Annual Infection Prevention and Contol Report Template

INFECTION PREVENTION AND CONTROL LEAD

ANNUAL INFECTION PREVENTION AND CONTOL REPORT TEMPLATE

Executive summary - Overview of infection control activities in the Care Home

• Progress towards Quality Assurance Award
• Progress towards compliance with the Code of Practice
• Progress against the objectives of the annual infection prevention & control programme

Description of infection control arrangements

• Infection Prevention and Control Lead (name and role)
• Infection Control Champion(name and role)
• Infection control meetings (or regular agenda item at other meeting, who attends, frequency etc)
• Reporting line (who reports to owner, registered provider, head office, mechanism of reporting and how often)
• Links to Clinical Governance/Risk Management/Patient Safety (if any)
• Responsibilities (all staff are made aware that they have responsibilities in infection prevention and control and this is now included in job descriptions and in all appraisals/supervision.
• Involvement of Residents (notice board, news letter, welcome pack, resident meetings, provision of fact sheets)
• Participation in Beds & Herts Quality Assurance Programme (demonstrating commitment to infection control)

Risk Assessments

• Risk assessments undertaken for prevention and control of infection (if any, this may need to be a target unless you have already implemented this)

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DIPC reports to Registered Provider / Head Office – summary

• Number and frequency (recommend at least quarterly)
• Progress towards annual Action Plan (what have you achieved)
• Decisions (if any, such as implement e-learning, purchase a new bed pan washer)
• Outbreak reports (number of outbreaks this year, what were they, any hospital admissions, any deaths)

Budget allocation to infection control activities (if any)

• Staff – what have you spent this year on IPC?
• Administrative
• Support (IT etc) (does this need to be increased to allow for e-learning?)
• Training

Infections/Outbreaks

• Number of annual cases of:
• MRSA bacteraemia(not colonisation – if none, state that you have had no cases of MRSA bacteraemia)
• Clostridium difficile (if any – if none state that you have had no cases)
• Untoward incidents including outbreaks (If none – state that you have had no outbreaks or serious untoward incidents)
• Action taken following an outbreak of infection or serious incident or even 1 case of c diff (if any action such as a change in practice was taken)

Hand hygiene and Standard Infection Control Practice

• Implementation of ‘cleanyourhands’ (Posters displayed, use of alcohol gel, use of glow box, information given to residents)
• Implementation of Essential Steps
• Completion of review tools (Urinary catheters, enteral feeding etc)

Decontamination (may not be applicable to all)

• Arrangements in place (Ozon, heat disinfector such as bed pan washer, industrial washing machine)
• Maintenance arrangements (were emergency repairs an issue?)
• Audit (If carried out on decontamination)
• Incidents/failures investigated (If none – state that there were no reported failures in equipment decontamination)

Cleaning services

• Management arrangements (in-house or contracted out)

• Monitoring arrangements (audit, checklist, how often, by whom?)
• Budget allocation (any equipment purchased this year such as steam cleaner/carpet shampoo machine)
• Clinical responsibility (for cleaning contaminated equipment)
• Clinical access (in and out of hours)
• Audit results
• Resident satisfaction measures (if any – or number of complaints received, if no complaints state that none were received)

Audit

• Audits undertaken (annual infection control environmental audit, frequency, date of next planned audit)
• Adoption of IPS audit tool (when published or state your alternative if using)
• Changes and benefits as a result of audit (progress towards action plan, changes made)
• Essential Steps self assessment (when carried out, score, progress made towards action plan, date of repeat self assessment – was an improvement seen?)

Training activities

• Induction for all staff (includes infection control, what exactly? Is this documented? Is there a checklist? Have all staff completed this?)
• Infection Control Training for all staff (how many of all staff have completed annual mandatory infection control training?)
• E-Learning/HPA DVD (if completed, mention pass rate)
• Skills for Health – (use of competency tool)
• Lead IPC – training received
• Champion – training received

Review and update of policies, procedures and guidance

• New policies (list any new policies introduced)
• Reviewed policies (list any reviewed policies introduced)
• Guidance – (any new guidance that may result in problems with compliance? Such as funding for staff immunisations)
• Have you implemented guidance such as the inter-healthcare transfer form / use of the Bristol stool chart?

Targets and outcomes

• Achievement of Beds & Herts HPU Quality Assurance award in Infection Prevention and Control
• All clinical and non clinical staff to complete NHS core learning Infection Control Training by e-learning and complete and pass the on-line assment.
• All clinical and non clinical staff to watch HPA Infection Control training DVD and complete and pass the related assessment.
• Infection Control Champion to attend one half day up-date session in 2010.
• Purchase of equipment (what do you need – bed pan washer? Carpet shampoo machine?)
• Refurbishment (what needs doing? Decorating, repairs? Re-organisation of lay out of the home)
• Any of the bullet points above that you do not yet have in place – list in targets if they are relevant to your home.
• Immunisation of Staff (if appropriate – I know some of you are hoping to implement hep B / flu for staff)

Assurance Framework

• This annual report from the IPC Lead will be reviewed and, where indicated, acted upon. (state the mechanism for this – who will review?)