ANNUAL REPORT OF
INFECTION PREVENTION
AND CONTROL
April 2014 to March 2015
Infection Prevention Control Annual Report 2014/15
CONTENTS
Executive introduction from the Director of Nursing & Operations and
Director of Infection Prevention & Control
Section One: Introduction..................................................................................... 1
Section Two: Who we are, our duties, arrangements and assurance ............. 3
Who we are ............................................................................................................. 3
Our Duties and Arrangements ................................................................................. 3
Assurance and Reporting to the Board .................................................................... 4
Section Three: Position in Relation to Health Care Associated Infections ..... 6
MRSA Bacteraemia Trust Target............................................................................. 6
Actions taken to prevent MRSA bacteraemia .......................................................... 7
MRSA Screening ..................................................................................................... 7
Clostridium difficile Infection (CDI) Targets.............................................................. 8
CDI 30 day mortality rate ....................................................................................... 10
Actions to reduce CDI ............................................................................................ 10
Periods of Increased Incidence ............................................................................. 12
Outbreaks .............................................................................................................. 12
Gastrointestinal Infection ....................................................................................... 12
Influenza Outbreaks .............................................................................................. 14
Glycopeptide-Resistant Enterococci (GRE) also known as Vancomycin-Resistant
Enterococci (VRE) ................................................................................................. 15
Extended Spectrum Beta-Lactamase (ESBL)........................................................ 16
Carbapenemase-producing Enterobacteriaceae (CPE) ........................................ 16
Safe Care Shropshire ............................................................................................ 16
Catheter-associated Urinary Tract Infection (CAUTI) Sub Group .......................... 16
The NHS Trust Development Authority (TDA) visit 14-15 May 2014 ..................... 17
Section Four: Progress against 2014/15 Infection Prevention and Control
Programme........................................................................................................... 19
Criterion 1 – Systems to manage and monitor the prevention and control of
infection. These systems use risk assessments and consider how susceptible
service users are and any risk that their environment and other users may pose to
them. ..................................................................................................................... 19
Criterion 2 - Provide and maintain a clean and appropriate environment in a
managed premises that facilitates the prevention and control of infections ........... 20
Criterion 3 - Provide suitable accurate information on infections to service users
and their visitors .................................................................................................... 24
Criterion 4 - Provide suitable accurate information on infections in a timely fashion
to any person concerned with providing further support or nursing / medical care 24
Criterion 5 - Ensure that people who have or develop an infection are identified
promptly and receive the appropriate treatment and care to reduce the risk of
passing on the infection to other people ................................................................ 25
Criterion 6 - Ensure that all staff and those employed to provide care in all settings
are fully involved in the process of preventing and controlling infection ................ 26
Criterion 7 - Provide or secure adequate isolation facilities ................................... 27
Criterion 8 - Secure adequate access to laboratory support as appropriate .......... 27
Criterion 9 - Have and adhere to policies, designed for the individual's care and
provider organisations that will help to prevent and control infections ................... 27
Medicines Management Report ............................................................................. 28
Infection Prevention Control Annual Report 2014/15
Criterion 10 - Ensure, so far as reasonably practicable, that care workers are free
of and are protected from exposure to infections that can be caught at work and
that all staff are suitably educated in the prevention and control of infection
associated with the provision of health and social care ......................................... 29
Section Five: Hand Hygiene ............................................................................... 38
Hand Washing Assessments ................................................................................. 38
Hand Hygiene Observational Audit ........................................................................ 38
Bare Below the Elbows .......................................................................................... 39
Section Six: 2014/15 Infection Prevention and Control Team Audit
Programme........................................................................................................... 40
Overall Score and Compliance Rating ................................................................... 40
Reporting and Monitoring ...................................................................................... 40
Summary of audit findings and actions taken: ....................................................... 40
Self-audits/checklists ............................................................................................. 40
Section Seven: Looking Forward to 2015/16 .................................................... 42
An Overview of Infection Prevention and Control Programme 2015/16 ................. 42
2015/16 Local Infection Prevention and Control Commissioning Objectives ......... 43
2015/16 Infection Targets ...................................................................................... 43
2015/16 IPC Key Performance Indicator ............................................................... 43
Section Eight: Glossary of Terms ...................................................................... 44
Appendix 1: 2014/15 Community Hospital Audit Programme ................................ 46
Appendix 2: 2014/15 Community Services Audit Programme ............................... 50
Appendix 3: 2014/15 Community Hospital Cleanliness Audit Scores .................... 52
Appendix 4: Analysis of HCAI Audits in Community Hospitals .............................. 55
Appendix 5: 2014/15 Community Hospital Self-Audit Scores ................................ 58
Appendix 6: Infection Prevention and Control Team 2014/15 Audit Programme ... 62
Infection Prevention Control Annual Report 2014/15
Executive introduction from the Director of Nursing & Operations and Director
of Infection Prevention & Control
Dear Staff, Patients, Carers, Service Users and Partners
Welcome to Shropshire Community Health Trust’s Infection Prevention and Control
Annual report which has been developed in collaboration with the Head of Infection
Prevention and Control and the Infection Prevention and Control team.
The purpose of this report is to outline the activities of SCHT relating to infection
prevention and control for the year from April 2014 to March 2015 and explain how
SCHT has arrangements in place to reduce the spread of infections. It also reviews
accountability arrangements, policies and procedures relating to infection prevention
and control, audit, and education necessary in order to support prevention and
control of infection.
Our key achievements were:
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Zero MRSA bacteraemia attributed to SCHT
The set target of no more than three post 72 hour cases of Clostridium
difficile infections was achieved
The set target of 95% MRSA screening compliance was exceeded
Mandatory training including Infection Prevention and Control attended by
95.5% of clinical staff
Positive report by the Head of Infection Prevention and Control at the NHS
Trust Development Authority following their visit in June. Constructive advice
was implemented through service improvement plans. No follow up visit was
required
Looking forward to 2015-2016 the IPC team and all SCHT staff will continue to work
hard and focus on the prevention of all infections.
Steve Gregory
Director of Nursing & Operations and Director of Infection Prevention & Control
Infection Prevention Control Annual Report 2014/15
Section One: Introduction
The purpose of this report to provide assurance to the Board of Directors and the public for
the reporting period 01 April 2014 – 31 March 2015 regarding the Infection Prevention and
Control (IPC) activity including compliance with the Health & Social Care Act 2008: Code of
Practice on the prevention and control of infections and related guidance (commonly known
as The Hygiene Code) and also in relation to National Institute for Health and Clinical
Excellence (NICE) guidance.
This annual report fulfils its statutory requirements under the Health & Social Care Act 2008:
Code of Practice on the prevention and control of infections, which sets out 10 compliance
criteria against which a registered provider will be judged on how it complies with the
registration requirements for cleanliness and infection prevention and control. It sets the
basis of our annual programme which is monitored at the Shropshire Community Health
Trust (SCHT) Infection Prevention and Control bi-monthly meeting. The aim of the Infection
Prevention and Control team is to increase organisational focus and collaborative working so
to ensure continued compliance and quality improvement.
SCHT is registered with the Care Quality Commission (CQC) and declared full compliance
with the ten compliance criteria as detailed in Table 1.
Table 1: The requirements of the Health and Social Care Act (2008)
Compliance
What the registered provider will need to demonstrate
criterion
1
2
3
4
5
6
7
8
9
10
Systems to manage and monitor the prevention and control of
infection. These systems use risk assessments and consider how
susceptible service users are and any risks that their environment
and other users may pose to them
Provide and maintain a clean and appropriate environment in
managed premises that facilitates the prevention and control of
infections
Provide suitable accurate information on infections to service
users and their visitors
Provide suitable accurate information on infections to any person
concerned with providing further support or nursing / medical care
in a timely fashion
Ensure that people who have or develop an infection are identified
promptly and receive the appropriate treatment and care to
reduce the risk of passing on the infection to other people
Ensure that all staff and those employed to provide care in all
settings are fully involved in the process of preventing and
controlling infection
Provide or secure adequate isolation facilities
Secure adequate access to laboratory support as appropriate
Have and adhere to policies, designed for the individual’s care
and provider organisations that will help to prevent and control
infections
Ensure, so far as is reasonably practicable, that care workers are
free of and are protected from exposure to infections that can be
caught at work and that all staff are suitably educated in the
prevention and control of infection associated with the provision of
health and social care
Infection Prevention Control Annual Report 2014/15
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The SCHT Board and ultimately the Chief Executive Officer carries responsibility for infection
prevention and control (IPC) throughout SCHT and is a vital component of Quality and
Safety. The day to day management is delegated to the Director of Infection Prevention and
Control (DIPC). All managers and clinicians ensure that the management of IPC risks is one
of their fundamental duties. Every clinical member of staff demonstrates commitment to
reducing the risk of HCAI through standard infection prevention and control measures. The
IPC team endeavours to provide a comprehensive proactive service, which is responsive to
the needs of staff and public alike, and is committed to the promotion of excellence within
everyday practice of IPC.
The 2014/15 NHS Outcomes Framework included reducing the incidence of Healthcare
Associated Infections (HCAIs), in particular Meticillin Resistant Staphylococcus aureus
(MRSA) bacteraemia and Clostridium difficile infections (CDI) as areas for improvement.
Within Domain 5: Treating and caring for people in a safe environment and protecting them
from avoidable harm of the Outcomes Framework reducing all HCAIs remained a priority.
As reported last year, the extension to the mandatory surveillance to meticillin sensitive
Staphylococcus aureus (MSSA) bacteraemia infections since January 2011 and Escherichia
coli (E.coli) bacteraemia infections since June 2011, together with the meticillin resistant
Staphylococcus aureus (MRSA) bacteraemia and Clostridium difficile national reduction
targets set for Acute and Clinical Commissioning Groups (CCGs) reflects the zero tolerance
approach for all avoidable HCAIs.
This report will provide information of the activities and performance of Key Performance
Indicators (KPI) for IPC during the period 1 April 2014 to 31 March 2015 by SCHT. The
report is aligned to the 2014/15 Infection Prevention and Control Programme, informing
progress against the objectives set and outlines performance of SCHT against the MRSA
bacteraemia and CDI reduction targets.
In addition the report aims to reassure the public that reducing the risk of infection through
robust infection prevention and control practice is a key priority for SCHT and supports the
provision of high quality services for patients and a safe working environment for staff.
Infection Prevention Control Annual Report 2014/15
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Section Two: Who we are, our duties, arrangements and
assurance
Who we are
SCHT provides community-based health services to around 460,000 people in Shropshire
and Telford and Wrekin. These include for example four community hospitals, community
nursing and inter-disciplinary teams, health visiting, advanced primary care services and
children’s services.
SCHT has a committed IPC team that is very clear on the actions necessary to deliver and
maintain patient safety. Equally, it is recognised that infection prevention and control is the
responsibility of every member of staff and must remain a high priority for all to ensure the
best outcome for patients. The IPC team utilises a proactive approach with the emphasis on
being visible so making their accessibility for guidance and advice a priority. This in turn has
led to an improved IPC team image i.e. being a regular familiar face rather than only visiting
for an audit or when there are problems.
Looking forward it is critical that we maintain this level of commitment. As in previous years,
we will continue to work with Shrewsbury and Telford Hospital Trust (SaTH), Robert Jones
and Agnes Hunt Hospital, Shropshire Clinical Commissioning Group (SCCG), Telford and
Wrekin Clinical Commissioning Group (TWCCG) in the Local Health Economy (LHE) as well
as experts in other organisations, Public Health England (PHE) and the NHS Trust
Development Authority (TDA), Midlands and East of England.
Our Duties and Arrangements
Infection Prevention and Control Service:

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Director of Infection Prevention & Control (also Director of Nursing and Operations)
Head of Infection Prevention and Control (0.8 WTE)
Infection Prevention and Control Nurses (1.6 WTE)
Infection Prevention and Control Nurse (1.0 WTE) left December 2014 - post not
replaced
Infection Prevention and Control Secretary (1.0 WTE)
Reduced staffing since the beginning of 2015 has proved to be challenging however it
created an opportunity to review the team’s
priorities and new ways of working.
The IPC team is led by Steve Gregory, Director of
Nursing and Operations who is the Director for
Infection Prevention and Control (DIPC) and
reports directly to the Chief Executive.
The IPC team devises and implements a robust
Annual Programme of Work to reduce HCAI. This
is achieved by working in collaboration with all
SCHT services and staff. The IPC team perform a
number of activities that minimise the risk of
infection to patients, staff and visitors including
advice on all aspects of infection prevention and
The IPC team: From left to right: Head of IPC
Rachael Allen, team secretary Alison Davies,
IPC nurse Liz Jones and IPC nurse Lizzie
Watkins
Infection Prevention Control Annual Report 2014/15
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control; education and training; audit; formulating policies and procedures; interpreting and
implementing national guidance at local level, alert organisms surveillance and managing
outbreaks of infection.
SCHT has a Service Level Agreement for specialist support from a Consultant Microbiologist
at SaTH to act as SCHT’s IPC Doctor. SCHT also sought advice from Public Health
England when additional advice was required.
Medical microbiology support is provided 24 hours a day, 365 days a year through on-call
arrangements by SaTH.
The IPC team also works with a team of 57 IPC link staff, with 35 working in community
services, 21 from the community hospitals and one from Stoke Heath Prison, who receive
additional training in infection prevention and control and also support clinical staff.
Assurance and Reporting to the Board
Trust Board – SCHT’s performance against the Meticillin Resistant Staphylococcus aureus
(MRSA) bacteraemia and Clostridium difficile infection (CDI) national reduction targets and
the MRSA screening threshold are included in the Performance Report and Quality Safety
Report which are presented at each SCHT Board meeting.
Quality and Safety Committee – Quarterly IPC reports are presented to the Quality and
Safety Committee meetings.
Infection Prevention and Control Meeting – The membership is multi-disciplinary and
includes representation from the operations and quality directorates, estates department and
medicines management. Additional members are, a Health Protection Nurse from Public
Health England; Shropshire and Telford & Wrekin CCGs’ Head of IPC and a patient
representative. The meeting is chaired by the Director for Infection Prevention and Control
(DIPC) and meets bi-monthly. The Terms of Reference (TOR) and membership are
reviewed annually to ensure responsibility for IPC continues to be embedded across the
organisation. This meeting monitors the progress of the annual IPC programmes, approves
IPC policies and monitors compliance with them.
Health Economy Infection Prevention and Control Group – This pan-Shropshire group
was established in 2014/15 with the first meeting being held in September 2014. SCHT is
represented by the Head of IPC. As with the Diagnosis Prevention and Control of Infection
Implementation Group which preceded it, the new group will aim to ensure a strategic
oversight. To facilitate and engage all agencies, a five year strategy has been developed to
support the ability to identify local needs and aspires to a common vision for infection
prevention and control for Shropshire and Telford and Wrekin. The strategy outlines five
strategic objectives which are based on the NICE Guidance Prevention and Control of
Infection – Quality Improvement Guide (NICE 2011) which will form the basis of the system
wide approach.
Infection Prevention and Control Team – The IPC nurses meet formally on a monthly
basis with the IPC Doctor to offer a supportive environment within which clinical issues are
discussed and a consensus obtained.
Infection Prevention and Control Link Staff – All IPC link staff have signed a roles and
responsibilities pro-forma. The aim of the link staff is to enhance the IPC knowledge of
healthcare professionals working within SCHT, ensuring the delivery of high standards of
Infection Prevention Control Annual Report 2014/15
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quality and patient safety in relation to IPC. They are also responsible for undertaking IPC
audits, where required and for disseminating IPC information to colleagues.
Clinical Service Managers, Sisters and Team Leaders – Clinical Service Managers
(CSMs), sisters and team leaders are responsible for ensuring that their work environments
are maintained at high levels of cleanliness. Bi-monthly cleanliness audits are under taken
with ward and housekeeping staff. These audits are reported in the CSM’s reports to the
IPC meeting. The CSMs, sisters and team leaders are responsible for ensuring the link staff
are supported in performing their role and have appropriate time and resources to do this
effectively. Audit and ongoing work undertaken by the link staff is included in the CSMs’
report submitted to the IPC meeting.
Organisational Development Team – Arrangements are in place for staff to attend
induction and mandatory training programmes which includes IPC. Arrangements are in
place for staff training to be effectively recorded and maintained in staff records. Alerts
inform managers of their staff’s non-compliance with mandatory training.
Role of all Staff – All staff are responsible for ensuring that they follow the standard IPC
precautions at all times and are familiar with IPC policies, procedures and guidance relevant
to their area of work. All staff have a duty of care to report any non-compliance and take the
appropriate action as appropriate.
Infection Prevention Control Annual Report 2014/15
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Section Three: Position in Relation to Health Care Associated
Infections
The local acute Trust, whose microbiology laboratory process specimens from SCHT
patients, submit data on SCHT’s behalf on Meticillin Resistant Staphylococcus aureus
(MRSA) bacteraemia, Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemia,
Escherichia coli (E.coli) bacteraemia infections and Clostridium difficile infections (CDI), to
PHE, as part of the national mandatory surveillance programme for Healthcare Associated
Infections (HCAI).
SCHT does not have nationally set targets for reducing HCAIs. These targets are set for
acute Trusts and CCGs. However, SCHT recognises it does have a responsibility in
contributing to the overall reduction targets of both Shropshire and Telford & Wrekin CCGs
and therefore agreed local infection targets with commissioners using the new 2014/15 NHS
England methodology for calculating organisational CDI objectives.
MRSA Bacteraemia Trust Target
Table 2 below outlines the performance of SCHT against MRSA bacteraemia and confirms
that SCHT succeeded in meeting its target for the second consecutive year with zero cases
in 2014/15.
Table 2: Pre 48hr MRSA Bacteraemia cases assigned to SCHT
Actual
Apr
14
0
May
14
0
Jun
14
0
Jul
14
0
Aug
14
0
Sep
14
0
Oct
14
0
Nov
14
0
Dec
14
0
Jan
15
0
Feb
15
0
Mar
15
0
Total
0
Year
End
Target
0
In the event of a MRSA bacteraemia the IPC team would work with the clinical team(s)
involved and facilitate a Post Infection Review (PIR), followed by a multi-disciplinary review
meeting. Subsequently, service improvement plans (SIPs) would be developed and lessons
that have been learnt and good practices identified shared with other services as
appropriate. Indeed this process was activated in June 2014 when the Shrewsbury and
Atcham community nursing team and podiatry were involved in the care of a patient whose
pre-48hrs blood culture was MRSA positive. A PIR was led by the SCCG IPC team and
following a review meeting it was agreed that the case should not be assigned to SCHT nor
was it to be finally assigned to SCCG on the national infection Data Capture System as it
was unavoidable. However, a number of issues with both the SCHT services involved were
identified and as a result a SIP was developed and a report was submitted to the IPC
meeting. The main conclusion was that the patient had received excellent care from both
SCHT and SaTH.
Again in January 2015 the IPC team assisted with a PIR led by the CCG IPC team involving
a pre-48 hours MRSA bacteraemia diagnosed in SaTH from a patient who was receiving
care from the Newport Community Nursing team. A PIR meeting was held where it was
agreed the case was unavoidable and requested that there should be a case review via the
arbitration process. The final outcome finds the case was assigned to a third party as there
were no lapses in patient care which would have contributed to the MRSA bacteraemia.
Infection Prevention Control Annual Report 2014/15
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Actions taken to prevent MRSA bacteraemia
In 2014/15 the focus continued on key interventions to prevent cases of MRSA bacteraemia.
These included:


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















Management of MRSA and MRSA Screening policies available
Screening of emergency and elective admissions to community hospitals for
MRSA. Compliance monitored by the IPC Meeting and included in the
Performance Report - see Table 2 for details
Continued emphasis on isolation and clearance treatment of MRSA infected and
colonised patients within community hospitals
Completion of isolation audits / checklists by ward staff on commencement of
source isolation and weekly thereafter whilst patient remains on the ward
Continue to monitor the care of patients with MRSA within community hospitals
using the management protocol and care pathway
Continued improvement in compliance with hand hygiene and alcohol hand rub
available in every bedspace
MRSA screening of high risk patients prior to urinary catheter change
Urine specimens taken prior to and/or at urinary catheterisation
Urinary catheter practices included in audit programme
Community antibiotic guidelines promoted and placed on computer desk tops
within community hospitals
Ward pharmacists review antimicrobial prescriptions and undertake regular
antibiotic prescribing audits
PIR undertaken on each case of MRSA bacteraemia, including as appropriate,
joint reviews between the community and the acute Trusts
Insertion and on–going care of peripheral vascular devices included in selfaudit/checklist programme
Letters sent to GPs informing them of MRSA diagnosed whilst an in-patient
MRSA staff screening/treatment policy available
Continued emphasis on importance of the cleanliness of the environment: revision
of community hospital cleaning policy and schedules
Continuation of the annual validation of hotel services cleanliness audits by IPC
nurses
Certificates awarded to areas who achieved an annual 100% MRSA screening
compliance
MRSA and Reducing the Risk of HCAIs information leaflets available to all
services and on SCHT website
MRSA Screening
In addition to the local infection targets, a compliance threshold of 95% for MRSA screening
for patients on admission was agreed with the CCG.
Again this year the threshold has been achieved with an overall MRSA screening
compliance of 99.29% a slight improvement compared with last year’s 99.1%. The Head of
IPC shares the monthly compliance reports of all four sites with Ward managers, CSMs and
with the Divisional Service Manager.
As shown in Table 3 below, Team 2 at Whitchurch Community Hospital and Bishops Castle
Hospital have consistently achieved 100% each month throughout the year and in
recognition have been awarded a certificate to acknowledge this achievement (see below).
Infection Prevention Control Annual Report 2014/15
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Ward Managers are responsible for investigating reasons for non-compliance and to
instigate actions to improve.
Table 3: Compliance in each Community Hospital with the MRSA screening policy
Bishops
Ludlow Ludlow Whitchurch Whitchurch
Bridgnorth
Overall
Castle
Dinham Stretton Team 1
Team 2
Apr-14
100
97
100
100
100
100
99.50
May-14
100
100
100
100
100
100
100.00
Jun-14
100
100
100
96
96
100
98.67
Jul-14
100
100
100
100
100
100
100.00
Aug-14
100
100
93
100
100
100
98.83
Sep-14
100
97
100
100
100
100
99.50
Oct-14
100
100
100
100
100
100
100.00
Nov-14
100
100
100
97
100
100
99.50
Dec-14
100
100
100
100
100
100
100.00
Jan-15
100
100
100
100
100
100
100.00
Feb-15
100
100
95
85
100
100
96.67
Mar-15
100
100
100
93
100
100
98.8
Overall
100
99.50
99.00
97.58
99.67
100
99.29
Green - >95%
Amber - 90-95%
Red - <90%
Staff at Bishop Castle Hospital with their certificate for
achieving 100% MRSA screening compliance for
patients on admission
Ward staff from Whitchurch Team 2 receive their
certificate for achieving 100% MRSA screening
compliance for patients on admission
Clostridium difficile Infection (CDI) Targets
The local target set for SCHT was to have no more than three cases of CDI diagnosed post
72 hours after admission in the community hospitals attributed to SCHT. Three cases were
recorded as seen in Table 4.
Infection Prevention Control Annual Report 2014/15
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Table 4: Post 72hr Clostridium difficile infections cases diagnosed in Community Hospitals
Actual
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
Total
Year
End
Target
0
0
0
0
1
0
0
1
0
0
1
0
3
No more
than 3
The first patient diagnosed with a post 72 hour CDI was in August 2014 and was transferred
to Bridgnorth Community Hospital from PRH with known CDI, and immediately isolated in a
side room. A further and unnecessary sample was collected at Bridgnorth Community
Hospital on Day 29 (therefore classed as another case) as the patient still had diarrhoea.
Both specimens were confirmed as the same Ribotype 015 therefore the second sample
was not a new infection. A Root Cause Analysis (RCA) was performed and reviewed at a
meeting where the findings were discussed, including issues with documentation e.g.
isolation self-audits not completed, inaccurate completion of stool chart, CDI care pathway
not commenced at the correct time and not always completed daily. The use of agency staff
(25% in August) to cover the ward was also noted. A SIP was completed.
The second CDI patient diagnosed post 72 hours was on Stretton Ward at Ludlow
Community Hospital in November. The patient had a number of risk factors for CDI. A RCA
was completed and at the review meeting in December the following issues were discussed:
delay in stopping antibiotics; date of specimen on label incorrect; lack of precise
documentation and staff awareness of patient’s condition which contributed to a delay in
treatment and in transfer to SaTH.
In conclusion, if the specimen had been dated correctly the case would have been deemed
pre 72 hours and therefore would not show against the SCHT target. At the RCA review
meeting, it was concluded that the acquisition of CDI was unavoidable; however because of
the identified lapses in care the case counted against SCHT’s target. A SIP was produced
to address the issues and all actions have been completed.
The third post 72 hour CDI was diagnosed in February, the patient was on Stretton Ward at
Ludlow Community Hospital. A joint RCA was undertaken by IPC, the ward staff and
Medicines Management, which was reviewed by the Head of IPC for CCGs and it was
agreed there were no lapses in care by SCHT which could have attributed to the patient
acquiring CDI. However, it was noted that SCHT do need to be aware of the wider
implications and importance of shared learning within the Health Economy.
In line with the RCA policy all three infections were reported to and discussed at IPC
meeting.
Table 5 shows the total number of CDI in Shropshire and Telford Health Economy in patients
over two years of age from April 2008 to March 2015, also showing the year-on-year
reduction in the total number of CDI and encouragingly a 66% reduction in seven years.
Infection Prevention Control Annual Report 2014/15
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Table 5: Total number and proportion deemed to be attributed to SCHT Community Hospitals
Year
Total Number of
Cases in LHE
Community Hospital
Attributed
2008/09
285
2 (0.7%)
2009/10
206
3 (1.4%)
2010/11
191
4 (2.1%)
2011/12
147
1 (0.6%)
2012/13
145
6 (4.1%)
2013/14
112
2 (1.8%)
2014/15
98
3 (3%)
CDI 30 day mortality rate
A consultant microbiologist at SaTH monitors the local health economy CDI mortality data
which includes patients in SCHT. Routinely the IPC team follows the progress of our CDI
patients and therefore would be aware if they died before 30 days. All three CDI patients
discussed above responded to treatment and were discharged. If the cause of death is
recorded as CDI on section 1 of the death certificate it is automatically reported as a Serious
Incident (SI). To improve future care and patient outcomes all Community Hospital deaths
are scrutinised by the Community Hospitals’ mortality group with a checklist approach, and
any unexpected deaths are subject to a review, which would include HCAI/infections
including CDI.
Actions to reduce CDI
In 2014/15 we continued to focus on the key actions to reduce the number of cases of CDI.
Actions specifically targetted at reducing CDI in 2014/15 included:

Promotion of, and referral to, the guidance sheet developed in previous year for
GPs, including those working in community hospitals, to support measures which
need to be adopted to assist in reducing CDI and improving patient care

Bespoke IPC training for medical staff working in Community Hospitals

Continued monitoring of antibiotic prescribing by the community hospital
pharmacists in line with community antibiotic guidelines and any non-compliance
brought to the attention of the prescribing doctor

Review of proton pump inhibitors in inpatients by community hospital pharmacists

Continuation of 7 day rapid testing for Clostridium difficile and use of typing to
search for clusters or linked cases

Continual surveillance, RCA and monitoring of the care of patients who develop
CDI whilst an in-patient in community hospitals and/or whilst receiving care from
our community services using the management protocol and care pathway

Multi-disciplinary team review meeting held after RCA completion to ensure SIP
developed as appropriate

Presentation of each CDI case at next IPC Meeting to discuss and gain assurance
the SIP completed and lessons learnt are shared

Rapid isolation of patients presenting with diarrhoea in community hospitals and
on-going isolation checklist performed
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Revision of community hospital cleaning policy and cleaning schedules

Continuation of increased cleaning, including use of chlorine based disinfectants
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Continue to promote use of decontamination status bands identifying equipment
which is clean and ready for use
Continued emphasis on de-cluttering, cleanliness and efficient use of ward space
Annual validation of hotel services’ cleanliness audits by IPC nurses
Antibiotic Awareness information board in William Farr House – to reinforce key
messages and remind staff about the importance of prudent antibiotic prescribing
and of the need not to ask for unnecessary antibiotics
In collaboration with Medicines Management promotion of the annual global
antibiotic awareness day on 18 November
Continued improvement in compliance with hand hygiene and emphasis on the
need to use soap and water, not alcohol hand gel, with Clostridium difficile and
other gastro intestinal illnesses
Hand hygiene observation audits completed monthly by ward Link Staff and
reported to IPC
IPC training programmes focused upon Clostridium difficile prevention,
management of individual cases including isolation practices
Reinforced public health messages regarding inappropriate use of antibiotics,
through Inform and staff desktops
Continue to issue the CDI passport (see below) to help clinicians improve patient
outcomes and increase patient understanding of Clostridium difficile and
involvement in decisions regarding their care
Letters to GPs informing them of CDI diagnosis (both infection and carrier status)
whilst an in-patient
The Shropshire and Telford Health Economy Clostridium difficile Task and Finish
Group ceased in July 2014 and SCHT worked in conjunction with the Health
Economy IPC Group on the CDI reduction programme
Continued to promote the SIGHT mnemonic protocol when managing suspected
potentially infectious diarrhoea
Issued and encourage all ward based staff to carry the credit sized ‘SIGHT’ cards
for reference :
Infection Prevention Control Annual Report 2014/15
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S
Suspect that a case may be infective where there is no
clear alternative cause of diarrhoea
I
Isolate the patient (within 2 hours), clean vacated bed
space and consult with the infection prevention and
control team while determining the cause of diarrhoea
G
Gloves and aprons must be used for all contacts with the
patient and the patient’s environment
H
Hand washing with soap and water should be carried out
before and after each contact with the patient, their
environment and following removal of PPE
T
 Hand wash with soap and water
 Use personal protective equipment (PPE)
 Keep all doors closed and avoid use of fans
 Designate patient equipment (commodes, bedpan
holders, hoist slings, glide sheets, BP cuffs, stethoscope)
 Allocate staff to work on affected or non-affected areas
 Use stool reord chart and fluid balance chart
 Use
Fuse and Jet for cleaning and disinfecting
 Avoid patient transfers unless clinical emergency
 Inform visitors of infection risks
 Terminal clean when patient 48 hours free of symptoms
Test faeces, by sending a specimen immediately
Periods of Increased Incidence
Since April 2010 all Trusts have been asked to report periods of increased incidence (PII) of
cases of MRSA bacteraemias and CDIs. The definition of a PII is two or more cases within a
ward in a 28 day period. In 2014/15 no PII were reported in the SCHT’s four community
hospitals.
Outbreaks
An outbreak of infection is described as two or more people with the same disease or
symptoms or the same organism isolated from a diagnostic sample and are linked through a
common exposure, personal characteristics, time or location.
Table 6 below summarises the outbreaks declared in the Community Hospitals during
2014/15.
Table 6: Total outbreaks declared in Community Hospitals in 2014/15
Patients
Affected/
Staff
Affected
Date
Commenced
Date
Declared
Over
14/12/2014
22/12/2014
5/2
05/01/2015
07/01/2015
2/0
07/01/2015
22/01/2015
8/5
26/02/2015
02/03/2015
3/2
11/03/2015
19/03/2015
6/0
Whitchurch
Team 2
15/03/2015
26/03/2015
15/2
Whitchurch
Team 1
15/03/2015
24/03/2015
5/2
Hospital
& Ward
Ludlow,
Dinham
Ludlow,
Dinham
Whitchurch
Whitchurch
Team 1
Ludlow,
Dinham
Symptoms
Causative
Organism
Diarrhoea
and vomiting
Diarrhoea
and vomiting
Influenza
like illness
Diarrhoea
and vomiting
Diarrhoea
and vomiting
Diarrhoea
and vomiting
Norovirus
Diarrhoea
and vomiting
Norovirus
Norovirus
Influenza
Nil
identified
Norovirus
Norovirus
Gastrointestinal Infection
Norovirus is the most common cause of gastroenteritis in the community but also causes
outbreaks in hospitals as it is very infectious. During 2014/15 there have been six
gastrointestinal infection outbreaks in SCHT’s community hospitals, one assumed to be and
five of which were confirmed by the laboratory to be caused by Norovirus. The outbreaks in
Infection Prevention Control Annual Report 2014/15
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Whitchurch Team 1 and Team 2 in February and March respectively resulted in bed closures
to control the infection due to all areas affected on Team 2. The ward was closed for several
days and reported as a SI. In all the outbreaks Norovirus was known to be circulating in the
local communities. Despite continual requests and communications it was acknowledged
that some visitors did not heed the advice discussed below.
As part of a campaign to help reduce the introduction
and spread of Norovirus within the community
hospitals, all four sites erected their display banners in
October (acknowledged as the start of the Norovirus
season) at the entrance to the wards/reception areas.
These advised visitors of the signs and symptoms of
Norovirus and requested they do not visit the hospital if
they are unwell or not clear of symptoms for at least 48
hours. In addition, in partnership with SaTH the IPC
team used the local media and the SCHT website to
reinforce these key messages.
In each of the outbreaks, enhanced cleaning of the
wards was immediately introduced and symptomatic
patients were either nursed in a single room or
cohorted in the same bay. To support the efforts of all
staff in their attempts to keep these outbreaks under
Banner at entrance of ward advising
control, the IPC team communicated at least once daily
visitors of signs and symptoms of
with the affected area to offer guidance of patient
norovirus
management and placement, adherence to control
measures and advised the use of a range of tools designed to assist in the care and
monitoring of affected patients. Close monitoring in this way meant that the disruption to
patients and SCHT was kept to a minimum.
Throughout the outbreaks the ward staff were encouraged to complete the isolation checklist
to ensure adherence with the isolation policy. The rationale being that staff address any
issues immediately to ensure safety for all; therefore a SIP is not required. A copy of the
checklist is faxed to IPC for assurance and advice if required.
Outbreak de-brief meetings were not required following the first four Norovirus outbreaks as
all the appropriate actions were taken at the time. A few IPC recommendations were made
to Dinham Ward in December and were discussed at the ward meeting.
A debrief meeting was held following the Whitchurch outbreaks in March, where good
practice was acknowledged: the epidemic curve (see Figures 1 and 2 below) and factors
which may have contributed to the outbreak discussed, including staff working on both
teams; challenges maintaining some patients in isolation rooms; patients requiring 1:1 care;
breaches in IPC isolation precautions e.g. doors open, fan in use, Personal Protective
equipment (PPE) not used appropriately; unable to designate staff and environmental issues
where some areas of the wards were too hot or too cold.
A SIP was developed with realistic completion dates and a follow up review meeting
arranged. Lessons learnt and best practice was shared with staff via the community hospital
sisters’ and ward manager forums, IPC Link Staff meeting and the IPC meeting.
Informing colleagues within the local health economy is a vital strategy to help contain the
spread of Norovirus. The IPC team email all organisations involved with health and social
Infection Prevention Control Annual Report 2014/15
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care to alert them of outbreaks declared within SCHT. Equally, SCHT is informed of
outbreaks elsewhere within the local health economy.
To enable accurate regional and national surveillance of diarrhoea and vomiting the IPC
team submitted reports of outbreaks to PHE and the TDA. All outbreaks are reported to Risk
Management via Datix.
Norovirus Outbreak
Team 1, Whitchurch Hospital
March 2015
6
5
4
3
2
1
0
17th
18th
19th
21st
New Cases Per Day
22nd
23rd
24th
Total Cases Affected
Figure 1: Whitchurch Team 1 Epidemic Curve
Norovirus Outbreak
Team 2, Whitchurch Hospital
March 2015
16
14
12
10
8
6
4
2
0
16th
17th
18th
19th
20th
New Cases Per Day
21st
22nd
23rd
24th
25th
Total Cases Affected
Figure 2: Whitchurch Team 2 Epidemic Curve
Influenza Outbreaks
Whitchurch Community Hospital Teams 1 and 2 reported to the IPC team on 7 January a
number of patients with influenza-like illness (ILI), including admissions with symptoms over
the New Year period. Throat/nose swabs and sputum specimens were obtained from 11
Infection Prevention Control Annual Report 2014/15
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patients in total. Five patients were confirmed as Influenza A positive and all prescribed
Oseltamivir six patients’ swabs were negative. A patient was admitted from SaTH with ILI
and chest infection and also tested positive for Influenza A.
Subsequently, three additional patients were treated on symptoms alone and 12
asymptomatic patients sharing the rooms or bays prescribed the prophylactic dose of
Oseltamivir. In total eight patients were treated as influenza positive.
Patients were nursed in source isolation in co-horted bays as there were insufficient single
rooms available.
In addition five members of staff reported symptoms but none were swabbed. The outbreak
was declared over on 22 January after only 13 days.
It was acknowledged at the debrief meeting which included colleagues from PHE and a
Consultant microbiologist that Influenza A was circulating in the community, including
identified outbreaks in local care homes. The epidemic curve (see Figure 3 below) was
discussed, with the overall conclusion the outbreak was not prolonged and it had been well
managed. However, several recommendations were made and would be addressed in the
SIP including the patient information leaflet not being available on the ward, delay in
prescribing of and insufficient stock of anti-viral medication and ward staff not alert for
influenza.
Influenza Outbreak
Whitchurch Hospital
January 2015
10
9
8
7
6
5
4
3
2
1
0
8th
9th
10th
15th
New Cases Per Day
16th
19th
20th
21st
22nd
Total Cases Affected
Figure 3: Whitchurch Teams 1 and 2 Epidemic Curve
Glycopeptide-Resistant Enterococci (GRE) also known as Vancomycin-Resistant
Enterococci (VRE)
IPC surveillance of antibiotic resistance organisms also includes VRE. The year 2014-15
has seen a rise in the number of SCHT patients identified as colonised and or infected with
VRE.
The Enterococcus is a bacterium that everyone has in their bowel. Vancomycin is one of the
antibiotics used to treat infections caused by the Enterococcus bacterium.
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Healthy people can carry GRE/VRE with no ill effects or signs and symptoms. This is called
colonisation. People who are colonised do not need treatment. GRE/VRE may cause
infection in compromised patients such as bacteraemia, wound infections, meningitis and
indwelling device infections. GRE/VRE infections can be difficult to treat because they are
resistant to Vancomycin. There is no treatment to clear colonisation of GRE/VRE and
therefore the control of GRE/VRE in a hospital environment can be very difficult once it has
become established. Seven patients known to have VRE have been admitted to the
community hospitals. In all cases IPC recommend source isolation precautions for 48 hours
while an assessment of the patient is made. Prevention of transmission is through effective
standard precautions. A GRE/VRE policy is available for all staff for reference. To date IPC
are not aware of any patients acquiring VRE while in the community hospitals.
Extended Spectrum Beta-Lactamase (ESBL)
ESBL is also included in IPC’s multi resistant organism surveillance. These Gram-negative
organisms are resistant to all cephalosporins, penicillins and usually also to ciprofloxacin,
trimethoprim and sometimes gentamicin. Transmission within hospitals mainly occurs via
the hands of healthcare workers which have been contaminated by contact with colonised or
infected patients; contaminated surfaces or inanimate objects. Gram-negative bacteria may
contaminate the environment around a patient and survive there for several days.
Environmental contamination is increased when patients have diarrhoea or colonised skin
lesions.
Prevention of spread is vital and precautions include effective hand hygiene, source
isolation, designated toilet facilities, keeping the environment clutter and dust free, and
cleaning of equipment and the environment using a chlorine dioxide based disinfectant.
Within the community hospitals the most common site for ESBL is in patients’ urine. On
receipt of a positive result IPC contact the ward to discuss IPC precautions and treatment
with staff. Patients’ hand hygiene is also important and advice is included in the information
leaflet.
Carbapenemase-producing Enterobacteriaceae (CPE)
PHE have published a toolkit for acute trusts to assist them with the early detection,
management and control of CPE. A key aspect of the control measures is to take special
precautions for patients recently treated in countries known to have high levels of CPE or in
UK hospitals with recent clusters or outbreaks of CPE. A patient safety alert was issued by
PHE in March 2014 which required all acute Trusts to have implemented the toolkit by 30
June 2014. The IPC team reviewed the advice and included CPE in the revised Multi
resistant gram negative policy. The PHE toolkit for the community has subsequently been
issued.
To date the IPC team is not aware of any in-patients diagnosed with CPE within the
community hospitals.
Safe Care Shropshire
Catheter-associated Urinary Tract Infection (CAUTI) Sub Group
SCHT is represented at Safe Care Shropshire and dedicated to the success of the project.
The objectives are:

To continue to develop and share best practice in relation to the reduction of
avoidable harm to patients across all care settings within Shropshire and Telford &
Wrekin
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To work together to increase the number of patients across the Local Health
Economy who are harm free as defined by the NHS Safety Thermometer point
prevalence data collection and through the “sign up to safety” campaign
To develop working relationships with other work streams and organisations
across the Local Health Economy
The aim of the CAUTI sub group is to facilitate the reduction of urethral urinary
catheterisations and thus the number of CAUTIs and implement urinary catheter
best practices across all health and social care providers in Shropshire and
Telford. The group continue to follow a work plan which is central to the group’s
work, the process of which was reviewed at the quarterly meetings with the focus
on the following key priorities:
Catheter assessment – insertion and removal
Care and management of urinary catheter including policies and pathway
Training
Prescribing - catheter products and antibiotics
Reinforcement of key policies
Patient information
SCHT Head of IPC continues to lead the CAUTI sub group and organised the expert
speaker and a patient’s perspective of urinary catheters at the ‘Safe Care Shropshire’
conference held in Telford on 2 April 2014 which was to celebrate the progress made with
the Safe Care: Harm Free project to reduce harm to patients in hospitals and in their own
homes.
The CAUTI group expert was Janet Blannin,
Independent Nursing Consultant, Continence Care
and Clinical Nurse Advisor to 21st Century Catheter
Project who talked about her work in preventing
CAUTIs. Janet was inspirational and her video
showing a urinary catheter in the bladder
demonstrated why all staff must think more than
twice before inserting a catheter.
Janet Blannin delivering her presentation at the Safe
Care Shropshire event.
The patient’s story about her experience of an indwelling urinary catheter was well received
and caused several grimaces from the audience! The CAUTI group was well represented at
the event by its members who manned the CAUTI information stand.
At the July meeting Dr Brian, Consultant Microbiologist gave a presentation to the group
about E.coli bacteraemias (blood stream infections) diagnosed in SaTH laboratory. A very
interesting talk which reinforced everyone must avoid the insertion of catheters and to
remove them as soon as possible. Also of note was the urgency about responsible use of
antibiotics as many of the organisms isolated are resistant to multiple antibiotics. He left the
group with the following memorable quote “If you dip a CSU then you’re going to grow a zoo”
(CSU being a Catheter Specimen of Urine). A timely reminder that CAUTIs should be only
be treated with antibiotics if the patient is symptomatic.
The NHS Trust Development Authority (TDA) visit 14-15 May 2014
The NHS TDA provides support, oversight and governance for all NHS Trusts to help deliver
high quality and safe services. In a supportive role, the Head of IPC for Midlands and East,
Infection Prevention Control Annual Report 2014/15
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NHS TDA visited the four community hospitals in May 2014. A positive report was submitted
which included three sections: 1. Action Points’ (must do’s). 2. Suggested Action Points. 3.
Points for Review. SIPs were developed for all three sections and progress was monitored
at IPC Meetings. The few outstanding actions include some Estates issues and policy
amendments and will be completed in line with the 2015-16 IPC annual programmes. A
number of the issues identified are reoccurring and were previously identified during IPC
audits. The main concern is what policies, procedures and support mechanisms are
required to be in place to ensure standards are constantly maintained. The Head of IPC for
Midlands and East NHS TDA felt sufficiently reassured that a return visit this year was not
required.
Infection Prevention Control Annual Report 2014/15
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Section Four: Progress against 2014/15 Infection Prevention
and Control Programme
SCHT is legally required to register with the CQC. As a legal requirement of their
registration, SCHT must protect patients, workers and others who may be at risk of acquiring
an infection. Compliance is judged against the ten criteria laid down in the Health and Social
Care Act 2008: Code of Practice on the prevention and control of infections (DH 2010)
The 2014/15 IPC work programme is based on this and progress shown under the relevant
criterion of the Code of Practice.
Criterion 1 – Systems to manage and monitor the prevention and control of infection.
These systems use risk assessments and consider how susceptible service users are
and any risk that their environment and other users may pose to them.

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IPC Policy – Arrangements and Responsibilities reviewed to reflect
management and reporting structure of SCHT, outlining its collective
responsibility for IPC and demonstrating responsibilities are devolved to all
staff/groups in the organisation
IPC Meeting TOR and membership reviewed
Head of IPC has provided regular reports to Quality and Safety Committee
including targets, risks and progress against objectives
The Annual IPC Report is produced and made available for public viewing
via the SCHT website
Risks associated with infection have been entered on the Operations
Directorate risk register
The IPC team continued to identify IPC risks and areas of weakness in
policy and practice though audit and surveillance
Governance and reporting frameworks in relation to IPC have been
strengthened across the Operations Directorate
CQC Provider Compliance Assessments completed
All infection outbreaks reviewed and service improvements plans developed
so that relevant learning was appropriately communicated and acted upon
RCA completed for all patients who developed a CDI whilst an in-patient at
community hospitals and report tabled at IPC meeting
Delivered the IPC Annual Audit Programme - refer to Appendix 1 and
Appendix 2 of this report for details of audits undertaken in 2014/15
IPC audit tools adapted in 2011/12 from the Department of Health/ Infection
Prevention Society Quality Improvement Tools and DH Saving Lives care
bundles have been revised
Verification of HCAI audit SIPs to assure completion of the audit cycle
In recognition of high IPC standards, Gold Certificates are issued to
services with audit compliance scores of 95% and above and Silver
certificates are issued to services with compliance score 91-94%
The IPC team have developed and delivered IPC training programmes
including a one hour update on the core mandatory day for clinical staff
Alert organism/alert condition surveillance by the IPC team continues
Local peer assessment of hand washing technique for all new staff and
yearly for existing staff continued
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Criterion 2 - Provide and maintain a clean and appropriate environment in a managed
premises that facilitates the prevention and control of infections
This criterion includes cleanliness and hand hygiene, but also includes the fabric of the
building and services such as air and water supplies, laundry, waste disposal and
decontamination of instruments. Control of MRSA bacteraemia and CDI also come within
this criterion. Actions to reduce them have already been described under their specific
sections but are briefly mentioned below.
General Environment Issues
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Publicly Available Specification (PAS) 5748:2011, the framework for
monitoring cleanliness standards implemented in April 2012 continues
In collaboration with the Community Hospital Environment Group (CHEG),
Community Hospitals’ cleaning policy and schedules revised
CHEG continued to meet to address and support the implementation of
environmental issues, share best practice, promote effective use of
resources and implement service improvement initiatives including a
standardised approach across all four sites
Monthly quality reviews are undertaken in community hospitals’ clinical
areas and prison healthcare unit; including general cleanliness of areas,
and discussions with patients regarding their experiences of the cleanliness
of the environment and staff hand hygiene practices
Community Hospital cleanliness annual validation audits by IPC team
continue
Further consideration of in-house community hospitals’ laundry facilities-see
section 4.
Periodic validation audits continue to be performed by the IPC team to
assess the cleanliness in community facilities cleaned by South
Staffordshire and Shropshire Foundation Trust (SSSFT)
IPC Team continue to advise on refurbishment/redevelopment and new
build projects to ensure IPC is adequately considered at all stages
Monthly report submitted to the Operations Directorate Estates Divisional
meeting by IPC team noting estate issues identified through audit and or
during visits
PLACE undertaken with focus on service user representation
Community Hospital Cleanliness Audit
The ward areas and departments within the community hospitals continued to monitor core
cleanliness standards using the Publicly Available Specification (PAS) 5748:2011 provided a
risk based system for the planning application and measurement of cleanliness.
The audits, undertaken jointly by nursing and domestic staff, were carried out bi-monthly. If
compliance rates fell or there was recurrence of specific issues then they would be
completed more frequently. The IPC team also undertook validation audits to ensure
compliance was being reported correctly. The compliance scores were publicly displayed on
the IPC notice boards.
The compliance scores of the Community Hospital wards are shown in Appendix 3.
Formal assessments using the Department of Health (DH) Patient Led Assessment of Care
Environments (PLACE) continue.
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The PLACE 2014 visits were undertaken between 3 March to week commencing 26 May,
results were made public on 27 August 2014.
An overall cleanliness score of 99.17% was awarded to SCHT compared with 98.24% in
2013. Table 7 shows the Community Hospitals’ scores.
Table 7: Community Hospitals’ PLACE scores
Cleanliness
Food
Privacy,
Dignity and
Wellbeing
Condition,
Appearance
and
Maintenance
Ludlow Hospital
98.11
90.82
76.74
86.30
Bishop’s Castle
Hospital
99.57
91.39
95.68
96.61
Whitchurch Hospital
99.87
93.72
83.86
96.92
Bridgnorth Hospital
99.11
95.65
95.28
98.26
Overall SCHT Scores
99.17
92.90
87.89
94.52
Site Name
New Builds and Refurbishments
The IPC team has been involved in reviewing and supporting refurbishments and new builds
within the SCHT. It is paramount that IPC implications for planning, construction and
renovation are considered at all stages. In addition the infection risk posed during
construction, demolition, refurbishment and planned preventative maintenance works must
be considered and action taken to minimise the risk due to environmental organisms e.g.
Aspergillus fumigatus by the use of dust screens.
The IPC team have advised on the following projects:
Ludlow Hospital
The IPC team was involved with advising on the refurbishment at Ludlow Hospital and an
IPC nurse attended the weekly progress meeting during the refurbishment. IPC Standard
Operating Procedures were used to minimise infection risks to patients, staff and visitors.
The TDA Head of IPC noted the good seal to keep dust out during her visit to Dinham ward.
Stretton ward have now had a hand wash basin installed in the sluice, an issue identified
during IPC audits for a number of years and also included in the TDA IPC report. The
addition of a ward commode store has addressed the issue of where to store commodes.
IPC audits in Minor Injuries Unit and Out Patients Departments identified lack of facilities for
disposal of body fluids and decontamination of equipment. The possibility of installation of
clean / dirty utility / sluice in Minor Injuries Unit (MIU) has been explored and discussed at
Capital and Estates meeting with the Estates advisor involved, surveying area and
requirements.
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Mayfair Church Stretton
IPC have commented and advised on the plans for the Church Stretton Well Being Centre.
Work has not yet commenced.
Community Hospitals Clinical Hand Wash Basin Compliance Audit
In view of the published Department of Health guidance in March 2012 on “water sources
and potential Pseudomonas aeruginosa contamination of taps and water systems”, clinical
hand wash basins in community hospitals were audited for compliance against Health
Building Note 00-10: Performance requirements of building elements used in healthcare
facilities. The report highlighted non-compliant clinical hand wash basins and they were
added to SCHT’s risk register and will be upgraded during any future refurbishment. In the
interim the Estates advisor is assessing taps and if too eroded by limescale a replacement
considered. A build-up of limescale is acknowledged as a problem in Shropshire but the
problem identified may be in part due to inadequate cleaning. All domestic staff have
therefore been made aware of the correct cleaning procedure and a trial of limescale
removal products assessed. A water softener is to be installed at Whitchurch Community
Hospital and if successful will be installed in all community hospitals.
Laundry
The Community Hospital’s onsite laundries were audited by the IPC team in August 2013.
Although some urgent issues were addressed, IPC continue to raise concerns around
compliance with the DH Choice Framework for Local Policies and Procedures (CFPP) 01-04:
Decontamination of linen for health and social care (2013).
A Laundry Options Appraisal Report was tabled at October’s IPC meeting followed by the
January’s Capital and Estates group who reported it did not clearly reflect requirement nor
did it recommend a preferred option. The Deputy Director of Operations is now leading on a
proposal to undertake, with financial resource, a market testing exercise to determine
whether outsourcing of laundry services will be more beneficial to SCHT.
Decontamination
The TDA advised that Decontamination Group be convened. Decontamination is now a
standing item on the IPC meeting agenda and the Chair is the SCHT Lead for
Decontamination. It is acknowledged that the level of risk is low, as the Central Sterilizing
Services Department (CSSD) in Telford, operated by SaTH, undertakes most of the
decontamination for SCHT including instruments used by the SCHT’s day surgery unit and
minor injuries units. The SCHT podiatry service changed to single use instruments in March
2015. Medical devices and associated issues continue to be addressed at Divisional
meetings
The Decontamination of Reusable Surgical and Dental Instruments policy is available to
support all staff involved in the decontamination of these instruments at a local level as well
as services which send instruments for reprocessing at the CSSD.
Local Decontamination
Dental
The SCHT dental service is compliant with the ‘essential quality’ requirements contained in
the Health Technical Memorandum 01-05 – Decontamination in Primary Care Dental
Practices. Plans are in place for each clinic site to progress to ‘best practice’. Castle
Foregate (downstairs) and Oswestry Health Centre clinics are now fully compliant with ‘best
Infection Prevention Control Annual Report 2014/15
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practice’. Work is on-going to consider the best way forward for other clinics to progress to
‘best practice’ which includes the installation of washer disinfectors
A quarterly and annual maintenance contract for ultrasonic baths is currently under review
by SCHT’s Estates Advisor.
Nasendoscopes
The Decontamination of Flexible Nasendoscopes Policy is in place to provide guidance on
the decontamination of flexible nasendoscopes as undertaken in community hospitals and
Advanced Primary Care Services (APCS).
A specific disinfectant wipe system is used by all SCHT locations undertaking nasendoscopy
as validated in the national guidance Choice Framework for local Policy and Procedures
(CFPP) 01-06 on the Decontamination of Flexible Endoscopes (June 12). The
manufacturers of the Tristel wipe system provide free-of-charge training to staff required to
use this method of decontamination.
In response to IPC audits of the Ear Nose and Throat (ENT) clinics, a storage cabinet and
trolley storage system have been purchased by Whitchurch and Bridgnorth Community
Hospitals respectively to provide appropriate storage of the nasendoscopes as
recommended by the manufacturers.
Endoscopes
A policy for the decontamination of flexible endoscopes is in place to support safe practices
for the use of an automated endoscope reprocessor (AER) for washing and disinfecting
these instruments. It includes national guidance on the testing for microbiological quality of
the final rinse water from the AER. The IPC team is notified of results and follow up any
abnormal ones.
Validation of AERs is a national requirement. PuriCore have continued to service the unit in
accordance with the testing standards.
Automated Endoscopy Reprocessor (AER) at Bridgnorth Community Hospital
Full validation and water testing has continued to be undertaken on the AER and the unit
staff have received appropriate training.
Anomalies with the final rinse water test results were noted several times in the summer and
Puricore attended to service and change filters. There appeared to be some connection with
the raised colony forming unit (cfu) and mains water replacement works in the vicinity of the
hospital. The Estates advisor has written to all utility companies asking for notification of any
work due to be undertaken in close proximity to SCHT premises.
A specialised storage cabinet with a high-efficiency particulate air (HEPA) filter is used to
store the disinfected endoscopes for up to 31 days and prevent contamination rendering
them safe for immediate use and enhances efficiency.
Water Safety Group
The Head of IPC for the TDA advised that SCHT should have a water safety group.
Following discussions, a new joint SSSFT and SCHT group has been formed. SCHT are
represented by Estates, Hotel Services and IPC. The TOR has been developed and the
meetings are bi-monthly at present. It is intended that the Group will monitor risk
Infection Prevention Control Annual Report 2014/15
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assessments especially around Legionella, flushing regimens, annual disinfection and AERs.
The water safety group report to the IPC meeting as a standing agenda item.
Criterion 3 - Provide suitable accurate information on infections to service users and
their visitors
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Head of IPC produced an annual report covering the organisation’s
approach to prevention and control of infections for publication on the
SCHT website
Hand hygiene included in patient/visitor information leaflets
Strategically placed hand hygiene products available for use with
information on how to use
Continued to encourage patient and public involvement in hand hygiene
and cleanliness campaigns and services’ Quality Review process,
satisfaction surveys and PLACE inspections
In conjunction with the SCHT Communication Team key IPC messages
were promoted through internal and external media communications
including the SCHT website, in particular prior to and during ‘Norovirus
season’
Large display boards were erected at each of the community hospitals to
raise public awareness during the months when Norovirus is prevalent in
the community
IPC information boards designated in all community hospitals display IPC
data and audit results
Polices related to specific organisms and care pathways remind staff of the
need to give affected patients and relatives leaflets about the infection
IPC page on the SCHT website further developed and now includes
monthly HCAI data
Quarterly IPC newsletter produced and published in Inform as aide
memoire and resource for clinical staff
Information leaflets revised and placed on the SCHT website informing
patient/public on specific infections and hygiene measure they can adopt to
reduce the risk of infection
The IPC team and other members of staff continue to respond to ad hoc
requests for information related to IPC under the Freedom of Information
Act
Criterion 4 - Provide suitable accurate information on infections in a timely fashion to
any person concerned with providing further support or nursing / medical care
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IPC requirements are included in the health economy transfer/discharge
form
Quarterly IPC newsletter produced and published in Inform as aide
memoire and resource for clinical staff
IPC team share infection rates and outbreak information with appropriate
services based upon local, regional and national surveillance
IPC page on the SCHT website
MRSA bacteraemia and CDI data published on the SCHT website
Alert organism surveillance by the IPC team
IPC policies available
IPC information boards sited on all community hospital wards and MIUs
Monthly MRSA screening compliance shared with CSMs
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Criterion 5 - Ensure that people who have or develop an infection are identified
promptly and receive the appropriate treatment and care to reduce the risk of passing
on the infection to other people
Arrangements to prevent and control infection come within this criterion and should be such
as to demonstrate that responsibility for IPC is effectively devolved to all groups involved
with delivering care.
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IPC Arrangements and Responsibilities Policy reflects the management and
reporting structure of SCHT outlining its collective responsibility for IPC and
demonstrating responsibilities are disseminated to all staff/groups in the
organisation
Responsibilities of groups and staff included in IPC policies
Support provided by IPC team included visits and daily telephone contact
Continued to develop Link Staff and supporting of their role
Link Staff Roles and Responsibilities revised and updated
Continued to audit compliance with IPC polices and care pathways
IPC team access to SaTH Laboratory IT systems allowed enhanced alert
organism surveillance
IPC team reported outbreaks and incidents of infection to our
commissioners, PHE and the TDA
IPC team emailed all organisations involved with health and social care to
alert them of outbreaks of infection declared within SCHT
IPC received notification of outbreaks of infection within the local health
economy
IPC specific organism e.g. MRSA, CDI policies available
Community antibiotic policy available to all prescribers
PIR undertaken on all MRSA bacteraemias and a RCA on CDI involving
community hospitals or community services involved with the patient’s care
Use of SIGHT mnemonic
Issued cards with SIGHT mnemonic to ward staff to use as an aide
memoire
Ward staff advised to use isolation audit tool as a checklist to ensure
compliance with isolation policy
Awareness of the National Ward Sepsis Screening and adaption of action
tool for SCHT
Ebola
Following advice issued by NHS England in response to the outbreak of Ebola virus, the IPC
team worked in collaboration with the Health Emergency Management Specialist and MIU
lead to ensure that in the event of a patient presenting with symptoms, staff were competent
in the management prior to transfer to the acute hospital. Utilising national guidance, an
algorithm for viral haemorrhagic fevers (VHF) and contents for decontamination boxes
(containing PPE and cleaning products etc.) were developed and made available in all MIUs.
The PHE Ebola poster to inform the public regarding Ebola was displayed in MIU entrances.
A priority for MIU staff was to ensure they were fit tested for respiratory masks; therefore
several staff received the fit test training and were then able to fit test staff locally. Staff were
also made aware of the correct processes for the application and removal of PPE.
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Criterion 6 - Ensure that all staff and those employed to provide care in all settings are
fully involved in the process of preventing and controlling infection
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Facilitated by the LHE IPC group, continued to work with NHS providers to
reduce all avoidable infections including MRSA bacteraemia and
Clostridium difficile
Continued to address the agreed maintenance Clostridium difficile plan
through the LHE group
Compliance with MRSA screening policy screening audited monthly
As appropriate, joint investigations and reviews held between SCHT and
the acute Trust on cases of MRSA bacteraemia and CDI
Quarterly IPC Link Staff updates allowed information to be disseminated
from the IPC team back to the individual services
Annual Study Day for IPC Link Staff focused on blood borne viruses
Outbreak masterclass for on-call senior managers and directors
Outbreak pack available to assist staff with managing outbreaks. This
included door notices, posters, monitoring forms, checklist which was
emailed by IPC nurse to the member of staff on notification of outbreak
IPC team continued to support SCHT to take forward national initiatives
which have an IPC element including the Safe Care: Harm Free Project
IPC team supported the development of SCHT clinical policies/procedures
IPC Always Events Poster displayed in all clinical services/areas
IPC pack developed for and distributed to medical staff who work in
community hospitals
New “clean safe hands” poster featuring Shrewsbury Town’s goalkeeper
developed and distributed to all SCHT premises
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Criterion 7 - Provide or secure adequate isolation facilities
Due to the nature of the patient population, it can at times be difficult to isolate patients to
minimise the spread of infection. The Isolation policy includes an Isolation Risk Assessment
Tool which allows staff to consider individual requirements for isolation to ensure patients
are managed on a case by case basis.
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IPC Isolation policy in place to support staff
Audits of compliance with isolation policy undertaken in community
hospitals by IPC team when incidents of infection and outbreaks occurred
Risk assessments performed by ward staff with support from the IPC team
when insufficient isolation facilities were available to meet demand
Cohort approach taken as necessary within community hospitals during
outbreaks of diarrhoea and vomiting
IPC training programmes include Clostridium difficile prevention,
management of individual cases including isolation practices
Work completed in the summer of 2014 to provide additional en suite
facilities at Ludlow Community Hospital to improve patient dignity and aid
cohort nursing during outbreaks
All episodes where staff are unable to isolate patients are reported to Risk
Management via Datix commenced September 2014
Criterion 8 - Secure adequate access to laboratory support as appropriate
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Laboratory services provided by SaTH
The microbiology laboratory at SaTH compliant with the standards required
for accreditation by Clinical Pathology Accreditation (UK) Ltd.
Continuation of seven day rapid testing for Clostridium difficile and use of
typing to search for clusters and linked cases
Continuation of local test for Norovirus to speed up diagnosis and outbreak
management of patients with infection
Adequate resources available in laboratory for MRSA screening in line with
national guidance
Mandatory surveillance also included MSSA and E.coli bacteraemia
infections
Consultant Microbiologist at SaTH is SCHT’s IPC Doctor
Monthly Consultant Microbiologist and IPC nurses meetings
Medical microbiology support provided by SaTH 24 hours a day 365 days a
year
Criterion 9 - Have and adhere to policies, designed for the individual's care and
provider organisations that will help to prevent and control infections
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Rolling programme of policy review continues
Published evidence reviewed whenever policies were developed or
reviewed on publication of new national guidance to ensure they reflect up
to date, evidence based, best practice national guidance
New policies developed as need identified
Community Hospital pharmacists and technicians review drug charts
In collaboration with Medicines Management team commenced work to
implement the relevant recommendations of the national 5-year strategy for
antimicrobial resistance issued by the Department of Health in March 2015
Infection Prevention Control Annual Report 2014/15
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The following polices were developed or reviewed in 2014/15:
Policies Reviewed:
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Aseptic Technique
Hand Hygiene
 Infection Prevention and Control Arrangements and Responsibilities
 Influenza
 IPC in the Built Environment
 Management of Norovirus and other GI Infections
 Multi resistant Gram Negative Bacteria
 Standard Precautions including surgical hand scrub, gloving, gowning
New policies developed
 Management of Group A Streptococcus
Compliance with policies was audited locally through the hand hygiene, cleanliness and IPC
audit tools and specific competency tools and peer assessments. Specific audits
undertaken by the IPC team as part of their annual programme, clinical incident reporting
and root cause analysis of infections including debrief meetings were also used to monitor
compliance. Community hospital pharmacists reviewed antibiotic prescriptions and advised
in accordance with local antibiotic policy. Antibiotic audits were undertaken by pharmacists.
The IPC team has also contributed to the development/review of the following Estates
policies:
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Waste
Legionella – Include control of pseudomonas and management of drinkable
and non-drinkable water supplies
Pest control
Contractors’ Site Access
Mobile Phone Use
Assistance Dogs
The IPC team are members of the Clinical Policies Group which reviews and approves all
clinical policies. As members it ensures accurate and relevant IPC advice is included in all
clinical policies.
Medicines Management Report
Community Hospitals:
The medicines management clinical team have undertaken antibiotic audits on a regular
basis to support the antibiotic stewardship agenda.
Elements measured included:
 Choice of antibiotic as compared to the formulary recommendation. Off formulary
antibiotics were challenged with the prescriber. Exceptions included antibiotic
recommendations made by the SaTH microbiologists where these were documented
in the patients’ notes.
 Duration of the antibiotic course
 Allergy status
 Challenge to prescribers where several courses of antibiotics had been prescribed
Infection Prevention Control Annual Report 2014/15
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Medical staff have been encouraged to record the indication and duration of the antibiotic on
the drug chart and the new drug chart has facilitated this. The main reminder we have to
give to prescribing medical staff is around defining the length of the course. Antibiotic
guidance is available on each ward.
District Nursing:
Non-medical prescribing by community nurses is monitored via ePACT data. Where higher
risk antibiotics (cephalexin, co-amoxiclav, 4-quinolones) appear on the data being
scrutinised, the prescriber is required to provide assurance that the prescription matches the
community antibiotics guidance.
Patient Group Directions:
Some antibiotics are available to patients via Patient Group Direction e.g. in Minor Injury
Units. As part of the development process, consultant microbiologist advice and approval is
sought.
Dental emergencies:
Some to take out (TTO) packs of a restricted range of antibiotics have been made available
to the dental service where supply at the point of consultation is in the best interests of the
patient e.g. out of hours, and only initiated by a dentist.
November 18th is Antibiotic Awareness day.
There is currently a particular focus on the appropriate use of antibiotics because of the
increasing resistance patterns seen in the community and in hospitals. The Antibiotic
Awareness day in 2014 was marked by the display of information at the community hospitals
and at William Farr House about the judicious use of antibiotics. The information was aimed
at both staff and the general public. The display materials comprised information, quizzes
and Frequently Asked Questions. The materials also invited people to sign up to become
antibiotic champions and directed people to the central website.
Similar information was provided by CCG colleagues to GP practices for display in the
surgeries.
Medicine Management report written by: Rita O’Brien.
Criterion 10 - Ensure, so far as reasonably practicable, that care workers are free of
and are protected from exposure to infections that can be caught at work and that all
staff are suitably educated in the prevention and control of infection associated with
the provision of health and social care
Staff Health
The IPC team continued to work with the Occupational Health Service (OHS) to ensure that
staff are protected from infection and did not pose a risk to others, including patients, from
their own infections. The use of hand moisturisers has been encouraged to protect care
workers’ hands from the effects of frequent hand decontamination.
Influenza
The OHS led the influenza campaign supported by IPC team flu champions and other flu
champions dispersed across SCHT. Following an evaluation of last year’s campaign, the
planning and promotion for this year was commenced earlier, the number of occupational
health influenza sessions was increased and these were on a drop-in rather than an
appointment basis.
All staff were offered and actively encouraged to have the seasonal influenza vaccination
and the communications team assisted by promoting key messages. Attendance by OHS at
Infection Prevention Control Annual Report 2014/15
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various meetings, corporate induction, staff awards and training sessions was also
undertaken and a series of health and wellbeing events held during the campaign also gave
staff the opportunity to have their influenza vaccination along with a mini lifestyle check
including blood pressure and cholesterol tests. The IPC Team flu champions also gave staff
the opportunity to receive vaccination at the Link Staff sessions and through their attendance
at meetings and visits.
For the year 2014-15, 67.2% of SCHT frontline staff were vaccinated against influenza which
is an increase on last year’s uptake of 64.8% and higher than the national average of
54.9%. SCHT was in the top three performing NHS Community Trusts behind only our
colleagues in the Wirral and Leeds. This is testament to all those who worked on the
campaign resulting in an increased awareness and uptake despite winter pressures and
challenging times.
An MRSA for Staff screening policy is available to help support the member of staff and their
manager to ensure that they do not put others at risk of acquiring the organism. In addition
to the MRSA policy a number of OHS policies, including staff immunisation policy, are
available. The IPC policies Prevention and Management of Needlestick Injuries including
inoculation incidents and Blood Borne Viruses (includes safe sharps handling), Standard
Precautions policy and the Hand Hygiene policy all support staff health.
The IPC nurses reviewed all infection prevention and control incidents including sharps
injuries and followed up with OHS to ensure the policy had been followed. In addition all IPC
incidents were reported to and monitored bi-monthly at the IPC Meeting.
Sharps safety
As previously reported the EU Directive 2010/32/EU was to be implemented by May 2013.
This directive required all healthcare providers to introduce further protection for health care
staff exposed to the risk of sharps injuries, and actions. The Head of IPC at the TDA in May
2014 raised concerns that safety engineered needle devices (SENDS) were not available
and or implemented in many areas. Further work with Shropshire Healthcare Procurement
Service, raising awareness of SENDS at IPC training sessions and through audit has been
undertaken. Occasionally it is inappropriate to use a SENDS device in which case a formal
risk assessment is undertaken and recorded on the Datix risk register. Progress with the
implementation of SENDS continues to be monitored at the bi-monthly IPC meetings.
Figure 4 below shows SCHT inoculation incidents for the past two years. Encouragingly in
2014-15 there has been an 18% reduction in the number of injuries reported with 23 injuries
compared with 28 reported in 2013-14.
Infection Prevention Control Annual Report 2014/15
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Figure 4: SCHT Inoculation incidents reported April 2013-March 2015
Education
As an organisation, SCHT is committed to the principle that IPC is the responsibility of all,
facilitated through a programme of education, both formal and informal, throughout the
organisation. One of the principal functions of the IPC team is to inform all clinical staff of
the standards expected of them. The team continued to contribute to SCHT’s induction and
core mandatory training days for clinical staff and provided additional ad hoc tailored training
to staff to ensure that IPC remained a high priority for all.
Induction Programme
The IPC team participated in the Induction Programmes for all new staff, both clinical and
non-clinical, which 185 staff attended. The objective of the team’s participation was to inform
staff how they could contact the IPC team, access IPC policies and raise awareness of IPC
national guidelines and local initiatives. It also provided an opportunity to highlight main IPC
principles and to raise awareness of the responsibility and role of IPC for all members of
SCHT. A local IPC induction is facilitated by the new member of clinical staff’s manager and
includes the hand washing assessment to be undertaken within the first week.
Mandatory Training
IPC face to face mandatory training for all clinical staff continued to be offered via SCHT’s
Organisational Development (OD) team and out of a possible 1,137staff, 1086 staff (95.5%)
attended the core days for clinical staff. The one hour of training focused on Standard IPC
precautions, multi-resistant organisms, newly published national guidance or changes to
current practices and policies.
The National IPC e-learning training package was made available to all staff via OD for nonclinical staff to complete every three years and was completed by 182 staff out of a possible
395 staff (46%).
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Additional Training
The IPC team continued to expand the provision of IPC training to as many groups as
possible including:
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IPC team participated on the six “administration of intravenous medication
via peripheral vascular access device” study days attended by 44 SCHT
staff in total. Content of the training included sources of intravenous
infections, evidence-based practice related to insertion and on-going
actions to reduce the risks of infection associated with peripheral vascular
devices
IPC team delivered IPC educational session covering standard precautions
and outbreak management to 10 HCAs attending a HCA Development day
run by Catherine Chaplin, Clinical Educator
IPC team delivered a Hand Hygiene educational session to 34 Speech and
language therapists at their study day.
Bespoke Training
In addition to the above the IPC team has delivered bespoke training to 121 staff of many
different disciplines as shown in table 8 below. Bespoke face-to-face sessions were also
arranged by the IPC team where need identified e.g. medical, domestic and portering staff
Attendees names were reported to OD for recording.
Infection Prevention Control Annual Report 2014/15
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Table 8: Bespoke IPC training
Porters
Porters
GPs
Volunteers
GPs
GPs
Outbreak Management for senior managers
Domestics
Domestics
Volunteers
Domestics
IPC for Ward Clerks
Volunteers and League of Friends
Total
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08/04/2014
09/05/2014
25/06/2014
01/07/2014
21/07/2014
19/09/2014
19/11/2014
12/12/2014
22/01/2015
24/02/2015
24/02/2015
26/02/2015
23/03/2015
Ludlow
Whitchurch
Ludlow
William Farr House
Bridgnorth
Whitchurch
William Farr House
Whitchurch
Bridgnorth
William Farr House
Ludlow
Bridgnorth
Bridgnorth
3
3
8
12
7
5
10
8
10
8
17
2
28
121
The IPC Outbreak Management Master Class was attended by Senior
Managers and Directors with the aim of the session to provide information
to assist when dealing out of hours with infective outbreaks in SCHT
community hospitals. The evaluation was very positive and attendees
found the information relevant and informative.
Bespoke IPC training concentrating on hand hygiene and general IPC
advice concerning visiting and movement within the community hospitals
and volunteer illness was delivered to volunteers
Antibiotic Awareness
In conjunction with Medicines Management the IPC team promoted the annual global
antibiotic awareness day on 18 November 2014 with a display board erected in William Farr
House during November. Information leaflets appropriate to healthcare professionals as well
as to patients and visitors were made available.
The aim of this initiative is to promote key messages and raise awareness of antibiotic
resistance which is driven by overusing antibiotics and prescribing them inappropriately. It is
important that antibiotics are used correctly to reduce the risk of antibiotic resistance and
make sure these life-saving medicines remain effective now and in the future.
Norovirus Roadshows
The IPC team held a Norovirus roadshow in all four community hospitals during November.
The information board and portable hand wash basin was particularly aimed at informing
visitors of the signs and symptoms of Norovirus and the reasons why they should not visit if
unwell. The portable hand washing basin was well used at the entrances to the wards; the
feasibility of permanent hand wash basins at the entrances to all community hospital wards
will be assessed by Estates.
Radio Shropshire presenter Genevieve Tudor interviewed Head of IPC Rachael Allen and
IPC nurse Lizzie Watkins when the roadshow was at Bridgnorth Community Hospital. The
interview provided information about Norovirus and hand hygiene and Genevieve Tudor
participated in a hand hygiene demonstration using the ‘GloBox’. She was wearing
numerous rings which provided the ideal opportunity to discuss why ‘Bare below the elbow’
is part of the uniform policy for clinical staff.
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The SCHT Board also invited the roadshow to attend their November meeting and a number
of the Directors and Non-Executive directors took the opportunity to use the portable hand
wash basin and, using the ‘GloBox’, could see how well they washed their hands.
IPC nurse Lizzie Watkins, Head of IPC Rachael Allen and Radio
Shropshire’s Genevieve Tudor with the portable hand wash basin
at Bridgnorth’s Norovirus Roadshow
Dr Ganesh Medical Director tries the portable hand wash basin
in a non-clinical setting
The Norovirus ‘roadshow’
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Infection Prevention and Control Link Staff
Link Staff are critical in the delivery of IPC within all
services. Link Staff meetings are held quarterly and
provide opportunities for networking, emphasising the
service provision throughout SCHT and between services.
This continues to be an extremely effective way of
distributing information and generates valuable question
and answer sessions. All link meetings include information
on national infection targets, RCA/PIR feedback, outbreak
summary, safety notices, incident reports, new or revised
IPC policies and discussion of IPC audits findings. All are
important elements to be taken back to clinical areas and
have the potential to reduce infections by promoting
optimal practice. The link person disseminates the
information to their area of work usually as a standing item
Congratulations to Ludlow Minor
Injuries Unit, who won the competition on team meeting agendas.
for the most informative Norovirus IPC
board
The Link Staff in community hospitals manage an IPC board in their area where possible to
display a different theme each quarter. Link Staff were asked to focus on norovirus for the
period 1 January to 31 March.
Link Staff Study Day
The third annual study day for IPC Link Staff was held on 12
February 2015. Following the welcome and overview of the
Director of IPC’s role by Steve Gregory, the day focused on
blood borne viruses (BBV) and included sessions from a
Consultant Microbiologist, a representative from the Terrence
Higgins Trust and PHE. The quiz was won by Rebecca
Barton, Clinical Practice Educator. The day was well attended
by Link Staff across SCHT services and received excellent
feedback. The IPC team intends to build on the success of
this event and are already planning next year’s study day.
Delegates participating in activities
at the Link Staff Study Day
During IPC audit
The IPC team use audit visits as an educational opportunity to reinforce good practice and
make suggestions how practices can be adapted and standards improved. This was
consolidated through the audit report subsequently sent by the IPC nurse and in the
development and return of a SIP where the score is less than 100%.
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Informal Education/Awareness
The IPC team continued to raise awareness of IPC issues using a variety of mediums
including regular visits to community hospitals, local road-shows and service-specific clinical
governance events. Posters and information leaflets were used to promote good IPC
practices and advice given accordingly, including ad hoc telephone advice to all services
within SCHT.
Check to Protect
This initiative has been developed to replace Essential Steps. Check to Protect is for clinical
staff and comprises of a set of eight assessment tools, including Aseptic Technique,
Catheter Care, Disposal of Sharps and PPE. It is designed to be easy to use and a
straightforward peer assessment tool. Intended to be used by staff to assess their peers
annually, it ensures safe, effective standards of IPC are being met and maintained within all
clinical services and also identifies areas for improvement. Check to Protect for Clinical staff
was launched in September 2014 as part of the Health Care Assistants’ Education
Programme, with support from SCHT’s Clinical Educator and is in the process of being
disseminated for use by all clinical staff.
IPC Team Development
The IPC nurses continue to be supported to increase their knowledge, understanding and
skills to assist deliver improved quality of care for our patients by relieving the burden of
avoidable healthcare associated infections.
This included attendance by an IPC nurse at the Annual Infection Prevention Society (IPS)
conference in Glasgow in September 2014. Among the themes addressed were the
Emergence of New Pathogens including CPEs, Ebola in Africa and how IPC nurses can
make care safer and combat the overuse of antibiotics. Following evidence presented at
conference, Community Hospitals are advised if appropriate to isolate all patients with CDI
for the duration of their stay not just their period of active infection.
The Head of IPC attended an IPS Implementation Learning Laboratories Event in
Birmingham in December and an IPC nurse attended a repeat session in February. The
event was aimed at IPC practitioners interested in best practice and focused on helping to
understand and overcome the barriers to implementing infection prevention guidance by
providing a package of resources and ongoing support from IPS and colleagues. The Head
of IPC attended the West Midlands PHE Carbapenemase Toolkit Launch in May 2014 which
provided the opportunity to learn more about this highly resistant organism from hospital staff
who have experience of managing patients with CPE.
The LHE IPC nurses’ forum quarterly meetings have continued to support the
implementation of national and local IPC priorities across Shropshire and Telford and
provide an arena to identify and address risks in relation to IPC and ensure an integrated
approach is taken to develop good practice across organisational boundaries.
The monthly IPC team meeting with the consultant microbiologist is viewed as another
educational opportunity for the IPC nurses as is IPC nurses meeting with feedback from
meetings and study days a standing item on the agenda again to ensure information is
shared.
The team are members of IPS and the Healthcare Infection Society and receive weekly
emails with up to date National and International IPC guidance/alerts/memo’s etc. Monthly
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journals are received which are a valuable medium for acquiring evidence-based up to date
research and ensures best practice is used when writing policies. Within the team the
monthly journal club has continued where a peer reviewed journal article is discussed.
The IPC team have maintained compliance with the mandatory training programme.
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Section Five: Hand Hygiene
Effective and timely hand decontamination is acknowledged as the most important way of
preventing and controlling infections. The IPC team continued its concerted efforts to ensure
that hand hygiene compliance remained a high priority.
Training on the importance of hand hygiene, being ‘bare below the elbow’ and the WHO
‘5 moments for hand hygiene’, was provided locally to new clinical staff on induction and was
reinforced by members of the IPC team at all IPC training events, during clinical visits and
whilst auditing.
Hand Washing Assessments
In 2012 a local peer assessment of hand washing technique was introduced and has
continued since for all new staff within one week of commencement of employment, with ongoing yearly assessment for existing staff. Assessments were undertaken by trained,
competent assessors within the area or department. Failed assessments were reported to
the ward manager/team leader and repeated within the week. In the event of a second
failed assessment it would be reported to the IPC team. Reassuringly, there were no such
reports. A ‘Healthy Hands’ educational leaflet was given to the member of staff at the time
of the assessment and the assessment record was retained by the service manager and a
copy given to the staff member. Hand washing assessments are included in clinical areas’
reports to the IPC Meeting.
A number of hand hygiene ‘train the assessor’ sessions were delivered by the IPC team ad
hoc when identified that it was required. The support was important to the clinical staff in
their role as an assessor, as it is it vital to ensure that all assessments are consistent and
subject to the same protocol and standard.
Hand Hygiene Observational Audit
The IPC Link Staff continued to undertake monthly hand hygiene observational audits in all
four community hospitals wards and ensured the compliance scores were displayed on the
IPC notice boards. If compliance fell below 95%, weekly audits were required until 95%
compliance was achieved. Hand hygiene verification observations were undertaken by the
IPC team to ensure compliance was reported correctly and assisted poorly performing areas
by reinforcing hand hygiene messages with ad hoc training. The observations identified the
staff group to enable feedback to be specific to the group who were not complying and to
assist IPC to focus training where required. This year, agency staff were included as a
separate category in the hand hygiene audit and this has enabled ward managers to discuss
poor compliance direct with the agency. Results of the audits were monitored by the CSMs
and reported to the IPC Meeting and the Quality and Safety Committee. Hand hygiene audit
results undertaken by the link staff are recorded in Table 9. Those undertaken by IPC
nurses are shown in Table 10.
Infection Prevention Control Annual Report 2014/15
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Table 9: Community Hospital Hand Hygiene Audits undertaken by Link Staff 2014/15
Apr
14
May
14
June
14
July
14
Aug
14
Sept
14
100%/
86%
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
Bishops
100% 100% 100% 100% 100%
***
***
***
***
***
Castle
Bridgnorth
77%/
90%
80%*
**
100
90
100%
Female
76%*
100% 100%
100%
100%
Bridgnorth
77%/
90%
60%*
**
100
90
96%
Male
76%*
Ludlow
****
****
****
****
****
****
****
****
**** 100% 100%
Dinham
Ludlow
****
****
****
****
****
**** 100% 100% ****
**** 100%
Stretton
Whitchurch
Not
100% 100% 100% 100% 100% 100% 100%
100% 100% 100%
Team 1
done
Whitchurch
100%/
100% 100% 100% 100% 100% 100%
100% 100% 100% 100%
Team 2
97%
*Redone until 100%
**A gap in Sept was when both infection control nurses were off for long term sickness and leave. This has
been addressed and senior staff will undertake if the situation arises again.
***Data not available – both link staff left and have not yet been replaced.
****Data not available
***
96%
96%
100%
100%
100%
100%
Table 10: Community Hospital Hand Hygiene Audits undertaken by IPC nurse 2014/15
Apr
14
Bishops
Castle
Bridgnorth
Female
Bridgnorth
Male
Ludlow
Dinham
Ludlow
Stretton
Whitchurch
Team 1
Whitchurch
Team 2
May
14
June
14
July
14
71%
Aug
14
Sept
14
89%
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
100%
80%
60%
86%
100%
100%
80%
80%
100%
100%
100%
100%
N/A
100%
100%
N/A
100%
100%
100%
Mar
15
100%
88%
90%
100%
100%
100%
90%
Performing regular observational hand hygiene audits within community based services has
proved a significant challenge; however the IPC Link Staff have used the hand washing
assessment to ensure staff are compliant with the hand washing technique.
Bare Below the Elbows
SCHT’s uniform policy and dress code promotes the bare below the elbow protocol in that to
ensure effective hand hygiene while working clinically, all staff MUST be ‘bare below the
elbow’. This message continues to be reinforced through IPC mandatory and bespoke
training and is monitored during IPC audits.
Infection Prevention Control Annual Report 2014/15
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Section Six: 2014/15 Infection Prevention and Control Team
Audit Programme
As in previous years audit continued to be an important activity that assists the monitoring
and improvement of practice. In total 82 audits were undertaken in the community hospitals
and 25 in community services. The objectives of the audits were to inform services of their
level of compliance to national IPC standards, local policies and procedures and allow
improvements to be made based upon the findings. It also identified target areas for
training. A rolling programme of IPC audit was developed and implemented in clinical and
non-clinical areas, using the adapted DH/IPS audit tools. A baseline audit was undertaken
when new services were developed or relocated. The results were used to determine the
frequency services will be re-audited. See Appendices 1 and 2 for the audit programme and
compliance scores for community hospital audits and community services audits.
Overall Score and Compliance Rating
For the purpose of these audits the aim is for a 100% compliance score. A SIP is generated
for scores of less than 100%.
Reporting and Monitoring
At the time of audit the IPC nurse verbally reported any areas of concern and of good
practice to the member of staff accompanying them and or the person in charge at the time
of the audit. A written summary report and detailed recommendations in the form of a SIP
was developed by the IPC nurse within two weeks and shared with the relevant clinical area
and manager for action. Support from the IPC team was offered to implement changes
required to improve practice.
Services were requested to return the completed SIP within two weeks to the IPC nurse,
detailing the actions taken and a timescale for completing any outstanding actions. Progress
was monitored locally and reported to the IPC meeting.
Summary of audit findings and actions taken:
The compliance scores remain variable, confirming that further work must continue to
improve and sustain IPC standards. However, it should be recognised that some areas did
achieve 100% compliance and generally improvements made in all areas on subsequent
visits have been noted. Staff have been receptive to discussion and comment, and the SIP
completed and findings addressed.
The standard most frequent to be found non-compliant was the hand washbasins which had
a buildup of limescale and or were not in a good state of repair. A separate audit covering
these was undertaken and a report submitted to the December IPC Meeting and all noncompliant areas added to the risk register.
An in-depth analysis of the community hospitals’ Prevention of HCAI audit findings is shown
in Appendix 4.
Self-audits/checklists
IPC have encouraged the use of the audit/checklist by ward staff as an aide memoire when
commencing isolation and on urinary catheter insertion etc. The intention is that any issues
identified are addressed immediately to ensure safety for the individual patient and other
patients and staff. For example if there is no single patient use blood pressure cuff in source
Infection Prevention Control Annual Report 2014/15
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isolation one is provided there and then. See Appendix 5 for details of self-audits
undertaken by ward staff. Self-audits/checklists undertaken:





Hand Hygiene Observations
Urinary Catheter
Isolation Practices - at time of isolation
Vascular Access Device - at time of insertion
Enteral Feeding
Infection Prevention Control Annual Report 2014/15
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Section Seven: Looking Forward to 2015/16
An Overview of Infection Prevention and Control Programme 2015/16
This section gives an oversight of the work planned to prevent and control infections in
2015/16 and to achieve external targets and comply with the Code of Practice on the
prevention and control of infections. It is designed to reflect SCHT’s Quality Strategy for
2015-2018 to deliver care that is clinically effective; care that is safe; and care that provides
a positive experience for patients as possible. The programme is also developed to deliver
the objectives in the newly agreed LHE IPC 2015-2018 Strategy which will provide a system
wide innovative vision for infection prevention and control for the next three years.
The key aims in 2015/16 will be to build on the work that has been done in previous years to
prevent HCAIs, and improve the lives of the people who come into contact with SCHT
services. Patient safety is at the heart of IPC, and to ensure our work is sustainable, SCHT
promotes that every member of staff takes responsibility for IPC in order that that no person
is harmed by a preventable infection.
Our focus will be to:
 Strengthen governance around estates, decontamination and water quality
 Achieve zero tolerance for MRSA bacteraemia
 Achieve local reduction target for CDIs
 Support wards to achieve a compliance rate of over 95% for MRSA screening
 Manage and control antibiotic-resistant bacterial infections
 Review IPC, clinical and estates polices in line with review dates, revised national
guidance and as a result of incidents and RCA/PIR
 Deliver IPC team 2015/16 Audit Programme. See Appendix 6
 Continue to review the audit programme regularly to ensure that the audit is
meaningful and helpful in generating best practice
 Enhance local monitoring and self-checklists of IPC practice using adapted tools
 Continue to promote the Check to Protect IPC peer assessment and competencies
 Challenge existing assurance mechanisms and validate self-assessment and
provide local support to areas of poor performance
 Continue to develop and support the role of the IPC Link Staff by planning an
annual IPC study day
 Develop and review IPC patient/public information leaflets in line with review dates
or revised national guidance
 Deliver IPC training on Core Mandatory Training and Induction days
 Deliver bespoke IPC training as need identified
 Support SCHT to deliver the Safe Care Shropshire Project in relation to CAUTIs
 Maintain high standards of hand hygiene
 Improve the monitoring of hand hygiene compliance
 Support SCHT to comply with European Directive 2010/32/EU sharps safety
devices
 In collaboration with SCHT Medicines Management, continue to monitor antibiotic
prescribing in community hospitals and implement the national 5-year strategy for
antimicrobial resistance
 In collaboration with SaTH, review the possibility of a commercial surveillance
system that facilitates more effective identification / prevention of infections
 Undertake SSI surveillance following hand surgery at Bridgnorth Day Surgery Unit
 Washable computer keyboards to be implemented in higher risk clinical areas
 Continue to provide telephone support to all SCHT Staff
Infection Prevention Control Annual Report 2014/15
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
Timely review and follow up microbiology laboratory reports
2015/16 Local Infection Prevention and Control Objectives as agreed with
Commissioners
2015/16 Infection Targets
The local infection targets agreed for 2015/16 are:
 MRSA bacteraemia – Zero tolerance
 Post 72 hrs Clostridium difficile infection – no more than two cases diagnosed on
the third day or later of an admission to one of the four community hospitals (where
the day of admission is day one)
2015/16 IPC Key Performance Indicator (KPI)
In line with SaTH, SCHT continue to undertake MRSA screening for all relevant elective and
emergency admissions.

MRSA screening – Threshold of 97% (increased from 95%) of all admissions to
community hospitals
Other KPI’s
 Compliance with Trust hand hygiene policy - Threshold of 95%
 Compliance with IPC checklists (adapted from the high impact interventions) Threshold of 95%
 Compliance with national environmental and equipment cleaning standards
(Publicly Available Specification (PAS) 5748:2011) /and local cleaning protocols.Threshold of 95%
Infection Prevention Control Annual Report 2014/15
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Section Eight: Glossary of Terms
AER
Automated Endoscopy Reprocessor. A specialised machine for
washing and disinfecting endoscopes
APCS
Advanced Primary Care Services
Bacteraemia
A bloodstream infection
ENT
Ear Nose and Throat
Care Quality
Commission
(CQC)
The CQC is the independent regulator of health and social care in
England. It regulates health and adult social care provided by the NHS,
local authorities, private companies and voluntary organisations.
CAUTI
Catheter Associated Urinary Tract Infection
CCGs
SCCCG and
TWCCG
Clinical Commissioning Group. The two commissioning organisations
in Shropshire and Telford & Wrekin are Shropshire Clinical
Commissioning Group and Telford and Wrekin Clinical Commissioning
Group.
CDI
Clostridium difficile infection. Clostridium difficile is a bacterium which
lives harmlessly in the intestines of many people. Clostridium difficile
infection most commonly occurs in people who have recently had a
course of antibiotics. Symptoms can range from mild diarrhoea to a lifethreatening inflammation of the bowel.
CHEG
Community Hospital Environment Group
CQC
Care Quality Commission
CPE
Carbapenemase-producing Enterobacteriaceae. Enterobacteriaceae
are a large family of bacteria that usually live harmlessly in the gut of all
humans and animals. They are also some of the most common causes
of opportunistic urinary tract infections, intra-abdominal and
bloodstream infections. They include species such as Escherichia coli,
Klebsiella spp. and Enterobacter spp. Carbapenems are a group of
antibiotics normally reserved for serious infections caused by drugresistant Gram-negative bacteria (including Enterobacteriaceae).
Carbapenemases are enzymes that destroy carbapenem antibiotics,
conferring resistance.
CSM
Clinical Services Manager
CSSD
Central Sterile Services Department
D&V
Diarrhoea and vomiting
DH
Department of Health
Director of Infection Prevention & Control
DIPC
E.coli
Escherichia coli. E. coli is the name of a type of bacteria that lives in
the intestines of humans and animals
ESBL
Extended-Spectrum Beta-Lactamases are enzymes that can be
produced by bacteria making them resistant to many of the commonly
prescribed antibiotics
Glycopeptide-Resistant Enterococci/Vancomycin Resistant
Enterococci. Enterococci are bacteria that are commonly found in the
bowels/gut of most humans. There are many different species of
GRE/VRE
Infection Prevention Control Annual Report 2014/15
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HCAI
enterococci but only a few that have the potential to cause infections in
humans and have become resistant to a group of antibiotics known as
Glycopeptides; these include Vancomycin. Patients who have already
taken many antibiotics are more at risk of acquiring GRE/VRE due to
the more bacteria is exposed to antibiotics, the more likely they are to
develop ‘resistance’ to that antibiotic.
Healthcare Associated Infection
HEPA filter
High Efficiency Particulate Air filter
IPC
Infection Prevention and Control
IPS
Infection Prevention Society
MIU
Minor Injuries Unit
MRSA
Meticillin Resistant Staphylococcus aureus. Any strain of
Staphylococcus aureus that has developed resistance to some
antibiotics, thus making it more difficult to treat.
MSSA
Meticillin Sensitive Staphylococcus aureus. Staphylococcus aureus is
a bacterium that commonly colonises human skin and mucosa (e.g.
inside the nose) without causing any problems. It most commonly
causes skin and wound infections.
OD
Organisational Development
OHS
Occupational Health Service
PEAT
Patient Environment Action Team
PHE
Public Health England
PII
Period of Increased Incidence
PIR
Post Infection Review
PLACE
Patient Led Assessment of the Care Environment
PPE
Personal Protective Equipment e.g. gloves, aprons and goggles
RCA
Root Cause Analysis
SaTH
Shrewsbury and Telford Hospital NHS Trust
SCHT
Shropshire Community Health NHS Trust
SIGHT
Suspect, Isolate, Gloves and Aprons, Hand washing, Test for Toxins
SI
Serious Incident
SIP
Service Improvement Plan
SSSFT
Shropshire and South Staffordshire NHS Foundation Trust
TDA
Trust Development Authority
TOR
Terms of Reference
WHO
World Health Organisation
Infection Prevention Control Annual Report 2014/15
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Appendix 1: 2014/15 Community Hospital Audit Programme undertaken by the IPC team
Bishops Castle Community Hospital
2014/15 Audit Programme
Area
Audit Tool
Quarter 1
Apr-14
May-14 Jun-14
Quarter 2
Jul-14
Aug-14 Sep-14
Quarter 3
Oct-14
Nov-14 Dec-14
HCAI Prevention
81%
81%
95%
Hand Hygiene Observations
Previous quarter HCAI SIP
Verification
HCAI Prevention
71%
89%
100%
Quarter 4
Jan-15
Feb-15
Mar-15
80%
Bishops Castle
Physio Dept
Key:
Verified
Verified
Verified
Verified
95%
Unable to assess due to patient group
Audit completed for this quarter
Infection Prevention Control Annual Report 2014/15
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Bridgnorth Community Hospital
2014/15 Audit Programme
Area
Audit Tool
Quarter 1
Apr-14
May-14
HCAI Prevention
Bridgnorth
Male Ward
Jun-14
80%
Aug-14
Quarter 3
Sep-14
Verified
09/05/2014
60%
Hand Hygiene Observations
80%
Verified
09/05/2014
Quarter 4
Dec-14
Feb-15
Mar-15
94%
100%
100%
96% 96%
Verified
16/10/2014
Verified
22/01/15
83%
100%
Verified
28/07/2014
Jan-15
83%
84%
30% / 80%
Nov-14
86%
Verified
28/07/2014
85%
Oct-14
85%
79%
HCAI Prevention
Previous quarter HCAI SIP
Verification
Jul-14
82%
Hand Hygiene Observations
Bridgnorth
Female Ward Isolation
Previous quarter HCAI SIP
Verification
Quarter 2
86%
100%
Verified
16/10/2014
100%
Verified
22/01/15
Invasive Procedures
14/01/2015
Endoscopy/Cystoscopy
22/01/2015
98%
Day Surgery
HCAI Prevention
99%
91%
MIU/OPD
Colorectal
ENT Clinic
Nasendoscope
Physio Dept
HCAI Prevention
X-ray
HCAI Prevention
Occupational HCAI Prevention
Therapy
Key:
70%
100%
Building
work
Building
work
95%
62%
98%
90%
Unable to assess due to patient group
Audit completed for this period
Infection Prevention Control Annual Report 2014/15
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Ludlow Community Hospital
2014/15 Audit Programme
Area
Audit Tool
Quarter 1
Apr-14 May-14
HCAI Prevention
Ludlow Dinham
Hand Hygiene Observations
Ward
Previous quarter HCAI SIP
Verification
HCAI Prevention
Hand Hygiene Observations
Ludlow
Previous quarter HCAI SIP
Stretton Ward Verification
Quarter 2
Jun-14
Quarter 3
Jul-14 Aug-14 Sep-14
Oct-14
Quarter 4
Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
90%
92%
93%
88%
100%
N/A
100%
88%
Verified
Verified
Verified
Verified
92%
89%
92%
100%
N/A
90%
Verified
Verified
Verified
Isolation
85%
MIU/OPD
HCAI Prevention
MIU
Colo-Rectal
ENT Clinic
Nasendoscope
Physio OPD
HCAI Prevention
Physio In-Pt
HCAI Prevention
Continence
Services
HCAI Prevention
92%
X-Ray
HCAI Prevention
93%
93%
Verified
100%
(Ward)
89%
89%
92%
94%
91%
86%
N/A: Not applicable to undertake HHOTs with insufficient patient and staff numbers during refurbishment
Key:
Unable to assess due to patient group
Audit completed for this quarter
N/A: Not applicable to undertake HHOTs with insufficient patient and staff numbers during refurbishment
Infection Prevention Control Annual Report 2014/15
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Whitchurch Community Hospital
2014/15 Audit Programme
Area
Audit Tool
Quarter 1
Apr-14
Whitchurch
Team 1
Jun-14
Jul-14
Quarter 4
Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
99%
89%
98%
91%
Hand Hygiene Observations
100%
100%
100%
100%
Verified
Verified
Verified
Verified
HCAI Prevention
94%
92%
94%
93%
Hand Hygiene Observations
100%
100%
100%
90%
Previous quarter HCAI SIP
Verification
Verified
Verified
MIU/OPD
HCAI Prevention
86%
ENT Clinic
Nasendoscope
77%
Physio Dept
HCAI Prevention
X-Ray
HCAI Prevention
Key:
Quarter 3
HCAI Prevention
Previous quarter HCAI SIP
Verification
Whitchurch
Team 2
May-14
Quarter 2
Verified
Verified
79%
81%
Unable to assess due to patient group
Audit completed for this quarter
Infection Prevention Control Annual Report 2014/15
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Appendix 2: 2014/15 Community Services Audit Programme
Community Services
2014/15 Audit Programme
Service
Location
Audit Tool
Quarter 1
Apr-14
May-14
Quarter 2
Jun-14
Jul-14
Aug14
Quarter 3
Sep-14
Oct-14
Nov-14
Quarter 4
Dec-14
Jan-15
Limeswalk
Invasive
Procedures
95%
Bridge School
HCAI Prevention
95%
Monkmoor
Centre
HCAI Prevention
Ludlow CH
HCAI Prevention
Whitchurch CH
HCAI Prevention
Portico House
HCAI Prevention
Burlington
Place
HCAI Prevention
Oswestry Health
Centre
Decon of
Nasendoscopes
100%
Gateway Craven
Arms
HCAI Prevention
90%
Rapid
Response,
Halesfield
HCAI Prevention
Oswestry Health
Centre
HCAI Prevention
Minor Injuries
Oswestry Health
Centre
HCAI Prevention
Occupational
Health
Gains Park
Shrewsbury
HCAI Prevention
APCS
Children's
Services
Continence
Service
Community
Substance
Misuse Team
ENT Clinics
Integrated
Community
Teams
Feb-15
Mar-15
80%
92%
100%
84%
90%
82%
90%
100%
94%
Infection Prevention Control Annual Report 2014/15
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Physiotherapy
Clinics
Market Drayton
HCAI Prevention
Newport
HCAI Prevention
Wem
HCAI Prevention
88%
HCAI Prevention
80%
Hummingbird
Centre
Newport Linden
Hall
Podiatry
Prison
Wheelchair
and Posture
Services
Neuro
Rehabilitation
Team
82%
HCAI Prevention
Market Drayton
HCAI Prevention
Shawbury
HCAI Prevention
Wellington
HCAI Prevention
Woodside
HCAI Prevention
HMP Stoke
Heath
Shropshire
Rehabilitation
Centre
Lancaster Road
Shropshire
Rehabilitation
Centre
Lancaster Road
81%
HCAI Prevention
HCAI Prevention
HCAI Prevention
93%
83%
89%
92%
90%
SIP
Verified
51%
79%
SIP
Verified
85%
Infection Prevention Control Annual Report 2014/15
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Appendix 3: 2014/15 Community Hospital Cleanliness Audit Scores
Bishops Castle Cleanliness Audits 2014-15
110
105
100
95
90
85
80
Nursing
75
Domestics
70
Estates
65
60
55
50
%
Bridgnorth Cleanliness Audits 2014-15
110
105
100
95
90
85
80
Nursing
75
Domestics
70
Estates
65
60
55
50
Infection Prevention Control Annual Report 2014/15
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%
Ludlow Cleanliness Audits 2014-15 - Dinham
Ward
110
105
100
95
90
85
80
Nursing
75
Domestics
70
Estates
65
60
55
50
%
Ludlow Cleanliness Audits 2014-15 - Stretton
Ward
110
105
100
95
90
85
80
Nursing
75
Domestics
70
Estates
65
60
55
50
Infection Prevention Control Annual Report 2014/15
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%
Whitchurch Cleanliness Audits 2014-15 - Team 1
110
105
100
95
90
85
80
Nursing
75
Domestics
70
Estates
65
60
55
50
%
Whitchurch Cleanliness Audits 2014-15 - Team 2
110
105
100
95
90
85
80
Nursing
75
Domestics
70
Estates
65
60
55
50
Infection Prevention Control Annual Report 2014/15
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Appendix 4: Analysis of HCAI Audits in Community Hospitals
HCAI audits undertaken in Community Hospitals
April 2014 – March 2015
A total of 42 Prevention of HCAI audits were undertaken in the four community hospitals. Table 1
below shows the number of instances each question was answered “no” in these audits and where
they occurred. As discussed on page 42 the question most frequently answered “no” was regarding
hand washbasins being clean and in a good state of repair
Those which always answered yes are shown in Table 2.
Table 1 – number of times each question answered “no” and where they occurred
Total
answered Question
‘No’
2 x Bishops Castle Ward
4 x Bridgnorth Female Ward
4 x Bridgnorth Male Ward
1 x Bridgnorth Physio
1 x Bridgnorth MIU
1 x Bridgnorth Occupational
Therapy
1 x Bridgnorth x-ray
2 x Ludlow Dinham
Are hand washbasins accessible, in a good state of
4 x Ludlow Stretton
30
repair visibly clean and free from mould, limescale
1 x Ludlow MIU
and extraneous items?
1 x Ludlow Outpatients
Physio
1 x Ludlow in-patient physio
1 x Ludlow x-ray
1 x Ludlow Continence Unit
1 x Whitchurch X-Ray
2 x Whitchurch Team 1
1 x Whitchurch Team 2
1 x Whitchurch Physio
3 x Bishops Castle
4 x Bridgnorth Female Ward
Is all furniture visibly clean, intact and made of
4 x Bridgnorth Male Ward
15
impervious material?
2 x Whitchurch Team 1
1 x Whitchurch Team 2
1 x Whitchurch MIU
1 x Bishops Castle
2 x Bridgnorth Female Ward
2 x Bridgnorth Male Ward
Are SENDS available and staff have been trained
1 x Ludlow Dinham
11
how to use?
2 x Ludlow Stretton
1 x Whitchurch MIU
1 x Whitchurch Team 1
1 x Whitchurch Team 2
1 x Bishops Castle
Are toilets visibly clean, in a good state of repair
3 x Bridgnorth Female
9
and free from extraneous items?
3 x Bridgnorth Male
2 x Whitchurch Team 2
2 x Bridgnorth Female
8
Is the sluice free from extraneous items?
2 x Ludlow Stretton
Infection Prevention Control Annual Report 2014/15
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8
Are bathrooms/showers and equipment visibly
clean and the area free from extraneous items?
8
Are examination trolleys/couches/plinths/chairs
visibly clean and in a good state of repair?
2 x Ludlow Dinham
1 x Whitchurch Team 1
1 x Whitchurch MIU
1 x Bishops Castle
2 x Bridgnorth Female Ward
2 x Bridgnorth Male Ward
1 x Ludlow Dinham
1 x Whitchurch Team 2
1 x Whitchurch Team 1
1 x Bishops Castle
2 x Bridgnorth
2 x Bridgnorth Male
1 x Whitchurch X-Ray
1 x Whitchurch MIU
1 x Whitchurch Physio
Table 2 - Questions which were ALWAYS answered “yes”
Question
Are hand hygiene products available and in date, including alcohol hand gel, liquid soap
and paper towels and detergent hand wipes?
Is alcohol hand gel available for use in the patients' bed space
Are hand wipes available for patients?
Is personal protective equipment available, accessible and stored appropriately?
Is there a range of sizes of sterile and non-sterile powder free gloves available?
Are waste bins enclosed, lidded and foot pedal operated?
Are staff aware of the procedure for managing an inoculation contamination injury?
Is there a mechanism to ensure that toilet cleaning can be carried out as needed?
Are the commodes in good condition?
Are all sterile products stored above floor level?
Are sterile products sealed, in date and undamaged?
Can staff describe the symbol used to indicate single use items?
Is there a designated deep sink for washing used equipment?
Are bedpans and urinals clean, in good condition and stored correctly to minimise
contamination?
Is the macerator in working order and clean?
Is the cleaner’s cupboard visibly clean, tidy and free from extraneous items?
Is the storage area/trolley visibly clean and free from extraneous items?
Is used linen placed in linen bags at the point of use and not carried by staff
There are no extraneous items in the ward kitchen
Is there a hand washbasin with the appropriate products available?
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Are green aprons used for handling/serving food?
Are fridge temperatures recorded on a daily basis and within appropriate ranges?
Are cleaning/disinfectant products available and easily accessible for decontamination?
Is the pulse oximeter visibly clean?
Are all stethoscopes visibly clean?
Are bladder scanners visibly clean?
Is blood glucose monitoring equipment visibly clean?
Are monitoring leads/straps decontaminated between patients?
Are tourniquets single-use?
Is the resuscitation trolley/equipment in date, clean, free from dust and in a good state of
repair?
Is the suction machine visibly clean and dry?
Are manual handling slings/sheets single patient use or laundered after use?
Are PAT (Patient Assisted Transfer) slides visibly clean and stored appropriately?
Are aids such as walking sticks, zimmer frames, helping hands visibly clean and stored
in a suitable area?
Are examination trolleys/couches/chairs visibly clean and in a good state of repair?
Are reusable patient wash bowls visibly clean and in a good condition?
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Appendix 5: 2014/15 Community Hospital Self-Audit Scores
Bishops Castle Community Hospital
2014/15 Self Audits
Area
Audit Tool
Quarter 1
Apr-14
Hand Hygiene Observations
Bishops
Castle
100%
Quarter 2
May-14 Jun-14
100%
100%
Jul-14
100%
Aug-14 Sep-14
100%
100%
86%
100%
100%
Quarter 3
Oct-14
Nov-14 Dec-14
Quarter 4
Jan-15
Feb-15
96%
100%
Mar-15
Urinary Catheter
Isolation Practices - at time of isolation
88%
97%
Vascular Access Device - at time of insertion
Enteral Feeding
Key:
Key
100%
Unable to assess due to patient group
Audit completed for this quarter
Unable to audit due to patient group
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Bridgnorth Community Hospital
2014/15 Self Audits
Area
Audit Tool
Quarter 1
Apr-14
Hand Hygiene Observations
Quarter 2
May-14 Jun-14
Jul-14
Quarter 3
Aug-14 Sep-14
77%
76%
90%
Bridgnorth Urinary Catheter
- Male
Isolation Practices - at time of isolation
Oct-14
100%
Quarter 4
Nov-14 Dec-14
Feb-15
100%
Mar-15
96%
100%
87%
73%
100%
Jan-15
3 x100%
100%
100%
100%
Vascular Access Device - at time of insertion
Enteral Feeding
88%
Apr-14
Hand Hygiene Observations
Bridgnorth Urinary Catheter
- Female
Isolation Practices - at time of isolation
May-14 Jun-14
90%
Jul-14
Aug-14 Sep-14
77%
76%
Oct-14
100%
Nov-14 Dec-14
97%
90%
Feb-15
100%
96%
90%
Mar-15
96%
100%
100%
86%
98%
Jan-15
100%
2 x 98%
100%
100%
100%
Vascular Access Device - at time of insertion
Enteral Feeding
Key
Key:
Unable
duetotopatient
patientgroup
group
Unableto
to assess
audit due
Audit completed for this quarter
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Ludlow Community Hospital
2014/15 Self Audits
Area
Audit Tool
Quarter 1
Apr-14
May-14 Jun-14
Quarter 2
Jul-14
Quarter 3
Aug-14 Sep-14
Oct-14
Nov-14 Dec-14
Quarter 4
Jan-15
Feb-15
Mar-15
Hand Hygiene Observations
Urinary Catheter
Ludlow Dinham
97%
Isolation Practices - at time of isolation
94%
92%
95%
87%
100%
100%
Vascular Access Device - at time of insertion
Enteral Feeding
100%
88%
100%
Apr-14
May-14 Jun-14
Jul-14
Aug-14 Sep-14
Oct-14
Nov-14 Dec-14
Jan-15
Feb-15
Mar-15
Hand Hygiene Observations
Ludlow Stretton
Urinary Catheter
Isolation Practices - at time of isolation
Vascular Access Device - at time of insertion
100%
95%
2 x 100%
96%
100%
Enteral Feeding
Key
Key:
Unableto
to assess
audit due
Unable
duetotopatient
patientgroup
group
Audit completed for this quarter
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Whitchurch Community Hospital
2014/15 Self Audits
Area
Audit Tool
Quarter 1
Apr-14
Hand Hygiene Observations
100%
Quarter 2
May-14 Jun-14
100%
100%
Jul-14
100%
Quarter 3
Aug-14 Sep-14
100%
100%
Oct-14
Nov-14 Dec-14
100%
Urinary Catheter
Quarter 4
100%
94%
Whitchurch
- Team 1 Isolation Practices - at time of isolation
100%
98%
100%
100%
100%
100%
100%
Jan-15
Feb-15
Mar-15
100%
100%
100%
100%
100%
100%
98%
98%
100%
100%
100%
96%
100%
98%
100%
Vascular Access Device - at time of insertion
Enteral Feeding
88%
Apr-14
Hand Hygiene Observations
Urinary Catheter
Whitchurch
- Team 2 Isolation Practices - at time of isolation
100%
May-14 Jun-14
100%
100%
100%
Jul-14
100%
Aug-14 Sep-14
100%
100%
Oct-14
100%
97%
95%
Nov-14 Dec-14
100%
Jan-15
100%
100%
98%
100%
100%
100%
100%
Feb-15
Mar-15
100%
100%
100%
100%
100%
100%
100%
Vascular Access Device - at time of insertion
Enteral Feeding
Key:
100%
100%
Unable to assess due to patient group
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Appendix 6: Infection Prevention and Control Team 2014/15 Audit Programme
INFECTION PREVENTION AND CONTROL TEAM
2015/16 AUDIT PROGRAMME
Location
Quarterly Audits
Bishops Castle Community
Hospital Ward
Bridgnorth Community Hospital
Male and Female Wards
Ludlow Community Hospital
Dinham and Stretton Wards
Whitchurch Community Hospital
Team One and Team Two
Quarterly Alternate Audits and Verification of Service Improvement
Plan
Quarterly Alternate Audits and Verification of Service Improvement
Plan
Quarterly Alternate Audits and Verification of Service Improvement
Plan
Quarterly Alternate Audits and Verification of Service Improvement
Plan
Service
Annual Audits
Advanced Primary Care
Services
Children’s Services
Continence Service
DAART
Integrated Community Teams
Minor Injuries Unit
Physiotherapy
Podiatry
Prison
School Nurses
Marysville
Rheumatology, Hollinswood
Oswestry Health Centre
Euston House
Severndale School
Phoenix School
Bridgnorth, Northgate
Radbrook
RJAH, Oswestry
RSH, Shrewsbury
Bridgnorth, Northgate
Broseley/Much Wenlock
Oswestry
Bridgnorth Community Hospital
Ludlow Community Hospital
Whitchurch Community Hospital
Oswestry Health Centre
Broseley
Princess House
Bayston Hill
Clive
Hadley
Marden
Market Drayton
Pontesbury
Princess House
South Hermitage
HMP Stoke Heath (to include the Dental clinic)
1 in Shrewsbury
1 in Telford and Wrekin
The audit programme is subject to amendments as need identified
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