eeast: annual quality report 2016 -17 june 2017 report 2016-17.pdf · eeast: dipc annual report...

EEAST: Annual Quality Report 2016-17

June 2017

EEAST: Annual Quality Report 2016-17

June 2017

Contents

Introducing the East of England Ambulance Service NHS Trust…………………………………………………………………………………………4

IPC Team statement…………………………………………………………………………………………………………………………………………………..6

Introduction………………………………………………………………………………………………………………………………………………………………7

What is the Director of Infection, Prevention & Control annual report?............................................................................................7

CQC Report……………………………………………………………………………………………………………………………………………………………….8

Significant Progress in 2016/17…………………………………………………………………………………………………………………………………….10

Trust IPC Infrastructure………………………………………………………………………………………………………………………………………………11

IPC Reporting and Assurance groups…………………………………………………………………………………………………………………………….12

IPC Auditing and Quality Assurance……………………………………………………………………………………………………………………………...13

IPC Vehicle Audit Results…………………………………………………………………………………………………………………………………………….14

IPC Vehicle Decontamination………………………………………………………………………………………………………………………………………15

IPC Station Audit Results…………………………………………………………………………………………………………………………………………….16

IPC Staff Audit Results………………………………………………………………………………………………………………………………………………..17

Untoward IPC related incidents……………………………………………………………………………………………………………………………………19

IPC activities……………………………………………………………………………………………………………………………………………………………..20

IPC Programme 2017/18………………………………………………………………………………………………………………………………………………21

EEAST: DIPC Annual Report 2016-17

August 2017 3

Welcome to the East of England Ambulance Service NHS Trust Director of Infection, Prevention & Control Annual Report for 2016/17. This document has been approved by the Trust Board and is an accurate account of the Trust’s infection, prevention and control activities. In developing this annual report, we have set out a summary of achievements for 2016/17, and goals for 2017/18.

Where can you get hold of this document?

This Annual Report is available on the East of England Ambulance Service website from www.eastamb.nhs.uk or write to: East of England Ambulance Service NHS Trust Headquarters, Whiting Way, Melbourn, Cambridgeshire SG8 6EN Tel: 0845 601 3733

http://www.eastamb.nhs.uk/


August 2017 4

Introducing the East of England Ambulance Service NHS Trust

Our Trust provides emergency and urgent care services throughout Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk.

We also provide non-emergency patient transport services for patients needing non-emergency transport to and from hospital, treatment centres and other similar facilities within Cambridgeshire, Great Yarmouth and Waveney, north, south and west Essex and Suffolk.

We cover an area of approximately 7,500 sq miles with a resident population of almost six million people.

We employ over 4000 staff operating from 130 sites and are supported by more than 1000 dedicated volunteers.

There is an emergency operations centre (EOC) at each of the three locality offices in Bedford, Chelmsford and Norwich, and the Trust Headquarters building is situated in Melbourn, Cambridgeshire.


August 2017 5

The eastern region is made up of both urban and rural areas with a diverse population. As well as a resident population of nearly six million people, several thousand more tourists enjoy visiting our area in peak seasons each year. Our area also contains major airports including London-Luton and London-Stansted which increase the number of people in our region on a daily basis. We have four main areas of service provision:

Response to 999 calls as an emergency and urgent care service

In 2016/17, our emergency operations centre received 1,140,394 contacts from the public. On average, nearly 3,200 emergency 999 calls come into the ambulance service every day and are answered and managed in our emergency operations centre (EOCs). The call handler records information about the nature of the patient’s illness or injury using sophisticated software to make sure they get the right kind of medical help. This is known as triaging, and allows us to ensure that the most seriously ill patients can be prioritised and get the fastest and most appropriate response. Once this key information is established, the response will be selected from a range of care providers including a single clinician in a fast response car, a double staffed emergency ambulance dispatched on blue lights, a clinical assessment conducted over the phone by an appropriate clinician for patients with conditions that do not require an ambulance service response. This response would include advice over the phone from a paramedic or a referral to their GP, pharmacist or local walk-in centre. Scheduled Care Service – Patient Transport Service

We provide a non-emergency Scheduled Care Service, more commonly known as the Patient Transport Service (PTS) to and from home to outpatient appointments at hospitals or other care centres around the region to help people who need assistance because of their medical condition or age. Special and partnership operations

The Trust operates two hazardous area response teams and has a resilience and emergency planning department who work closely with critical care charities and community volunteers to respond to a variety of emergency situations. Commercial services

We operate a number of services which generate income for the Trust. These include training for blue -light drivers and first aid at work. In addition there is a contact centre and a medical service which cover events, festivals and medical repatriation.


August 2017 6

IPC Team statement

2016/17 has been good year for IPC in EEAST, despite some setbacks and challenges good progress has

been made in raising the standards and developing assurance across the Trust. There have been

significant steps made to improve the levels of reporting and the completion of actions where issues are

found, although further work is required in reporting on the completion of the actions. This has been

worked into the team work plan for 2017/18.

The regular decontamination of vehicles is an area which has been highlighted as requiring improvement

and the team has begun to undertake a substantial quality improvement project to review this process

and develop a model that delivers the highest levels of patient safety. The work undertaken in this

project is part of a national project to contribute to a standardised approach for all UK ambulance Trusts.

Throughout 2016/17 the team has been expanded and developed wider networks of IPC lead roles

throughout the Trust operational teams, this has worked well to develop good levels of local ownership

and improve staff access to IPC information. Further work is planned for 2017/18 to revitalise the IPC

Champions role and develop them as part of the wider IPC team to help support the operational staff and

local management teams.

Along with the re-launch of the IPC Champion role additional funding has been allocated to recruit an

additional IPC Specialist Practitioner to address the capacity gap within the team. This will be a great

addition to the team and increase the capacity of the team to allow them to provide a higher level of

support to all service lines and provide a higher level of assurance to the Trust.


August 2017 7

The Trust puts infection control and basic hygiene at the heart of good

management and clinical practice, and is committed to ensuring that

appropriate resources are allocated for effective protection of patients,

their relatives, staff and members of the public. In this regard, emphasis is

given to the prevention of healthcare associated infection,

and the sustained improvement of cleanliness of our

vehicles and stations.

The issues that the Trust must

consider include:

The number and type of

procedures carried out across

the Trust and the systems in place to

support infection control and decontamination.

The different activities of staff in relation to the

prevention and control of infection.

The policies relating to infection prevention control and

decontamination.

The staff education and training programs.

The accountability arrangements for infection prevention and

control.

The infection prevention and control advice received by the Trust.

The integration of infection prevention and control into all service

delivery and development activity.

What is the Director of Infection, Prevention & Control annual report?

The annual Director of Infection, Prevention & Control (DIPC) report is a

mandatory report for NHS healthcare trusts, and is required to be

completed in line with the Health and Social Care Act (2012).

It gives an account of infection, prevention and

control activities within the East of England

Ambulance Service NHS Trust during

April 2016 to March 2017.

The DIPC annual report covers:

The Infection, Prevention & Control (IPC) team infrastructure and

Trust progress against this current objectives

How IPC standards and compliance is monitored

Sets out the goals and objectives for the coming year

How IPC standards and compliance is monitored

Introduction


August 2017 8

Overall compliance for hand

hygiene in Bedfordshire and

Hertfordshire was 96.6% CQC Report

The Care Quality Commission carried out an inspection of the Trust on the 4th to 8th April 2016 with an

unannounced inspection on the 19th April 2016. The final report was published on the 19th August and is available

through the CQC website (www.cqc.org.uk) or via the link on the Trusts website (www.eastamb.nhs.uk). The

overall rating for the Trust was “Requires Improvement” and the Trust complete overall Trust action plan is

available on the website. There is a specific action plan relating to all the areas for improvement found during the

visit which is reviewed at the bi-monthly IPC Group meetings and is also available on the Trust website.

With the changes to the way CQC inspections are performed the rating gives

an overall view of the findings from the visit in relation to the key lines of enquiry

questions and does not give a defined view on individual elements e.g. Infection,

prevention and control.

There were a number of positive points found regarding IPC during the visit and also some areas for improvement

highlighted, one of the key points highlighted was in relation the vehicle decontamination. This was found to be good for

the emergency vehicles but there were concerns highlighted within the non-emergency vehicles. in that they were not being

thoroughly decontaminated to the standards set out within the Trust’s policies. And, furthermore did not always have the full

level of PPE available for the staff.

Although these points were specific to the non-emergency vehicles a full review was performed for

both emergency and non-emergency vehicles and areas of improvement found. Measures were put

in place for an immediate quick resolution of the issues and also for the longer term improvement

of the standard.

Advice regarding IPPC was available in prominent places at all ambulance stations

All equipment within vehicles was visibly clean

http://www.cqc.org.uk/



August 2017 9

Other areas for improvement found during the inspection were:

Lack of assurance that reliable systems were in place to protect patients from the risk o infection in non-emergency vehicles

Low levels of uptake on mandatory training including IPC and hand hygiene training

Not all non-emergency vehicles had a full range of personal protective equipment available for staff

Not all areas had complete or consistent action plans when areas for improvement were highlighted during audits

Although most staff were found to be compliant with the Trust ‘bare below the elbows’ policy and followed good hand hygiene practice,

this was not the case in all areas

In some areas there were some out of date disinfectants found

Throughout the remainder of the year following the release of the CQC report there have been a number of measures put in to address and

improve the issues highlighted. The key measures put in place are:

Introduced the central recording of vehicle decontamination to increase visibility and highlight discrepancies.

The Trust has begun a quality improvement project alongside the National ambulance service IPC Group to review vehicle cleaning

procedures and frequencies against impact on patient safety.

Review of the practice and requirements of the non-emergency staff roles with regards to PPE and implementing a process with

additional monitoring to ensure consist availability of PPE to staff

Introduction of including exceptions reports and actions taken within the IPC Monthly report

Ongoing review and increased monitoring of staff compliance with ‘Bare below the elbows’ incorporated with staff awareness notices.

Changes to the Trust IPC assurance database, which enables the management teams to record steps taken to address issues and record

appropriate evidence. This helps to raise the awareness of the local teams and also continually keeps the focus on these areas so they are

not overlooked.


August 2017 10

Significant Progress in 2016/17

The approach within the Trust is that Infection Prevention and Control is

everyone’s business and without the efforts of every member of staff the

Trust would not have made the significant progress with the IPC agenda that

it has.

During 2016/17 there has been progress made in the following key areas:

The IPC team has taken a more strategic and supportive role,

promoting local management ownership and accountability

Increased levels of quality assurance audits

Improved audit system to enable easier recording, monitoring and

reporting of IPC audits with live data available to all areas

Improvements in the recording and compliance of vehicle “Deep

cleaning”

Improvements in the reporting, monitoring and management of IPC

occupational exposure incidents

Production of an easy access guide to infectious disease for operational staff

The IPC team resourcing has been reviewed and vacancies filled, with additional funding agreed for a second IPC Specialist role


August 2017 11

Trust IPC Infrastructure

NHS organisations are required to have in place systems to manage and

monitor the prevention and control of infections, which should include all

parts of the organisation from the front line to the board.

Within EEAST everybody plays a part in the reducing the risk of infection for

patients, staff and the public. The trust has a dedicated IPC team which

provides specialist IPC advice and guidance.

The main IPC team consists of:

Director of IPC

Head of IPC

IPC Administrator

IPC Auditor

The Trusts Director of Nursing and Clinical Quality performs the duties of the

Director of IPC role, so has an integral part in developing and guiding the Trusts

clinical governance and patient safety strategies. He is responsible for providing

oversight and assurance on all aspects of IPC to the Trust Chief Executive and

the Board.

The Head of IPC is an experienced Emergency Care Practitioner with eight

years’ experience of working within IPC in the emergency care environment.

The IPC team provide expert knowledge, direction and education in IPC issues

across the Trust. The team liaise with clinicians, service line and directorate

managers together with managers who have responsibility for estates, clinical

governance, risk management, health and safety, occupational health, medical

devices, procurement and waste management.

.


August 2017 12

IPC Reporting and Assurance groups

The IPC Group is the main forum for discussion concerning changes to policy or practice relating to infection prevention and control. The membership of the

group is multi-disciplinary and includes representation from all directorates and senior management. The Gr oup is chaired by the DIPC and currently meets bi-

monthly.

There are multiple groups which feed into the Infection Prevention & control group, which in turn reports into the Clinical Quality Safety Group, who report to the

Quality Governance Committee, which is a sub-group of the board.

Trust Board

Quality Governance

Committee

Clinical Quality & Safety

Group

IPC Group

Estates Group

Waste Management

Cleaning Contractors

Locality IPC Group

Infection Control

Champions

Vehicle Working

group

Occupational Health

Medical Devices &

safety Group


August 2017 13

IPC Auditing and Quality Assurance

The Trust has a comprehensive audit schedule which is reviewed annually; this incorporates audits for emergency and non-emergency vehicles, operational

stations, and staff uniform and IPC procedure compliance audits.

Three levels of audit are carried out as recommended by the NPSA (2009) these are

technical, managerial and external audits. Technical level audits are carried out by

operational staff at a local level. Managerial audits are carried out by members of the local

senior management team, IPC team or Clinical Quality team managers at a Trust, rather

than local level. The aim of carrying out the managerial audits is to verify the results of the

technical level audits and identify trends and areas of concern. External audits are carried

out by the Trust User Group throughout the year, with the aim being for each station/ area

received two unannounced visits per year. All of the Trusts clinical commissioning groups

are invited to perform unannounced external audits throughout the year.

During 2016/17 the Trust has developed an additional level of assurance level of quality

assurance by introducing Locality IPC meetings, which primarily focus on reviewing and

comparing the result of the different levels of audits completed. This not only helps to

promote local ownership and improve standards but also ensures that issues highlighted

during the audit process are picked up and addressed.

The Trust utilises an online audit system for recording and analysing audit data, this system

is live and allows for all central and local monitoring of the latest data, as well as comparison against

previous results to establish trends and progress. It also has the capability to include pictures taken during the audit

to help visualise any issues or elements of good practice.

The IPC team produce a comprehensive Monthly IPC report which includes details of all of the audit activity, results and exception reports; this is

available on the Trust website www.eastamb.nhs.uk from the 15th of each month.



August 2017 14

IPC Vehicle Audit Results The Trust target is to audit 85% of the operational vehicles (Emergency

and Non-emergency) each month. During 2016/17 the overall average

audit submission level was 92% and the 85% target was achieved every

month except August. The drop in submissions levels during August were

primarily related to an increase in operational pressures.

The audits primarily focus on vehicle cleanliness, but also include elements

relating to waste, equipment servicing and availability, medicines

management.

.

The National recommendations for compliance levels is 85%, however the

Trust has set an aspirational target of 95%, and managed to achieve this in

every month of 2016/17, with an overall average of 97% The results are

generally consistent with no major areas of concern highlighted.

The cab interior was predominately found to have the lowest compliance

level consistently throughout the year; although the cab interior is

highlighted as the area with the lowest compliance it still achieved a year

end average of 95% compliant. This is not a patient treatment area.

Both the vehicle saloon (patient treatment area) and the medical

equipment had the highest results consistently throughout the year with

both elements achieving an overall average of 97% compliance.

Throughout the year there are regular quality assurance audits performed,

the results of these are variable and generally a few percent lower than the

local audits, the average results have been consistently above 90% for the

entire year, as shown the in chart below.

The main areas for improvement highlighted throughout the audits

relates to the following:

Cleanliness of vehicle cab areas

Cleanliness of some equipment brackets

Management of sharps containers, primarily relating to assembly

and documentation

Staff awareness of Occupational exposure incident management


August 2017 15

IPC Vehicle Decontamination

The Trust has a vehicle cleaning program in place which ensures that the vehicle are decontaminated at key points , the key points from the program are:

Between patient cleans- Between patient clean- this is a clean of the frequently touched surfaces following patient

care and includes any equipment used by the clinicians during the patient care episode. It is primarily carried out

during the hospital turnaround time utilising Clinell universal sanitizing wipes by the crew.

Daily clean- this is a more thorough clean of the vehicle surfaces and floor, this clean does not cover the inside of the

cupboards (unless required) and includes the vehicle exterior and cab as required. This clean is primarily carried out on

station utilising a detergent and hot water mix with disposable cloths by either the vehicle cleaning teams or crew.

Deep clean- this is a full clean of the vehicle whereby all equipment and consumables are removed and cleaned, the

vehicle interior and exterior is fully cleaned and disinfected if required prior to all the equipment and consumables

being replaced. The schedule being for all patient carrying vehicles to be deep cleaned every six weeks. Where

required in addition to a general purpose detergent a chlorine based disinfectant is used.

Emergency Decontamination clean- this is similar to the deep clean but is performed following incidents where the

vehicle is heavily contaminated or has conveyed a highly infectious patient and requires full decontamination. This is

performed as a two-stage clean first using a general purpose detergent followed by a chlorine based disinfectant.

The recording of the vehicle deep cleaning was moved on to the Trust central reporting system part way through 2016, to help raise awareness

and improve the central monitoring. The records of the deep cleans are shown live on the system and give a snap-shot of the compliance level at the

time of viewing. When records first began to be recorded on the system in August the recorded compliance level was 41%, there was an element of

reporting issues noted during the first few months of recording as the vehicle cleaning teams became familiar with the system. The compliance level

gradually improved over the following months to 62%.

There is still a considerable improvement required in the overall compliance to achieve the Trust target of 90% of vehicles deep cleaned every six weeks.

However, although there is improvement required the vehicles continue to be cleaned after each patient care episode and regularly through the daily

cleaning process.


August 2017 16

IPC Station Audit Results The Trust schedule is for all operational stations to be audited every

month; this does not include response posts or standby points*. The

rationale for this is that the response posts and standby points are smaller

sites and do not hold clinical stores or dirty utility areas. As with the

vehicle audits the NPSA compliance standard is set at 85%, however the

Trust has set the aspirational target of 95% compliance.

The station audits focuses on key areas within the station for compliance

with cleanliness standards and Trust procedures. It includes:

Medical consumables stores

Dirty utility

Handling and management

of linen

IPC notices/ information

availability

Management of clinical waste

and sharps

Management of medical

equipment

Kitchens

Toilets

The result of the audits were found to be consistently above the 95%

aspirational target for the entire year , the medical consumables store was

found to have the lowest compliance results with an average of 95%, this

was closely followed by the kitchen and IPC notice/ information elements

at 96%. These areas consistently achieved compliance levels above 94%.

The quality assurance audits results were found to be a true reflection of

the local audits in the majority of cases, although generally found to be 5-

10% lower than the local audit results. With the exception of a dip in May

the quality assurance results are around 90% and consistently above the

National recommendations of 85%. The number of quality assurance

audits varied throughout the year (10-65% completed), primarily due to

geographical and staffing issues, the monthly average was 40% of stations

receiving a quality assurance audit.

The main areas for improvement highlighted throughout the audits

relates to the following:

Cleanliness of medical consumables stores

Cleanliness of dirty utility areas

Updating of IPC notices, particularly monthly audit results

Cleanliness of kitchen areas, primarily appliance e.g. microwaves

Staff awareness of Occupational exposure incident management

*No patient care is provided on any of the Trusts premises.


August 2017 17

IPC Staff Audit Results The Trust audits staff compliance with IPC procedures and practice

through three different audit types:

Uniform compliance- primarily relates to compliance with bare

below the elbows policy

IPC practice- this is a theory based audit whereby staff are asked

question relating to IPC practice and procedures

QA10-this is carried out during a clinical ride-out observing

compliance with IPC practice and procedures

Due to the fact that clinical staff work individually or in pairs and cover

a large geographical area it is not realistic for high numbers of

observational audits to be performed.

Uniform audits were increased to monthly submission for 2016/17

following feedback from management teams and to simplify the audit

and reporting schedule. For 2016/17, there was an initial drop in

submission levels as some areas adapted to the change to the schedule;

the compliance level was consistently above 95% for the entire year.

The numbers of IPC practice and QA10 audits completed throughout

the year is limited due to the availability of clinical staff and the

logistical and geographical challenges of the trust.

The IPC practice audit is carried out through a discussion with the

clinical staff whereby they are asked a series of questions regarding

their understanding and compliance with IPC practices and procedures.

A total of 170 IPC practice audits were completed during 2016/17. The

average overall compliance level for the IPC practice audits was 75.3%.

This is below the target level set by the Trust and the main areas for

improvement relate to:

Understanding and compliance with Trust wrist watch policy,

staff are permitted to wear a washable wrist watch (in line with

DH guidance) providing it is removed for hand hygiene

Bare below the elbow compliance regarding wrist and hand

jewellery

Recognition of the “Five moments of hand hygiene”

Awareness of Occupational exposure incident management


August 2017 18

The QA10 audits are carried out during clinical ride-outs with

operational staff, primarily on ambulances to allow for the observation

of the complete patient care episode. There were a total of 133 QA10

audits performed during 2016/17, the average overall compliance level

for these was 96%.

The main areas for improvement relate to:

Compliance with the aseptic non-touch technique for

cannulation, primarily relating to the recording of ANTT/

Emergency cannulation on patient record

Uniform compliance, primarily due to compliance with bare

below the elbows due to wrist/ hand jewellery

The IPC practice audits highlighted that recognition of the “five

moments of hand hygiene” was an area requiring improvement

however this was found to be an area with consistently high results in

the QA10 audits which achieved above 95% every month, with the

exception of May.

.


August 2017 19

Untoward IPC related incidents

The Trust records incidents through the online reporting system, Datix to

ensure ease of access staff are able to submit incident reports either

online or via a single point of contact phone number. The IPC related

incidents are split into two main themes and reported on through the

monthly IPC report, they area classed as:

Occupational exposure incidents

o Contaminated needle stick injuries

o Splashes of blood or bodily fluids to mucous membranes

o Exposure to highly infectious patients

Incidents which cause or have the potential to cause harm to staff,

patients or the public

o Clean sharp injuries

o Poor practice

o Waste compliance

During 2016/17 there were a total of 222 incidents

48 contaminated needle stick injuries

o 23 relating to intravenous needles

o 6 relating to intravenous needles

o 1 relating to an intraosseous needle

o 7 relating to patients own devices

o 4 relating to razors

o 7 relating to others e.g. broken glass, bites etc.

42 splashes of blood or bodily fluids

12 exposures to potentially highly infectious patients

29 clean sharp injuries

92 other incidents* e.g.

o Poor practice relating to decontamination and preparation

of equipment and vehicles

o Wrong waste disposal/ segregation

*There were 50 incidents relating to decontamination declaration on the defective equipment

form. This was as a result in a change to practice and failure of areas to adopt change in

practice in July.


August 2017 20

IPC activities

Seasonal Flu vaccinations

As a responsible healthcare provider the Trust promotes and

encourages its entire staff group to get the seasonal flu vaccination. The

vaccination, although recommended and acknowledged as the most

effective method of reducing the spread of flu, is not mandatory. All

NHS Trusts face challenges in delivering the flu vaccinations and this is

particularly challenging within ambulance Trusts due to the large

geographical areas and logistical issues. During the 2016/17 flu

campaign a total of 46.2% of EEAST staff were vaccinated, the national

uptake for all ambulance Trusts was 53.1%. Which although the level of

uptake was below the desired level it is an increase of almost 10% on the

previous year and 20% increase in the past three years.

Outbreaks

The Trust was not involved in any significant outbreaks

or infection control incidents during 2016/17.

Training

IPC training is cover with all staff in multiple formats. All clinical staff

receives specific IPC training relating to their role and clinical level, this

is covered through all clinical training courses.

Non-clinical staff also receives IPC awareness training through the Trust

induction upon joining the Trust.

Further to this IPC is included within the regular mandatory training for

all staff; this is delivered as mixture of classroom sessions and

eLearning/ workbooks. A total of 76% of clinical staff completed their

mandatory training during 2016/17, and 67% of new starters (non-

clinical) had completed their induction training at the end of 2016/17

(new starters have a six month period to complete induction training).

1005 of new clinical staff received IPC training as part of their clinical

course.

The Trust also supports local universities with delivery of IPC training to

paramedic science students prior to operational placements.


August 2017 21

IPC Programme 2017/18

The Trusts IPC programme and annual plan are maintained within a

dynamic governance and assurance framework program. This is utilised to

monitor Trust compliance with regulatory requirements and compliance.

This system supports the local management teams in having clearer

visibility of their requirements and supports local ownership.

During 2016/17 there was still a degree of under resourcing to the IPC

Team which has limited some of the work capacity of the team. This is

being addressed for 2017/18 by the allocation of addition funding for an

IPC Specialist Practitioner within the team, which will be recruited during

the year. This will allow for greater focus on improving standards and

reviewing the audit and quality assurance results. It will also allow for the

development and training of the IPC Champion network and local IPC

leads.

Priorities for 2016/17 include:

During 2017/18 the IPC team will continue to take a strategic role

and further support the development of local ownership in all

areas, to increase the local focus and compliance of IPC issues.

Recruit to the new IPC Specialist Practitioner role

Review the Trust Quality Assurance process and develop areas for

improvement, to maximise the available resources

Review and improve the recording and monitoring of the actions

taken elements of the audit cycle

Work in conjunction with the National Ambulance Service IPC

group to develop consistency across all UK Ambulance Trusts.

Continue to improve networking and communications across all

aspects of healthcare economy.

Carry out a complete review of the IPC annual programme and

associated policies to ensure compatibility with the new Trust

structure and compliance with the recent changes to the CQC

monitoring process and standards.

Continue to monitor and quality assure the Trust third party

providers e.g. Independent private ambulance services, Air

ambulance providers

Review, improve and update the Trust training presentations for all

clinical grades to ensure high standard training is provided to all

clinical staff

Review the IPC related products in use within the Trust to ensure

practicality, efficiency and suitability.

Increase participation and networking across the wider healthcare

environment and the National Ambulance Service IPC group,

including Health Protection England and local CCGs

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