DECONTAMINATION STRATEGY

Responsible Directorate: Public Health Date Approved: 9 April 2008 Committee: Governance Committee Signature of Accountable Director: Print Name: Dr Judith Hooper

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Version Control

Document Title Decontamination Strategy

Document number

Author Jane O’Donnell

Terry Service

Contributors

Version 1

Date of Production April 2008

Review date March 2010

Post-holder responsible for revision

Jane O’Donnell

Terry Service

Primary Circulation List

Web address

Restrictions

Standard for Better Health Map

Domain

1, Safety

Core/Development Standard Reference

C4c

Performance Indicators 1. Compliant decontamination process to reduce incidence of healthcare associated infections.

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Contents

Section Page

1 Policy Statement 3

2 Introduction 3

3 Associated Policies and Procedures 3

4 Aims and Objectives 3

5 Scope of the Policy/Procedure 3-4

6 Accountabilities & Responsibilities 4

7 Infection Control Committee 4

8 Commissioning 4

9 Information 4-5

10 Strategic intention 5

11 Future Planning 5

12 Next Steps 5

13 Equality Impact Assessment 5-6

14 Training Needs Analysis 6

15 Audit 6

16 Risk Management 6

17 Performance indicators 6

18 References 7

Appendix 1 – 5 8-19

Appendices

1 Definitions - Decontamination 8

2 National Decontamination Programme Standards 9-10

3 Training Needs Analysis 11-15

4 Action Plan 16-18

5 Equality Impact Assessment Tool 19

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1. Policy Statement

Kirklees PCT is committed to implementing National and European policy and guidance on decontamination. To ensure safe systems of work and to reduce the transmission of health care associated infection, it is essential that decontamination of equipment is in accordance with legislation including the Health Act 2006.

2. Introduction

The national decontamination strategy for modernising the provision of decontamination services – “National Standards, Local Delivery” was formally launched by the Department of Health in 2003.

Improving and sustaining re-usable medical device decontamination services forms an important component of the Chief Medical Officer’s strategy to combat Healthcare Associated Infection (HCAI) and is included in the reports ‘Winning Ways’ and ‘Getting Ahead Of The Curve’.

Healthcare organisations are required by the Health Act 2006 Code of Practice to provide a safe decontamination service that generates a clean and sterile product and is embedded as part of the Service culture in support of successful clinical outcomes and the associated wellbeing of patients and staff.

As of 31 March 2007, all healthcare organisations undertaking reprocessing of surgical instruments are judged by the same standards regardless of whether they are managed by the NHS, independent, or private sector.

The duty of care of all patients and staff crosses boundaries into all sectors of healthcare services and the risk of encountering pathogens e.g. MRSA, C difficile infections which may lead to Healthcare Associated Infection (HCAI), exists in Primary care as well as the Secondary and Tertiary care sectors. General Medical and Dental Services and other healthcare service providers will need to have in place modern services, and where relevant facilities that ensure decontamination is achieved in compliance with current DH Policy such that the quality and safety of the reprocessed or single use products is equal across all sectors.

3. Associated Policies and Procedures

This strategy should be read in accordance with the following PCT policies:

• Infection Control Policy • Health and Safety Policies • Incident reporting Policy • Decontamination Policy • Medical Devices Policy • Management of MRSA Bacteraemias

4. Aims and Objectives

The purpose of this document is to set out the strategic direction for decontamination services that Kirklees PCT will adopt in order to comply with the national decontamination strategy and European legislation.

This strategy outlines the current and future requirements for decontamination services, proposed service configurations and key milestones to be achieved in the PCT.

5. Scope of the Policy/Procedure

This strategy must be followed by all PCT employees and staff on temporary or honorary contracts as well as pool staff and students. The strategy should be considered as a key component in the

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management of contracts regarding all independent contractors and service providers who are required by law to ensure that they also comply with appropriate legislation.

6. Accountabilities & Responsibilities

The Chief Executive (CE) is accountable for ensuring that effective arrangements for decontamination of re-usable medical devices are in place within the PCT.

The Director of Infection Prevention and Control (DIPC) has responsibility to give assurance to the board and to have direct accountability for the decontamination of medical devices in the PCT.

The infection control team will:

• Ensure the policy on decontamination is reviewed as required and work with Heads of Service to implement necessary changes in practice.

• Take a key role in investigating untoward occurrences related to decontamination and managing associated hazards.

• Act as a link between the PCT and specialist agencies and networks. • Act as a resource for the purchase and monitoring of equipment.

All directors must ensure that the appropriate resources are made available to support effective decontamination within their sphere of responsibility and that systems process and policy is in place.

Heads of Service are responsible for ensuring that the strategy and policy on decontamination of reusable medical devices are brought to the attention of staff and observed by them. Heads of Service must make provision such that every member of staff has a clear understanding of the content and its application to the health care environment.

7. Infection Control Committee

Kirklees Infection Control Committee is responsible for the implementation of the decontamination strategy and reports through the Governance Committee.

8. Commissioning

The PCT accepts the need to involve decontamination principles at all stages of new practice development, including environment, building, competence of staff, and new service planning. The PCT will apply a risk based assessment approach to decontamination, to ensure risk avoidance in purchasing and commissioning facilities, equipment and services.

The establishment and assessment under relevant Healthcare Standards is seen as key to ensuring effective and compliant decontamination services. As part of the empowerment agenda in ‘shifting the balance of power’, the responsibility for maintaining Standards is established with Commissioners, and other Service providers.

9. Information

The strategy provides an overview of key principles and elements of decontamination and identifies how Kirklees PCT will meet current and future demands for quality standards, by minimising risk and integrating into core business the planning and delivery of effective measures for decontamination.

The strategy enables the PCTs to carry out the statutory duties imposed upon it by law, and mandatory duties required by the Department of Health in respect of decontamination.

The Regulatory responsibility for Healthcare Standards is vested with the Healthcare Commission, with the decontamination of reusable medical devices being included in their assessment programme from April 2007. The decontamination standard in Standards for Better Health for the NHS and alternatively

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for the Independent sector, National Minimum Standards equally applies.

Both of these require decontamination to be responsibly carried out in facilities, which accord to guidance issued, by MHRA and the MDD 93/42/EEC. NHS Litigation Authority risk management standards provide assurance to the organisation other inspecting bodies, stakeholders including patients.

The strategy establishes a vision for the development and review of policy to deliver effective decontamination, both within directly managed services and with independent contractors, in the interests of patients, staff and visitors’ safety.

The strategy identifies priorities in the changing healthcare environment, setting out a framework for action to ensure that principles and practice of decontamination are integrated into all service development and reducing economic risk.

Implementing this strategy will achieve compliance with the NHS Standards for Better Health.

The National Decontamination Strategy states that “all health care systems in the NHS need to have access to decontamination facilities which, comply with the highest current technical standards, and have in place plans to anticipate changes in demand and react to improvements in technology and are subject to rigorous inspection and registration regimes”.

A full list of the standards can be found in ‘Appendix 1’.

Effective decontamination requires the implementation of a number of processes, from purchasing instruments through to effective washing and disinfection, to sterilisation, delivery and use and ultimate disposal. To be effective, it requires standards to be met for all elements of the life cycle.

10. Strategic intention

Kirklees PCT are committed to protecting patients and staff by identifying and minimising risks. It is Kirklees PCTs intention to put in place systems and processes to ensure compliance with current legislation, national guidance and best practice.

The PCT will demonstrate that there are systems in place to fulfil monitoring requirements and to reassure patients, staff and the general public about quality and safety of decontamination of medical devices.

11. Future Planning

A key component in the strategy will be the consideration of the methodology used to decontaminate in Community premises which in turn will have an effect how investment in premises e.g. room segregation of clean/dirty areas as detailed by NHS Estates. The decisions made regarding decontamination will further impact on capital investment e.g. instrumentation purchase to enable central reprocessing.

12. Next Steps

A detailed action plan attached which sets out steps that will be taken to ensure that Kirklees PCT complies with the national decontamination strategy. This will be reviewed by Kirklees Infection Control Committee.

Reviews of service provision will be required for all new buildings and service delivery.

13. Equality Impact Assessment

All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.” This

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obligation has been increased to include equality and human rights with regard to disability age and gender. The PCT aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others.

In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This strategy was found to be compliant with this philosophy.

14. Training Needs Analysis

The PCT is committed to the training and continuing development of all staff including independent contractors on all relevant issues surrounding the decontamination of medical devices.

All induction programmes and infection control mandatory training will include decontamination of medical devices.

15. Audit

Mechanisms will be in place to ensure that all PCT provider and commissioned services, will have an infection control premises audit conducted on annual basis or when service redesign takes place; this will be conducted by the Infection Control team. This will ensure that all services are implementing the National Decontamination Strategy.

16. Risk Management

The reporting of incidents or near misses involving decontamination of medical devices is an integral part of the Kirklees Risk Management process. This will be strongly encouraged with a proactive, organisation-wide approach and clear systems established for monitoring and feedback. All incidents will be reported via the PCT incident reporting mechanism.

17. Performance indicators

The PCT will have key indicators for the monitoring of the decontamination of medical devices and these indicators will be included in all PCT performance processes including the Assurance Framework. The key indicators are Audit findings from PCT and Commissioned services, internal and external evaluations, complaints, Incident reports, reports on equipment failure, reports and information from other services and trusts, healthcare associated infections due to inadequate decontamination related to completed Root Cause Analysis.

The Infection Control Committee is responsible for ensuring that annual audits are planned and completed to review decontamination systems and processes and that these are reported and acted upon. The annual audits are reported to the Governance Committee. The Director of Infection, Prevention and Control is the accountable Director who will ensure that these audits are completed.

The audits will be completed by the infection control team who will follow a standard template tool and a planned programme to ensure that all results can be measured against a standard. The frequency of the audits will be on a rolling basis but subject to a planned audit programme agreed by the infection control committee.

Incident reports and MRSA RCA reports will be reviewed and actioned by both the infection control committee and the Risk Management Operational Group to identify and manage risk trends. The responsibility for managing these incidents is with the Assistant Director of Infection Control and the Assistant Director of Corporate Services and Risk Management.

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18. References

1. Winning Ways: Working Together to Reduce Healthcare Associated Infection in England, Chief Medical Officer, 2003

www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPAmpGBrowableDocument/fs/en?CONTENT ID=4095070&chk=J9Gyqw

2. Getting ahead of the Curve: A Strategy for Combating Infectious Diseases, Department of Health, 2002

www.dh.gov.uk/Consultations/ClosedConsultations/ClosedConsultationsArticle/fs/en?CONTENT ID=4016942&chk=092Kh4

3. The Health Act 2006. Code of Practice for the Prevention and Control of Health Care Associated Infections. Department of Health.

www.dh.gov.uk/assetRoot/04/13/93/37/04139337.pdf

4. Professional Letter (PL) Decontamination of Surgical Instruments (CMO, Department of Health Feb 2007)

www.dh.gov.uk/PublicationsAndStatistics/LettersAndCirculars/ProfessionalLetters/ChiefMedicalOfficerLetters/fs/en

5. HSC 2000/032: Decontamination of Medical Devices, Department of Health, 2000

www.dh/gov.uk/PublicationsAndStatistics/LettersAndCirculars/HealthServiceCirculars/HealthServiceCirculars/Article/fs/en?CONTENT ID=4002990&chk=sHEhLb

6. The Decontamination of Surgical Instruments in the NHS in England – Update report – “A Step Change.” Department of Health (June 2005) www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT ID=4113543&chk=lclkSf

7. Shifting the Balance of Power the next steps. Securing Delivery – Human Resources Framework, Department of Health, January 2002

www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPAmpGBrowsableDocument/fs/en?CONTENT ID=4099025&chk=H2U0lr

8. Medical Devices Directive 93/42 EC, (Annex 1 Essential requirements) EU Council 1995

www.mhra.gov.uk/home/idcplg?IdcService=SS GET PAGE&NODEId=175

9. National Decontamination Project. A process for commercial involvement in improving NHS Decontamination. NHS Estates June 2003.

www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4024422&chk=5M6qI0

10. About the Healthcare Commission. Inspecting, Informing, Improving. Commission for Healthcare Audit and inspection 2005.

www.healthcarecommission.org.uk/homepage.cfm

10. Standards for Better Health. Legislative basis Section 46 of the Health and Social care (Community Health and Standards) Act 2003.

www.opsi.gov.uk/ACTS/acts2003/20030043.htm

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Appendix 1 Definitions

Decontamination

This strategy recognises the National Decontamination Strategy definition of decontamination. The definition of decontamination is defined as:

“The combination of processes (including cleaning, disinfection and sterilisation) used to make re-useable surgical instruments safe for further use on patients and handling by staff. This is primarily aimed at those reusable instruments that are invasive by intent or could be invasive inadvertently”.

Medical Device

This strategy recognises the Medical Devices Directive definition of Medical Devices. The definition of a medical device is defined as:

“Medical Device means any instrument, apparatus, appliance, material or other article, whether used alone or in combination, including the software necessary for its proper application intended by the manufacturer to be used for human beings for the purpose of: • Diagnosis, prevention, monitoring, treatment, treatment or alleviation of disease. • Diagnosis, monitoring, treatment, alleviation of or compensation for an injury or handicap. • Investigation, replacement or modification of the anatomy or physiological process. • Control of conception.

And which does not achieve its principle intended action in or on the human body by pharmacological; immunological or metabolic means, but which may be assisted in its function by such means”.

Infection Control

Infection control is the use of evidence based practice, training and education, policies and procedures to prevent or minimise the risk of cross infection, through a managed environment, which minimises the risk of infection to patients, staff and visitors.

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Appendix 2

National Decontamination Programme Standards

A. Every organisation must have a Nominated Lead who, irrespective of other activities, is responsible for decontamination in accordance with HSC2000/032 (Decontamination of Surgical Instruments). The line management relationship should be to a “senior responsible person” at executive director level within the organisation.

B. That there should be a common standard applied to decontamination units throughout the NHS, regardless

of whether or not a unit falls within the scope of the Medical Devices Directive. The criteria of the national decontamination registration scheme with regard to the Sterile Services Departments (SSDs) should therefore meet the applicable Essential Requirements of the Medical Devices Directive (MDD), 93/42/EEC.

C. All decontamination activities carried out within NHS Trusts are to comply with these requirements and this

should also be extended to other organisations that use reprocessable instruments for invasive human procedures.

D. All facilities reprocessing surgical instruments to have tracking and traceability systems. E. The Trust is to have submitted their assessments and action plans with regard to the relevant Controls

Assurance standards associated with decontamination of reusable medical devices. F. The Trust will have established and documented robust and comprehensive policies and procedures with

regard to decontamination issues. G. Unless original equipment manufacturer’s instructions indicate otherwise, manual cleaning of those

instruments deemed to be in the high-risk category must be phased out immediately. H. All instruments that are manually cleaned in the clinical setting, i.e. locally reprocessed, should be

undertaken in accordance with the Department of Health protocol and under the control of the Sterile Services Manager or nominated person. This may necessitate their being reprocessed by a central facility.

I. Healthcare facilities are to develop an organisation-wide strategy to centrally reprocess any items currently

still reprocessed locally (e.g. in clinical units), thereby ensuring that all reprocessing is transferred to central facilities with the possible exception of flexible endoscopes. This includes dropped instruments, instruments currently in short supply and surgeon’s personal instruments.

J. Where possible all instruments should be processed through automated processes. The only exception

being where the instructions supplied by the manufacturer of the device states that the product is incompatible with automated processes. These instruments should be cleaned in accordance with the Protocol for Local Decontamination of Surgical Instruments and be under the control of the nominated person.

K. Wash processes, regardless of whether they are automated or manual, are to be validated. L. Difficult to clean devices are to be identified. A risk assessment of these items should be conducted and a

strategy developed to phase them out using an appropriate solution. The strategy should identify timescales for implementation.

M. Equipment acquired for the purpose of decontamination should be specified, installed and commissioned

according to recognised standards.

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N. All key equipment and plants used for the decontamination of reprocessable medical devices is to be subjected to planned preventative maintenance in accordance with an appropriate standard.

O. Where applicable, all key equipment used for the decontamination of reprocess able medical devices (e.g.

washer disinfectors and sterilizers) is to be subjected to periodic testing and validation to a recognised standard. (This should be in accordance with an established schedule). Results of tests and validations must demonstrate satisfactory results for all equipment that is available for use.

P. Equipment tests and validations are to be independently verified by a suitable qualified and experienced

person (e.g. Authorised Person). Q. All facilities should, as a minimum, comply with the principles contained within Health Building Note HBN

13 to ensure that the built environment does not compromise the process of decontamination. This includes the need for ‘clean’ and ‘dirty’ equipment and processes to be segregated.

R. Inspection, assembly and packing of cleaned and disinfected medical devices prior to sterilization should

take place in a controlled environment to prevent recontamination of clean product. S. The controlled environment(s) in which clean product is inspected, assembled and packed is to be

monitored and validated. T. Cleaning and decontamination should not be carried out in patient areas for Health and Safety reasons.

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Appendix 3 Training Needs Analysis

Decontamination

It is a legal requirement that all staff receive training on decontamination as part of their infection control training. Infection control training (incorporating decontamination) is to be undertaken annually. This training forms part of the Trust Mandatory training programme and training courses are held at regular intervals throughout each year, organised through the Trust Training Department.

Who needs to attend? How can the training be delivered?

All Clinical staff Delivered by infection

control team

Delivered by infection control

team All non-Clinical staff, including

temporary, bank and contractor

staff.

All new employees,

including bank, temporary and contractor staff.

Level 3 In-depth for clinical staff

Level 2 40-minute training course

40 minute training presentation for non-clinical staff – part of the

Trust Mandatory training Programme to be undertaken

annually.

Delivered by infection control

team Level 1 Basic Awareness

30-minute session for all new starters provided within the Trust Induction Programme for all

new starters.

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Who is responsible for delivering this training: Infection Control staff (Assistant Director of Infection Control) Name of current Post-holder(s) Jane O’Donnell Training needs assessment

It is estimated that there are approximately 1223 staff (as at 11.02.08) employed by the Trust who require this training annually. This is broken down as follows:

Level 3 – Clinical

All clinical staff including District Nurses, Community Nurses, HCAs, AHPs, Health Visitors, School Nurses, Nursery Nurses and Dental Staff. Clinical staff total = 664.

Level 2 – Non Clinical

All non-clinical staff including administration, management and support. Non-clinical staff total = 559 (as at 11.02.08).

Level 1 - Induction - Basic awareness

All new employees to the Trust.

The learning aims and objectives for the 3 levels of training are as follows:

Overall Aim: That the staff and Trust operate a safe environment in compliance with regulations and guidance and that the management of infection control is inherent in all systems and processes.

Objectives for the learner

Level 1 – Induction all new staff

Basic understanding and knowledge of Infection control.

Level 2 – non-clinical staff

This course explains roles and responsibilities in infection prevention, the importance of personal and environmental hygiene, how to care for your own health, and how the correct use of personal protective equipment helps to maintain a safe environment for patients and staff.

Level 3 – Clinical staff

Standard Precautions, outbreaks and reporting of incidents, management of high risk needlestick injuries, decontamination, safe disposal of waste, use of sterile equipment, use of cleaning equipment and chemicals, blood borne viruses, MRSA, Scabies, fleas. Reducing the risk of infection.

.

Levels 1 and 2 - Links to KSF Profile/Outlines

Core: Level: Examples of KSF indicators that this course/programme may contribute to

1. Communication

3 – Develop and maintain communication with people about difficulty matters and/or in difficult situations.

e) communicates in a manner that is consistent with relevant legislation, policies and procedures

2. Personal and people development

2 – Develop own knowledge and skills and provide information to others to help their development

b) takes an active part in the development review of own work against the KSF outline for the post with their reviewer and suggests areas for learning and development in the coming year.

3. Health, Safety & Security

2 – Monitor and maintain health, safety and security of self and others

a) identifies and assesses the potential risks involved in work activities and processes for self and others. b) identifies how best to manage the risks. c) undertakes work activities consistent with: - legislation, policies and procedures - the assessment and management of risk f) supports others in maintaining health, safety and security

4. Service improvement

2 – Contribute to the improvement of services.

f) constructively identifies issues with direction, policies and strategies in the interests of users and the public

5. Quality 2 – Maintain quality in own work and encourage others to do so

a) acts consistently with legislation, policies, procedures and other quality approaches and encourages others to do so.

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Specific Dimension:

Level: Examples of KSF indicators that this course/programme may contribute to

HWB4 2 c) effectively prepares for and undertakes activities to enable people to meet their ongoing needs consistent with the care plan, legislation, policies and procedures.

IK1 1 inputs data and information accurately and completely: using the correct formats, consistent with legislation, policies and procedures.

Level 3 – Links to KSF Profile/Outlines

Core: Level: Examples of KSF indicators that this course/programme may contribute to

1. Communication3 – Develop and maintain communication with people about difficulty matters and/or in difficult situations.

e) communicates in a manner that is consistent with relevant legislation, policies and procedures

2. Personal and people development

2– Develop own knowledge and skills and provide information to others to help their development

b) takes an active part in the development review of own work against the KSF outline for the post with their reviewer and suggests areas for learning and development in the coming year.

3. Health, Safety & Security

2 – Monitor and maintain health, safety and security of self and others

a) identifies and assesses the potential risks involved in work activities and processes for self and others. b) identifies how best to manage the risks. c) undertakes work activities consistent with: - legislation, policies and procedures - the assessment and management of risk F) supports others in maintaining health, safety and security

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4.Service improvement

2 – Contribute to the improvement of services.

f) constructively identifies issues with direction, policies and strategies in the interests of users and the public

5.Quality 2 – Maintain quality in own work and encourage others to do so

a) acts consistently with legislation, policies, procedures and other quality approaches and encourages others to do so

6.Equality and Diversity

2 – Support equality and value diversity.

a) recognises the importance of people’s rights and acts in accordance with legislation, policies, procedures.

Dimension: Level: Examples of KSF indicators that this course/programme may contribute to

HWB3 3 Prepares for and undertakes the protective interventions that s/he is responsible for as part of the protection plan in a manner that

- is consistent with evidence-based practice, legislation, policies and procedures.

- is appropriate to the people concerned.

- is appropriate for the setting.

- Maintains health and safety.

HWB4 2 c) effectively prepares for and undertakes activities to enable people to meet their ongoing needs consistent with the care plan, legislation, policies and procedures.

IK1 1 a) inputs data and information accurately and completely: using the correct formats, consistent with legislation, policies and procedures.

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Action Plan

Subject Decontamination Strategy

Appendix 4

Date Started 17.12.07

Directorate Public Health

No. Task Action Responsibility Priority Completion date

1 Trust strategy needs to be ratified. Decontamination strategy to go through Trust

Governance process and then implement across the Trust.

Jane O’Donnell 28 Feb 08

2

Effective decontamination requires the implementation of a number of processes, from purchasing instruments through to effective washing and disinfection, to sterilisation, delivery and use and ultimate disposal. To be effective, it requires standards to be met for all elements of the life cycle.

Ensure that decontamination is a key consideration with the purchase of new equipment by ensuring that it is integral with the Trust Medical Devices policy.

Ensure standard policy on decontamination of reusable medical devices is developed and implemented.

Robert Flack

Jane O’Donnell

01 April 08

28 Feb 08

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3

All directors must ensure that the appropriate resources are made available to support effectivedecontamination within their sphere of responsibility and that systems process and policy are in place

Advise Board of their legal responsibilities re infection control via the Board Mandatory training programme.

Jane O’Donnell

Terry Service

09 Jan 08

4

Heads of Service are responsible for ensuring that the strategy and policy on decontamination of re-usable medical devices are brought to the attention of staff and observed by them. Heads of Service must make provision such that every member of staff has a clear understanding of the content and its application to the health care environment.

Policy and strategy needs to be implemented across the Trust and made available on the website.

Launch policy via weekly team talk.

Place documents on website.

Ensure that locality managers advise staff of document availability.

Jane O’Donnell

Peta Wolstencroft

Terry Service

Julie Livesey

31 March 08

31 March 08

31 March 08

5 Kirklees Infection Control Committee is responsible for the implementation of the decontamination strategy and reports through the Governance Committee

ICC to monitor action plan and sign off completed actions.

Jane O’Donnell

17 Dec 2007

onwards

6 All induction programmes and infection control mandatory training will include decontamination of medical devices.

Review Infection control training programme.

Introduce new training programme

Jane O’Donnell

Terry Service

Liz Butterfield

31 March 08

31 March 08

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7 Mechanisms will be in place to ensure that all PCT commissioned services, will have an infection control premises audit conducted on annual basis or when service redesign takes place, this will be conducted by the Infection Control team. This will ensure that all services are implementing the National Decontamination Strategy.

Infection control environmental audit plan to be agreed and implemented.

Review premises design for decontamination and IC requirements.

Jane O’Donnell +ICC

David Henwood.

Ongoing

Ongoing

8 The reporting of incidents or near misses involving decontamination of medical devices is an integral part of the Kirklees Risk Management process. This will be strongly encouraged with a proactive, organisation-wide approach and clear systems established for monitoring and feedback. All incidents will be reported via the PCT incident reporting mechanism.

Policy to be linked to Trust Incident Reporting policy.

IR to be reviewed by Risk Management Operational Group

Jane O’Donnell

Terry Service

28 Feb 08

Ongoing

9 Reviews of service provision will be required for all new buildings and service delivery.

Appraisal option of outsourced services for Podiatry and Community Dental.

Review premises design for decontamination and IC requirements.

Procurement process of sterile and decontamination services which comply with medical devices directive.

Jane O’Donnell

David Henwood.

Jane O’Donnell

Terry Service

Ongoing

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Appendix 5

Equality Impact Assessment Tool

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Insert Name of Policy / Procedure

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

NO

• Race NO

• Ethnic origins (including gypsies and travellers) NO

• Nationality NO

• Gender NO

• Culture NO

• Religion or belief NO

• Sexual orientation including lesbian, gay and bisexual people NO

• Age NO

• Disability - learning disabilities, physical disability, sensory impairment and mental health problems

NO

2. Is there any evidence that some groups are affected differently? NO

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

NO

4. Is the impact of the policy/guidance likely to be negative? NO

5. If so can the impact be avoided? NO

6. What alternatives are there to achieving the policy/guidance without the impact? NO

7. Can we reduce the impact by taking different action? NO

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