Date Published: 24 November 2008

Watchdog praises NHS progress on infection control and urges trusts to maintain pressure

The Healthcare Commission today (Monday) praised NHS trusts for showing increasing commitment to reducing healthcare-associated infections (HCAIs).

But it added that the NHS must maintain the pressure because spotchecks have revealed gaps in many trusts' systems. It said that comprehensive and consistent systems are needed to ensure infection rates continue to drop.

The Commission published an analysis of unannounced inspections at 51 acute NHS trusts in England, representing about 30% of the acute sector.

The spotchecks are part of the biggest ever programme of inspections in the NHS, designed to assess the compliance of acute NHS trusts with the government's hygiene code.

The Commission found that most trusts had improved arrangements to ensure good leadership, appointed staff with clear responsibilities for infection prevention and control, and put in place policies to ensure staff uniforms are clean and fit for purpose.

But only five trusts were compliant with all requirements of the hygiene code assessed, with more than half of the remainder being told to ensure a clean and well-maintained environment across all their premises.

While almost all lapses (97%) did not represent an immediate risk to the safety of patients, the analysis suggests that almost all acute trusts have more work to do to get systems for infection prevention and control in place.

Anna Walker, the Commission's Chief Executive, said:

"It is clear that the NHS is paying close attention to infection prevention and control. Trusts have made real progress with many getting good systems in place and demonstrating clear board leadership on this important issue. Where we have raised concerns, we have generally been encouraged by the positive and prompt response at those trusts. Importantly, we have found few breaches requiring immediate action to protect the safety of patients - and where we have we have taken swift action. There are signs that all this is paying real dividends in terms of the impact on infection.

Now the challenge for trusts is to ensure they drive further sustained improvements by getting the right systems in place all of the time. At nearly all trusts we have found gaps that need closing. It is important to be clear that at these trusts we are not talking about the most serious kind of breaches. But these are important warning signs to trust boards that there may be a weakness in their systems.

In particular, trusts need to ensure that their wards are consistently clean and well maintained, and that they have good decontamination and isolation arrangements. We want trusts to ensure they are compliant with the government's hygiene code all of the time, in all parts of the organisation and for every patient. It is the consistent application of these systems that will ensure infection rates continue to drop. These issues are a top priority for the public. We make no apologies for demanding high standards. We have been asked by the government to help maintain the concentration on these issues and we intend to do just that."

The Commission found that the vast majority of trusts were compliant with the requirements relating to having:

* An agreement between board members on how to combat HCAIs, which is crucial for ensuring that the trust has a clear strategy that can be shared with staff at all levels;
* A director assigned to preventing and controlling infections, who keeps a close watch on the trust's performance and drives improvement and good practice;
* Appointed leaders for cleaning and decontamination to ensure that there are effective trust-wide systems for each;
* Suitable uniforms and workwear for staff, so that the risk of infectious agents being carried on clothing are minimised and hand washing can be effective.

However:

* 27 of the 51 trusts inspected were failing to keep all areas of their premises clean and well maintained. These lapses covered issues ranging from basic cleanliness, to clutter which makes cleaning difficult, to poorly maintained hospital interiors.
* One in five trusts in this sample did not comply with all requirements for the decontamination of instruments and other equipment used in the care of patients. Trusts that breached this duty tended to have no clear strategy for decontamination or to lack an effective process to assure compliance.
* In one in eight trusts, the provision of isolation facilities was not adequate. The containment of infections is extremely important to managing outbreaks. Hospitals without adequate facilities must ensure they have contingency plans so that the risk of infections spreading between patients is minimised.
* The analysis also highlights areas where trusts' systems for minimising risks of HCAIs are not ‘joined up'. For example, for over one in five trusts there were issues related to staff training, information and supervision. While training on preventing and controlling infection was often in place, boards could not always ensure that training days were well attended or that staff used their knowledge in practice.

The Commission said it was encouraged by the positive steps many trusts took to remedy breaches. Changes included: further cleaning; clarification of procedures for cleaning; replacement of equipment; replacing carpets with easy-to-clean vinyl; and new audits.

Where breaches triggered serious concern about risks to the safety of patients, the Commission issued an improvement notice requiring urgent action. Since it was given the power in 2006, it has issued improvement notices to four trusts, three of which are in this sample.

The Commission emphasised that trusts that performed well overall tended to have strong leadership on infection control. For example, they had a board-level agreement on HCAI and a director for infection prevention and control.

From April next year, every NHS trust will need to be registered with the new Care Quality Commission (CQC). To achieve this, they will need to demonstrate that they meet requirements on infection prevention and control set by the government. The CQC will have powers to enforce these requirements for registration, including the imposition of conditions or fines.
The Healthcare Commission urged all trusts to prepare for registration by looking at the findings from its inspections to help identify any weaknesses in their own practices. It said even minor lapses were a warning sign to trusts that there could be gaps in their systems.

As part of its annual health check performance ratings, the Commission checks compliance with three core standards related to infection prevention and control. It is possible for trusts to be compliant with these standards yet still have more to do on the hygiene code.

Of the 51 trusts, 29 met all three standards for the whole of the year 2007/8. The Commission identified breaches of the hygiene code in all but three of these trusts.

The core standards measure broad compliance over a full year while the spotchecks against the hygiene code assess trusts systems and performance in greater detail over one or two days. Depending on the details, extent and duration of non-compliance, a breach of the hygiene code may not reflect non-compliance with core standards.

The hygiene code applies to all types of NHS trust and the Commission's recent performance ratings show that not all primary care, ambulance and mental health trusts are doing all they should be to prevent and manage infection. For this reason, the Commission is starting to expand its inspection programme to include these trusts.

The hygiene code, introduced by government in 2006, outlines 11 duties that all NHS bodies must follow. Assessors check how well trusts are following at least three duties of the code, focussing mainly on management systems, cleanliness and decontamination, and isolation facilities. The Commission tailors each inspection based on the information it holds on each trust, which includes input from patients. During the visit, assessors visit wards, interview members of staff and check paperwork, such as policies and audit results.

The results of each inspection are published on the Commission's website as soon as they are finalised. Where the Commission finds breaches and makes recommendations for improvement, it follows up with trusts within a specified timeframe, often six months, so that trusts can provide assurance that they have acted.

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