Working together to prevent and control infections A study of the arrangements for infection prevention and control between hospitals and care homes September 2009 About the Care Quality Commission The Care Quality Commission is the independent regulator of health and adult social care services in England

Working together to prevent
and control infections
A study of the arrangements for infection prevention
and control between hospitals and care homes
September 2009

About the Care Quality Commission
The Care Quality Commission is the independent regulator of health and
adult social care services in England. We also protect the interests of people
whose rights are restricted under the Mental Health Act.
Whether services are provided by the NHS, local authorities, or private or
voluntary organisations, we make sure that people get better care.
We do this by:
? Driving improvement across health and adult social care.
? Putting people ?rst and championing their rights.
? Acting swiftly to remedy bad practice.
? Gathering and using knowledge and expertise, and working with others.

Contents
Summary 2

Our recommendations 4

Introduction 10

1. How is information shared between health

and social care settings? 12

2. How is information shared with people living

in a care home and their relatives? 19

3. What kinds of advice and support are available
to care homes? 22

4. How are care staff trained and supported
in preventing and controlling infections? 25

5. How well prepared are care homes for the
forthcoming regulatory changes? 29

Appendix 1: Methods 33

Appendix 2: Details of our case study sample 36

Appendix 3: Acknowledgements 38

References 40

Care Quality Commission: Working together to prevent and control infections 1

Summary
Infection prevention and control is not simply an
issue for hospitals – many infectious diseases can
spread within care homes, where large numbers of
people, many of whom may be susceptible to
infection, share living accommodation. Infection can
be a major cause of illness among residents of care
homes, which can result in them being admitted to
hospital. For people living in care homes in some
developed countries, infection is a common cause
of hospitalisation.
1 People can enter care homes
colonised with organisms acquired in hospital that
are resistant to antibiotics. These homes can then
become ‘reservoirs’ of infection. This, and the fact
that many people living in care homes have frequent
contact with healthcare services, has created a
‘revolving door’ situation, where people are re­
admitted to hospital for conditions that could be
managed within a care home.
Infections can range from mild food poisoning to life
threatening bloodstream infections and are caused in
many different ways. This report is about those
infections that are associated with the care provided
by healthcare organisations or care homes. Infections
caused by Meticillin resistant Staphylococcus aureus
(MRSA) and Clostridium difficile can often be
portrayed by the media in a way that can be
alarming to residents of care homes, their relatives
and carers. Information on the standards of infection
prevention and control in care homes is therefore
very important, not only so that people who use
services can make informed choices, but also
because it promotes con?dence in the care being
provided. Families and carers want to be assured that
the care their relatives and dependants are receiving
is being provided in a clean and safe environment.
2
Programmes for preventing and controlling infections
are important in hospitals and care homes and they
should address the complex care services provided.
However, little is known about the impact of these
programmes in care homes. The Department of
Health’s current infection prevention and control
strategies focus on acute hospitals, since these are
perceived to present a greater risk of infection.
However, some studies have suggested that the
number of infections in care homes may be
comparable to those in hospitals.
3,4 There is a wealth
of information about infection risks in hospitals, but
little is known about the risks associated with care
homes, particularly the arrangements for preventing
and controlling infections at the interface between
these settings. This is complicated by changes in
regulation. From 1 April 2010, all NHS healthcare
providers will be required to comply with the
requirements of the Heath and Social Care Act 2008
(Registration Requirements) Regulations 2009 and
to follow the requirements contained in the Care
Quality Commission’s guidance about compliance
and the Department of Health’s Code of Practice
related to infection prevention and control. By
October 2010, all care homes and independent
providers of healthcare will be registered against the
same regulatory requirements. The requirements that
this report focuses on are that providers of care
should:

Summary continued

made worse, because staff are confused about
what information they can share, and with whom,
in the discharge summary information, while
complying with data protection and con? dentiality
requirements.

5
2

Summary continued

Our ? ndings
How is information on infection prevention and
control shared between health and social care
settings?
Sharing information is important because it allows
staff, whether in a hospital or care home, to care for
a person with an infection in a way that increases the
chances of a positive outcome for that person and
reduces the risk of transmitting infections to other
people. Primary care trusts use service agreement
contracts when they commission health services.
These contracts clearly specify the types of
information that should be provided when someone
is discharged from hospital and this includes
information on infections. In addition, the Health
and Social Care Act 2008 Code of Practice relating to
infections speci?es that information regarding
infections or a person’s care needs should be passed
between health and social care settings when a
person moves from one to the other.
Our case studies showed that, although some care
settings communicate well with each other, there
seemed to be particular problems with information
being communicated when somebody was
discharged to a care home from hospital.
Signi?cantly, 17% of care homes that responded to
our survey received no information at all regarding
infections when people were discharged from a
hospital to their care. This was not thought to be due
to a lack of commitment or will on the part of
hospital staff, but because they are overloaded with
work. However, it may simply be because the
information provided when a person is discharged is
sent to their GP, as speci?ed by the NHS standard
contract, and not to their care home. We found that
the information required by standard NHS contracts
in a written discharge summary, including
information on relevant infections, was often
incomplete or missing. Homes that only provide
personal care seemed to have the greatest dif? culty
in accessing this information from hospitals. Crucially, ambulance crews, a common link between
hospitals and care homes, are often left out of the
information loop, even though they could perform a
vital role both in caring for people and transferring
information about their care needs. Also, if
ambulance crews are not told about someone’s
infection status, they could facilitate further
transmission of infections.
Our survey revealed a variety of ways in which health
and social care staff communicated with each other
about infections varied, with the most common
being verbally. This is contrary to the NHS standard
contract, which speci?es that this information should
be presented in a written summary. Care plans were
also a common way of communicating.
We were told that staff were sometimes confused by
data protection, patient consent and con?
dentiality
issues. This confusion could lead to inef? cient
communication. This is a complex area, involving
different pieces of legislation and guidance, which
may explain why this information is provided
inconsistently. Current Department of Health
guidance states that information should not be
shared by clinicians with a third party without
informed consent, but this may be dif?cult to obtain
in some circumstances. Clinicians and care home
staff rightly focus on the rights and needs of the
individual and it is likely that data is withheld for the
best reasons. However, attempts to protect the
rights of an individual may result in unsafe practice
by undermining infection prevention and control
measures for that individual and others. This is an
area that requires clear guidance to ensure that
carers carry out their responsibilities in a way that
balances these needs.
When someone living in, or moving to, a care
home has an infection, how is this information
shared with them and their family members?
Good communication, for example regarding hand
washing, personal hygiene and treatment, is
Care Quality Commission: Working together to prevent and control infections
6

essential to help a person recover from an infection
and prevent it being transmitted. Our case studies
showed that care homes placed a strong emphasis
on verbal communication to introduce and reinforce
messages about infections to their residents and
their families, particularly when somebody is being
isolated or is concerned about a change to their
routine due to an infection. They use a wide range of
information and resources of varying quality, which
means its effectiveness depends on the knowledge
and judgement of the staff using the materials.
Information within a home should be shared in a way
that promotes good infection prevention and control
measures, while protecting people’s rights to dignity
and con?
dentiality.
What kinds of advice and support on infection
prevention and control are available to care
homes?
Care homes, unlike hospitals, generally have fewer
resources and may not have ‘in house’ expertise
relating to infection prevention and control,
therefore relying on specialist advice from other
organisations.
Our case studies showed that care homes had very
different experiences when seeking advice and
support, especially in the availability of proactive and
reactive advice. For example, all homes knew where
to seek advice in the event of an outbreak of
infection, but there was a general need for advice to
help them develop policies and procedures in line
with current good practice.
Our survey showed that homes sought external
advice most often when they were developing
policies and procedures, caring for an individual with
an infection or when dealing with an outbreak. This
was most commonly sought from primary care
organisations, the Health Protection Agency and
local authorities. The majority of homes (87%) said
that advice and support was always available when
needed but 13% disagreed. When asked whether they paid for this advice, the majority of care homes
(86%) said “no”, 11% said “occasionally” and only a
small minority (3%) said “yes”. Historically, this
advice has been provided free of charge by various
organisations, but this is currently being reviewed,
which means that care homes may need to fund this
in the future. GPs commonly provided advice to care
homes during an outbreak, but they also helped
11% of homes to develop their infection prevention
and control procedures.
How are staff trained and supported in
preventing and controlling infection in
care homes?
Good leadership and training, ?
rmly embedded
within the culture of an organisation, is regarded as
a key component in successfully preventing and
controlling infections in healthcare settings.
6
However, our case studies showed that care homes
found it dif?cult to maintain a fully trained workforce
due, in part, to a high turnover of staff. Also, since
many care homes employ staff whose ? rst language
is not English, they need to provide training
materials in different formats and languages. And we
found that where sick pay was not available, staff
sometimes worked with an infection such as
in?uenza or diarrhoea without disclosing it. There is
currently no information to indicate how common
these events are and so it is dif?cult to estimate the
risk to staff and residents. However, care homes
should have clear infection prevention and control
policies on when staff should not attend work.
Our survey showed that nearly all homes train their
staff in preventing and controlling infections on
induction and that further mandatory training and
updates are widely used. However, staff with nursing
quali?cations received considerably less training than
others – perhaps because it is perceived that nurses
learn enough about infection prevention and control
during their professional training.
Care Quality Commission: Working together to prevent and control infections 7

Summary
continued

How well are care homes prepared for the
forthcoming regulatory changes?
We asked care homes what management systems
they had to prevent and control infections, including
policies and procedures and performance indicators.
We also assessed how well they were following two
key pieces of national guidance.
We did not scrutinise these policies and procedures
but asked whether staff found them useful. The
quality and content of policy and procedure
documents on infection prevention and control
varied immensely, as did the way they were applied.
Some care home managers were more familiar with
their policies than others.
We also asked care homes whether they used
indicators to track their performance on infection
prevention and control. We would expect indicators
on the number of infections, and compliance with
hand washing and cleaning, as well as adherence to
good practice around procedures such as enteral
feeding (for people unable to be fed orally) and
catheter management. The majority of respondents
(61%) used no performance indicators at all, and
those that did used them because they were required
as part of the contracts with organisations that
commissioned their services.
The two key documents that have been published by
the Department of Health to help care homes meet
essential requirements of infection prevention and
control are Essential Steps and Infection Control
Guidance for Care Homes – both published in 2006.
These provide a framework for good practice in care
homes, including preventing the spread of infection,
urinary catheter care and enteral feeding. Essential
Steps also provides a way of auditing compliance
with its requirements. Our case studies showed that
knowledge of this guidance was extremely variable;
some homes were aware of it and had found it useful
and relevant, whereas others, while aware of it, were not applying it. Some care homes were also confused
over which document applied and whether one
publication had superseded another.
Forty per cent of care homes that responded to our
survey told us that they were not using Essential
Steps. Those that were reported varying levels of
implementation, with only 38% saying that they
were using the measures recommended for safe
urinary catheter care and only 21% implementing
the steps relating to enteral care. These are
important because enteral feeding is becoming more
common in care homes and urinary tract infections
are common in people who are catheterised. In
addition, specialists in social care infection control
who were in our Reference Group said that care
homes may ?nd it dif?cult to implement Essential
Steps because they may not appreciate that it
contains broader good practice guidance, despite its
primary design as an audit tool.
A quarter of respondents to our survey were not
using the Department of Health’s Guidance on
Infection Prevention and Control for Care Homes,
which includes advice on cleaning and
decontamination, food hygiene, antibiotic
prescribing and general infection prevention and
control measures. Care homes that used this
guidance were implementing it inconsistently.
Sixty nine per cent of homes had implemented the
recommendations on decontamination and cleaning,
just over half (55%) followed the guidance on
managing infections, including isolation, but less
than a quarter (22%) had implemented the guidance
on antibiotic prescribing and management. This
guidance has been redrafted by the Department of
Health and accompanies the consultation on the
draft Code of Practice on healthcare associated
infections and related guidance to help care homes
meet the proposed registration requirements.
Care Quality Commission: Working together to prevent and control infections
8

From 2010, care homes will be required to register
with the Care Quality Commission and comply with a
new version of the Health and Social Care Act 2008
Code of Practice on the prevention of care
associated infections. When asked whether they
were aware of the new requirements for registration
and regulation by the Care Quality Commission, over
half of respondents (55%) said that they were not. However, this is likely to have changed now because
the study was carried out as the Care Quality
Commission was being established and a number of
events have been held and documents published for
consultation which will have raised the pro?
le of
these requirements.
Care Quality Commission: Working together to prevent and control infections 9

Summary continued

Introduction
Who is this report for?
We have written this report chie?y for providers of
care – social care homes themselves, those who
commission their services, and NHS healthcare
providers. The report will also be of interest to
policymakers and regulators at both national and
local levels, because the ?ndings could contribute to
an evidence-based approach to regulating social care
homes.
Background
Infections associated with healthcare have received
much media and Government attention in the last
?ve years, with infections such as Meticillin resistant
Staphylococcus aureus (MRSA) and Clostridium
difficile becoming familiar household names.
However, infection prevention and control is not
simply an issue for hospitals. Although the
Department of Health’s strategies for preventing and
controlling infections have focused on large
hospitals, care homes play an important role in the
transmission and management of infections. For
people living in care homes in some developed
countries, infection is a common cause of
hospitalisation.
1 People can enter care homes with
organisms that they acquired in hospital that are
resistant to antibiotics. These care homes can then
become ‘reservoirs’ of infection. This, and the fact
that many people living in care homes have frequent
contact with healthcare services, has created a
‘revolving door’ situation, where people are
re-admitted to hospital for conditions that could be managed within a care home. Residents of care
homes are at particular risk of infection because of
the following factors:

Code of Practice for health and adult social care on
the prevention and control of infections and related
guidance will apply to all providers in 2010 as a
condition of registration with the Care Quality
Commission. This system will replace the current
regulatory system made under the Care Standards
Act 2000 and national minimum standards.
The anticipated increase in the elderly population in
the next few decades means that although social
care is a growing industry, there is increasing
pressure on both health and social care to manage
costs. Measures to manage these costs, and to meet
peoples’ wishes, have included increased home-
based care, decreased numbers of hospital beds and
people spending less time in acute healthcare
facilities. This has resulted in the homecare and
managed care industry becoming major providers
of care.
Care homes face particular challenges in preventing
and controlling infections:

1 How is information shared between health and
social care settings?
Good communication between health and social care
professionals is crucial to make sure that somebody
with an infection can be cared for properly and that
the chances of an infection being passed on to other
people are reduced. It is important that this
information is sent to the right people at the right
time so that they can act on it. For example, if
somebody with diarrhoea is discharged from hospital
to a care home, hospital staff must tell the care
home’s staff about this so that suitable precautions,
such as isolation and increased levels of cleaning,
can be arranged.
Legal and contractual requirements
Providers of healthcare are obliged to provide
information on infections to other professionals and
to people in their care and their relatives. Although
vital in ensuring good continuity of care, the sharing
of information is governed by a number of pieces of
legislation and guidance which, when considered
together, make the issue somewhat complex (see
Box 1). The legislation and guidance available on
con?dentiality, disclosure and data protection is
clear. However, the responses we received indicated
that staff responsible for providing information were
sometimes confused about what they could and
could not provide to third parties. Providers of care
need to have clear policies concerning information
governance, including information about infections,
and these should be based on legal requirements
and guidance. Staff who may be required to disclose
information should be trained and supported to
make these decisions. We found some good examples of communication
but, generally, communication between hospitals
and care homes was not as good as it should be.
A particular problem was that, even where
information on an individual was communicated, it
sometimes arrived at the care home weeks after the
discharge date, drastically reducing its potential to
prevent or control infections. It’s possible that, in
accordance with NHS standard contracts, information
is provided directly to the person’s GP. However, it is
unlikely that GPs systematically review this
information and feed it back to care homes in a
timely fashion that would allow good infection
prevention and control. Other examples described
how care homes had to chase up and seek
clari?cation from the discharging hospital because
they were concerned about an individual’s apparent
condition on their return. Many homes told us of
problems they had when visiting a hospital to assess
a new care home resident before they are
discharged. Even though they were allowed access to
the person’s ?les, they were unable to identify key
information on infection status due to the quality or
volume of the notes.
12 Care Quality Commission: Working together to prevent and control infections

Box 1 – Legislation and guidance relating to information sharing
General duty of con? dentiality
The common law duty of con?dentiality requires that information is not disclosed without the consent
of the individual, other than where required by legislation or where there is a robust public interest
justi?cation for disclosure. The person disclosing the information must be able to show that they have
balanced the bene?ts of releasing the information with the rights of the individuals concerned and
maintaining public trust in a con? dential service.
The Data Protection Act 1998
Information about an individual must not be disclosed to other people, unless there is a legal or other
overriding legitimate reason to share the information. The Data Protection Act makes it an offence for
other people to obtain this personal data without authorisation.
Informed consent
Consent must be sought from a person before information about their care can be divulged to third
parties. There are exceptions to this rule if the clinician thinks that, in the absence of consent, the
person or other persons are put at risk. In such cases, they may waive this right and provide the
information to third parties.
Standard NHS contract
This contract speci?es the levels of service expected between organisations that commission healthcare
services (primary care organisations) and those that provide them (hospitals). They clearly stipulate
that a discharge letter and a copy of a discharge summary should be provided to the patient’s GP and
the patient upon their discharge from their care. The discharge summary information should include
information on infections, any immediate post-discharge requirement from the primary healthcare team
and any other planned follow-up arrangements. This arrangement does not currently apply to care
homes, yet local arrangements or policies should specify that this information be provided when a
resident is transferred to another care setting.
The Health and Social Care Act 2008 and associated regulations
Among other requirements, these specify that any care provider should:
? Co-operate and share information with others involved in the person’s care, treatment and support,
while having regard to people’s rights to con?dentiality, particularly when they are sharing or
transferring responsibility for care, treatment or support.
? Provide accurate and timely information on infections to any person concerned with providing
further support or nursing/medical care to that person.
? Ensure that others are involved, including ambulance and other transport services, when developing
joint plans to arrange the transfer of a person from one care setting to another.
Care Quality Commission: Working together to prevent and control infections 13

How is information shared between health and social care settings? continued

Crucially, ambulance crews are often left out of the
information loop, and often seemed to be considered
as more of a transport service than as a healthcare
service, even when dealing with an emergency
admission. From our discussions with ambulance
trusts, this may have arisen because most discharges
from hospital are contracted out to independent
patient transfer services. They are therefore not
carried out directly by the hospital, except on the
rare occasion that someone is discharged who is
known to be very unwell.
Healthcare perspective
“The information disclosed to ambulance staff
is usually restricted to the patient’s current
problem and no information is usually given
about their infection status, as staff regard that
as breaching patient con? dentiality.”
Ambulance trust infection control coordinator
The mechanisms used f

or sharing information
between professionals are different when people are
admitted to hospital from a care home and when
they are discharged from hospital to a care home.
Our survey showed that before and during hospital
admission, care homes used the care plan to share
information (42% before admission and 48% after),
as well as providing verbal information (65% before
admission 52% after) and other written information
(49% before admission and 54% after).
When people are discharged from hospital however,
the patterns are different. Hospitals are much less
likely to use care plans, with only 28% of homes
receiving information this way. They are much more
likely to receive verbal information (61%) or in
another written format, usually letters or various
standard forms (51%). Signi?cantly, up to 17% of
homes said that they received no information at all
when people are discharged to their care from
hospital. The logistics of transferring somebody from a
hospital to a care home or vice versa can be complex
and involve many people, and verbal communication
cannot always be relied upon. In addition, written
notes preserve people’s con?dentiality more than
word of mouth and so should be used wherever
possible.
In our survey, almost 300 (28%) care home
managers raised concerns about hospitals’
communication when they discharge someone –
especially providing illegible or inadequate papers. Case study
Mr X broke his femur in a fall at home in his
own ?at. Up until then he had been active and
mobile, coping well at home. Aft
er the
fracture he remained in hospital for six or
seven months and was then discharged from
hospital into the care home with tuberculosis
(TB), which was not reported in the hospital
discharge summary, and identi? ed
subsequently by the care home staff . He
became very frail and afraid, and was
dependent on monthly blood transfusions,
and eventually died after readmission to
hospital. His death was the subject of a
coroner’s inquiry in January 2009 when it was
determined that the root cause of death was a
TB infection contracted in hospital.
Use of discharge summaries
Standardised discharge information forms, as well as
often being incomplete, generally did not include a
speci?c section on infection status, even though this
is speci?ed in standard NHS contracts. This means
that information on infection has to be included in
the “other” box and relies on an individual
remembering to include this information, rather than
requiring it as a standard item.
14 Care Quality Commission: Working together to prevent and control infections

Care home perspective
“Information on infections such as MRSA and C. difficile are not always communicated from the

hospital.”

“The local hospital does not always inform us of the presence of infection and we have, in the past,

found out by the medication the person is on. This stage of communication could be improved but

sometimes Data Protection and con?dentiality ar
e quoted as the reason.”

“My experience has been that the healthcare professionals have insisted that they are discharging the
person fully recovered. Within 12 hours we have had to get a GP out as the person has an infection.
Recently this has happened three times in six months.”
“NHS transfer information is often inadequate, relying upon a ‘transfer letter’ which is only as good as
the nurse or doctor who wrote it. No formal inter-healthcare infection control transfer form is used by
hospitals in this area.”
“Sometimes discharge sheets from hospitals are duplicate copies that are illegible. This can make life

very dif?cult, par
ticularly if residents are discharged home late in the evenings.”

“I have on several occasions been sent an illegible pink discharge sheet which apparently informed me
of an MRSA infection being present. I think it important to advise more clearly.”
“I feel sometimes the truth about infections is hidden, especially when transferred back home, as the

acute beds are needed. Limited information is given on how to treat infections when discharged from

healthcare.”

“There is an expectation from health professionals that social care workers have some nursing

knowledge, so tend to assume a greater level of knowledge regarding infection control.”

Care home managers
Healthcare perspective
“This is an ongoing and widespread problem.

Many acute trusts do not have speci? c

discharge/transfer forms, and if infection status
is included in the discharge letter, it is often
sparse or illegible. If an infection status form is
being used, it is usually a separate document,
thus relying on someone to ?ll it out. However
,
“ward pressures” are frequently used as a
reason not to introduce extra documentation.”
Infection control specialist nurse
Dif?culties experienc ed by homes
providing personal care only
We found that homes that only provide personal care
often had more dif?culties in obtaining timely and
reliable information than those that provide nursing
care. Homes that only provide personal care told us
about having to rely on the district nursing staff for
information about infection management, and
tended to have the lowest levels of access to
information when people are discharged from

hospital.

Care Quality Commission: Working together to prevent and control infections 15

How is information shared between health and social care settings? continued

Healthcare perspective
“As homes providing personal care generally
have people who are less dependent, any
information may be sent to the GP instead of to
the home. This is the practice for people who
are discharged back to their own homes.”
Infection control specialist nurse
Homes that only provide personal care seem to have a
stronger ethos and focus on the rights and needs of
the individual, but occasionally this may contribute to
the problems of information ?ow. This is because staff
may be more prepared to defer to a hospital’s decision
not to share information, based on its claim of
wanting to maintain con?dentiality as part of
protecting an individual’s rights. However, in nursing
homes the rights-based ethos is sometimes less clear,
and this seems to be linked to information ? owing
better. This could be partly because nursing staff are
less likely to be de?ected by a rights-based argument.
Healthcare perspective
“Information sharing from care homes to
hospitals could also be improved. Though there
may be a care plan for ‘revolving door’ patients,
the colonisation status of a patient may not be
known”.
Infection control specialist nurse
What helps good communication?
We also found some examples of excellent
communication between hospitals and care homes
when people are discharged. However, these tended
to be in services for younger adults. Younger adults
often have lifetime needs (speci?cally, people with
learning disabilities and some people with physical disabilities) so their care planning tends to be more
comprehensive and structured. The frequency of
movement between health and care settings for
some groups of younger adults is likely to be less
than older people. However, other groups, for
example those with mental health or substance
misuse needs, may move between different care
settings more frequently.
Many care homes escort their residents when they
are admitted to hospital – particularly if it is during
the day when there are more staff available, or if the
person has dementia and is likely to be confused and
distressed by the transfer. This seems to help
effective communication, but care homes are
unlikely to do this consistently, due to their reliance
on resources and the availability of staff.
Case study
Mr R has C. diffi
cile, which was contracted in
hospital, and had been in an unsuccessful
placement in a care home. He was re-admitted
to hospital and his family had difficulties
?nding a care home that would take him. Staff
from a home visited him in hospital to carry
out an assessment and agreed to
accommodate him. A room was set up for him,
which is next door to a bathroom with
incontinence ?ooring which has been isolated
for use only by Mr R. Speci? c cleaning
products are used to clean his room and the
bathroom. Mr R is most at risk when he is
taking antibiotics, so staff work very closely
with his consultant infection control nurse and
two consultant microbiologists at the hospital.
If any clinical professional visiting him at the
home identi?es that he may need antibiotics,
the staff encourage them to contact the
infection control nurse so that options can be
discussed.
16 Care Quality Commission: Working together to prevent and control infections

Barriers to good communication
We do not think that poor communication is related
to a lack of commitment or will on the part of staff
in hospitals, but rather to the pressures of the wards
being overloaded and understaffed. Many people
who use services and their carers were unsure
whether they should tell us about their concerns
because they did not wish to be critical of health
staff clearly doing their best in very challenging
circumstances. Our discussions with healthcare­
based infection control specialists seem to bear out
these ?ndings, indicating that current systems in
place for recording and sharing information may
often be inadequate.
Healthcare perspective
“Results about positive infections and
specimens are kept in patient notes in the form
of laboratory reports, but may not always
follow the patient through their journey. Some
trusts have electronic access to laboratory
results on every ward, but others are working
from outdated systems and rely on hard copies,
which are not necessarily ?led correctly. Other
sources of information are doctor and nursing
notes, but these may not state the information
needed in an easily accessible manner. Some
patients have multiple volumes of notes,
adding to the problem.”
Infection control specialist nurse
Impact of data protection and
con? dentiality
People seemed to be confused about what data can
be shared in relation to infection prevention and
control, with regard to data protection and
con?dentiality, despite the fact that there is clear
guidance on this subject, as outlined earlier.
Current policy on con?dentiality and consent is
clear that, subject to certain exclusions, any
con?dential information about a person should
not be shared unless the provider can demonstrate
otherwise. The NHS cannot infer a patient’s
consent without allowing them to disagree or
prevent their personal information being shared
with others. Securing consent within one hospital
may be relatively straightforward but implied
consent is particularly dif?cult to justify when it
involves sharing information outside the NHS.
10
This may partly explain why homes that provide
nursing care reported less dif?culty in obtaining
this information, since hospital staff may consider
disclosing information on infection to a quali? ed
nurse from a nursing home does not breach the
guidance, as it is information shared between clinical
peers. This confusion seems to be compounded by
the perception held by hospital staff that care homes
are reluctant to accept people with known infections.
Other initiatives have been developed to clarify
practice in this area. For example, the Department of
Health introduced its single assessment programme
in recognition that many older people have wide-
ranging welfare needs, and that agencies need to
work together to ensure that assessment and
subsequent care planning are effective, coordinated
and involve people who use services. As part of this
programme, guidance on sharing information locally
is provided, including information on data sharing.
Care Quality Commission: Working together to prevent and control infections 17

How is information shared between health and social care settings? continued

Healthcare perspective
“There is confusion about data protection and
con?dentiality among hospital staff. This is an
issue that is not addressed during data
protection training. There is also sometimes a
reluctance to share information as there are
documented cases of homes refusing to take
people with a perceived infection.”
Infection control specialist nurse
Summary
Our key ?nding is that hospitals and care homes do
not have adequate procedures that are
systematically implemented to ensure that
information is transferred (particularly on transfer
from hospital) reliably and at the right time, which
always includes speci?c information on infection or
colonisation status.
18 Care Quality Commission: Working together to prevent and control infections

2 How is information shared with people living in
a care home and their relatives?
The Health and Social Care Act 2008: Code of
Practice for the prevention and control of infections
places duties on providers of care to provide
information on infections to people in their care and
their relatives. This information should include the
general principles and policies related to infection
prevention and control, help people to be aware and
empower them to provide safe care, explain outbreak
management and give information that is focused on
the patient pathway or care plan.
Ways of sharing information
Care homes described different ways of sharing
information with people living in their homes who
have an infection. In our case study visits and in our
survey, all homes emphasised the importance of
verbal communication as the main way of sharing
information – often stressing the importance of
repeating messages, particularly when caring for
people with cognitive impairment who may be easily
confused and forgetful. Some homes used visual aids
such as picture cards to help convey information,
particularly when normal routines had been
disrupted – for example when introducing isolation
measures.
Case study
Mr Y, in his 80s, was admitted to hospital with
chest-related problems from his own ? at
where he lived alone. He was discharged from
hospital to the care home for respite and
rehabilitation with the aim of returning home
aft
er three weeks. The hospital did not provide
any information on his infection status, but
the home suspected a MRSA infection, which
was subsequently con?rmed. Mr
Y is on
continuous oxygen and it seems less likely
that he will be able to return to his own home
as planned. When we interviewed him, Mr Y
(who has no cognitive impairment) was aware
that he had had “lots of infections” but did
not seem to know that he had contracted
MRSA speci?cally
. He appeared to be feeling
very low, and during the interview referred
consistently to his desire to return home and
his anxiety and uncertainty about when this
might happen.
Some care homes, particularly those for younger
adults, described using care plans as a way of
structuring their discussions with individuals and
family members, and making sure that the
information is available in written form as well as
verbally. Responses to our survey showed that once
a person has moved into a home, 72% of homes
used the care plan to share information with the
individual and their family, with 80% also
communicating the information verbally. As well as
verbal and written updates provided routinely and
when an outbreak occurs, 12% of the homes in our
Care Quality Commission: Working together to prevent and control infections 19

How is information shared with people living in a care home and their relatives continued

survey described other means of keeping all their
residents up to date on infection prevention and
control matters. Examples included using regular
meetings, and training and information sessions for
residents.
Most homes stressed the importance of preventative
practice, by explaining to residents how important
regular and frequent hand washing is when living in
a shared environment, and by helping them make
more informed choices about washing their hands.
Most care homes also involved family members in
this, and explained the measures that would be
taken in the event of an outbreak. Generally, this
tended to be verbal communication with written
material more likely to be provided only in the event
of an outbreak.
Case study
When there was an outbreak of TB in a care
home, letters were sent to all the residents
and their families, explaining what had
happened and what people needed to do. The
care home gave out lea?ets to those who
wanted more information and provided
contact details for the TB nurses.
Many people living in care homes value regular visits
and contact with their family members, so it is
important that these relationships do not break
down as a result of fear or misunderstandings about
infections. Care homes placed a strong emphasis on
verbal communication and discussion with family
members, particularly where information about
infection status might affect their visiting patterns or
relationship with their relative. Some homes provided
written information to family members to help
explain some of the details of the infection and the
care management arrangements they had put in
place to protect the individual, other residents and
visitors to the home. Some homes told us that they relied on family
members to ?nd out about a residents’ infection
status when they were not obtaining it from the
hospital.
Case study
The home tells residents, and phones family
members, about new infections, explaining
the situation, and letting them know about
any swabs or samples that are going to be
taken and when test results are due. Staff will
then contact the family again once the results
have come through, explaining the planned
treatment and care to family members, and
discussing any concerns.
Balancing the need to protect
the rights of the individual with
protecting others
Several care homes stressed the importance of
sharing information about infections with other care
home staff and with family members in ways that
continued to respect an individual’s dignity and right
to privacy. Some homes had such a strong culture
and ethos around con?dentiality that it might
sometimes be dif?cult to manage the balance
between protecting the rights of an individual and
managing the risks of infection to other residents,
staff and visitors. In some cases, homes used small,
discrete stickers above the door of an individual’s
room to alert staff and relatives to any particular
measures they should take. Others described placing
notices in the individual’s room, while others
commented that the use of notices in rooms would
be unacceptable. Clearly, managers of care homes
need to consider how acceptable these measures are
before implementing similar initiatives.
20 Care Quality Commission: Working together to prevent and control infections

Healthcare perspective
“Patient con?dentiality can be compromised by
notices, etc, so these should be used with
caution. Informed consent from the patient or
resident should always be sought before
sharing personal information, but in my
experience this frequently does not occur.”
Infection control nurse specialist
Resources to help share
information
Care homes from our case studies described
receiving (or copying) the information and resources
they use to communicate about infections from a
variety of sources, including hospitals, the local
primary care trust, central services within their
organisation, social services, and the internet.
Similarly, care homes responding to our survey
described using assessment forms and letters, notice
boards, signs on doors, posters, health information
packs and downloaded information from the
internet. Clearly the quality and reliability of this
information may vary, particularly for information
downloaded from the internet, and will also depend
to a degree on the knowledge and judgement of the
member of staff using or interpreting the materials.
Healthcare perspective
“There have been recorded instances of
managers not really understanding the
infection itself, and practice and care being
compromised as a result – for example, a care
home where the manager would not allow a
MRSA colonised resident out of her room.”
Infection control nurse specialist
Summary
The main way of sharing information with residents
and their relatives is verbally, but this should be
supported with standard written information in
suitable formats and languages.
Care Quality Commission: Working together to prevent and control infections 21

3 What kinds of advice and support
are available to care homes?
Clearly, care homes require reliable sources of good
quality advice on infection prevention and control in
order to develop effective policies and procedures
and be able to react to incidents and outbreaks. In
this section, we summarise the ?ndings from our
case studies and survey, which indicate the kinds of
advice and support available.
Sources of advice and support
Care homes had very different experiences and
resources when seeking advice and support on
infection prevention and control. Some homes that
were part of larger organisations described very good
internal support. This often included:

Seventy per cent of homes told us that they receive
advice and support from a GP when there is an
outbreak of infection in the home, and 81% when a
resident with an infection requires care. More
unexpectedly, 11% of homes said that they received
help from a GP in developing policies and procedures
on infection prevention and control.
Although there is some regional variation, larger homes
are generally more likely to receive external advice
from the Health Protection Agency (HPA) than smaller
homes, which may be less aware of HPA services. It is
worth noting that the Health Protection Agency
practice varies across the country but it is not generally
the major provider of routine infection prevention and
control advice to care homes. Although still providing
some locally delivered specialist advice, the Agency is
now working with other agencies such as health trusts
to convey advice and support rather than providing
advice directly to homes.
Availability and funding for advice
and support when needed
In our survey we asked homes if advice and support
was available when they needed it. The majority of
respondents (87%) answered “yes” to this question,
but 13% said it was only available “sometimes”. The
majority of homes (86%) did not pay for the advice
and support they received, while a small minority
(3%) did pay and 11% paid occasionally. Where
homes did pay, the advice was most likely to be
funded through the home’s general budget rather
than through a dedicated budget or through an
organisational budget.
Our ?ndings suggest that the availability of
proactive rather than reactive advice varied. All
homes knew where they would seek advice from
when an outbreak occurs, but a number commented
that they would value more written updates on
current good practice. Unsurprisingly, advice and support is requested and received much more
frequently when there is an outbreak within the
home or when there is an individual needing care.
Homes also told us that they would appreciate
general updates and information on equipment and
materials as well as practice, although one home said
that it was dif?cult to implement advice on new
products because purchasing arrangements were
centralised within the organisation.
Healthcare perspective
“There is a shortage of trained infection control
nurses in our region and therefore there isn’t
the capacity to take on care homes as well as
the ordinary workload. Acute trusts and primary
care trusts generally seem to have very little to
do with care homes unless there is local
agreement – it is very much a case of who the
nursing teams are and what they are prepared to
get involved in. There is very little joined-up
local healthcare economy working in some areas

What kinds of advice and support are available to care homes? continued

? Introducing written guidelines and updates that
are regular, relevant, up to date, well publicised,
simple and paper-based. These could be lea? ets,
newsletters, posters and booklets, including
picture-based descriptions of procedures that
would help residents as well as staff to understand
(58 care homes).
More training and education (47 care homes).
More detailed information when people are being
discharged from hospital to the home, to include
the results of screening processes (42 care
homes).
An easily accessible website, online advice or
portal with hyperlinks that can be used when staff
work at weekends (29 care homes).
Other suggestions included more preventative
information and advice, and standardising the
same recommended procedures and documents
across different agencies.
?
?
?
?
Summary
Care homes have very varied experiences of advice
and support, but overall there appears to be a need
for more proactive and preventative advice, including
advice in specialist areas – for example, tissue
viability and continence.
24 Care Quality Commission: Working together to prevent and control infections

4 How are care staff trained and supported in
preventing and controlling infections?
Good infection prevention and control depends on
the right people taking the right action to prevent a
person’s condition deteriorating or passing on their
infection to others. The measures needed to do this
are not complicated, but staff need to have some
background and competence to do this effectively
and consistently.
Managers of care homes
Our ?ndings suggest that positive leadership and
good management within care homes are essential,
irrespective of how the organisation is structured.
The overall success of the home in preventing and
controlling infection is therefore dependent on good
leadership from the home manager, because care
homes tend to operate as ‘stand alone’
organisations, even when they are part of a larger
group or chain. This means that a focus on the
manager’s competence, skills and knowledge in
relation to infection prevention and control is
particularly important if these are to be effectively
shared with the care staff team.
Case study
The manager of a home that is part of a large
national chain described her role in rebuilding
the home’s reputation after the previous
manager’s departure and intervention by the
regulator and commissioners. A number of
residents were now returning from temporary
placements elsewhere, or from hospital aft er a
period when the home had not been
permitted to take any new referrals or
residents discharged from hospital. Part of the
problem had been caused by complacency
from being part of a big infrastructure with
good resources and reputation and an
attractive and smart new building. The new
manager needed to work hard to rebuild staff
morale and con?dence by providing a strong
role model and assertive and directive
leadership.
Other care staff
Nearly all homes responding to our survey reported
that they train and induct staff in infection
prevention and control – mainly through mandatory
training and regular updates. Where training is
provided by an external provider, this is most likely
to be an independent provider (56%), the primary
care trust (29%) or the local authority (26%).
Care Quality Commission: Working together to prevent and control infections 25

How are care staff trained and supported in preventing and controlling infections? continued

Generally, most homes told us in our case studies
and survey that, rather than learning the theory, it
was more effective to carry out practical training,
such as:
? On-the-job mentoring.
? Informal auditing.
? The use of tools, such as training DVDs.
? Role modelling.
? Mentoring.
? Regular refreshers and updates.
The topics most regularly covered in training were
hand-washing techniques (95%) and day-to-day
practice on the prevention of infection (94%). Care
of people who have an infection was a training topic
for 75% of homes and outbreak management for
71% of homes. The majority of homes (69%)
reported training on the Department of Health’s
Infection Control Guidance for Care Homes
2 and 60%
reported training on the Department of Health’s
Essential Steps guidance
5. Other topics covered
included:
? Food hygiene.
? Laundry services.
? Tissue viability and wound infections.
? Control of contamination.
? Infection control audit.
? Policies and procedures.
? Training on speci?c types of inf ection.
Ther
e were some comments in the survey on the
consistency and levels of training for different staff
grades and roles:
Care home perspective
“I think that within the Care national vocational
quali?cation (NVQ), infection prevention and
control should be a standard unit and not an
optional or additional unit.”
“There seems to be no uniform level of required
training, for example some care staff who have
studied NVQ2 with a particular training provider
have gone into infection control in much
greater depth than those with another
provider.”
“I feel that all staff should be trained in

infection control.”

Our survey suggests that staff with nursing
quali?cations receive considerably less training on
infection prevention and control than other
managerial or care staff. The reasons for this are
unclear, but it may be because managers, the nurses
themselves, or both make assumptions that staff will
have received suf?cient infection prevention and
control training during their professional
quali?cation. However, these assumptions are
?awed: many nurses will have trained a long time
ago; infection prevention and control may not have
been covered in suf?cient depth during training;
and, as with all staff, homes need to satisfy
themselves that the knowledge of nursing staff is
regularly refreshed and updated at the right levels.
26 Care Quality Commission: Working together to prevent and control infections

Healthcare perspective
“Currently, training for nurses at university
generally has a session of infection control each
year, but this is not enough to cover in
suf?cient depth the level of knowledge
needed.”
Infection control nurse specialist
Barriers to maintaining a well
trained and competent workforce
A signi?cant theme that emer ged for many homes
was the impact of high staff turnover, including
managerial staff, and the dif?culties in maintaining a
fully trained workforce. All homes had mandatory
training on infection prevention and control for the
entire workforce, but some struggled to update
existing staff when they had to prioritise training for
newly arrived staff. This appeared to be an issue
across the entire workforce and not just lower paid
care staff.
A number of homes told us how important it is to
translate training materials for staff whose ? rst
language is not English. Also, for some care staff it
was important not to rely on their ability to read and
write, but to provide training and information in a
wider range of accessible formats, including for
example DVDs, practical demonstrating and role
modelling.
Case study
The manager of a care home ran her own
internal training sessions for staff , which she
opened up to a number of other homes that
were part of the same organisation in her
area. They reciprocated, and also shared
practical, real life issues within the homes.
This meant that training was distributed more
consistently and frequently between the
homes, the training material helped to tackle
“live” issues that the homes were dealing
with, and staff
bene?
ted by learning about
the experiences and practices of other homes
as well as their own.
Healthcare perspective
“Training is almost totally reliant on the
management structure in care homes and
mandatory training is generally around the
basics of infection control, such as hand
hygiene and universal precautions. There is
scope for training to be extended into areas
which would reduce the transmission of
healthcare associated infections, but this may
be limited by lack of resources or specialist
trainers.”
Infection control nurse specialist
Sick pay was also a critical fact

or, although this did
not apply in the one public sector run scheme
included in the sample. Staff in some homes will not
be paid if they do not come to work because they
think they may be infectious. There is therefore an
in-built perverse incentive for lower paid care staff to
come to work when carrying infection. The risk to
others is linked to the type of work that somebody
carries out. Therefore, anyone recovering from an
infection can carry out duties that present a lower
risk of transmitting it to residents or staff – although
this may present problems in very small care homes.
Care Quality Commission: Working together to prevent and control infections 27

How are care staff trained and supported in preventing and controlling infections? continued

Case study
The manager of a care home told us that she
was sympathetic to the ? nancial problems
faced by staff when they ring in sick. She
therefore manages the rota ?exibly, so that if
a member of staff behaves responsibly when
ill, she ensures that they are able to make the
time and money up when they are better.
Summary
The overall success of a care home in preventing and
controlling infection depends on good leadership
from the home’s manager, as care homes tend to
operate as ‘stand alone’ organisations, even when
they are part of a larger group or chain. It is
therefore important to focus on the competence,
skills and knowledge of the manager in relation to
infection prevention and control in order to ‘cascade’
good practice throughout the care staff team.
28 Care Quality Commission: Working together to prevent and control infections

5
How well prepared are care homes
for the forthcoming regulatory changes?
Until 2010, infection prevention and control in care
homes will be judged against the requirements of
the Care Standards Act 2000 and the national
minimum standards. However, during 2010, care
homes will be required to register with the Care
Quality Commission against a range of regulatory
requirements, including one relating to infection
prevention and control.
9 In addition, the Department
of Health has published two documents to help care
homes meet existing requirements and expectations
on preventing and controlling infection – Essential
Steps
5 and Infection Control Guidance for Care
Homes (under revision and subject to consultation)
2,
both published in 2006.
This is a major change to the way this area is
regulated in the social care sector and we asked care
homes a series of questions to assess how prepared
they were for it. These included questions on:

How well prepared are care homes for the forthcoming regulatory changes? continued

Case study
The manager described the ‘update weeks’ the
company runs regularly across all its homes.
For that particular week the home
concentrates on updating their knowledge on
a particular area (such as infection prevention
and control) going through an update brie? ng
at team meetings, practicing certain tasks
under supervision and undertaking fun
activities such as quizzes on the topic to
reinforce learning and with a potential prize.
Use of performance indicators
Our survey asked care homes if they used any
performance indicators to help them manage
infection prevention and control. Examples we gave
as prompts were the number of people with
catheters who developed a urinary infection, and
monitoring the number of cases of C. difficile over
time. The majority (61%) of homes did not use
performance management information.
The care homes included as case studies described
using performance indicators for a number of
reasons:

Healthcare perspective
“Since Essential Steps is essentially an audit
tool, there has been a reluctance to implement
it in some areas. Its uptake could do with being
higher, as the information behind it is robust,
and although it is currently being reviewed by
the Department of Health, its format is unlikely
to change.
Infection control nurse
Those homes implementing the guidance told us
that they mainly used Essential Step 1 – Preventing
the Spread of Infection (81%) and the Self
Assessment tool (71%). Only 38% of homes used
Essential Step 2 – Urinary Catheter Care, 30% used
the review tools and only 21% used Essential Step 3
Healthcare perspective
“In care homes, urinary tract infections and
wounds are possibly the largest healthcare
associated infection risks. Enteral care is
another forgotten area. All three of these can
easily become a sepsis issue resulting in
bacteraemia. Unfortunately because of the high
publicity surrounding MRSA, bacteraemia from
other pathogens tend to go unpublicised.”
Infection control nurse specialist
Implementation of the Department
of Health’s
Infection Control
Guidance for Care Homes
Similar patterns were apparent for the Department of
Health publication, Infection Control Guidance for
Care Homes
2, and some homes in our case studies
were not clear which was which or whether one had
replaced the other. This shows how important it is to
continue to promote a targeted publication after its
initial launch, particularly in this sector where
turnover of managers is high, and staff can miss out
on key information as a result of job moves or
promotion. This guidance is currently subject to
revision and public consultation due to end in
November 2009.
In our survey, a higher proportion (75%) of homes
told us that that they had read the guidance, but a
still signi?cant minority of 17% had not read it and
a further 8% were not aware of it at all. Smaller
homes, in particular, were less likely to be aware of
this guidance.
Of the homes implementing the guidance, 97% were
applying the element on infection prevention and
control, 85% the element on food hygiene, 69% the
element on decontamination and cleaning, and 55%
the element on managing infections, including
isolation.
However, only 22% had used or implemented the
antibiotic prescribing and management element.
This is a matter for concern because, although care
homes are not responsible for prescribing, they do
play a key role in the management of antibiotic use
and reliable knowledge is essential for both their
own practice and to challenge poor practice by other
agencies.
Care Quality Commission: Working together to prevent and control infections 31

How well prepared are care homes for the forthcoming regulatory changes? continued

Care home perspective
“We had an infection in 2008, and for the ?rst time monit ored the spread of the infection, had an audit
trail of whom we contacted, and an action plan etc, which was very effective and kept everyone
informed.”
“We have developed a protocol for enteral feeds in line with Essential Steps and are currently working
on a protocol for room decontamination.”
“Our laundry system was commented on as excellent with the Health Protection Agency last year.
We have a dirty and clean entrance with a walkway which they commended us on.”
“We have introduced a ‘grab bucket’ on each level within the home. The bucket contains all the
essential equipment to deal with an incident that may involve clearing up bodily ?
uids. This allows staff
to access the equipment they need immediately.”
“We have recently had a tenant who has been diagnosed with bone cancer and the team has worked
well with Cancer Research Technology Limited and the consultant at the hospital to ensure that
guidelines have been put in place for control of infections if any.”
Awareness of forthcoming changes
to the regulation of care
Only 45% of survey respondents were aware of the
forthcoming changes. There were lower levels of
awareness in:
? Homes for younger adults with drug and alcohol
care needs.
? Smaller homes.
? The East and West Midlands.
Of those who knew about the forthcoming changes,
most (88%) were aware of the speci?c changes f or
their home. Where homes were aware of the
forthcoming changes, their sources of information
were the Department of Health (36%), Commission
for Social Care Inspection (29%), primary care trust
(16%) and the local authority (9%).
Preparing for change
In our survey, we asked homes about the support
they might need to help them prepare for the new
arrangements. Over 600 respondents wanted help,
including training, clear and concise guidelines, and
help with preparing for an outbreak.
We asked homes for any examples of good practice
they wanted to share (see above).
Summary
The existing guidelines that are designed to help
care homes improve infection prevention and control
have not been implemented widely or
comprehensively, and knowledge of the forthcoming
changes in regulation is not widespread across the
care home sector. Care homes have expressed a need
for more help with preparing for the forthcoming
changes.
32 Care Quality Commission: Working together to prevent and control infections

Appendix 1: Methods
There were two main elements within the study
which were:

Appendix 1: Methods continued

Each case study also involved gathering perspectives
from health practitioners, including infection control
specialists and social care commissioners. During
each case study, we visited each home and
interviewed the manager and other key staff. We also
talked directly to people living in the home who had
experienced infection and to family members where
possible.
Survey
We asked all care homes to complete the
questionnaire either online or on a paper form with a
freepost return address. A request to participate,
with an electronic link to the survey and information
on the paper version, was sent out by CSCI to all
homes on its electronic mailing list – approximately
12,000 care homes, and 70% of all homes registered.
Because this could distort the response to exclude
homes less likely to use electronic communication,
the reference group membership organisations also
sent out paper-based brie?ngs and paper copies of
the form to their members. The survey was
anonymous, although we asked for postcode
information to help with regional mapping and to
ensure there was no double counting. Participating
homes were all guaranteed con?dentiality subject to
our ethical and data protection protocols.
The survey ran for a six-week period from 13 March
to 27 April 2009. The questionnaire was completed
by home managers or the person with lead
responsibility for infection prevention and control
within the home. We reviewed the pro?le of surveys
returned on a weekly basis to ensure the response
pattern was broadly similar to the pro?le of homes
registered with the CSCI, and towards the end of the
survey period we asked the membership organisation
to send out brie?ngs, which targeted types of homes
that were under-represented. As a result we received
1,064 survey returns in total from a pro?le of homes
broadly in line with the pro?le of homes registered with CSCI. This represented around 4% of care
homes in England, which was deemed to be a
suf?cient sample size from which to draw statistical
inference.
Social care reference group and
project steering group
To ensure that social care providers were actively
involved and able to collaborate with us from the
outset, we established a reference group which
involved an ‘expert by experience’ nominated by
CSCI and representatives from each of the four
membership organisations – English Community
Homes Association, National Care Association,
National Care Forum and the Registered Nursing
Homes Association. This group acted as advisors as
we designed the research tools, publicised the
research among their membership and encouraged
members to participate, including some follow-up
publicity to make sure the survey response was
representative, and helped us to review and validate
the ?ndings and recommendations. The reference
group also helped us to pilot the survey
questionnaire. Detailed membership of this group is
provided in Appendix 3. A project steering group was
convened, comprising both health and social care
professionals to ensure a balanced perspective to
the work. The membership of this group is described
in Appendix 3.
Methodological challenges
To the best of our knowledge, this is the ?
rst
attempt to research the arrangements for infection
prevention and control at the interface between
social and health care – an area where the continuity
and quality of care can easily break down. Our study
has provided a wealth of new information on the
experiences and perspectives of care home providers
in preventing and controlling infection.
34 Care Quality Commission: Working together to prevent and control infections

Our study was designed and carried out in a short
timescale, in order to give our ?ndings in time to
help social care homes and other care providers
prepare for the publication of the new Code of
Practice on infection prevention and control, which
will apply to care homes in 2010. In addition, we will
present our detailed ?ndings to the Department of
Health as part of the consultation on the new Code
of Practice. Due to the timescale and because we are
the ?rst to study this area, there are inevitably
limitations. However, we have sought to ensure that
our ?ndings are as accurate as possible in the
following ways.

Summary continued
Appendix 2: Details of our case study sample
Infection
Case control PI
ref Needs Size Region Category
rating Ownership
1 Older people
(all dementia) 35
North East Care home with
nursing 1
Private
2 Older people
(some dementia) 34
North West Care home with
nursing 4
Private
3 Older people
(some dementia) 40
North West Residential care
home 4
Voluntary
4 Older people
(no dementia) 50
London Care home with
nursing 1 but moved
to 3 Voluntary
5 Older people
(all dementia) 30
South West Residential care
home 1
Voluntary
6 Older people
(all dementia) 17
Eastern Residential care
home 1
Private
7 Older people
(some dementia) 120
West
Midlands Care home with
nursing 1
Private
8 Older people
(some dementia) 36
East
Midlands Care home with
nursing 1
Private
9 Older people
(no dementia) 21
South West Care home with
nursing 1
Private
10 Mental illness 11
London Residential care
home 4
Voluntary
11 Learning and
physical disability 6
South East Residential care
home 4
NHS
36 Care Quality Commission: Working together to prevent and control infections

Infection
Case control PI
ref Needs Size Region Category
rating Ownership
12 Learning disability 21
Yorkshire Residential care 1 Private
and home
Humberside
13 Physical disability 12
Yorkshire Residential care 4 Local
and home authority
Humberside
Care Quality Commission: Working together to prevent and control infections 37

Summary continued

Appendix 3: Acknowledgements
To ensure good participation, to develop appropriate
research design and data collection methods and to
help validate our ?ndings, we convened a social care
reference group. We are very grateful to the
members of this group for their help and support
throughout the study. The membership of this group
was:

Summary continued
References
1. Loeb, MB, Seminars in respiratory and critical care medicine, ‘Pneumonia in nursing homes
and long term care facilities’, 2005.
2. Department of Health, Infection Control Guidance for Care Homes, 2006.
3. Nicolle, LE, Clinical infectious diseases, ‘Infection
control in long term care facilities’, 2000.
4. Nicolle LE, Strausbaugh LJ, Garibaldi RA, Clinical microbiological reviews, ‘Infections and
antibiotic resistance in nursing homes’, 1996.
5. Department of Health, Essential steps to safe, clean care: reducing healthcare-associated
infections, June 2006.
6. Healthcare Commission, Healthcare associated infection: What else can the NHS do?, 2007. 7. Safdar N, Maki DG, Annuls of internal medicine,
‘The commonality of risk factors for nosocomial
colonization and infection with antimicrobial-
resistant Staphylococcus aureus, enterococcus,
gram-negative bacilli, Clostridium dif? cile, and
Candida’, 2002.
8. Barr B, Wilcox MH, Brady A, Parnell P, Darby B, Tompkins D,
Infection control and hospital
epidemiology, ‘Prevalence of methicillin-
resistant Staphylococcus aureus colonization
among older residents of care homes in the
United Kingdom’, 2007.
9. Care Quality Commission, Guidance about compliance with the Health and Social Care Act
2008 – Consultation, 2009.
10. Department of Health, Confidentiality Code of Practice, 2003.
40 Care Quality Commission: Working together to prevent and control infections

© Care Quality Commission 2009
Published September 2009
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