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3. Definitions

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4. Duties

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5. Consultation and Communication

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6. Monitoring

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7. Scope of Policy

This policy and guidance applies to all members of staff employed by the organisation, as well as agency and bank workers who are contracted by the organisation.

All adjustments to infection prevention and control arrangements and policy should be assessed and approved by the designated IPC lead.

The organisations Chief Executive and/or Registered Manager has overall accountability for the provision of high standards of IPC.

8. Governance

IPC has a key role to play in the clinical governance framework of any health and care organisation.

The following activities should be considered an essential element of local IPC activity:

 Development of annual IPC programme and annual report

 Implementation and monitoring of compliance with IPC policies and procedures

 Education of all staff in all aspects of IPC relevant to their role

 System for reporting concerns by staff relating to any aspect of IPC

The nominated Infection Prevention & Control lead should prepare and regularly report on the annual IPC Programme which outlines organisational activities required to be undertaken to provide assurance under the Code of Practice

The IPC lead should report directly to the organisation’s registered manager (or equivalent) and produce an annual statement (retrospectively) outlining the organisation’s IPC arrangements and activities including compliance information.

The IPC Lead will support all Home Care staff and will be contactable if there are any concerns which a member of staff may wish to discuss.

9. Training

IPC training is a mandatory requirement at induction for all staff groups and as part of regular updates for all staff involved in providing direct care to service users. Training attendance records must be maintained and reported through governance frameworks.

The Code of Practice does not specify the frequency of update training. However, the UK wide Core Skills Training Framework (www.skillsforhealth.org.uk) specifies a frequency of annual training for mandatory core subjects, which includes infection prevention and control for some staff groups.

Details of the IPC training programme should be outlined in the IPC Annual Programme of the organisation.

10.Information Sharing

The Code of Practice requires the provision of accurate information to service users and their families / carers. This can be undertaken in a variety of ways including the provision of patient information leaflets (on infections), who’s who in IPC locally, compliance with hand hygiene requirements etc.

Providers are also required to share service user information as appropriate with other health and care providers having due regard to patient confidentiality.

11.Audit

Staff compliance with the Organisation’s IPC policies and procedures is a requirement of the Code of Practice. An audit plan should be prepared annually by the IPC lead with clear timescales for completion and progress should be monitored through governance frameworks.

The audit plan should be detailed in the Annual Programme and results shared with staff.

12.Review

Policies and procedures should be subject to regular review in compliance with the Code of Practice. All documentation should clearly state the review date

13.Uniform and Dress Code

Uniform and work wear policies ensure that clothing worn by staff when carrying out their duties is clean and fit for purpose. Particular consideration should be given to items of clothing that may inadvertently come into contact with the person being cared for. It is a requirement of the Code of Practice that all organisations have a written uniform and dress code policy. Compliance with local policy should form part of the annual audit programme.

Clothing must facilitate effective hand hygiene practice. Stoned rings and wrist jewellery (inc. watches) should not be worn when washing hands or delivering direct care to service users. Long sleeves, if worn, should be rolled up to the elbow for hand washing and personal tasks.

14.Surveillance of Infections

There is no formal requirement for home care providers to routinely undertake surveillance of infections in service users. However, all staff working in a service users’ home should be actively encouraged to report any concerns regarding the clinical condition of a service user to their Line Manager so that this can be escalated appropriately. There should be a system in place for this reporting which is known to all staff. Equally, all staff must be informed if the service user they are caring for has an infection so that they can take appropriate precautions e.g. wearing of Personal Protective Equipment (PPE).

EQUALITY IMPACT ASSESSMENT

TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Project/Policy Manager:

Date:

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Q2. Is there likely to be an adverse impact on one or more minority/underrepresented or community groups as a result of this initiative? If so, who may be affected and why?

Or is it clear at this stage that it will be equality “neutral”?

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age

© MDA 2007