Director of Infection Prevention and Control...Page 5 of 27 Director of Infection Prevention and...

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Director of Infection Prevention and Control, Annual Report 2018-19. Final copy 27th June 2019. Joanna Craven.

Director of Infection Prevention and

Control

Annual Report 2018/19

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1. Executive summary……………………………………………………………………p3

2. Action plan review (2018/19).………..…………………………………..…….…….p6

3. Achievements………………………………………………………………………….p6

4. Audits and action plan………………………………………………………………...p7

5. Vehicles………………………………………………………………………………...p8

6. Buildings………………………………………………………………………………..p9

7. Individual hygiene……………………………………………………………..………p11

8. Flu………………………………………………………..……………………………..p13

9. Education…………………………………………………………..…………………..p13

10. Adverse incidents…..……………………………………………..…………………..p14

Appendix 1………………………………………………………………………………..p17

Appendix 2 ……………………………………………………………………………….p18

Appendix 3 ……………………………………………………………………………….p19

Appendix 4 …………………………………………………………………………...…..p20

Appendix 5 ..………………………………………………………………………………p22

Appendix 6 ………………………………………………………………………………..p26

Contents

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South Central Ambulance Service NHS Foundation Trust (SCAS) was formed in 2006,

providing; 999 emergency services, non-emergency patient transport services (PTS), NHS

111 services, logistics and commercial services, and training services. The Trust covers

Berkshire, Buckinghamshire, Hampshire, Oxfordshire, Surrey and Sussex, serving a

residential population of over seven million. SCAS employs over 3,300 clinical and non-clinical

staff who are supported by over 1,000 volunteers, with a fleet of over 600 vehicles and 108

buildings.

The Trust is committed to the prevention and control of infectious diseases, minimising the

risks and impact of healthcare associated infections for patients, staff and the organisation

overall. The Health and Social Care Act (2008), defines a healthcare associated infection

(HCAI) as:

“Any infection to which an individual may be exposed or made susceptible (or more

susceptible) in circumstances where – a) Health care is being, or has been, provided to that

or any other individual, and b) The risk of exposure to the infection, or of susceptibility (or

1. Executive Summary

554,000

Urgent calls each year

608

Number of vehicles

1,144

Community First Responders

and Co-responders

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increased susceptibility) to it, is directly or indirectly attributable to the provision of the health

care.”

Little research has been conducted into HCAI’s as a direct result of ambulatory care, however

the risk is generally perceived as low. There are some activities that greatly increase the risk

of infection such as the use of needles and sharps. The Trust encourages an open reporting

culture for adverse incidents.

Within SCAS, the Chief Executive has overall accountability for ensuring that the Trust

maintains adequate and appropriate controls and procedures to minimise the risks of infection

to staff and patients. The prevention and control of HCAIs is designated as a core part of the

organisation’s governance and patient safety programmes. IPC is delegated through the

Board to the Director of Patient Care and given the role of Director of Infection Prevention and

Control (DIPC). The DIPC is further supported by the Infection Control Lead to embed IPC

practices Trust wide (see appendix 1 and 2).

The Trust also receives support from the microbiology team at the Queen Alexandra Hospital,

Portsmouth and the occupational health service, Team Prevent. SCAS are part of a wider

network of Infection Prevention and Control (IPC) groups sharing learning and developments

in IPC. These include; the Infection Prevention Society, Public Health England, National

Ambulance Service Infection Prevention and Control Group (NASIPCG), Thames Valley

Infection Prevention Group, Bucks Infection Control Committee, and the Oxfordshire Joint

Infection Control Committee (OJICC). The Trust Consultant Pre-Hospital Care Practitioner

represents SCAS at a number of sepsis groups.

SCAS IPC is regulated by Infection Control committees from our Clinical Commissioning

Groups (CCG), legislation, Care Quality Commission (CQC), Department of Health and NHS

England. Care should be based upon national standards, where they exist, and monitored

through the Trust’s clinical governance framework. Standards may be related to policy,

procedures and outcomes, and include the provision of high-quality facilities and standards of

practice. The Trust has taken measures to ensure that our policies and processes adhere to

the requirements and performance outlined by the following:

- Hygiene Code 2008

- CQC HCAI registration

- CQC, Fundamental Standards

- Department of Health HAIC Ambulance Guidelines

- Department of Health 2007 Saving lives: reducing infection, delivering clean and safe care

- Department of Health 2015 NHS Outcomes Framework 2015/16

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- Health and Social Care Act 2008 (Regulated Activities) Regulations 2015

- Health and Safety Executive advisory committee on dangerous pathogens

- NICE Guidelines

- EPIC 3 - National Evidence-Based Guidelines for Preventing Healthcare-Associated

Infections in NHS Hospitals in England

- Standard infection control precautions: national hand hygiene and personal protective

equipment policy (2019)

Compliance with relevant national and local standards, guidance and policies supports

effective infection prevention and control practice Trust-wide. Success depends on personal

accountability, skilled and competent staff, transparent and integrated working practices, and

clear management processes. IPC practice is integrated into each new employee’s induction

and is continued throughout their SCAS career with additional face to face training and e-

learning.

IPC compliance is monitored through a live online audit system currently focusing on individual

staff compliance, vehicle cleanliness and building cleanliness. Data from SCAS specific

systems is imported to Doc Works on a weekly basis to ensure staff, vehicle and building data

is accurate. Reminders are sent in email format to Team Leaders and individuals when audits

are due to expire or are required. Action plans are created when an element is found to be

non-compliant and automatic reminders are sent to Team Leaders.

Datix is a reporting system for untoward incidents including needlestick injuries, exposure to

body fluids and infectious diseases. SCAS promotes an open reporting culture and

encourages all staff to report IPC incidents.

IPC compliance and incidents are reported to the SCAS Patient Safety Group (PSG), and the

Health, Safety and Risk Group on a bimonthly basis. This ensures that all aspects of infection

control are reviewed by representatives of all services and that the risks are fully discussed,

lessons learnt and actioned where required. The PSG upwardly reports to the Trust’s Quality

and Safety committee.

This report has been developed by the Infection Control Lead on behalf of the Director of

Infection Prevention and Control (DIPC). It will highlight the development, progress and risks

across the Trust and the actions taken to prevent harm to the patients in our care during

2018/19. It will also provide assurance of the improvements made alongside the Health and

Social Care Act (2008) Code of Practice for the prevention and control of infection, the CQC

standards and the working environment for staff over the last twelve months.

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A detailed programme of work was outlined for 2018/19 in the form of an action plan. This

has been reviewed and provided as appendix 4.

April/May 2018 eCars (staff database) updated so individuals can see their own level of compliance

Cleaning specification updated – pilot sites trialled

June/July 2018 Tour-de-clutter commenced Trust wide

IPC logo created to improve visibility (appendix 3)

IPC risk assessments collated and introduced to audit

Significant increase in PTS vehicle audits completed

Discussion audits went live for non-patient facing staff

Zip lock bags for razors introduced to reduce injury to staff

August/September 2018

Two new buildings opened: Loverock Road opened (PTS) and Milton Park (Fleet)

Tour-de-clutter completed and received well. Stations deep cleaned.

October/November 2018

Flu vaccination campaign commenced with target of 75% uptake

December/January 2019

New Infection Control Lead commenced in post

February/March 2019 Hand Hygiene Roadshow commenced

PTS individual hygiene discussions reached 100%

IPC staff guide booklet printed and distributed

New building; White Knights (PTS), has gold standard sluice area

Southern House refurbished and now easier to clean

Flu vaccination campaign finished; uptake of 70%

SCAS hosted NAISIPCG

Cleaning contract specification approved

2. Action plan review (2018/19)

3. Achievements

Significant IPC achievements have been seen Trust wide in 2018/19, see table below.

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Prevention and control of infection is a fundamental part of keeping patients and staff safe.

IPC compliance is monitored through a live online audit system currently focusing on individual

staff compliance, vehicle cleanliness and building cleanliness. Action plans are created when

an element is found to be non-compliant.

The graph below shows the audit activity for Emergency and Urgent Care (E&UC) and PTS

over the last year. More audits were completed Trust wide in July and March corresponding

with increased communication between the IPC Lead and management.

Action plans are created when an element is found to be non-compliant and then assigned

to a member of staff to complete it. In 2018/19, 391 IPC related action plans were created, of

which 270 were closed. There are currently 121 action plans outstanding, either waiting to

be accepted or actioned, some dating back to April 2018. Further work will be completed in

this area in the new year (please see appendix 5).

Achievements in 2018/19

The Infection Control Lead has been working closely with the Doc Works team to gain

assurance that the data is accurate. Work continues to develop the action plan function and

has seen the addition of the ‘poke’ button. This feature compliments the reminder emails and

enables the Infection Control Lead to escalate the action to higher management.

Training has been given to PTS management to support them to complete audits. Further

training is expected to be delivered to E&UC and Churchill Support Services.

0

100

200

300

400

500

600

700

Audit Activity

Northern Cluster Southern Cluster PTS

4. Audits and action plans

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Monthly emails of audit activity and compliance are sent to E&UC and PTS management. The

email provides support and encouragement to the teams and has seen an increase in the

completion and compliance rates for IPC audits.

Actions for 2019/20

Please refer to appendix 5.

SCAS has a fleet of over 600 vehicles. Patient carrying vehicles are required to be audited

biannually to ensure they comply with Trust policy and standards for cleanliness, personal

protective equipment availability and IPC safety for both staff and patients.

The use of a ‘Make Ready’ service is embedded throughout the Trust. This helps SCAS to

consistently meet the required standards of cleanliness for IPC. Churchill Support Services

are contracted to clean (EU&C vehicles on a daily, weekly and 12 weekly ‘deep clean’ basis,

and ‘deep clean’ PTS vehicles every six weeks. A ‘deep clean’ is where all equipment and

consumables are removed and a thorough clean takes place before the vehicle is re-equipped

and put back into service. There is no daily make ready contract for PTS vehicles and the staff

are required to clean their vehicles at the end of their shift.

The graph above shows the amount of vehicle audits completed by E&UC (blue) and PTS

(orange) across the year. A target (grey) is set to complete a certain number of audits per

month to ensure each vehicle is audited bi-annually. The target is established by dividing the

total fleet number by six. Work is underway to increase the completion rate of vehicle audits.

020406080

100120140160180

Vehicle AuditsTarget vs Actual

E&UC Actual PTS Actual Target

5. Vehicles

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Work has been undertaken to combine the Churchill Support Services audit with the SCAS

vehicle audits. This will enable one audit to be completed and disseminated into two. Churchill

have agreed to complete these audits using the Doc Works app, 10% of which will be quality

checked by a Team Leader within 48 hours. SCAS will ultimately be responsible for ensuring

the completion of audits but, with the support of Churchill Support Services, the completion

rate of vehicle audits is expected to increase. The audit and app are ready to be introduced

once training has been facilitated.

Communication between the Infection Control Lead, Operations Support Desk, the Support

Services Manager, and Churchill Support Services has improved throughout the year. Weekly

emails are shared with details of vehicle deep cleans and a monthly meeting has been re-

established.

Actions for 2019/20


SCAS has a total of 108 buildings across their service area including two Clinical Control

Centre’s (CCC), E&UC and PTS stations, and education centres. Busy Bee Cleaning Services

(BBCS) has the contract to supply all premises cleaning, which commenced in April 2015.

Monthly client satisfaction cards are completed and returned to BBCS for them to monitor and

correct any deficiencies reported. All cleaning staff employed by BBCS are trained in IPC

measures and procedures by the external contractor.

All Resource Centres where E&UC and PTS operate, as well as stand-by points, are audited

against NHS standards every two months and Northern and Southern House headquarters

and CCCs, twice a year. The audits are completed locally by Team Leaders and Clinical

Mentors. Any standard that does not pass an audit question develops an action plan for that

non-compliance. This can be tracked to give assurance that the issue has been rectified or is

awaiting approval for completion. These action plans are subsequently monitored through the

PSG.

The graph below shows the number of building audits completed by E&UC (blue) and PTS

(grey) across the year. A target is set to complete a certain number of audits per month to

6. Buildings

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ensure each building is audited bi-monthly. The target is established by dividing the total

number of buildings in half.

The graph shows audit activity has fluctuated throughout the year but generally stays near to

the target line. Work has been untaken to increase the level of building audits completed.


BBCS cleaning contract has been extended to September 2019. Extensive work has been

undertaken to review the cleaning specification prior to being put out to tender. The new

specification provides a more detailed breakdown of what is expected from the cleaning

company. This work will provide a consistently improved standard of cleaning across the

organisation. Maybe expand using notes from Marie from meetings

The tour de clutter campaign was well received by staff and a repeat has been requested.

Skips were provided to stations for staff to clear out and dispose of unrequired items. This

enabled the cleaning company to thoroughly clean areas that may have previously been

covered.

Work continues to align the elements and frequency of the IPC building audits with the estates

audit and the health and safety audit. The group meet every six weeks and will be working

with Doc Works to facilitate this merger. Doc Works will create one ‘parent’ audit to be

completed rather than three individual audits. Post completion, Doc Works will disseminate

the information from the one audit in to the three topic areas. This will avoid duplicating

questions, increase organisation compliance and will be more time efficient.

0

5

10

15

20

25

30

35

Building AuditsTarget vs Actual

E&UC total E&UC target PTS PTS target

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PTS have seen the addition of two new buildings, one being described as the ‘gold standard’

for sluice areas. The Infection Control Lead has been working with the Estates Department to

develop a design guide that will be used as a reference for future building or refurbishment

work. Aspects of this new station will be included in this guide.

Staff have recently moved back into Southern House after a refurbishment. The staff have

highly praised these changes and state it is much easier to clean. Further plans to refresh

stations with new kitchens, sluices and paint will be ongoing throughout the coming year.

Milton Keynes and Bletchley stations will be moving into an exciting new hub shared with the

Fire Service.

Actions for 2019/20


SCAS employs over 3,000 clinical and non-clinical staff all of whom are responsible for IPC.

It is imperative that staff adopt best practice at all times in order to protect patients and each

other. To ensure IPC practices are met, staff are audited on an annual basis. The audit focuses

on hand hygiene, aseptic techniques, and disposal of sharps and waste.

The graph above shows the number of building audits completed by E&UC (blue) and PTS

(grey) across the year. A target is set to complete a certain number of audits per month to

ensure each employee is audited annually. The target is established by dividing the total

0

50

100

150

200

250

300

350

400

Individual Hygiene Observation AuditsTarget vs Actual

E&UC total E&UC target PTS PTS target

7. Individual Hygiene

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number of employees by 12. PTS have remained close to their target; however, E&UC have

fluctuated dramatically. Work has been undertaken to increase the level of audits completed.


Discussion audits were introduced last year for staff who are not patient facing (appendix 6).

This audit enabled staff to be audited without being observed. Further work has been carried

out this year to advise staff of this change. Guidance and support have been offered to

increase rate of completion. By year end PTS has 100% compliance for Individual Hygiene

Discussions.

Email reminders have been reinstated to identify when a staff member’s compliance is due to

expire. This places responsibility on the individual to remain compliant. In addition, Team

Leaders and Clinical Mentors are now able to see their team’s compliance on eCars. This is

to support a higher completion and compliance rate.

Effective hand decontamination is recognised as crucial in reducing avoidable infection. SCAS

wants to demonstrate a commitment to emphasising the importance of good hand hygiene

continuously across all services. The Hand Hygiene Roadshow has been rolled out across the

Trust to reinforce good IPC practice including; a presentation, a group quiz, and interactive

activities. A booklet has been produced to support the roadshow and for staff to keep as an

educational aid (appendix 7). The Infection Control Lead has attended Level 1 meetings and

team meetings for PTS and E&UC staff, and provided drop in sessions for Northern and

Southern House staff. The roadshow has been received well and will continue into the new

year.

A target was set at the beginning of the year for 95% of SCAS staff to be audited. By year end

73% of the Trust had received an observation audit; 100% of these were compliant. The graph

below show the completion of individual observation audits over the last three years.

0%

10%

20%

30%

40%

50%

60%

70%

80%

2016/17 2017/18 2018/19

39%54%

73%

Individual Hygiene Observation Audits

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A significant improvement has been seen in the completion rates since 2016. Work has

commenced to engage staff on light duties to increase the number of IPC audits completed.

Actions for 2019/20


The flu vaccination program commenced on 8 October 2018 (appendix 8). Prizes of Amazon

vouchers and echo dots were used as incentives and were received well by staff.

SCAS achieved 70% of frontline staff being vaccinated against a national target of 75%.

Therefore, SCAS will receive 75% of the Commissioning for Quality and Innovation payment.

This is almost a 7% increase from last year and a 19% increase compared to 2016/17.

A workshop was held in January to review what had worked well in the campaign, as well as

what the group had learnt and will change. Having fridges located in CCC’s enabled a wider

range of times that staff could be offered a vaccine; incentives were well received and staff

appreciated the weekly communications. Losses were less this year as vaccines were spread

over the SCAS footprint.

The use of Team Prevent giving vaccines in Surrey and Sussex requires further consideration

as uptake was poorer in these areas.

Vaccines for 2019/20 have been ordered along with some additional refrigerator equipment

(essential to maintain the cold chain). The training date for vaccinators has been booked for

September 2019. SCAS aspires to offer the flu vaccine to all staff. The consent form is being

reformatted as two separate forms in order to maximise data collection of numbers and

reasons of staff who decline the vaccine.

Actions for 2019/20


IPC training is included in the SCAS corporate induction provided to all new starters. The

training packages have been tailored for the various roles within SCAS and are delivered by

the Education department. The training is linked to Health Education England and national

8. Flu

9. Education

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standards and complies with the requirements of the CQC Fundamental Standards and the

Health and Social Care Act guidelines.

Employees remain up to date with IPC learning through mandatory e-learning modules.

Currently 95% of staff have completed the IPC e-learning, a 10% improvement from 2017/18.


To embed good IPC practice at the very beginning of their SCAS career the Infection Control

Lead has been attending and presenting at inductions. It has been recognised that new

employees feel valued when the subject matter expert is present during the induction process.

Work has started to develop a welcome day to compliment the current induction package. This

will enable each new beginner to meet the subject matter experts. The Infection Control Lead

is developing a fun and engaging presentation to encourage a positive IPC culture Trust- wide.

New employees are compliant after receiving the IPC induction. Work has been completed

with the education department and Doc Works to automatically create an Individual Hygiene

Observation audit. With an influx of new starters this should help support an increase in audit

completion.

Actions for 2019/20


Adverse incidents are reported via an online system, Datix. SCAS encourages an open

reporting culture and all staff have access to this system to file a report. IPC untoward incidents

are split into two categories; exposure to body fluids/infectious diseases, and needlestick and

sharps injuries.

Exposure to body fluids/infectious diseases

Periods of direct patient contact in E&UC services and PTS are usually short (normally less

than one hour), therefore it is difficult to produce information on HCAI outcomes specific to

ambulance services. However, the Trust takes infection control extremely seriously and has

in place strict measures for cleaning vehicles to maintain the cleanliness for the benefit of

patients and staff. The Infection Control Lead produces reports for commissioning groups

detailing the measures the Trust takes to reduce the risk of HCAIs to service users.

- No incidents of three or more staff being off at one single time from a single resource

centre with gastrointestinal disease

10. Adverse incidents

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- No incidents of HCAI’s reported

- No incidents of Public Health England informing SCAS of infectious and/or notifiable

disease

- Exposure to body fluids include; sputum, blood, vomit, faeces, and urine

- No high-risk exposures reported

Needlestick and sharps

It is a requirement under the European Union (EU) regulations (2010/32/EU) that all

needlestick injuries are reported and investigated; as such each individual case is reviewed

by the Infection Control Lead and an investigator, usually a Team Leader appointed. These

incidents, including sharps injuries, are reported back to the Health and Safety Risk Group.

- 62 reports of needlestick and sharp incidents (31 needlestick, 31 sharps)

- No high-risk incidents reported

- Trends include injuries caused by razors stored in the defib. Ziplock bags were

introduced in July 2018 to store razors. A reduction in injury has been seen

Achievements

The IPC Lead has been working alongside Health and Wellbeing to clarify the process post

needle stick injury. Staff who have received a three-day course of post-exposure prophylaxis

(PEP) from A&E have subsequently been turned away from GUM clinics. This caused

significant stress to staff. Solent Sexual Health have confirmed they will provide support and

the remaining PEP prescription. Work to continue to establish clarification Trust wide.

Actions for 2019/20

- Please refer to appendix 5.

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Appendix

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APPENDIX 1

Infection Prevention and Control Structures

The Trust Board and the Director of Infection Prevention and Control (DIPC) have overall

responsibility for patient safety and that all infection prevention and control issues ensuring

they are managed safely and appropriately.

Trust Board

(includes DIPC)

Quality and

Safety

Committee

Health and

Safety

Committee

Trust Infection

Control Lead

Patient Safety

Group

External Infection

Control Groups

Education

Team

Directors, Assistant

Directors and Area

Managers

Assistant

Director of

Quality

A & E Ops

PTS

Fleet

HR

Occupational

Health

Provider

Estates

CCC

NASIPCG

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APPENDIX 2

Infection Control Statement

The Trust Board of South Central Ambulance Service NHS Foundation Trust is committed

to compliance with the Hygiene Code 2006 and as amended to prevent and control Health

Care Associated Infections (HCAI). The Code is presented under three headings which

form the basic Code and the Trust has pledged to undertake these duties by:

1. Management, organisation and the environment;

▪ Protect patients, staff and others from HCAI ▪ Put in place appropriate management systems to prevent and control infections ▪ Assess the risks of acquiring an HCAI in the pre-hospital environment and take

action to reduce or control these risks ▪ Provide a clean and appropriate environment ▪ Provide information on HCAI to patients and the public ▪ Provide information when a patient moves from the care of one healthcare body to

another ▪ Co-operate at all times with other health care professionals ▪ Provide facilities to prevent or minimise the spread of HCAI ▪ Acquire micro-biology and laboratory support

2. Clinical care protocols;

▪ Have in place appropriate evidence based core policies and protocols that are monitored and maintained to provide clear guidance on the prevention and control of HCAI in the Ambulance Service

3. Health care workers;

▪ Ensure so far as is reasonably practicable that ambulance staff are free of and protected from exposure to communicable infections

▪ Access to relevant occupational health services is provided to all staff ▪ Ensure that all staff are educated in the prevention and control of HCAI

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APPENDIX 3

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APPENDIX 4

SOUTH CENTRAL AMBULANCE NHS FOUNDATION TRUST

CONTROL OF INFECTION IMPROVEMENT PLAN 2018/19 (and related work streams)

Challenge Standard Action

Lead Date Comment

2019

CQC actions to

ensure compliance

Participate in IPC Awareness

campaign for all SCAS employees

To increase hand hygiene

compliance across all services

Q2/3/4 from Q1 baseline

Achieve 95% compliance

▪ Plan and deliver IPC themed stories and media releases and hand hygiene roadshows, to SCAS employees during 2018/19

▪ Conduct a hand hygiene campaign in Q1 and Q3

▪ Monitor and report on hand hygiene rates per service

Infection Control Lead

Simon Holbrook

Ongoing Hand Hygiene

Roadshow

commenced Feb

2019.

Ongoing

▪ SCAS Assurance

▪ IPC compliance for auditing processes and procedures.

▪ Following review of auditing system, improve IPC audit tool to include all new buildings opened and due to open in 2018/19.

▪ Further system improvements

▪ Improvements to system to make it more user friendly

▪ Greater transparency.

▪ Improvements to auditing systems to allow bespoke reports to be produced for individual CCGs.


Assistant Director of Quality

System

upgrade

February 2018

Continued review of audit system

Completed

▪ SCAS Assurance

▪ Timely auditing processes for

Timely audits for:-

▪ Stations

▪ Vehicles

Auto reminders when each type of audit is

due, nearly due and overdue.

Infection Control

Lead

System

upgrade

February 2018

Completed

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contractual obligations

▪ Staff observations.

Continued

review of audit

system

▪ SCAS Assurance

▪ Health and Social care act for preventative vaccination

Plan for Flu vaccination, train Team

Leaders and Clinical Mentors and /

or alternative duty staff in

vaccination procedure to enable

greater capture of staff

Develop PGD and training package

Medicines and

Research

Manager

August 2018

Completed

▪ SCAS Assurance

▪ Health and Safety at Work Act for PPE and COSHH regulations

Identify and train team of IPC

Representative to take forward IPC

at local levels.

▪ Engage with DIPC, COO and Non-Executive Directors

▪ Identification of staff

▪ Release of staff for IPC training

▪ Plan and deliver basic IPC course for IPC Representatives.

Infection Control

Lead

Partial

agreement

from Head of

Ops. To carry

over to 2018

plan

Ongoing

▪ SCAS Assurance to ensure compliance with all IPC needs

Surrey and West Sussex PTS

contract

Ensure all PTS buildings / sites and vehicles

are compliant with IPC policy and procedures

Infection Control

Lead

End June 18 Ongoing

▪ SCAS Assurance to ensure compliance with all IPC needs

▪ To ensure building cleanliness standards are improved across SCAS

▪ Implement revised cleaning specification and standards across the organisation

▪ Planned tour across the trust to de-clutter and deep clean SCAS buildings

Infection Control

Lead

End June 2018

End August

2018

Completed

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APPENDIX 5

SOUTH CENTRAL AMBULANCE NHS FOUNDATION TRUST

INFECTION PREVENTION AND CONTROL IMPROVEMENT PLAN 2019/20

Challenge Standard Action

Lead Date

CQC actions to

ensure compliance

The Trust should ensure all

ambulances and rapid response

vehicles are clean and dust free.

The Trust should ensure resource

centres are maintained to a safe

standard for staff to carry out their

duties safely.

Vehicles:

▪ Monitor vehicle deep cleans and establish quality assurance

▪ Establish deep clean of VOR vehicles prior to being put back in to service (Q2)

▪ Continue regular meetings with IPC, Churchill and Support Service Manager (Julie Larner to lead)

Buildings:

▪ Continue developing cleaning specification ready for tender

▪ Re-establish regular meeting between IPC, Estates and cleaning company for quality assurance and consistency (Q2)

▪ Consider repeating the tour de clutter campaign (Q3)

▪ Develop a fridge hygiene campaign (Q3)


Simon Holbrook


Julie Larner

Ongoing, Q2, Q3

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SCAS Assurance

▪ IPC compliance for auditing processes and procedures.

To ensure accurate and good quality audits.

▪ Continued improvements to system to make it more user friendly and accessible

▪ Work with ESR and Doc Works to ensure data accuracy (Q1)

▪ Establish a quality assurance process ie introducing IPC Champions (Q1)

▪ Work with Doc Works to increase completion of action plans

▪ Deliver Doc Works training (Q2)



Ongoing, Q1,

Q2

SCAS Assurance

▪ Timely auditing processes for contractual obligations

Timely audits for:-

▪ Stations

▪ Vehicles

▪ Staff observations.

▪ Continue auto reminders from Doc Works

▪ Continue to monitor audit activity on a weekly basis

▪ Continue monthly audit updates to management to prompt completion

▪ Continue to work with Estates and Health and Safety to merge three audits in to one

Infection Control

Lead

Ongoing

SCAS Assurance

▪ Hand Hygiene

To ensure 95% of SCAS are

compliant with hand hygiene

▪ Continue the Hand Hygiene Roadshow

▪ Utilise staff on light duties to deliver the roadshow Trust wide (Q1)

▪ Continue to monitor rates and report to PSG

Infection Control

Lead

Ongoing, Q1

SCAS Assurance

▪ External providers

To ensure external providers are IPC

compliant; cleaning, make ready,

E&UC and PTS private providers

▪ Develop an assurance strategy for the external companies IPC training

▪ Develop an assurance strategy to ensure private providers building and vehicles comply with IPC policies and procedures

Infection Control

Lead

Q2

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SCAS Assurance

▪ Education

To ensure high quality IPC education ▪ Develop welcome day inductions adhering to Skills for Health

▪ Monitor impact of audits completed post induction

Infection Control

Lead

Ongoing, Q1

SCAS Assurance

▪ Adverse incidents

▪ Health and wellbeing

To ensure the health and wellbeing

of staff

▪ Continue to work with Health and Wellbeing to ensure staff have access to PEP

▪ Continue to work with Health and Wellbeing to ensure staff have access to immunisations

▪ Continue to monitor adverse incidents and report to HSRG

▪ Monitor staff sickness for patterns

▪ Establish effectiveness of Sterile Light Units at Northern House on staff sickness levels (Q2)

Infection Control

Lead

Health and

Wellbeing

Ongoing, Q2

SCAS Assurance

▪ Flu

To deliver the flu vaccination Trust

wide

▪ Develop PGD and training package

▪ Identify staff

▪ Plan and monitor program through regular meetings

Infection Control

Lead

Assistant

Director of

Quality

Health and

Wellbeing

Medicines and

Research

Manager

Ongoing, Q2

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SCAS Assurance

▪ IPC team

To deliver IPC at a local level and

embed good IPC practice.

To provide quality assurance of IPC

audits.

▪ Utilise staff on light duties

▪ Develop IPC Representatives;

o Identify staff

o Release of staff – duties could be completed as overtime

o IPC training – could be delivered by QA Microbiology team

▪ Engage with DIPC, COO and Non-Executive Directors

Infection Control

Lead

Ongoing, Q1

SCAS Assurance

▪ Areas for attention

To ensure all staff have access to

FFP3 masks

To develop and implement a sterile

cannulating kit

▪ To work with NASIPCG to establish whether a national recommendation will be made regarding FFP3 hoods

▪ Start a task and finish group with resilience and Health and Safety to establish FFP3 within SCAS (Q1)

▪ To work with NASIPCG and SCAS Equipment and Vehicles Group to develop and implement a sterile cannulation kit (Q2)

Infection Control

Lead

Health and

Safety

Equipment and

Vehicles Group

Ongoing, Q1,

Q2

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APPENDIX 6

Would you like to develop your clinical skills further?

Would you like to add to your CPD?

If so…

We are looking for clinicians to deliver the Flu Vaccination at various

times and locations throughout October/November/December 2018

to suit you!

Full training will be provided.

Training Date: 18th September 2018

At: Bone Lane Education Centre

Time: 10am – 3pm

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