Page 1

Infection Control Management Arrangements Policy

Responsible Directorate:

Public Health

Date Approved:

5 May 2010


Governance Committee



Revision Date:

February 2012

Accountable Director:

Dr Judith Hooper



Section 1


Page 3


Associated Policies and Procedures



Aims and Objectives



Scope of the Policy





Accountabilities and Responsibilities Making Contact with the Infection Prevention and Control Team Surveillance data collection and reporting of HCAIs


Outbreak Management



Reporting of Incidents



Equality Impact Assessment



Training Needs Analysis



Monitoring Compliance with this Policy





Definitions Key stakeholders consulted/involved in the development of the document Equality Impact Assessment Tool Sign off sheet regarding dissemination of procedural documents Notifiable Diseases

9 10


Appendices Appendix A Appendix B Appendix C Appendix D Appendix E

6 6

11 12 13


Policy Statement NHS Kirklees is committed to delivering a safe, effective and efficient infection prevention and control service that is fit for purpose and is able to discharge its duties in accordance with The Health and Social Care Act (2008). The policy will establish ownership of infection prevention and control at all levels in the organisation from NHS Kirklees Board to individual clinicians.


Introduction All NHS organisations must ensure that they have effective systems in place to control and prevent healthcare associated infection and communicable diseases. This forms part of its responsibilities to keep patients and staff safe. This is reflected in Government policy:


The Health and Social Care Act (2008): Code of Practice for the NHS on the prevention and control of healthcare associated infection and related guidance (December 2009).

The NHS Operating Framework

Associated Policies and Procedures This policy should be read in accordance with the following NHS Kirklees bodies, procedures and guidance.


Infection prevention and control policies

Management of infections and infectious diseases

Health and safety policies

Incident reporting policy

Risk management / Governance policies

Aims and Objectives ●

To ensure that infection prevention and control is embedded into the culture of NHS Kirklees and that there is ownership at all levels.

To ensure that the organisation is compliant with the Care Quality Commission Standards and the infection prevention and control legislation and NHSLA risk management standards.

To ensure that there is robust governance reporting arrangements and lines of accountability for infection prevention and control.

To ensure that there are clear monitoring and reporting arrangements for all commissioned services.

To ensure compliance with Care Quality Commission Criteria / Health and Social Care Act (2008).



Scope of the Policy This policy must be followed by all NHS Kirklees employees and staff on temporary or honorary contracts as well as bank staff and students. This policy should be considered and included in services that are contracted and commissioned.


Accountabilities and Responsibilities


Chief Executive The Chief Executive is the accountable officer regarding all infection prevention and control arrangements but delegates this responsibility to the NHS Kirklees Director of Infection Prevention and Control.


The Board The Board ensures that the arrangements which NHS Kirklees has in place to prevent and control infection are effective. Systems are implemented to ensure that the Board gains assurance that all risks are being managed. The Board will use the Assurance Framework to achieve this aim.


Director of Infection Prevention and Control (DIPC) The DIPC is responsible for effective infection control throughout the PCT. Responsibilities in practice; tactical and operational action is delegated to the Deputy Director Infection Prevention and Control and for the development and implementation of infection prevention and control policies. The DIPC reports directly to the Chief Executive and the Board. The DIPC has the authority to challenge inappropriate clinical hygiene practice as well as inappropriate antibiotic prescribing decisions. The DIPC assesses the impact of all existing and new infection prevention and control policies and makes recommendations for change / action. The DIPC or designated Deputy is an integral member of NHS Kirklees’ Governance and Patient Safety structures to monitor assurances on managing the risks. The DIPC produces an annual report which will include detail regarding the level of healthcare associated infections within NHS Kirklees and will ensure that this is available in the public domain.


Infection Control Committee The Infection Control Committee will meet quarterly. The Chair of the Infection Control Committee is the Director of Public Health / DIPC or in their absence the Deputy DIPC. The Infection Control Committee reports to the Governance Committee, which reports to the NHS Kirklees Board as part of the formal governance system for the PCT. The Infection Control Committee identifies and prioritises actions required for NHS Kirklees based upon national guidance, Board directives, external reports and internal incident reports, trends and patterns from the risk management reporting system.


The Infection Control Committee approves and monitors the annual infection prevention and control programme and supports the work of the infection prevention and control team. The Infection Control Committee receives the annual infection control report which is then submitted for approval to Governance Committee required by The Health and Social Care Act (2008). 5.5

Infection Prevention and Control Team The Infection Prevention and Control Team develop an annual infection prevention and control programme, with clearly defined objectives approved by the Governance Committee. This will include: ●

Development of key policies and procedures. Implementing and monitoring of the policies and review in collaboration with clinical service leads.

Education and training on infection prevention and control to all clinical and non clinical staff.

Working closely with the clinical governance, risk management, provider and contractor services, to ensure that the risks of healthcare associated infection are identified, assessed and managed appropriately.

Providing timely reports to relevant committees and producing an annual infection prevention and control report.

Reacting in a timely manner to outbreaks / incidents of infection.

Ensuring that root cause analysis investigations are undertaken for all pre-48 hour MRSA bacteraemia cases by the appropriate clinical teams in conjunction with the infection prevention and control team.

Working with NHS Kirklees Estates and Facilities Department to ensure that the environment is fit for purpose, and maintained in order to provide environments for patients, visitors and staff which are safe and clean.

The team consists of a number of key staff who are suitably qualified and directly managed by the Deputy Director of Infection Prevention and Control and lead nurse, Infection Prevention and Control who reports to the DIPC. The team is supported by Consultant Microbiologists through an agreement with Mid Yorkshire Hospital Trust and Calderdale and Huddersfield Foundation Trust. This includes provision of 24 hour advice and support. The Infection Prevention and Control Team will ensure information on infection prevention and control to the public and patients is available. This is communicated to the public and patients via the intranet / internet, and leaflets. The framework for local health protection services agreed with West Yorkshire Health Protection Agency identifies priorities in health protection for Kirklees and provides a context for shared governance and performance management.



Healthcare Professionals Local responsibility for infection prevention and control is not limited to the DIPC and Infection Prevention and Control Team, but to everyone in the organisation; all professional groups, clinical specialities and directorates. The Hygiene Code Duty requires that responsibility for infection prevention and control is reflected in all job descriptions, appraisals and personal development plans. All staff have a mandatory responsibility to undertake infection prevention and control training, to ensure that infection prevention and control policies are effectively implemented in their area of work. Staff are also responsible for reporting infection control incidents and risks to their line manager and / or the Infection Prevention and Control team via the incident reporting system.


Making Contact with the Infection Prevention and Control Team In normal office hours, advice can be sought by contacting the team on 01924 512159, or e-mailing them at Out of office hours, the on-call microbiologist can be contacted via the hospital switchboards: Mid Yorkshire Hospital Trust Calderdale and Huddersfield Foundation Trust


08448118110 01484 342000

Or contact the Public Health on call specialist via the above switchboards. 7.

Surveillance data collection and reporting of HCAIs It is the responsibility of the medical doctor looking after a patient to notify promptly the Health Protection Agency (HPA) of any potential infection control problem, or if a patient is diagnosed as having an infection / infectious disease. Additional information is available in the policy “Management of Infections and Infectious Diseases”. This is a legal requirement. Other surveillance activities undertaken by the Infection Prevention and Control team include the monitoring of MRSA and Clostridium difficile organisms. Such surveillance allows rapid detection of incidents of infection and the development of potential outbreaks of infection. It also allows the timely prescribing of suppression treatment for MRSA and early prescribing of appropriate antibiotics for Clostridium difficile infection if necessary.


Outbreak Management Effective control of any outbreak depends on early recognition and timely intervention. This in turn depends upon active surveillance of infection in both the hospital and community. Infections which need to be recognised and reported promptly include: ●

notifiable disease (Appendix E details the list of notifiable disease)

any infection which carries a significant risk of cross-infection.

In the event of an outbreak / incident, the HPA will support staff within NHS Kirklees to control the problem. Such a situation must be viewed as a priority. Staff, therefore, need to understand the importance of working with the Infection Prevention and Control team, and an incident group will be formed which will assess the resources required. The NHS Kirklees Outbreak Policy identifies steps to be taken in response to an outbreak.



Reporting of Incidents In the event of an outbreak of infection, a “near miss”, or a serious infection control incident, an incident report must be completed. Consideration whether to invoke the “Serious Untoward Incident Procedure” will be made by the Service Manager responsible for the service, or the on-call Director if “out of hours”. The HPA Infection Prevention and Control staff must be notified in order to gain knowledge appropriate to the type of serious untoward incident, and to ensure lessons learned are shared within the Trust.


Equality Impact Assessment This policy has been assessed for the potential adverse impact as set out in Appendix C. The policy has not identified an impact.


Training Needs Analysis The contents of this policy will be highlighted within the infection prevention and control mandatory training sessions.


Monitoring Compliance with this Policy NHS Kirklees will have key indicators to monitor infection prevention and control that will be included in all NHS Kirklees performance processes including the Assurance Framework. The performance indicators will be: ●

PEAT assessment scores for cleanliness.

The percentage of clinical and non-clinical healthcare workers, undertaking annual mandatory infection prevention control training.

All incident reports associated with healthcare associated infections will be reviewed and actioned by the Infection Prevention and Control Team reported to the Infection Control Committee and the Risk Management Operational Group.

Audit findings from Essential Steps to Safe Clean Care to ensure key infection prevention and control practices are being implemented.



References The Health and Social Care Act (2008). Code of Practice for Health and Adult Social Care on the Prevention and Control of Infections and Related Guidance. HMSO London (December 2009). Department of Health 2003 Winning Ways: Working Together to Reduce Healthcare Associated Infection in England, Chief Medical Officer HMSO London Department of Health 2002 Getting Ahead of the Curve, A Strategy for Combating Infectious Diseases. HMSO London Department of Health 2006 Essential Steps to Safe Clean Care. HMSO London National Institute for Clinical Excellence 2003 Prevention of Health Care Associated Infections in Primary and Community Care HMSO London


Appendices A

Definitions 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.


Appendix B Key Stakeholders consulted/involved in the development of the document

Stakeholders name and designation

Infection Prevention and Control Nurses Kirklees Infection Control Committee Governance Committee

Date feedback requested

Detail of feedback received

Date feedback received

Action taken


Appendix C: Equality Impact Assessment Tool

Insert Name of Policy / Procedure Yes/No 1.

Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race • Ethnic origins travellers)




No No

• Nationality


• Gender


• Culture


• Religion or belief


• Sexual orientation including lesbian, gay and bisexual people


• Age

2. 3. 4. 5. 6. 7.

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


Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? Is the impact of the policy/guidance likely to be negative? If so can the impact be avoided? What alternatives are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action?

No No No



Appendix D: Sign off Sheet regarding Dissemination of Procedural Documents To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of Document:

Infection Control Management Arrangements Policy

Lead Director:

Dr Judith Hooper

Date Approved:

Where approved:

Dissemination Lead:

Placed on Website:

Review Date:



Notifiable Diseases The diseases listed below are notifiable by a registered medical practitioner to the Health Protection Agency, Seacroft, Leeds.

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Acute encephalitis Acute infectious hepatitis Acute poliomyelitis Acute viral and bacterial meningitis Anthrax Botulism Brucellosis Cholera Diphtheria Enteric fever (typhoid or paratyphoid fever) Food poisoning Leprosy Malaria Measles Meningococcal septicaemia Mumps Plague Rabies Rubella (German Measles) SARS Smallpox Tetanus Tuberculosis Typhus Viral Haemorrhagic fever Whooping cough Yellow fever

Registered medical practitioners are required to notify the proper office of the local authority in which the patient resides when they have “reasonable grounds for suspecting” that the patient has an infection not included in Schedule 1 which in the view of the registered medical practitioner presents, or could present, significant harm to human health (eg, emerging or new infections).