Introduction The role is often carried out by Infection Prevention Link staff who also have the role of providing care to the patients. LOROS changed this profile three years ago by employing a dedicated qualified infection prevention specialist. As most of the patients within the hospice are vulnerable to infection this role was to look at areas which could be improved and reduce the risk of hospice acquired infections and promote patient, staff and visitors’ safety.

Aims The aims were to ensure that LOROS was compliant with national and local guidelines on Infection Prevention. To identify any areas for concern or non-compliance and how it could improve the patient’s journey and ensure infection prevention and safety were everyone’s business.

Method A review of national and local infection prevention literature was undertaken and the Infection Prevention Lead was part of the Infection Prevention Society (IPS) whose vision is that ‘no person should be harmed by a preventable infection’. They have also produced a suite of infection prevention audits that can be used in all healthcare settings. These were used as a starting point for starting to identify any good/excellent areas of compliance and any areas which may need improvement.

The hospice also wanted to ensure compliance with the Department of Health’s Health and Social Care Act 2008 The Hygiene Code. This Act established the CQC and sets out the overall framework for the regulation of health and adult social care activity. Outcome 8 of the CQC was the driving force for some of the changes that were implemented.

Conclusion From the initial audits areas of good practice were identified, for example the general cleanliness of building, staff adherence to uniform/dress code and hand hygiene but they also identified area for improvement. The list below is an example of some of the changes implemented but it is not an exhaustive list and work continues to identify good practice and areas for improvement

The purchase of all new commodes

Fabric riser recliner chairs started to be phased out

Green labels were introduced identifying equipment had been cleaned

Detergent cleaning wipes

Link Staff had a dedicated two day training day

Oak Ward refurbishment

Safer needles

Introduction of Sepsis Pathway

Patient leaflets

Cleaning schedules and policy

Development of an audit Programme.