Infection Prevention & Control in Health and Social Care
By Daniel Dutton (21st May 2020)
Effective infection prevention and control is essential in all health and social care settings. Not only is it needed to comply with legislation and regulation but is also required to protect both service users and workers from illness and disease as well as the wider public.
In this essay, I will be examining current national legislation and organisational policy relating to infection management and how my organisation responded to the coronavirus pandemic of 2020, which resulted in changes to existing policy. I will also look at how policy may differ between settings and the need for a proportionate approach.
Several pieces of legislation relate directly to infection management in the workplace. Primarily, the Health and Safety at Work Act 1974 puts the responsibility on employers to ensure that their employees, clients and the wider public are protected from potential harm caused by workplace activities as much as possible. More detail of how employers must do this is provided in the Management of Health and Safety at Work Regulations 1999, which includes assessing and managing risks and the provision to employees of sufficient training and any Personal Protective Equipment (PPE) needed for their work. Employees also have a responsibility to follow organisational policies and procedures to ensure that they work safely as well as reporting any risks to the health and safety of others to their manager or other appointed person(s).
Other regulations under the umbrella of the Health and Safety at Work Act include the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 and the Control of Substances Hazardous to Health (COSHH) Regulations 2002.
RIDDOR puts the duty on employers to report to the Health and Safety Executive (HSE) all serious workplace accidents, occupational diseases and certain dangerous occurrences or near-misses.
COSHH requires employers to risk assess and control any hazardous substances that employees and others may come into contact with when carrying out their work. Hazardous substances can include, but is not limited to, cleaning products, bodily fluids and fumes. Employers may reduce the risk of harm by providing training, PPE, instruction on usage and suitable storage.
Also (related to COSHH) are the Hazardous Waste Regulations 2005, which regulates the control and tracking of certain waste which is of particular high risk to health or the environment and the Health and Safety (Sharp Instruments in Healthcare Regulations) 2013, which deals with the safe use and disposal of sharps including needles and surgical blades.
The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance provides guidance for registered providers about effective infection prevention.
In addition, Key Lines of Enquiry (KLOEs) from the regulatory body, the Care Quality Commission (CQC) query if service users are receiving safe and effective care and so infection control is a key part of the inspection process. These are based on the framework of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. For example, regulation 12 states the service provider’s responsibility for ‘assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated’.
Finally, the Coronavirus Act 2020 grants the government additional discretionary powers to prevent the spread of infection, such as suspending public gatherings and detaining individuals suspected to be infected with coronavirus.
My organisation’s Infection Control Policy and Procedure provides instruction and guidance to employees to comply with the legislation above and keep themselves and others as safe as possible from infection. Our policy and procedure identify several factors that can contribute to the spread of infection in my work setting as well as practices that can help reduce the spread. It identifies that many healthcare associated infections are preventable through good hand hygiene to remove dirt and transient microbes. It continues by instructing when hands should be washed, handwashing agents to be used and correct handwashing technique. PPE in the form of gloves, aprons and masks is discussed and assessed as necessary when there is risk of contact with bodily fluids to create a barrier between potentially infected substances and the care worker’s clothes and skin. In response to the coronavirus pandemic, this policy was changed to include the use of gloves when supporting clients that require any form of touch including helping into and out of bed. Overshoes are also discussed but are stated to be “unlikely to be required in a homecare setting” and that “staff must be aware that the use of overshoes increases the risk of slips, trips and falls”. As such, these are not used in my setting and this demonstrates a proportional approach to infection control. Other factors that can increase the risk of infection include individuals touching their face, breaks in the skin and underlying health conditions. Therefore, following best practices and maintaining a healthy lifestyle can reduce the risk of infection. Although this policy and procedure does cover all aspects of infection prevention and control, I did notice that it does not specify who has the role of Infection Prevention Lead. I have recommended to the registered manager that this person should be named within the policy.
It is important that employees understand and adhere to the policy, procedures and practices relating to infection control so that likelihood of infection and infection outbreak are minimised as much as possible. As such, it is written into all employee’s contracts and job descriptions that they must read organisational policies and procedures and adhere to them. In addition, training is provided around infection control during induction and refreshed annually.
To ensure employee understanding and performance, infection control is built in to individual and team performance management. As a Team Manager, it is my responsibility to ensure that my team follows correct procedures relating to infection control. This is achieved using a combination of observation and professional discussion. If I am made aware of policies not being complied with, I will speak with the team member to clarify any misunderstandings they may have and explain the importance of infection control. If non-compliance continues, action must be taken which could include providing additional training for the individual or disciplinary action. To assist understanding and promote good practice, it is also important for me to model best practice in my own work.
Although I primarily work with a single client in a supported living setting (supporting them in their own home), it is important that I understand that policy, procedure and practice with regards to infection control will differ between settings and that a proportionate approach should be used.
For example, domiciliary care services would not expect care staff to provide cleaning services when they visit a service user’s home, however other infection control practices such as the wearing of gloves, aprons and other PPE, washing hands and following correct procedures for care tasks would still apply. Conversely, in a hospital or nursing home setting, there may be individuals that are more susceptible to illness or not physically able to perform cleaning tasks themselves. In these settings, the services provider has the duty to make sure that the environment is clean and appropriate for the control of infection. However, respect should still be given to an individual’s personal space, such as their bedroom.
In my own setting (supported living, adult social care), due regard should be taken to the abilities of the individuals that are being cared for and so cleaning and infection control is written into an individual’s person-centred care plan. Some individuals may be physically unable to perform cleaning tasks, in which case care staff have the responsibility of keeping the environment safe from infection. Other individuals may be fully independent in being able to maintain a clean and healthy environment themselves. Whilst some individuals may be physically able to perform cleaning and hygiene tasks, they may not have the knowledge or skills to be able to do so effectively. In these cases, staff would work with them to gain skills and independence in this area.
During 2020, the outbreak of the coronavirus resulted in changes to legislation and infection control policies and procedures. This represented many challenges for our organisation because guidance changed rapidly as the government attempted to control infection rates in Great Britain.
In January and February 2020, the first signs of the pandemic were being observed and on the 25th February, the government published the ‘Guidance for social or community care and residential settings on COVID-19’, which provided information about the virus and how health and social care settings should respond to it. This document was distributed to all managers on the same day, including myself, and then I disseminated the information to my team. Although the general message was “there is no need to do anything differently in any care setting at present”, it is always important that information is shared in timely fashion to ensure that employees are up-to-date with current practice, have confidence that their employers are performing their roles correctly and to allay any fears that may have arisen from the other sources, such as the press and social media.
This guidance was withdrawn on 13th March, due to the government’s publication of a new policy document on 3rd March entitled ‘Coronavirus action plan: a guide to what you can expect across the UK’, which outlined their response towards the coronavirus and their plan of action. Again, this was relayed to managers and then to team members.
As the threat of coronavirus continued to increase, 13th March was also the date that Team Managers got together for a face-to-face meeting to discuss the organisation’s own plan of action. I declined the invite as I felt that it was not appropriate for so many people to be in close proximity. I also expressed my concerns to senior management that if a delegate of the meeting did have coronavirus then it could potentially result in the whole management team becoming ill. Although my concerns were considered and my decision to not attend was respected, the meeting went ahead nonetheless.
Action steps as a result of this meeting included our main office closing and, where possible, staff to work from home as well as the cancellation of all upcoming training sessions. Managers were to discuss what coronavirus with each client (easy-read documents were supplied) and a coronavirus risk assessment was conducted for each client. A coronavirus hospital passport for each client was also created to provide information to healthcare professionals about the individual, as staff would not be able to provide support for them in a hospital setting. Social distancing was encouraged for all clients and letters were sent to family members to explain the actions we were taking and request their views. To ensure service provision in case of staff shortages, contingencies were drawn up for clients to live with their families (where possible and agreeable by all parties) and a list of services with vacant bedrooms was created so that staff could work with clients 1:2 if necessary. Weekly bulletins were arranged to keep everybody up to date with the changing situation. Guidance was given to frontline support workers to explain what was happening and what to do if they or their client displayed coronavirus symptoms. For the benefit of my team, I collated government advice, organisational policies and changes that I felt appropriate for my particular service and wrote them up as a handy one-page overview so that staff knew everything they needed to perform their jobs correctly. This can be found in Appendix A.
As part of my role as Team Manager, I also ensured that we had adequate supplies of PPE available at my setting in case it was needed – although PPE is not usually required in my setting because there isn’t a need for close contact, my client does very occasionally need some personal care support. Gloves, antibacterial wipes and disposable bags were sourced and acquired before the outbreak began as a contingency.
On 23rd March, the government announced “lockdown” measures to prevent the spread of coronavirus and reduce the load on the National Health Service (NHS). This meant that the general public could only leave their homes to obtain shopping, medical supplies or to go to work if they were classed as a keyworker.
Since the coronavirus outbreak, team members have worked hard to ensure that standards are even higher than before with respect to infection prevention and control. This has included the daily laundering of hand towels, tea towels and dishcloths and maintaining a distance of at least two metres between clients. As the individuals that we work with have learning disabilities, it has been challenging to help them to understand the reasons why they can no longer touch or hug their staff but we have achieved positive outcomes using discussion aids, such as social stories and easy-read explanations, as well as persistent positive reinforcement. Clients have also learned the importance of good hand hygiene and are washing their hands far more frequently than they were previously as well as using more soap and better hand-washing techniques. This is something we did work on with clients before the pandemic, with mixed results, however I believe that because they are seeing it being reinforced more and more on television and on social media, they have been more susceptible to changing their own behaviour.
These policies, procedures and practices appear to have been successful because we have only had one possible case of coronavirus and, because that staff member rang in sick and self-isolated for fourteen days (as required by governmental guidelines), no other cases have been reported. This absence was reported to our registered manager, who is keeping a list of all coronavirus-related absences, to be used to spot any patterns that may emerge across the organisation and to be used for business intelligence and planning as the coronavirus pandemic unfolds.
- Department of Health (2015). The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. [online] Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/449049/Code_of_practice_280715_acc.pdf [Accessed 24 May 2020].
- HM Government (2020). The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. [online] Available at: https://www.legislation.gov.uk/ukdsi/2014/9780111117613/contents [Accessed 24 May 2020].
- HM Government (2020). Coronavirus Act 2020. [online] Available at: http://www.legislation.gov.uk/ukpga/2020/7/contents/enacted [Accessed 24 May 2020].
- HM Government (2020). Health and Safety at Work etc. Act 1974. [online] Available at: http://www.legislation.gov.uk/ukpga/1974/37/contents [Accessed 24 May 2020].
- HM Government (2020). The Control of Substances Hazardous to Health Regulations 2002. [online] Available at: http://www.legislation.gov.uk/uksi/2002/2677/regulation/7/made [Accessed 24 May 2020].
- HM Government (2020). The Hazardous Waste (England and Wales)Regulations 2005. [online] Available at: http://www.legislation.gov.uk/uksi/2005/894/contents [Accessed 24 May 2020].
- HM Government (2020). The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. [online] Available at: http://www.legislation.gov.uk/uksi/2013/645/contents/made [Accessed 24 May 2020].
- HM Government (2020). The Management of Health and Safety at Work Regulations 1999. [online] Available at: http://www.legislation.gov.uk/uksi/1999/3242/contents/made [Accessed 24 May 2020].
- HM Government (2020). The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. [online] Available at: http://www.legislation.gov.uk/uksi/2013/1471/contents [Accessed 24 May 2020].
Appendix A: Managing COVID-19 at Services
A brief guide for staff (Dan Dutton 25/03/2020)
Due to current circumstances, we need to keep on top of hygiene and cleanliness at our services. Therefore, all staff must be performing the following tasks whilst on shift:
- Wash hands immediately on arrival on shift
- Wash hands regularly throughout the day, especially:
- before after food preparation
- before and after providing personal care
- After using the toilet
- Before and after handling medication
- Ensure clients are washing hands regularly as well
- Staff to perform correct handwashing techniques
- Staff bedding to be changed each day
- Staff and clients to maintain a distance of at least 2 metres between one another – no hugging or touching.
- Staff to ensure all communal hand towels, tea towels and dishcloths are changed each day and the dirty ones are put in the washer.
- Staff to disinfect all door and cupboard handles each day
- Staff/client to only leave the premises a maximum of once per day for exercise or to get essential supplies
- No non-essential visitors to the service
- Where practicable, staff and clients to handle only their own laundry (e.g. clients to carry their own laundry to the washer and put it on)
- Toilets to be cleaned/bleached each day
- Try to avoid touching your face and encourage clients to do the same
- Cover your mouth when coughing/sneezing, ideally with a tissue then dispose of tissue and wash hands immediately afterwards. Encourage clients to do the same.
- Be aware that symptoms of COVID-19 include a fever, persistent cough and/or difficulty breathing. If you or the client experience these symptoms follow government advice:
- Self isolate for 7 days
- If someone in your household displays symptoms, self isolate for 14 days
- If a client displays symptoms, staff must withdraw from them, wash hands, call NHS 111 for advice and inform their manager.
- Personal Protective Equipment (e.g. gloves, aprons) should be used where applicable.