Outcome of hygiene code visit for: Southampton University Hospitals NHS Trust Site visited: Southampton General Hospital Date of visit: 17 July 2007 Hygiene Code Inspections The Code of Practice for the Prevention and Control of Healthcare Associated Infections (the hygiene code) was introduced under the Health Act (2006) and came into force on 1 October 2006. The code sets out the duties that NHS organisations need to observe to ensure that patients are cared for in an environment in which the risk of healthcare associated infections (HCAI) is kept as low as possible.

The Healthcare Commission is carrying out inspections at 120 trusts to check compliance with the hygiene code. The visits are unannounced to allow assessment managers to see the hospital as a patient or visitor would view it when coming for an appointment or procedure.

On the day of inspection (17th July 2007), our assessment managers evaluated the trust's compliance with three duties from the hygiene code. These were: duty 2 - the trust must have in place appropriate management systems for infection prevention and control; duty 3 - the trust must assess the risk to patients of acquiring healthcare associated infections (HCAI) and take action to reduce or control such risks; and duty 8 - the trust must provide adequate isolation facilities for infected patients.

Findings On the day of the visit the trust was able to show that good infection control was an integral part of the way the trust operated. The trust develops monthly MRSA performance monitoring reports for each division and care group, showing MRSA rates, and the infection control team monitor infections within the trust and reports to the board on a regular basis.

The chief executive promotes improvements in the control of infection across the trust by providing staff with updates and information on the control of infection via a chief executive officer bulletin, team briefings and letters to specific staff groups.

In addition, the director of infections prevention and control (DIPC) chairs any trust wide outbreak meeting, and receives daily updates on minor outbreaks of infection. The trust acknowledges that the job descriptions need to be reviewed for executive and non-executive board members to reflect infection control and prevention responsibilities.

The trust has a system for examining the risk of infection and the trust considers that an ongoing emphasis on hand hygiene is essential to control infections. The trust has systems to identify and communicate infection prevention and control risks across the organisation.

The trust has a policy that sets out the infection prevention and control principles that must be applied to bed management, and movement of patients to minimise the risk of infection. This policy considers the impact of admissions, discharges, movements within the hospital and transfers via the ambulance service.

The trust has an audit programme for a range of infection control issues, which includes use of antibiotics and hand hygiene. The trust audit programme should be reviewed to ensure that areas identified for improved cleaning are included.

The infection control link staff provide local training in infection control, to clinical staff, to support divisional action plans. The trust has developed a specific infection control education programme and staff can obtain guidance on infection control education resources from the trust's intranet, which shows specific courses for different staff groups, delivered through half day workshops, learning resource packs or e-learning tools. The trust has prepared tailored training material for infection control.

The trust has an isolation policy that includes a risk assessment tool, an isolation priority scoring system and a chart that links the condition of infection against patient risk groups and the specific period of isolation. The hospital has an infectious diseases unit and some isolation rooms, but as isolation facilities are limited the trust applies a risk assessment process to prioritise infected patients.

During our visit we were able to confirm that the trust's policies and systems were being translated into sound arrangements on the ground There were areas where cleaning responsibilities and supervision arrangements for trust staff need improving which includes the organisation of its contract cleaners.

Conclusion On the day of inspection, our assessment managers considered Southampton University Hospitals NHS Trust had the necessary systems in place to help protect patients, the public, and staff from healthcare associated infection. The trust needs to ensure that those systems continue to work effectively. Recommendations are made to strengthen these systems.

Recommendations The Healthcare Commission has made recommendations to further improve and strengthen the systems in place within the trust to manage the risk of healthcare associated infections:

  • The trust must update job descriptions for executive and non-executive board members to reflect infection control and prevention responsibilities
  • The job description for the director of nursing should be updated to include her role as DIPC more explicitly
  • Training records must be accurately maintained to support regular monitoring and reporting to the board.
  • Cleaning responsibilities and supervision arrangements for trust staff and contract cleaners must be clearly allocated to ensure all areas of the trust are kept dust-free and that all equipment is maintained in a clean state.
  • The audit programme must be reviewed to ensure that areas identified for improved cleaning are included.