Trustwide Infection Prevention and Control (IPC) Policy

  1. Why Nottinghamshire Healthcare NHS Foundation Trust requires this policy
    This policy details the arrangements for the prevention and control of infection.

  2. Who this policy is applicable to
    This policy applies to all staff working within Nottinghamshire Healthcare NHS Foundation Trust [the Trust] and should be used in conjunction with Trust related related policies/procedures and the new Trust Infection Prevention and Control (IPC) Guidelines Manual.

  3. Policy summary
    This policy identifies the Trust’s responsibilities for the prevention and of Health Care Associated Infections (HCAIs), as legislated in the Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance. London. Department of Health and Social Care (DHSC) (2022).
    This is an overarching policy intended to outline how the Trust will manage the broad and complex issues with regard to IPC in accordance with relevant legislation, Department of Health (DoH) directives and evidence-based research and best practice. This policy is aligned to the National Infection Prevention and Control Manual (NIPCM) for England via the new Trust IPC Guidelines Manual.
    See Appendix 1 Trust Infection Prevention and Control (IPC) Guidelines Manual.

  4. Essential information
    This policy outlines the roles and responsibilities of specific categories of staff in relation to the governance systems relating to IPC. The requirements and objectives for compliance are set by the key criteria within the HandSCA (2008) Code of Practice for the Prevention and Management of Infections. The broad responsibilities relating to every member of staff are:
    • All employees are responsible for ensuring that they undertake relevant available IPC training, either face-to-face or via electronic learning.
    • All employees of the Trust have a duty of care to adhere to all Trust policies and guidelines applicable to IPC.
    • All employees who are seconded to the Trust, all bank and agency staff, together with any contractors employed by the Trust will be personally accountable for their actions and are responsible for ensuring that they comply with IPC policies and guidelines.
    • It is the responsibility of employees involved in patient care to ensure that they utilise safe working practices as outlined in IPC policies and guidelines. Any breach in IPC policies or practice will place staff, patients, and visitors at risk.
    • All employees involved in the care of patients with HCAIs must ensure they are aware of the plan for managing the HCAI and complete all relevant documentation as required.
    • All employees have a duty to act on and report to the IPC Team, at the earliest opportunity, an infection that may be deemed infectious to others i.e. communicable/notifiable diseases or resistant organisms or potential outbreak.

  5. Changes made to this policy since last review
    September 2024: This is a new policy and aligns with the new Trust Infection Prevention and Control (IPC) Guidelines Manual.
 

Version number

01

Version date

12/09/2024

Review date

04/09/2027

Latest ratification date

04/09/2024

Ratification committee

Trustwide Clinical Policies and Procedures Group (CPPG)

Expert writer

Lead Matron, Infection Prevention and Control

Champion

Director for Infection Prevention and Control

 

 

 

Version control

Version Number

Date

Expert Writer

Status (New, Edited)

Comments and Details of Changes Being Made

(Issue 1)

September 2024

Kim Shaw

New

This is a new policy and aligns with the new Trust Infection Prevention and Control (IPC) Guidelines Manual.

 

Contents 

1.0 Introduction
2.0 Policy principles
3.0 Definitions
4.0 Duties and responsibilities
4.1 Trust board
4.2 Chief Executive
4.3 Director of Infection Prevention and Control (DIPC)
4.4 Trustwide infection prevention and control group
4.5 Antimicrobial Steward
4.6 Directors, Assistant Directors, Clinical Directors, General Managers
4.7 Infection Prevention and Control Team
4.8 Senior Nurses/Modern Matrons/Clinical Nurse Managers
4.9 Department/Ward Managers
4.10 Infection prevention and control link champions
4.11 All employees
5.0 Consultation, dissemination, access, implementation, monitoring and review date
5.1 Consultation
5.2 Dissemination
5.3 Access
5.4 Implementation
5.5 Monitoring
5.6 Review date
5.6.1 This policy
5.6.2 Trust Infection Prevention and Control (IPC) guidelines manual
6.0 Compliance with legislation and national guidance
7.0 Training
8.0 Exceptional circumstances
9.0 References and source documents
Appendix 1 Trust Infection Prevention and Control (IPC) guidelines manual
Appendix 2 Equality Impact Assessment (EIA) screening tool

 

1.0 Introduction

1.1 The Trust recognises that it has a duty of care to protect patients, staff, contractors, and visitors from healthcare associated infection (HCAIs) and supports the need for effective systematic arrangements for surveillance, prevention, and control. It is therefore committed to reducing the incidence of HCAIs and, more importantly, to prevent the risk of avoidable infection.

1.2 Within the NHS, national and local targets have been set to reduce the incidence of HCAIs and various documents have been produced by the Department of Health and Social Care (DHSC) to provide organisations with a framework to enable this reduction to occur. See References and Source Documents section. The latest of these is, The Health and Social Care Act: code of practice on the prevention and control of Infections and related guidance (HandSCA 2008) (Revised 2022). This provides a framework to enable organisations to plan and implement measures to prevent and control infections.

1.3 The Trust, through governance structures and monitoring processes, evidence compliance with the Health and Social Care Act (HandSCA 2008) (Revised 2022). Monitoring of compliance is ongoing. It is undertaken internally by the Trust through adherence to this policy and the IPC Assurance Framework and Work Plans, and externally by the Care Quality Commission (CQC).

1.4 The key criteria listed below are the ‘Code of Practice’. Compliance demonstrates that the Trust is taking the necessary measures to provide good quality, safe care to its patients and staff: 

  1. Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of patients and any risks that their environment and other users may pose to them.
  2. Provide and maintain a clean and appropriate environment in managed premises which facilitates the prevention and control of infections.
  3. Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.
  4. Provide suitable, accurate information on infections to patients, their visitors and any person concerned with providing further support or nursing/medical care in a timely fashion.
  5. Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely the appropriate treatment and care to reduce the risk of transmitting infection to other people.
  6. Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infections. 
  7. Provide or secure adequate isolation facilities.
  8. Secure adequate access to laboratory support as appropriate.
  9. Have and adhere to policies designed for the individual’s care and provider organisations that will help to prevent and control infections.
  10. Providers have a system in place to manage the Occupational Health needs and obligations of staff in relation to infection.
  11. This policy will provide assurance for compliance with CQC outcomes 8: Cleanliness and Infection Control, Regulation 12, that states “People should be cared for in a clean environment and protected from the risk of infection”.

 

2.0 Policy principles

This policy identifies the Trust’s responsibilities for the prevention and control of HCAIs as legislated in the HandSCA 2008 (Revised 2022). 

 

3.0 Definitions

Alert Organisms – are those identified as posing a public health risk to patients, staff and visitors defined by the Department of Health (NHS, 2024). 

Care Staff – refers to both health and social care staff.

Hazard – is something that has the potential to cause harm (Trust Policy 16.01 Health, Safety and Welfare).

Healthcare Associated Infection (HCAI) – are those which arise during any contact with healthcare either in hospital or in the community setting, whether in patients themselves or in the health or social care worker undertaking intervention.

Healthcare Facility – is a hospital, clinic, outpatient department or residential nursing home which provides medical and related services aimed at maintaining good health, especially through the prevention and treatment of disease.

Infection Prevention and Control (IPC)– is the prevention and management of infection through the application of research-based knowledge to practices that include standard precautions, decontamination, waste management, surveillance, and audit.

Patient - this term is used when referring to the NHS population.

Risk - is the chance of an undesirable outcome. Risk includes consideration of both the likelihood and severity of the outcome (Trust Policy 16.01 Health, Safety and Welfare).

 

4.0 Duties and responsibilities

 

4.1 Trust Board

The Trust Board has overall responsibility for ensuring that there are effective arrangements and adequate resources provided for IPC within the Trust and for monitoring the impact of the policies of the Trust. 

 

4.2 Chief Executive

The Chief Executive has overall responsibility for ensuring that there are effective management and monitoring arrangements provided for IPC to meet all statutory requirements, and that appropriate resources are available.

 

4.3 Director of Infection Prevention and Control (DIPC)

  • The DIPC will have overall responsibility for IPC and will report directly to the Chief Executive and the Board quarterly and as required.
  • The DIPC is an integral member of the Trust’s quality and clinical governance safety structure.
  • The DIPC has overall responsibility for the IPC infrastructure and management of the IPC teams.
  • The DIPC oversees local infection control guidelines and their implementation and also has authority to challenge inappropriate clinical practice, as well as antimicrobial prescribing decisions.
  • The DIPC produces the IPC annual report. This is presented to the Trust Board together with the annual IPC Programme of work for Board approval.
  • The DIPC will chair the Trust Wide Infection Prevention and Control Group (TWIG).

 

4.4 Trustwide infection prevention and control group

  • A Trust Wide Infection Prevention and Control Group (TWIG) is a mandatory requirement. It is a key forum in providing assurance that the Trust has in place structures and arrangements to meet all statutory requirements for IPC.
  • The purpose of the Trust Wide IPC Group is to appraise the Chief Executive, the Quality Oversight Group and the Trust Board on issues relating to IPC within the Trust, in particular to highlight, in advance where possible, potential problems and risks. 
  • Whilst strategic leadership of IPC is the responsibility of the DIPC, operational responsibilities are held with the Associate Directors (Nursing, Quality and Patient Experience) Forensic and Mental Health Care Units and Community Health Services (CHS).
  • Information will be cascaded through Associate Directors (Nursing, Quality and Patient Experience), Care Group IPC leads for onward circulation.
  • The Trust has procedures and guidelines, aligned with the National Infection Prevention and Control Manual (NIPCM) for England in place for the diagnosis, prevention, surveillance, and control of infection. This IPC policy and its associated guidelines are developed, maintained, and monitored for the Trust by the Trust Wide IPC Group. In shared premises or where the service is provided via service level agreements, the other Trust’s procedures and policies will be adopted. This must be agreed by all parties.

 

4.5 Antimicrobial Steward

The designated Antimicrobial Steward leads the Trust’s programme of work designed to ensure the appropriate and safe use of antimicrobials. Refer Trust Policy 14.04 Use of Antimicrobial Medicines. The Antimicrobial Steward is supported by clinical pharmacists, with input from microbiology, to ensure all aspects of antimicrobial stewardship are met. The Antimicrobial Steward is a member of the Trust Wide Infection Prevention and Control Group and the Trust Wide Medicines Optimisation Group and provides regular assurance reports to these groups.

 

4.6 Directors, Assistant Directors, Clinical Directors, General Managers

  •  Directors, Assistant Directors, Clinical Directors, and General Managers are responsible for ensuring the compliance with all relevant criterions of the Health and Social Care Act 2008 (HandSCA 2008) (Revised 2022) within their Care Units. 
  • They must also: 
    • Ensure that Heads of Service/Senior Nurses/Matrons provide a three-monthly progress report to the Trust Wide Infection Prevention and Control Operational Group (TWOG) which meets quarterly.
    • Ensure that all IPC related operational matters raised by Heads of Service/Senior Nurses/Matrons/Senior Clinical Practitioners/Allied health Professionals in their area are reviewed and actioned.
    • Following risk assessments or audits, they must ensure adequate allocation of resources to facilitate remedial action.

 

4.7 Infection Prevention and Control Team (IPCT)

  • The IPCT manages, develops, plans, and implements a comprehensive IPC service for the Trust. It is responsible for: 
    • The Trust Board Assurance Framework and associated Annual Work Plan.
    • Providing a management, consultative and advisory service to the Trust in order that the Trust ensures effective systems are in place for the monitoring, prevention and control of infection and ensure compliance with the Health and Social Care Act 2008 (HandSCA 2008) (Revised 2022).
    • Providing specialist advice and support for staff, patients, carers, and visitors in order to reduce the risk to patients, staff, and the public of avoidable HCAIs. 
    • Undertaking routine surveillance of alert organisms to monitor trends, detect outbreaks and increased prevalence. 
    • Dissemination/sharing of surveillance data to relevant parties as requested.
    • Monitoring and responding to outbreaks of infection.
    • Leading a process of Root Cause Analysis (RCA) or Post Infection Review (PIR) for all incidents of MRSA bacteraemia, Clostridioides difficile infection, Clostridioides difficile deaths, Gram Negative organism bacteraemia and outbreaks of infection.
    • Sharing the learning from the RCA/PIR to inform changes to practice. 
    • Ensuring that the recommended IPC guidelines and clinical practice guidance are reviewed and updated as required. All policies and clinical practice guidance will reflect national guidance and other relevant evidence-based practice. See Appendix 1 Infection Prevention and Control (IPC) Guidelines Manual.
    • Providing IPC training for all staff appropriate to their role. All patient-facing/clinical staff will receive face-to-face training in IPC every three years and electronic IPC training each year where face to face IPC training is not undertaken. 
    • Undertake an extensive programme of clinical audit of healthcare environments and clinical practice.
    • Ensuring that IPC is considered within all relevant estates and facilities to ensure the provision and maintenance of clean and appropriate health care environments.
    • Work closely with the Occupational Health Department and other relevant stakeholders to develop policies and guidelines for the protection of all Trust employees from exposure of communicable infections during their work.
    • Develop and produce an annual IPC work programme with clearly defined objectives.
    • Assist the DIPC with the writing of the annual IPC report which outlines the progress of the programme.
    • Attend working groups across the health economy to share learning and implement standardised practice across services.

 

4.8 Senior Nurses/Modern Matrons/Clinical Nurse Managers

  • Senior Nurses/Modern Matrons/Clinical Nurse Managers are responsible for: 
    • Reporting to TWOG on a quarterly basis to provide evidence of all IPC related activity.
    • Working closely with Department/Ward Managers and Infection Control Link practitioners to ensure identified IPC actions are achieved e.g. audits, RCA/PIR outcomes. 

 

4.9 Department/Ward Managers

  • Department/Ward Managers are responsible for ensuring the implementation of advice, policies, and procedures within their department. This includes: 
    • Being responsible for the inclusion of IPC in every relevant employee’s induction and personal development plan.
    • Inclusion of IPC responsibilities in every relevant employee’s job description and contract of employment. 
    • Ensuring all seconded staff, bank and agency staff and any contracted workers are made aware of all policies and procedures related to IPC during local induction.
    • Ensuring that all staff attend relevant IPC training sessions, of which records are to be maintained.

 

4.10 Infection prevention and control link champions

  • The IPC Link Champions (ICLC) acts as a facilitator of good IPC practice within their area of work. The ICLC acts as a link between the IPC Service and their colleagues. The ICLC will:
    • Attend quarterly meetings and feedback the information gained to colleagues, managers, and other health care professionals.
    • Act as a resource for colleagues, patients, and the public.
    • Participate in IPC clinical audits. 
    • Participate in IPC promotions and campaigns.

 

4.11 All employees

  • All employees are responsible for ensuring that they undertake relevant IPC training available to them, either face-to-face or via electronic learning.
  • All employees of the Trust have a duty of care to adhere to all Trust policies and guidelines applicable to IPC. 
  • All employees who are seconded to the Trust, all bank and agency staff together with any contractors employed by the Trust will be personally accountable for their actions and are responsible for ensuring that they comply with IPC policies and guidelines.
  • It is the responsibility of employees involved in patient care to ensure that they utilise safe working practices as outlined in IPC policies and guidelines. Any breach in IPC policies or practice will place staff, patients, and visitors at risk.
  • All employees involved in the care of patients with HCAIs must ensure they are aware of the plan for managing the HCAI and complete all relevant documentation as required.
  • All employees have a duty to act on and report to the IPCT, at the earliest opportunity, an infection that may be deemed infectious to others i.e., communicable/notifiable diseases or resistant organisms or potential outbreak.

 

5.0 Consultation, dissemination, access, implementation, monitoring and review date

 

5.1 Consultation

  • Trustwide Infection Prevention and Control Group
  • Trustwide Operational Infection Prevention and Control Group
  • The Trust Quality Committee
  • Executive Leadership Team 
  • Trustwide consultation 

 

5.2 Dissemination

5.2.1 Information available to patients, and the public about the Trust arrangements for the prevention and control of HCAIs can be found on the Trust’s Intranet site in the form of the IPC Annual Report and Annual Programme of work, along with local area specific information leaflets.

5.2.2 Learning from root cause analysis and any other IPC incidents will be shared within the Trust and across organisations within the health community.

 

5.3 Access

This policy applies to all staff working within the Trust and should be used in conjunction with other related policies and guidelines.

 

5.4 Implementation

5.4.1 This policy supersedes Trust Clinical Policy 07.05 (Issue 11) Infection Prevention and Control Policy (incorporating surveillance of alert organisms and sharing of information) and is now known as the Trustwide Infection Prevention and Control (IPC) Policy (Issue 1) and aligns with the new Trust IPC Guidelines Manual structure. 

5.4.2 This policy is now the only Trustwide IPC policy available on Connect and the Trust website. All previous Trust IPC policies and procedures have been archived. See Trust IPC Policies and Procedures Now Archived for a full list. All previous Trustwide policies and procedures have been replaced with the new Trust IPC Guidelines Manual Chapters 1-4 i.e. Chapter 1: Standard Infection Control Precautions (SICPs) – links directly to the National IPC Manual (NIPCM) for England, Chapter 2: Transmission based precautions – links directly to the National IPC Manual (NIPCM) for England, Chapter 3: A-Z conditions – local procedural guidelines with links to the National IPC Manual (NIPCM) for England and Chapter 4: Operational guidelines – Trustwide-specific procedural guidelines with links to the Royal Marsden Manual and to the National IPC Manual (NIPCM) for England. 

5.4.3 Trust IPC Policies and Procedures Now Archived

5.4.3.1 Previously existing Trustwide IPC policies and procedures which were located within Section 7 Infection Prevention and Control on the Trust Intranet ‘Connect’ and which were also published on the Trust website have now been archived. These include:

  • 07.01 (Issue 11) Decontamination of Patient Equipment Policy
  • 07.02 (Issue 6) Obtaining Clinical Samples for Microbiology Procedure
  • 07.03 (Issue 6) Outbreaks of Infection Policy and Procedure
  • 07.04 (Issue 9) Hand Hygiene Policy
  • 07.05 (Issue 11) Infection Prevention and Control Policy (incorporating surveillance of alert organisms and sharing of information) Policy and Procedure
  • 07.06 (Issue 11) Occupational Exposure to Blood Borne Viruses Policy and Procedure
  • 07.07 (Issue 11) Methicillin Resistant Staphylococcus Aureus (MRSA) Management and Control Policy and Procedure
  • 07.08 (Issue 7) Transfer of Patients with Known or Suspected Infection Policy and Procedure
  • 07.09 (Issue 5) Isolation Policy
  • 07.10 (Issue 10) Safe Management and Disposal of Sharps Policy and Procedure
  • 07.11 (Issue 5) Management of Service Users with Confirmed Suspected or at Risk of having Creutzfeldt-Jakob Disease or any Transmissible Spongiform Encephalopath Policy
  • 07.12 (Issue 7) Management of Clostridioides difficile Infection Policy
  • 07.13 (Issue 7) Aseptic Non-Touch Technique (ANTT) Policy
  • 07.14 (Issue 5) Management and Control of Carbapenemase-Producing Enterobacteriaceae (CPE) within Inpatient Facilities Policy
  • 07.16 (Issue 5) Infestation Management Policy (previously known as 07.16 Scabies Management)
  • 07.17 (Issue 5) Management of Patients with Extended Spectrum Beta-Lactamase (ESBL) Producing Coliforms Policy
  • 07.18 (Issu 5) Blood and Other Body Fluid Spillages Policy
  • 07.19 (Issue 5) Group A Streptococcus Infection – Management and Control Policy
  • 07.23 (Issue 7) Decontamination and Safe Handling of Linen and Laundry Policy and Procedure
  • 07.25 (Issue 1) Management of Viral Respiratory Tract Infections and Outbreaks Policy 

5.4.5 ‘Previously existing’ (see Item 5.4.3.1 above) means before September 2024. 

5.4.6 The responsibility for implementing this policy rests with the manager responsible for each individual or group of staff. Managers are required to ensure that all staff are aware of the Trust IPC Guidelines Manual and are able to practice in accordance with the requirements of this. 

5.4.7 Managers are also responsible for ensuring that all staff are aware that the Trust IPC policies and procedures listed in Item 5.4.3.1 above have been archived and replaced with the new Trust IPC Guidelines Manual and that staff have been instructed/provided with information on how to navigate the new Trust IPC Guidelines Manual. 

5.4.8 Further assistance, information and guidance regarding the changes described above can be obtained by contacting clinical.policies@nottshc.nhs.uk or by contacting the IPC Team.

 

5.5 Monitoring

5.5.1 Untoward incident reports, serious untoward incident reports, sharps incidents and HCAI surveillance and associated activity will be discussed at the Trust Wide Infection Control Group, which meets quarterly.

5.5.2 Matrons and Clinical Directors are to report quarterly to the Trust Board on Infection Control and Cleanliness via the TWOG. 

5.5.3 Lessons learned from incidents and good practice will be shared via the appropriate channels including the IPC groups, local team meetings and shared with the health economy as relevant.

5.5.4 IPC audits of clinical areas will be undertaken. The audit plan is reviewed annually and updated accordingly. Action plans will be developed as necessary and reviewed by the TWOG. 

 

5.6 Review date

5.6.1 This Policy

5.6.1.1 This policy will be reviewed every three years or in the event of organisation changes or new Department of Health and Social Care guidelines or legislation. 

5.6.1.2 This policy will be reviewed and approved according to the requirements of Trust Policy 18.09 Production of Trust Policies, Trustwide and Local Procedures, and Internal Working Instructions (IWIs) via the Trustwide Clinical Policies and Procedures Group’s (CPPG) established governance route in collaboration with the Trust Clinical Policies Team. 

5.6.2 Trust Infection Prevention and Control (IPC) Guidelines Manual

5.6.2.1 Chapter 1: Standard Infection Control Precautions (SICPs) and Chapter 2 Transmission based precautions will not be required to be reviewed and updated by the Trust IPC Team since these chapters will be reviewed nationally. Chapter 3: A-Z of conditions and Chapter 4: Operational guidelines will be reviewed and updated by the Trust IPC Team as and when required. 

5.6.2.2 Notification of national changes affecting Chapters 1 and 2 will be anticipated to be via alerts received from NHS England. These changes will be communicated via the Trust IPC Team to the CPPG and thereafter disseminated to Trust staff via the Trustwide Clinical Policies Bulletin. 

5.6.2.3 Notification of ‘local’ changes to Chapters 3 and 4 will be communicated by the Trust IPC Team to the CPPG and thereafter disseminated to Trust staff via the Trustwide Clinical Policies Bulletin. 

5.6.2.4 Notification of either national or local changes may also take place by the IPC Team via other relevant, appropriate routes and channels of communication at their discretion. 

5.6.2.5 ‘Updated’ in Item 5.6.3 means amendments, removal of information, or the incorporation of new and additional information to Chapters 1-4 of the new Trust IPC Guidelines Manual. 

5.6.2.6 Chapter 3 and Chapter 4 of the new Trust IPC Guidelines Manual will be updated by the Trust IPC Team and IPC administration staff in collaboration with the Trust Connect Team.

 

6.0 Compliance with legislation and national guidance

  • The Health and Safety at Work Act 1974.
  • Department of Health and Social Care (2022) Health and Social Care Act 2008: Code of practice on the prevention and control of infections and related guidance.

 

7.0 Training

7.1 The Trust is committed to make available resources to support the training requirements of all employees in IPC.

7.2 The training needs of individual members of staff will be identified as part of the Performance Appraisal and Development process.

7.3 Patient-facing staff training – annual updates required. These will be delivered face to face to all patient facing and clinical staff as a minimum every three years, with an IPC electronic learning package available in the interim years for all staff to undertake updates annually.

7.4 Non-patient facing staff are required to update their IPC training three yearly.

 

8.0 Exceptional circumstances

  • There may be occasions when a policy/procedure may have to be adapted operationally given the circumstances staff might be presented with e.g. insufficient staff numbers/staff shortages.
  • The operational adaptation of a policy/procedure should be viewed as an exceptional circumstance. 
  • In the first instance, and where time permits, deviation from the stated operational requirements of a policy/procedure should be escalated to the Nurse In Charge/General Manager/On-Call Manager and/or advice and support should be sought in advance of implementation of changes.
  • There is a standard expectation that, should there be a requirement to adapt clinical practices from that which is stated in a policy/procedure due to exceptional circumstances, the clinician must be able to justify their decision-making, and that decision-making is clearly reported on an IR1 incident form.

 

9.0 References and source documents

 

Appendix 1

Trust Infection Prevention and Control (IPC) guidelines manual

National Infection Prevention and Control Manual (Chapter 1 and 2)

Chapter 1: Standard Infection Control Precautions (SICPs)

Chapter 2: Transmission based precautions

Chapter 3: A-Z of conditions

Chapter 4: Operational guidelines 

 

Appendix 2

Equality Impact Assessment (EIA) Screening Tool (Towards an Equality and Recovery Focused Organisation)

Name of policy/procedure/strategy/plan/function etc. being assessed:

 Trustwide Infection Prevention and Control (IPC) Policy

Brief description of policy/procedure/strategy/

plan/function etc. and reason for EIA:

This policy detail the arrangements for the prevention and control of infection. The policy identifies NHCTs responsibilities for the prevention and control of HCAIs as legislated in the HSCA 2008 (Revised 2020). This is an over-arching policy intended to outline how NHCT will manage the broad and complex issues with regard to IPC in accordance with relevant legislation, DH directives and evidence-based research and best practice.

Names and designations of EIA group members:

 Kim Shaw, Trust Lead Infection Prevention and Control

List of key groups/organisations consulted:

 IPC Team, IPC Operational Group, Trust Wide Infection Prevention and Control Group

Data, Intelligence and Evidence used to conduct the screening exercise:

 Department of Health and Social Care (2022) The Health and Social Care Act 2008. Code of Practice for the NHS on the Prevention and Control of Healthcare Associated Infections and related Guidance. London. Department of Health.

 

 

F. Equality Strand

Does the proposed policy / procedure / strategy / plan / function etc. have a positive or negative (adverse) impact on people from these key equality groups? Please describe

Are there any changes which could be made to the proposals which would minimise any adverse impact identified? What changes can be made to the proposals to ensure that a positive impact is achieved? Please describe

 Have any mitigating circumstances been identified? Please describe Areas for review / actions taken (within timescales and name of responsible officer).

Race

There is no impact positive or negative in respect of Race. Application of the policy is dependent entirely on clinical presentation.

NA

NA

Policy to be reviewed inside current agreed timescales led by the author.

Gender: Including Transgender and Pregnancy and Maternity

As above in respect of gender, inclusive of transgender

NA

NA

As above

Disability: Including Mental Health, Intellectual and Learning Disabilities

There is no impact positive or negative in respect of Disability with regard to application of the policy.

NA

NA

As above

Religion/Belief

None

There is no impact positive or negative in respect of Religion/Belief, with regard to application of the policy.

NA

NA

As above

Sexual Orientation Including Marriage and Civil Partnership

There is no impact positive or negative in respect of Sexual orientation, with regard to application of the policy.

NA

NA

As above

Age

There is no impact positive or negative in respect of Age, with regard to application of the policy

NA

NA

As above

Social Inclusion*1

There is no impact positive or negative in respect of social inclusion, with regard to application of the policy

NA

NA

As above

Community Cohesion*2

There is no impact positive or negative in respect of community cohesion, with regard to application of the policy

NA

NA

As above

Human Rights*3-Including Safeguarding

There is no impact positive or negative in respect of Human Rights, with regard to application of the policy

NA

NA

As above

*1 For Social Inclusion please consider any issues which contribute to or act as barriers, resulting in people being excluded from society e.g. homelessness, unemployment, poor educational outcomes, health inequalities, poverty etc.

*2 Community Cohesion essentially means ensuring that people from different groups and communities interact with each other and do not exclusively live parallel lives. Actions which you may consider, where appropriate, could include ensuring that people with disabilities and non-disabled people interact, or that people from different areas of the City or County have the chance to meet, discuss issues and are given the opportunity to learn from and understand each other.

*3 The Human Rights Act 1998 prevents discrimination in the enjoyment of a set of fundamental human rights including: The Right to a Fair Trial; Freedom of Thought, Conscience and Religion; Freedom of Expression; Freedom of Assembly and Association; the Right to Education; the Right Not to be Subjected to Torture, Degrading or Inhumane Treatment; and the Right to Enjoy Private, Family and Home Life Without Unjustified Interference from Public Authorities.

 
G. Conclusions and Further Action (including whether a full EIA is deemed necessary and agreed date for completion) N/A
H. Screening Tool Consultation End Date 14/06/2024
I. Name and Contact Details of Person Responsible for EIA (tel. e-mail, postal) Kim Shaw
Trust Lead Infection Prevention and Control
Infection Prevention and Control Team
Nottinghamshire Healthcare NHS Foundation Trust
Moorgreen House, Highbury Hospital, Highbury Road, Nottingham, NG6 9DR
Mobile: 07392 284497
Kim.shaw@nottshc.nhs.uk
J. Name of Group Approving EIA (i.e. Directorate EandD Group; Divisional Workforce, Equality and Diversity Group; Trust-wide EandD Subcommittee; or Divisional Policy and Procedures Group) Equality and Diversity Subcommittee of the Board of Directors

 

 

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