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Questions for inspectors on infection prevention and control for NHS acute and mental health trusts

Categories:
  • Organisations we regulate

During the conversation with your inspector, the focus will be on establishing whether your trust has full assurance on infection prevention and control when providing care for patients and when re-establishing non-COVID services. The discussion prompts will help the inspector to understand whether you need support with anything. Your inspector may not need to cover all the discussion prompts as things may already be clear, so you don’t need to spend time preparing for them.

1. Has the trust’s board received or carried out an assessment of the infection prevention and control procedures and measures in place across all services since the COVID-19 pandemic was declared? Does this include an assessment of the estate/isolation facilities?

Discussion prompts:

  • If not, is the trust planning to produce an assessment, and when?
  • If yes, how did you carry out the assessment?
  • Which services did you assess?
  • What did you learn?
  • How did you assess the environment and estate?
2. Are there systems in place to manage and monitor the prevention and control of infection? Do these systems use risk assessments and consider the susceptibility of service users, and any risks that their environment and other users may pose to them?

Discussion prompts:

  • What is the governance around infection prevention and control (IPC)?
  • How do you know that risk assessments are carried out?
  • How do you consider the susceptibility of service users?
  • How is risk assessed at the front door?
  • How do you ensure staff know about national guidance on moving patients, for example, transfer or discharge from hospital?
  • How are risk registers used for IPC risks?
3. Are there systems in place to provide and maintain a clean and appropriate environment in managed premises, facilitating the prevention and control of infections?

Discussion prompts:

  • How are different rooms cleaned systematically to the required standard?
  • What have you learned from audits?
  • Are there specific teams for specific processes?
4. Is there appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance?

Discussion prompts:

  • What did you learn from antimicrobial or prescribing audits?
  • Are there any areas not covered by audits?
  • How are antiviral stocks monitored?
5. Does the trust provide suitable accurate information on infections, in a timely way, to service users, their visitors and any person concerned with providing further support or nursing/medical care?

Discussion prompts:

  • Did you have a communications plan for this? What have you put in place?
  • What challenges have you experienced in providing information to service users, visitors, and people concerned with their care?
6. Is there a system in place that ensures prompt identification of people who have, or are at risk of developing an infection, so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people?

Discussion prompts:

  • How do you identify people who have, or are at risk of, infection, and at what stage?
  • Have you evaluated understanding of your protocol to identify and manage these patients?
  • How do you minimise the risk of cross-infection?
  • How is contact tracing actioned?
7. Are there systems in place to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection?

Discussion prompts:

  • How do you ensure that PPE training is up to date with advice?
  • How are bank/agency staff trained?
  • How do you audit hand hygiene and use of PPE and what have you learned?
8. Are there secure or adequate isolation facilities?

Discussion prompts:

  • What facilities do you have for isolation?
  • How do you know whether there are enough isolation rooms to meet demand?
  • Is there a system for monitoring isolation guidance?
  • How do staff know when and how to cohort patients with any infection?
9. Is there adequate access to laboratory support?

Discussion prompts:

  • Is your laboratory support external or in-house, and how do you ensure that this runs smoothly?
  • What is the testing capacity, and is there a prompt turnaround of results?
10. Is there evidence that the trust has policies designed for the individual’s care that will help prevent and control infections?

Discussion prompts:

  • What are your policies regarding preventing and controlling infections? How do you know whether they are effective?
  • Did you develop any new policies in response to COVID-19?
11. Does the trust have a system to manage the occupational health needs of staff regarding infection?

Discussion prompts:

  • What is the system for testing the fitness of staff to work?
  • What action is taken on results?
  • What support is given to staff who are living with mental or physical impacts of COVID-19?

 

Last updated:
22 June 2020