Document Title…3 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)23 – Infection, Prevention and Control Policy – V06.1 Oct 19 PGN No: Intranet Links to PGN

Document Title Infection Prevention and Control Policy

Reference Number CNTW(C)23

Lead Officer Executive Director of Nursing and Chief Operating

Officer

Author (name and designation)

Kay Gwynn (Modern Matron – Infection Control)

Ratified by Business Delivery Group

Date ratified November 18

Implementation Date November 18

Date of full implementation

November 18

Review Date November 21

Version number V06.1

Review and Amendment

Log

Version Type of change

Date Description of change

V06 Review Nov18 Re-write

V06.1 Review Oct 19 Governance Changes

This policy supersedes:

Document Number Title

NTW(C)23 – V06 Infection Prevention and Control Policy

2 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)23 – Infection, Prevention and Control Policy – V06.1 Oct 19

Infection Prevention Control Policy

Section Contents Page No:

1 Introduction 4

2 Purpose 4

3 Duties, Accountability and Responsibilities 4

4 Assurance Framework 9

5 Training 10

6 Definition of Terms 10

7 Identification of Stakeholders 10

8 Implementation 11

9 Equality and diversity 11

10 Fair Blame 11

11 Fraud, Bribery and Corruption 11

12 References 11

Standard Appendices – attached to policy

Appendix A Equality and Diversity Impact Assessment Form

13

Appendix B Communication and Training Needs Information

15

Appendix C Monitoring Tool 17

Appendix D Policy Notification Record Sheet - click here

Appendix – Attached to policy

Appendix Description

1 Information from Training or Risk Assessment

Internet Link - Infection Prevention and Control Policy and Practice Guidance Notes

https://www.cntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

https://www.cntw.nhs.uk/about/policies/infection-prevention-control-policy/

3 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)23 – Infection, Prevention and Control Policy – V06.1 Oct 19

PGN No: Intranet Links to PGN Title

IPC-PGN 01 Access to IPC Advice

IPC-PGN 2.1 Standard Precautions

IPC-PGN 3.1 Safe Use and Disposal of Sharps

IPC-PGN 4.1 Hand Hygiene and use of Alcohol Hand rub

IPC-PGN 05 Reporting and Notification of infectious diseases

IPC-PGN 06 Outbreak Management including management of major incidents relating to infectious agents

IPC-PGN 08 Isolation of Infected Patients in hospital GW

IPC-PGN 09 Precautions to be taken after Death of Infected Person (known or suspected) GW

IPC-PGN 10 Disinfection and Decontamination Practice

IPC-PGN-12 Management of Used Hospital Laundry

IPC-PGN-13 Lice, Fleas and Scabies Prevention

IPC-PGN 14.1 IPC Considerations in the purchase and use of equipment: Water Coolers and Ice Making machines

IPC-PGN-15 Antimicrobial Prescribing Guidance

IPC-PGN-17 Transferring Patients with known or suspected infectious disease

IPC-PGN-21 Management of MRSA in Hospitals

IPC-PGN 22 Management of Clostridium Difficile in Hospital

IPC-PGN-23 The Immediate Management of Meningococcal Disease

IPC-PGN-24 Management of Parvovirus B19 in Healthcare Settings

IPC-PGN-26 Guidance for the Management of Patients with an Influenza-like Illness (ILI) or confirmed Influenza

IPC-PGN-27.1 Legionella Management and Control

IPC-PGN 27.2 Control of Legionella and Legionnaires Disease: Preventing the accumulation of stagnant water-

IPC-PGN-29 Animals in Healthcare

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4 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)23 – Infection, Prevention and Control Policy – V06.1 – Oct 19

1 Introduction 1.1 Cumbria Northumberland Tyne and Wear (CNTW) NHS Foundation Trust are

committed to ensuring the safety of our patients, staff and visitors by minimising the risk from infection as so far as is reasonably practical. Patients who present with infection on admission or who acquire infection during treatment will be identified promptly and managed according to best practice. Infection Prevention and Control is the responsibility of all staff working into the Trust. Clinical staff have a responsibility to ensure Infection Prevention and Control principles are embedded and applied into practice at all times. This policy and related PGNs is a statutory requirement and has been updated by the Infection Prevention and Control Team (IPCT) in line with the current legislation and guidance and meets the requirements of the Health and Social Care Act 2008, Code of Practice for the NHS on the prevention and control of Healthcare Associated Infections and related guidance.

2 Purpose 2.1 This policy and relating PGNs applies to all staff working in, and those working

on behalf of CNTW. 2.2 The purpose of this policy is to:

Set out the management arrangements of the IPCT and the role of the Director of Infection Prevention and Control (DIPC)

Set out the roles and responsibilities of the Infection Prevention and Control Committee (IPCC) and of other key individuals

Ensure compliance to the Code of Practice for the prevention and control of health Associated infections 2008

3 Duties, Accountability and Responsibilities 3.1 Chief Executive

The Chief Executive Officer (CE) has overall responsibility for ensuring that there are robust processes in place to ensure effective infection prevention procedures are in place in CNTW. The CE, via the Executive Director of Nursing and Chief Operating Officer, devolves responsibility for Infection Prevention and Control (IPC) to the Trust’s Director of Infection Prevention and Control (DIPC).

3.2 The Trust Board

The Trust Board are responsible for maintaining and reviewing the effectiveness of IPC systems and processes:

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Ensuring there are effective and adequately resourced arrangements for infection prevention and control within the Trust

Ensuring that the role and functions of the Director of Infection Prevention and Control are satisfactorily fulfilled by appropriate and competent persons as defined by DH (2008, updated 2015).

Approving the IPC Annual Plan, receiving the Infection Control annual report and any other reports regarding the state of IPC within the organisation

Ensuring compliance with the Health and Social Care Act 2008

Ensuring IPC advice is provided by a suitably qualified and resourced team

Supporting education in IPC in all staff 3.3 The Infection Prevention and Control Committee

The role of the Infection Prevention and Control Committee is to provide the Quality and Performance Committee with assurance that appropriate systems are in place to reduce infection risks to patients, staff and visitors. The Committee, chaired by the Group Nurse Director for Safer Care in the role of Director of Infection Prevention and Control (DIPC), meets on a quarterly basis and is responsible for:

Discussing, approving and monitoring the IPC annual work plan and incorporated Key Performance Indicators.

Receiving, approving and contributing to the annual report

The development of IPC policy, Practice Guidance Notes and standards

Setting and monitoring local priorities related to IPC

Ensuring compliance with national standards by development and implementation of robust monitoring systems

Evaluating the impact of infection on service delivery

Directing and supporting the IPC Team

Identifying organisational learning and development

Ensuring the effective implementation of HCAI guidance.

Receiving and reviewing reports from IPC projects e.g. audits, risk assessments and any required recommendations to Trust Boards

Reviewing trend analysis from the IPC surveillance to ensure appropriate action and learning is disseminated Trust wide

Receiving and reviewing reports from the IPCT on adverse incidents, After Action Reviews and recommending any change in practice or policy as highlighted by those reports

Monitoring and advising on the Trust’s cleaning specification to ensure high standards of cleanliness across the organisation

Regularly monitoring progress of the Annual Work plan by discussing at each quarterly meeting

Receiving assurance reports from the Water Safety Group for the Trust regarding water hygiene standards, risks and management plans

Liaising with external organisations with a remit for Infection Prevention and Control

3.4 The Director of Infection Prevention and Control

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The DIPC reports to the Chief Executive and the Trust Board The DIPC:

Has overall responsibility for creating a culture of effective hygiene practice i.e. to ensure that Infection Control is everyone’s business

Oversees local control of infection policies and their implementation

Is responsible for the IPC team within CNTW

Reports directly to the Chief Executive and the board and not through any other officer

Has the authority to challenge inappropriate clinical hygiene practice as well as antimicrobial prescribing

Assesses the impact of all existing and new policies and plans on infection and make recommendations for change

Is an integral member of the CNTWs Clinical Governance and Patient Safety teams and structures

Produces an annual report on the state of Healthcare Associated Infection in CNTW for which he/she is responsible and release it publicly

3.5 Microbiologist

Microbiological support to CNTW is provided through the provision of a local Service Level Agreement with Northumbria NHS Foundation Trust, this includes access for specialist advice.

3.6 Infection Prevention and Control Nurses To support the role of DIPC:

Providing strategic advice to enable the Trust to meet necessary standards of care and fulfill its obligations under the Health and Social Care Act 2008

Acting as a specialist resource for all healthcare workers both clinical and non-clinical, patients, relatives and visitors in all infection prevention and control matters

Providing expert management of infection outbreaks / incidents

Developing and update IPC Practice Guidance Notes using current best practice

Producing an annual IPC work plan with Key Performance Indicators

Providing specialist advice to clinical staff on the care and management of patients with infections / infectious diseases

Undertaking Infection Prevention Control risk assessments in clinical areas and support the wards and community teams to embed and maintain good IPC practice

Liaising with the Occupational Health provider in matters relating to staff health and provide advice and support to staff regarding infection agents and their return to work

Carrying out alert organism surveillance and report into the IPCC and Locality Care Group Quality standards meetings

Undertaking audits to ensure compliance to NICE guidance and best practice

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Providing advice and support to the Trust in the planning and construction of new / refurbishment of building work

Providing advice on IPC issues prior to commissioning of new buildings and upgrading of Trust premises and completion of the relevant documentation

Plan and deliver IPC training to all staff, constantly reviewing the IPC education programme to ensure it remains in line with best practice and legislation

Plan and deliver a seasonal flu vaccination programme to all CNTW staff

Providing advice on the procurement of new equipment in relation to IPC issues

Providing advice on aspects of decontamination, including levels of equipment decontamination and cleaning

Conduct Root Cause Analyses of relevant infection incidents

Reviewing and responding appropriately to adverse incidents / near misses related to IPC

Working in collaboration with and liaise with Public Health England, Clinical Commissioning Group, Social Services and other local agencies

Ensuring provision of information to patients and visitors so that they are aware of their role in the prevention of Healthcare Associated Infections

Undertaking Responsible Person training in relation to safe water management systems and be an integral part of the Trust Water Safety meeting

3.7 Pharmacy

Pharmacy will be represented at the IPCC and are responsible for:

Producing, disseminating and updating any local clinical guidelines involving the use of anti-infective agents

Collecting, collating and analyse data regarding antimicrobial prescribing and produce a report for the IPCC

Working closely with local Microbiologists, the IPCT and other members of the Healthcare team to ensure the safe and rational use of antibiotics

Participating in Root Cause Analysis in the case of Clostridium Difficile infection and post infection review in cases of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia to review any antimicrobial contributing factor(s)

3.8 Group Nurse Directors / Associate Directors / Clinical Nurse Managers

Act as role models, encouraging good compliance to Infection Prevention and Control practice, driving a culture of cleanliness and compliance to the hand hygiene policy

Embed a culture of IPC as “everyone’s business”

Ensure that all staff have received / attended IPC training

Challenge poor practice and raise awareness with the IPCT

Implement the IPC policy and associated Practice Guidance Notes

Ensure IPC risk assessments are undertaken in relevant clinical areas

Support staff to attend IPC link worker meetings / study day

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Take appropriate action following receipt of risk assessments and audit results

Monitor the implementation of standards relating to cleanliness in patient areas

Ensure when commissioning and planning services and / or equipment that any developments take IPC issues into account

3.9 Medical Staff

Are expected to implement the IPC policy and associated PGNs to ensure the safety of patients and staff.

Should discuss IPC as part of appraisal by all staff with clinical responsibilities.

Ensure any infection incidents are treated appropriately in accordance with the antimicrobial prescribing guidance

3.10 Ward Managers

Actively encourage compliance with the Policy and associated PGNs

Act as ‘role models’ of good hand hygiene practice and encourage good compliance by example

Ensure that standards relating to cleanliness are implemented in patient areas

Ensure clinical staff undertake IPC training in accordance with CNTW(HR)01 – Induction Policy and Practice Guidance Notes I-PGN-01 to I-PGN-05

Challenge poor practice and discuss with the IPC matron where significant risks have been identified

Ensure timely reporting of infections through the Safeguard report system

Include IPC as an objective in their Personal Development Plans

Support staff to attend IPC link worker meetings / study day

Ensure wards, including near patient environment, is clutter-free, to allow environment to be cleaned effectively

3.11 Estates / Capital Projects and Facilities

The Trust will ensure buildings are fit for purpose, clean and well maintained to NHS standards. Infection Control advice will be sought regarding new buildings, refurbishment projects including equipment, furniture and fittings.

Develop strategies for the maintenance of cleanliness throughout the Trust and related properties

Ensure representation at the IPCC

Provide assurance to the IPCC that all Facilities procedures are reviewed in order to ensure effectiveness

Ensure compliance to the Hygiene Code, Essential Steps, Saving Lives, The Matrons Charter, PLACE and national guidance

Ensure that the IPC Committee is made aware of any significant risks in relation to facilities in particular those which may impact on water hygiene and water quality

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3.12 All staff

Understand and apply the principles of Infection Prevention and Control as set out in this policy and associated PGNs

Maintain competence, skills and knowledge in IPC through attendance at training

Communicate the IPC practices to be taken by colleagues, those being cared for, relatives and visitors without breaching confidentiality

Have up to date occupational immunisations / health checks / clearance requirements as appropriate

Report to line managers and document any equipment or facilities incidents that may result in transmission of infection e.g. sharps / exposure incidents, cleanliness failures or incidents

Must not provide care while at risk of potentially transmitting infectious agents to others. If in any doubt staff must consult with their line manager, the IPCT or the Occupational Health provider

Contact the IPCT if there is a suspected outbreak

Liaise with IPCT when purchasing new equipment to ensure adequate cleaning and disinfection is taken into consideration

3.13 Occupational Health Provider

OHP Services are currently provided to all employees of CNTW by Team Prevent. It is the responsibility of the OHP to:

Develop policies and procedures to be delivered across CNTW

Provide advice on Occupational Health standards to all CNTW employees

Support the delivery of immunisation and vaccination services for all CNTW staff

Receive and support referrals of ill-health, sickness management, return to work, fitness to practice and utilise the teams’ experience of complex health

Have representation at the IPCC 4. Assurance Framework

The Trust’s Assurance framework for the provision of Infection Prevention and Control is designed to build upon the systems and structures that already exist to maintain best practice and ensure high standards of IPC. This framework provides the Trust with the necessary monitoring and reporting systems to enable the standards to be maintained.

Will be delivered through:

An annual report to the Board of Directors, published on the Trust intranet and available to the public

An annual work plan

A report to Trust wide Quality and Performance Committee

Six monthly reports to Locality Care Groups Quality Standards meetings

IPC Committee quarterly meeting

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Surveillance of infections across the Trust

Risk assessment programme of all inpatient clinical areas and community areas with treatment rooms

Root Cause Analysis and post infection review on all mandatory HCAI, this includes Clostridium difficile infection and MRSA bacteraemia reported through the Healthcare Acquired Infection Reduction Partnership North of Tyne and Sunderland and South Tyneside Clinical Commissioning Group for HCAI s

5. Training

All staff will receive Infection Prevention and Control training at induction. IPC training will be provided as part of an ongoing education programme, registers will be held by the training department and reported on individual dashboards

6. Definition of Terms

CE Chief Executive of CNTW DIPC Director of Infection Prevention and Control DoN Executive Director of Nursing and Chief Operating Officer of CNTW HCAI Healthcare Associated Infections IPC Infection Prevention and Control IPCC Infection Prevention and Control Committee IPCT Infection Prevention and Control Team NHS National Health Service CNTW Cumbria Northumberland, Tyne and Wear NHS Foundation Trust SLAs Service Level Agreements

7. Identification of Stakeholders

Any people, groups or organisations that may require involvement or consulted with; e.g. service users and carers, local authorities

North Locality Care Group

Central Locality Care Group

South Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

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8. Implementation

This policy has been amended with only minor changes and will be embedded immediately with training required delivered every three years. If any of the Practice Guidance Notes require significant change the training needs will be addressed as part of that process.

9. Equality and Diversity

In conjunction with the Trust’s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. (See Appendix A)

10. Fair Blame

The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

11. Fraud, Bribery and Corruption

In accordance with the Trust’s CNTW(O)23 – Fraud, Bribery and Corruption Policy, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

12. References

Department of Health (2003). Winning Ways: Working Together to Reduce Healthcare Associated Infection in England. Available at: https://www.gov.uk/government/organisations/department-of-health-and-social-care

Department of Health (2000). Getting Ahead of the Curve .A strategy for combating infectious diseases (including other aspects of health protection). Available at: https://www.gov.uk/government/organisations/department-of-health-and-social-care

NHS Estates; Department of Health (2004). A Matron’s Charter: An Action Plan for Cleaner Hospitals. Available at: https://www.gov.uk/government/organisations/department-of-health-and-social-care

Department of Health (2006). Essential steps to safe, clean care: reducing healthcare-associated infections. Available at:

https://www.gov.uk/government/organisations/department-of-health-and-social-care






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Public Health England (2015). Antimicrobial Stewardship: Start Smart-Then Focus. Antimicrobial Stewardship. Available at: https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus.

Department of Health Guidance (2015). The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance. Available at: https://www.gov.uk/government/organisations/department-of-health-and-social-care

National Institute for Health and Care Excellence Guidance (2014). Infection Prevention and Control. NICE Quality Standard 61. Available at: https://www.nice.org.uk/guidance/qs61

Loveday, H.P., Wilson J.A., Pratt, R.J. et al., (2014). Epic3 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England. Journal of Hospital Infections. Available at: https://improvement.nhs.uk/resources/epic3-guidelines-preventing-healthcare-associated-infections/



https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus

https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus



https://www.nice.org.uk/guidance/qs61

https://improvement.nhs.uk/resources/epic3-guidelines-preventing-healthcare-associated-infections/

https://improvement.nhs.uk/resources/epic3-guidelines-preventing-healthcare-associated-infections/

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Directorate

Christopher Rowlands Nov18 Nov21 Trust wide

Policy to be analysed Is this policy new or existing?

Infection Prevention and Control Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

The Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (CNTW Trust / the Trust) are committed to the prevention and control of infection amongst patients, staff and visitors throughout the organisation. In order to achieve this, the Trust will put in place a clinical and managerial infrastructure to support the prevention and control of infection that accords with national and local guidance and conforms to current best practice in the area. The Trust will ensure that this infrastructure is supported by the resources required to meet these objectives. The Trust recognises that infection prevention and control cannot be delivered without the involvement and commitment of all staff, regardless of role. Therefore all staff will accept personal responsibility for delivering effective infection prevention and control supported by adequate specialist knowledge where appropriate.

The Corporate Decision Team

The Trust wide Safer Care Group

The Trust wide Integrated Emergency Management Committee and subgroups

The Trust wide Health and Safety Committee

Other groups as appropriate

Who will be affected? e.g. staff, service users, carers, wider public etc

Staff / Service users

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability N/A

Sex N/A

Race N/A

Age N/A

Gender reassignment

(including transgender)

N/A

Sexual orientation. N/A

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Religion or belief N/A

Marriage and Civil Partnership

N/A

Pregnancy and maternity N/A

Carers N/A

Other identified groups N/A

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Yes, through the policy review process

How have you engaged stakeholders in testing the policy or programme proposals?

Yes, through the policy review process

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

policy review process

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

No negative impact

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

N/A

Advance equality of opportunity N/A

Promote good relations between groups N/A

What is the overall impact? No negative impact

Addressing the impact on equalities No negative impact

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? If yes, has a Full Impact Assessment been recommended? If not, why not? Manager’s signature: Chris Rowlands Date: November 2018

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Appendix B

Communication and Training Check list for policies

Key Questions for the accountable committees designing, reviewing or

agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Existing Policy -

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

To ensure all staff are familiar with the principles and practise of Infection Prevention and Control, including effective hand hygiene practice

Are the awareness / training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need e.g. National Guidance, CQC, NHS Resolutions etc.

Please identify the risks if training does not occur.

To conform to the Health Act 2006.

To train all permanent staff in hand hygiene NHS Resolutions standard 4.6.

To train staff in the process of management of an inoculation incident as specified in NHS Resolutions standard 4.7

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

All staff (see matrix)

Is there a staff group that should be prioritised for this training / awareness?

All staff

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy

IPC training is delivered by eLearning. Hand hygiene competency training is delivered by the IPC matron to the IPC link worker to disseminate across the clinical area.

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Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

Training Needs Analysis

Staff/Professional Group Type of training

Duration of

Training

Frequency of Training

All CNTW staff e-learning 3 yearly

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Appendix C Monitoring Tool

CNTW(C)23 – Infection, Prevention and Control Policy - Monitoring Framework

Auditable Standard / Key Performance Indicators

Frequency / Method / Person Responsible

Where Results and Any Associate Action Plan Will Be Reported To, Implemented and Monitored; (this will usually be via the relevant Governance Group).

1 The Board of Directors review IPC arrangements annually by receiving the IPC annual report

DIPC report annually. Trust Board meeting

2 There is representation on the IPC committee from all locality groups; this is monitored annually

DIPC report annually Trust Board meeting

3 The Trust Q&P committee receive a 6 monthly report from the DIPC

DIPC report annually Trust wide Q&P

4 IPC training is delivered by an e-learning module 3 yearly to all staff. This includes hand hygiene training and inoculation injuries training.

Delivered by E learning. This is centrally held by training.

Locality Groups

5 Major updates to PGNs are circulated to the full membership of the IPCC. This includes external staff such as a Microbiologist from the acute Trust and staff from Public Health England

As required Trust wide Q & P

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1 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust Appendix 1 Training and Risk Assesment CNTW(C)23 – Infection, Prevention and Control Policy – V06.1 – Oct 19

Appendix 1 Infection, Prevention and Control (IPC) Practice Guidance Notes

Document

Number

Document Name

Information from training or risk assessment

Training Risk Assessment

IPC-PGN-01 Access to IPC Advice x

IPC-PGN-02.1 Standard Precautions x

IPC-PGN-03.1 Safe use and disposal of sharps x

IPC-PGN-04.1 Hand Hygiene and use of alcohol rub

x

IPC-PGN-05 Reporting and Notification of Infectious Diseases

x

IPC-PGN-06 Outbreak Management - Major Incidents

x

IPC-PGN-08 Isolation of infected patients in hospital

x

IPC-PGN-09 Precautions to be taken after death of infected person (known or suspected)

x

IPC-PGN-10 Disinfection and Decontamination Practice

x

IPC-PGN-12 Management of used hospital laundry

x

IPC-PGN-13 Lice, Fleas and Scabies Prevention

x

IPC-PGN-14.1 IPC Considerations in the purchase and use of equipment - Water Coolers and Ice making machines

x

IPC-PGN-15 Antimicrobial Prescribing Guidance

x

IPC-PGN-17 Transferring patients with known or suspected infectious disease

x

IPC-PGN-21 Management of MRSA in Hospitals

x

IPC-PGN-22 Management of Clostridium Difficile in hospitals

x

IPC-PGN-22.3 Management of deceased patients

x

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2 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust Appendix 1 Training and Risk Assesment CNTW(C)23 – Infection, Prevention and Control Policy – V06.1 – Oct 19

Document Number

Document Name

Information from training or risk assessment

Training Risk Assessment

IPC-PGN-23 Immediate management of Meningococcal Disease

x

IPC-PGN-24 Management of Parvovirus B19 in healthcare settings

x

IPC-PGN-26 Guidance for the management of patients with a Flu-like illness

x

IPC-PGN-27.1 Legionella Management x

IPC-PGN-27.2 Control of Legionella and Legionnaires Disease – preventing accumulation of stagnant water

x

IPC-PGN-29 Animals in Health Care x

Please note all the topics are covered in training

Documents

Document Title…3 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)23 – Infection, Prevention and Control Policy – V06.1 Oct 19 PGN No: Intranet Links to PGN