INFECTION CONTROL STANDARDS FOR ADULT CARE HOMES: FINAL STANDARDS
Healthcare Associated Infection (HAI) is a priority issue for Scottish healthcare. The profile of prevention and control of HAIs has been transformed within the past few years. Significant milestones include the Carey Report "Managing the risks of healthcare associated infections in NHSScotland" (August 2001); the NHS Quality Improvement Scotland (NHSQIS)/Clinical Standards Board for Scotland HAI Infection Control Standards (December 2001) AND Cleaning Services Standards (June 2002); "A framework for national surveillance of healthcare associated infection in Scotland" (July 2001); the Antimicrobial Resistance Strategy and Scottish Action Plan (June 2002); the Ministerial HAI Action Plan "Preventing infections acquired while receiving healthcare (October 2002); the Audit Scotland review of cleaning services and the NHSQIS review of HAI infection control standards (both published January 2003) and the "champions" educational initiative (April 2003).
A major programme of work to improve the prevention and control of HAI across Scotland was laid out in the Scottish Executive Health Department's Ministerial Action Plan on HAI. This programme is now being actioned by the Scottish Ministerial HAI Task Force, led by the Chief Medical Officer. These standards fit into the overarching work of the Taskforce.
The Care Commission
1. From 1 April 2002 a new national body, the Scottish Commission for the Regulation of Care (the Care Commission), has been responsible for the regulation of care services. The Care Commission regulates against the requirements of the Regulation of Care (Scotland) Act 2001 and its associated Regulations and taking account of National Care Standards issued by Scottish Ministers.
2. The Care Commission has the following functions:
regulating care services in Scotland;
keeping Scottish Ministers informed about the provision and quality of care services;
encouraging improvement in the quality of services; and
making information available to the public about the quality of care services.
3. The National Care Standards focus on the people using care services. Regulated care services will be expected to demonstrate to the Care Commission that they promote and enhance the quality of life of service users taking account of the principles of dignity, privacy, choice, safety, realising potential and equality and diversity. Further information can be obtained from the Care Standards and sponsorship website: http://www.scotland.gov.uk/about/HD/CCD1/00017652/careStandardshome.aspx
4. The Regulations associated with the Act require care service providers to have appropriate procedures for the control of infection. The National Care Standards documents similarly state that users of services can be confident that service providers will take measures to prevent the risk of infection and that the service operates in line with best practice guidelines.
5. Care home services for adults range from individually owned and managed care homes to care homes which are part of local (e.g. Local Authority) and national groups (e.g. national care home company). These Standards apply to all. Care homes for adults can provide a range of care: personal support, personal care, nursing care (healthcare). The Standards address an aspect of care provision, infection control, that is important to all types of care, but especially so to healthcare.
6. The evidence and expertise on which the Standards are based are mainly, if not wholly, sourced from the healthcare sector. This and the use of infection control standards developed for the NHS as the basis of the Standards (CSBS 1 Standards on Healthcare Associated Infection - Infection Control) means there is a tendency for the terminology and emphasis to have a healthcare and large organisation focus. It is hoped that this does not detract from their very important relevance to and implementation in Care Homes for Adults no matter the size of the home or the care provided by it. The monitoring of the Standards, and associated application of the audit tool, will be tailored to take account of the characteristics of individual care homes.
The case for infection control Standards
7. It follows that from 1st April 2002, care providers - whether private or public sector - have been required to show that their staff take measures to control the spread of infection or face proportionate enforcement action.
8. However, what is best practice in infection control for adult care homes is not immediately apparent. There are currently no underpinning national standards for infection control in adult care homes and other care services for adults. And, although some guidelines and policies have been set by some NHS Boards across Scotland, they are not uniform and they have no regulatory substance.
9. Therefore, in June 2002 the Minister for Health and Community Care announced plans to address this need for national infection control Standards for adult care homes and other care services for adults by:
Establishing an external Working Group to develop detailed proposals for such national Standards, by 31st October 2002;
Adopting those proposals as interim national Standards from 1 November 2002; and
inviting comments from all interested parties by 31st January 2003; and
Taking account of the views emerging from that consultation process, to develop agreed national Standards in 2003
10. This document was originally published in draft form in 2002 and considered the need for, and nature of, national infection control standards for adult care homes. It set out detailed draft proposals for such standards and was widely distributed to initiate a broad debate around these issues . The views which emerged from this consultation process have been taken into account in this final version of the Standards. The group wish to thank all those who contributed to the consultation process.
Remit and membership
11. A Working Group, chaired by Margaret Tannahill of Argyll and Clyde NHS Board, began work in August 2002, with the following remit: "To prepare and publish, by 31st October 2002, a consultation paper setting out detailed proposals for new national infection control standards for private and public sector adult care homes, and other care services for adults. The proposals should seek to build upon any consistency in (or best practice emerging from) current local policies and standards. They should also take account of the regulatory responsibility of the Scottish Commission for the Regulation of Care, and, if appropriate relevant developments elsewhere in the UK. The group took the view that the definition of care home should include care homes in the public, private and voluntary sector. While it was considered that care in the home be included in the definition of "care homes" it was decided that this be omitted, although it is acknowledged that the principles contained within these standards could be applied to other settings.
12. The Membership of the Working Group is set out at Annex A. The Working Group is grateful for the valuable contribution of Dr David Steel, formerly Clinical Standards Board for Scotland (now NHS QIS), and Dr David Old, Chair of the HAI Reference Group, Clinical Standards Board for Scotland. The members of the Working Group would also like to acknowledge the contribution of Dr Martin Donaghy, Joe Brown, and in particular Marianne Cook in the production of these Standards.
13. In addressing its remit the Working Group recognised that a considerable amount of work had already been undertaken to develop standards on healthcare associated infection by:
A Scottish Executive Health Department (SEHD) Working Group, established in November 2000 chaired by Mr Richard Carey, Chief Executive, Highland Acute Hospitals NHS Trust. The Group's role was to provide guidance to NHSScotland about assessing and managing risks related to healthcare associated infection. This resulted in the Working Group report "Managing the Risk of Healthcare Associated Infection in NHSScotland". The development of appropriate HAI Standards was an important part of the remit of the Working Group.
An HAI Reference Group was established by the Clinical Standards Board for Scotland (CSBS) in June 2001 chaired by Dr David Old, Consultant Clinical Scientist (retired) to build on the work of the Carey Group and finalise HAI related Standards. See Annex E for references.
14. The scale of the problem of HAI means that tackling it involves the mobilisation of a range of resources and effective management control of these. To guide this process, healthcare organisations need to have developed and implemented systems to assess the risks of infection to those using their services, to put in place measures to reduce these risks and to monitor and report on how these are working. In the NHS, standards have been developed by the Clinical Standards Board Scotland to assess whether healthcare organisations have these systems in place and how well they are using them to prevent infections. This systems-based approach is similar to that adopted in other industries and has been endorsed by the Health and Safety Executive. It does not replace the need for ensuring good practice is carried out on a day to day basis but provides a framework for ensuring that this happens every day.
15. The Working Group therefore decided to use the CSBS Standards on Healthcare Associated Infection (HAI) Infection Control and the CSBS Standards on Healthcare Associated Infection (HAI) Cleaning Services Standards as the basis for the development of the national Infection Control Standards for Adult Care Homes . The Working Group considered that there was merit in seeking to align infection control standards, as far as possible, across healthcare and social care boundaries.
16. Consistent with that, all the Standards follow the same format:
Each standard has a title, which summarises the area on which that standard focuses.
This is followed by the standard statement, which explains the level of performance to be achieved.
The rationale section provides the reasons why the standard is considered to be important.
The standard statement is fleshed out in the section headed criteria, where it states what needs to be achieved for the standard to be reached. As already explained, the Group aimed to set Standards that are achievable but stretching. This is reflected in the criteria. The criteria are numbered, for the sole reason of making the document easier to work with, particularly for the assessment process. The numbering of the criteria is not a reflection of priority.
A self-assessment audit tool appears immediately following each standard. A glossary is included at Annex C and a flow chart at Annex E outlines key relationships and summarises this guidance.
17. The review undertaken by the Working Group included:
identifying equivalent Scottish, English, Welsh and American guidance - statutory and mandatory;
obtaining, reviewing, updating and augmenting, where necessary, all reference material;
cataloguing reference material used as the evidence base for the Standards;
amending the CSBS Standards, where considered appropriate, for use by private and public sector adult care homes.
18. The Working Group also agreed to produce draft Standards in the form of a consultation document published in November 2002, which were both stretching and achievable. These draft Standards can be accessed at: http://www.scotland.gov.uk/consultations/health/icsa-00.asp
19. The majority of the Standards address the structures and processes supporting effective infection control. Their principal purpose is to assess how effectively an organisation is managing the risk of infection. As such, the Standards mainly relate to the organisational structures and processes needed to identify, assess and treat specified risks of infection.
20. Hand Hygiene (Standard 12) is most directly related to care practice and was included because of the importance of the topic.
21. The Working Group acknowledges the importance of surveillance as a means of monitoring infection rates and of targeting effective interventions for the control of infection. An appropriate infrastructure is necessary to support surveillance of infection in Adult Care Homes, and the Working group therefore recommends that further work is undertaken on the development of this infrastructure.
22. In the draft Standards published in 2002, the Working Group included provisional proposals relating to cleaning Standards in support of infection control in adult care homes. Consultation responses indicated that cleaning Standards are desired and that the Working Group therefore recommends that further work is progressed in this area. The National Cleaning Services Specification could be used within the Care Home Sector.
Health & Safety Enforcement
24. The responsibility for the enforcement of the Health & Safety at Work, Act 1974 and associated regulations, currently falls to the Health & Safety Executive (HSE) and Local Authorities. Specific responsibilities are laid down in the Health & Safety (Enforcing Authority) Regulations 1998 (which are currently under review). The current position is the same as that which has been in place for a number of years - the enforcing authority for adult care homes where nursing care is part of the care service provided by them is the HSE. Local authorities are the enforcing authority for adult care homes where nursing care is not part of the adult care service provided.
25. A Memorandum of Understanding is currently being discussed by the Scottish Commission for the Regulation of Care, HSE and local authorities. The main purpose of such a document would be to set out the respective roles and responsibilities, areas of regulatory overlap, principles of understanding, and mechanisms to facilitate communications.
26. The following Standards were originally presented by the working group primarily for consultation and also for use as interim national Standards from December 2002. Following widespread consultation these Standards have been revisited and revised by the working group at the request of SEHD following feedback received from the consultation. Although out with the original remit the Working Group, following substantial positive feedback ,the Working Group also undertook to develop a simple audit tool for use by Adult Care Homes.
27. An audit tool has been developed for each of the Standards to assist adult care homes in self audit. For ease of reference this appears on the page following each individual standard. The audit tool is intended to provide clarification on certain aspects of the Standards which were unclear to consultees and examples which could be provided as evidence of compliance with the Standards. The examples enclosed are illustrative only and many organisations may already be using different self- developed audit tools or tools provided by other practising IC specialists. 28. Requests for additional copies should be sent to:
Public Health Policy 1.1
St Andrews House
or emailed to firstname.lastname@example.org
29. This document may also be viewed on the Scottish Executive Website at:www.scotland.gov.uk