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?)