Public Board of Directors papers 27.01.22

There are check and challenge opportunities by the executive/senior leadership teams of IPC practice in both clinical and non-clinical areas.

Challenge and check opportunities are not limited to executive/senior leadership teams and are applicable across all areas of the organisation and to all staff members irrespective of grade or position and addressed in real time. At a minimum IPC practices are in line with or an enhancement of national guidance and compliance monitored by the individual areas. IPC practices are monitored and reported through the IPC governance structure that feeds into the trust wide quality and governance assurances. Adherence to good IPC practice is jointly monitored in real time and regularly audited in clinical care areas e.g. hand hygiene audits. All staff, including agency and external contractors undergo IPC training relevant to their role and area of work. IPC practices are monitored in real time and supported by relevant policies whose efficacy is monitored by the IPC committee with onward escalation via the trusts governance process as required. Regular hand hygiene audits are undertaken in line with the Hand hygiene policy. See Hand hygiene Policy. To prevent self-contamination of virus' and bacteria, additional donning and doffing training has been delivered during the pandemic by the IPC team and Practice Education Facilitators (PEF) in clinical areas. Donning and doffing information is available on the intranet page utilising links to the latest national resources and guidelines. See Donning and doffing quick guide. Decontamination is a combination of processes used to ensure a reusable medical device or care equipment is safe for further

Resources are in place to implement and measure adherence to good IPC practice. This must include all care areas and all staff (permanent, agency and external contractors). The application of IPC practices within this guidance is monitored, e.g. • hand hygiene. • PPE donning and doffing training. • cleaning and decontamination.

C1501: Infection prevention and control board assurance framework (24 December 2021 Version 1.8) – January 2022

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