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INFECTION CONTROL STANDARDS FOR ADULT CARE HOMES: A CONSULTATION

Introduction

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 against the requirements of the Regulation of Care (Scotland) Act 2001 and 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 Regulation of Care website: www.scotland.gov.uk/government/rcp

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.

The case for infection control standards

5. It follows that from 1^st 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.

6. However, what that might mean in real terms 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.

7. 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 31^st October 2002;
• Adopting those proposals as interim national standards from 1 November 2002; and inviting comments from all interested parties by 31^st January 2003; and
• Taking account of the views emerging from that consultation process, to develop agreed national standards in 2003.

8. This document considers the need for, and nature of national infection control standards for adult care homes and other care services for adults. It sets out detailed proposals for such standards and is being widely distributed to initiate a broad debate around these issues . The views emerging from this consultation process will help to revise and develop an agreed set of national standards for this care service sector. The Care Commission may be invited to adopt these standards in relation to their regulation of adult care homes and other care services for adults.

Remit and membership

9. 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 31^st 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.

10. The Membership of the Working Group is set out at Annex A.

11. The Working Group is grateful for the valuable contribution of Dr David Steel, Clinical Standards Board for Scotland, and Dr David Old, Chair of the HAI Reference Group, Clinical Standards Board for Scotland.

12. The members of the Working Group would also like to acknowledge the contribution of Dr Martin Donaghy, Dr Peter Christie, Joe Brown, and in particular Marianne Cook in the production of these proposed standards.

Development of national infection control standards - broader context and process

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, decontamination of reusable medical devices and hospital cleanliness. 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 established by the Clinical Standards Board for Scotland (CSBS) in June 2001 chaired by Dr David Old, Consultant Clinical Scientist (retired December 2000) to build on the work of the Carey Group and finalise healthcare associated infection related standards.

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 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 and other care services for adults. The Working Group considered that there was merit in seeking to integrate infection control standards, as far as possible, across healthcare and social care boundaries.

16. Consistent with that, all the proposed standards follow the same format:

• a title, which summarises the area on which that standard focuses;
• a standard statement, which explains the level of performance to be achieved;
• a rationale which explains why the standard is considered to be important;
• a section on criteria, which describes what must be achieved for the standard to be reached. The criteria are numbered, for the sole reason of making the document easier to work with, and not as an indication of relative priority.

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 evidence base for the standards;
• Amending the CSBS Standards, where considered appropriate, for use by private and public sector adult care homes, and other care services for adults.

18. The Working Group also agreed to produce proposals which are both stretching and achievable.

19. The majority of the proposed 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 proposed standards mainly relate to the organisational structures and processes needed to identify, assess and treat specified risks of infection.

20. Hand Hygiene (Standard 13) is most directly related to care practice and was included because of the importance of the topic and the sound supporting evidence base.

Other Matters

Surveillance

21. Although the Working Group decided not to include a standard on the surveillance of infection, members acknowledged both the importance of surveillance as a means of decreasing and monitoring infection rates, and the need to develop further the infrastructure required to support surveillance of infection in adult care homes, and other care services for adults. The Working Group has highlighted the importance of ensuring that service providers have effective mechanisms in place to ensure that incidents or outbreaks of infection are reported to the local NHS Board’s Department of Public Health and for collaboration thereafter (e.g. Standard 3, Criterion 3.6; Standard 6, Criterion 6.4f)

Antimicrobial resistance

22. The inclusion of standard information on antimicrobial resistance was another area discussed by the Working Group. Antimicrobial resistance makes infections more difficult to treat. It may also increase the length and severity of illness, the period of infectiousness, and adverse reactions (due to the need to use less safe alternative drugs). The Working Group acknowledges that those providing care in adult care homes, and other care services for adults, do not have significant influence on antimicrobial prescribing, but supports the Scottish Executive's Antimicrobial Resistance Strategy and Scottish Action Plan.

Cleaning standards

23. In developing detailed standards for infection control in adult care homes, the group sought to build on the framework provided by both the Clinical Standards Board Scotland (CSBS) Standards for HAI Infection Control and the CSBS Standards for HAI – Cleaning Services. However, in the time available to the Group, it was not possible to successfully integrate these two strands in the context of infection control in adult care homes.

24. The Working Group has therefore produced provisional proposals relating to cleaning standards in support of infection control in adult care homes. These are set out in Annex B, for comment. The Scottish Executive will take account of views expressed as a by-product of this consultation process in determining how best to take this work forward.

Health & Safety Enforcement

25. 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.

26. 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.

Consultation

27. The following draft standards are presented by the working group primarily for consultation, but also for use as interim national standards from December 2002. A list of consultees is at Annex E.

28. Your comments and requests for additional copies should be sent to:

Marianne Cook
Public Health Policy 1.1
3E(S)
St Andrews House
Regent Road
Edinburgh
EH1 3DG
or emailed to marianne.cook@scotland.gsi.gov.uk

29. The consultation period will end on 28^th February 2003.

30. This document may also be viewed on the Scottish Executive Website at: www.scotland.gov.uk

31. To help inform debate on the issues set out in this consultation paper, the Scottish Executive intends to follow its normal practice of making available to the public, on request, copies of the responses received. The Executive will assume, therefore, that responses can be made publicly available in this way. If respondents indicate that they wish all, or part, of their responses excluded from this arrangement, confidentiality will be strictly respected.

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