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policy for the prevention and control of infection

3.0

EQUALITY IMPACT
The Trust strives to ensure equality of opportunity for all, both as a major
employer and as a provider of health care. This Policy for the Prevention and Control of
Infection has therefore been equality impact assessed by the Infection Control
Committee to ensure fairness and consistency for all those covered by it
regardless of their individual differences.

Version: 3.0
Authorised by: Infection Prevention and Control
Committee
Date authorised: September 9th 2008
Next review date: January 2010
Document author: Angela Hallas
TAMESIDE HOSPITAL NHS FOUNDATION TRUST policy for the prevention and control of infection

VERSION CONTROL SCHEDULE


policy for the prevention and control of infection

Version : 3.0-

Version Number Issue Date Revisions from previous issue


. 1.0 Sept 2005 First issue
2.0 January 2008 Second issue
Additions/updates:
Definitions
Guideline Statement
Health Care Associated Infection
Hand Hygiene
Personal ProtectiveEquipment
Safe Handling and Disposal of sharps.

3.0 September Third issue


2008 Addition ‘bare below the elbows’

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INDEX/ TABLE OF CONTENTS


INTRODUCTION ........................................................................................................ 4
PURPOSE/RATIONALE/OBJECTIVES ..................................................................... 4
Scope ......................................................................................................................... 4
Definitions................................................................................................................. 13
DUTIES ...................................................................................................................... 5
GUIDELINE STATEMENT.......................................................................................... 4
The prevention and control of healthcare associated infection ................................... 4
Healthcare Associated Infections............................................................................ 4
Policy Development & Consultation.......................................................................... 13
Implementation ......................................................................................................... 13
Monitoring................................................................................................................. 14
REFERENCES ......................................................................................................... 14
APPENDICES .......................................................................................................... 14
Appendix 2 ............................................................................................................ 15
Review...................................................................................................................... 16

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INTRODUCTION
An estimated 5,000 patients die as a direct consequence of Health Care Associated
Infection (HAI) every year throughout the NHS.

PURPOSE/RATIONALE/OBJECTIVES
This policy sets out the Trust’s arrangements for the prevention and control of Health
Care Associated Infection. The policy outlines the responsibilities shared by all for
minimising the risk of infection to patients, visitors and staff.

SCOPE
This policy is applicable to all staff, patients (adults and children) and visitors to
Tameside General Hospital.

GUIDELINE STATEMENT
All NHS organisations must comply with The Health Act 2006 Code of Practice for
the Prevention and Control of Healthcare Associated Infections. The code of practice
requires effective prevention and control of Healthcare Associated Infections to be
“embedded into everyday practice and applied consistently by everyone”.
Every clinician has the potential to significantly reduce the risk of infection to their
patients by ensuring that they consistently apply evidence based practice and follow
established guidelines whenever they undertake a clinical procedure.

The policy will describe the principles underpinning infection/prevention control


practice that must be applied by all staff in the every day care of patients. This policy
is applicable to all health care environments and should be followed in all
circumstances and in conjunction with all relevant policies, procedures and guidance.
In particular the following
Aspergillus Policy http://tis/documents/AspergillusPolicy.pdf
Guidance on the Management of Risks Associated with Transmissible Spongiform
Encephalopathies
http://www.dh.gov.uk/en/Publichealth/Communicablediseases/CJD/CJDGeneralInfor
mation/DH_4031067
Decontamination Policy
http://tis/documents/Decontamination%20Policy%20version1%203%201%2007.pdf

This policy when applied in conjunction with the Trusts assurance framwork will
ensure organisation compliance with the duties described in the Health Act 2006
Code of Practice.

THE PREVENTION AND CONTROL OF HEALTHCARE ASSOCIATED


INFECTION

Healthcare Associated Infections


Healthcare associated infections (HCAI) impact on the high quality of care we all

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strive to provide for patients. Infection is a significant cause of harm and can result in
patient suffering , unnecessary pain, anxiety and possible death. Many HCAIs are
avoidable and everyone can contribute to reducing their burden.
Effective prevention and control needs to be embedded in every day practice
(DOH2006). In 2007 the EPIC group (Evidence Based Practice for Infection Control)
noted that standard infection control precautions need to be applied by all health care
practitioners to the care of all patients .

DUTIES
Management Organisation and Environment
Tameside Hospital NHS Foundation Trust will ensure that at all times appropriate
sytems, structures and processess are in place to protect patient, visitors and staff
from the risk of health care associated infection. The Trust Board will commission
and approve an annual programme of work setting out the organisations strategic
objectives for the prevention and control of infection. Delivery of the objectives will be
managed under the clinical governance framework. Responsibilities for the
prevention and control of infection are assigned to key officers as outlined:

Chief Executive
The Chief Executive has overall responsibility and is accountable for ensuring that
there is a managed environment which minimises the risk of infection to patients,
visitors, staff, contractors and all who use the hospital site for any purpose.

Director of Infection Prevention and Control


The Director of Nursing is the Chief Executives nominated Director for Infection
Prevention and Control and is responsible for ensuring that there are effective and
appropriate arrangements for the prevention and control of infection throughout the
Trust.

Associate Director of Facilites


The Associate Director of Facilities is the nominated lead for the management of
medical devices and decontamination. The Associate Director of Facilities is
responsible for ensuring that adequate arrangements for decontamination of medical
devices are designed and implemented and that a system is in place for monitoring,
reviewing and updating these arrangements. In addition the Associate Director of
Facilities has the duty to ensure that adequate arrangements for routine cleaning of
the care environment are designed and implemented and that a system is in place for
monitoring, reviewing and updating these arrangements.

The Infection Prevention and Control Committee


The Infection Prevention and Control Committee is accountable to the Chief
Executive and reports to the Trust board through the Clinical Governance
Committee. The Infection Prevention and Control Committee is an executive
committee and is responsible for the endorsement and implementation of Infection
Prevention/Control policies, guidelines and procedures: and monitors progress of the
Trust’s Infection Prevention/Control Programme.

The Infection Prevention and Control Team


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The Infection Prevention and Control Team report directly to the Director of Infection
Prevention and Control and are responsible for aspects of surveillance, prevention
and control of infection within the Trust. The Infection Prevention and Control Team
are responsible for the implementation of the Trust’s Infection Prevention/ Control
programme and for the development and dissemination of policies, guidelines and
procedures.Key functions of the infection control team include:

• Prompt and effective identification and control of outbreaks and potential


outbreaks of infection
• Education and training of staff
• Provision of an annual report to the Chief Executive celebrating
achievements and highlighting matters for concern/recommendations for
improvement
• Liason with Clinical teams and service managers to ensure infection
control elements of service planning and delivery are appropriately
considered
• Liason with Occupational Health Teams
• Liason with the Trusts Risk Management team and the provision of advice
and support in the investigation of infection control related incidences
• Liason with external bodies / agencies within the wider community.

Directors/Lead Clinicans/Senior Managers


All Directors, Lead Clinicians and Senior Managers have a delegated responsibility
for ensuring that this policy is known to their staff and that its requirements are
followed by all staf within their Directorate/Division/Department.

Department Heads/Service Managers/Clinical Leads


Are responsible for ensuring infection control risk assessment is undertaken and that
all possible measures are taken to reduce the risk of infection to patients, visitors and
staff.
All managers are responsible for ensuring that staff have access to up to date
training to enable them to adopt safe working practices at all times and are
appropriately trained to minimise risks to themselves and others. Service Managers
and Departmental heads are responsible for ensuring that the infection control
elements/implications of all service developments , structural alterations,
environmental changes are duly considered and brought to the attention of the
infection control team.

Microbiology Laboratory
The Microbiology laboratory provides a 24 hour, accredited service for the diagnosis
of infection. The laboratory supports the Infection Control Team by processing
microbilogical specimens , providing immediate notification of “alert” organisms and
by facilitating the collection, interpretation and dissemination of surveillance data.

Estates Operations Manager


The Estates Operations Manager has special responsibility for ensuring that all

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environmental services and facilities are maintained and operated to required


standards in order to protect the Trust from breach of duty of care and the risk of
infection. The Estates Operations Manager must ensure that the infection control
team are involved in all structural works and advised of any system failures/
interruptions at the earliest opportunity.

Estates Planning Manager


The Estates Planning Manager ensures the inclusion and involvement of the infection
control team in the planning and project management of all capital schemes,
structural developments, alterations and refurbishments. This responsibility is
formalised by the maintenance of accurate and appropriate documentation recording
infection prevention/control requirements, guidance and advice.

Hospital Sterilisation and Disinfection Unit (HSDU) Manager


The HSDU manager ensures that all resusable medical devices (surgical instruments
etc) are decontaminated in compliance with all current legislation, regulation and
guidance. The HSDU manager must ensure that the infection control team are
involved in the planning of structural works within the unit and are advised of any
incidents ,system failures/ interruptions at the earliest opportunity.

Hotel Services Manager


The Hotel Services Manager is responsible for ensuring that all practices involved in
the purchase, preparation and service of food is undertaken with due diligence and is
in line with all current food hygiene regulations. The Hotel Services Manager must
ensure that the infection control team are advised of any system failures (food
storage or production)/food contamination etc. at the earliest possible opportunity.

Occupational Health Team


The occupational health team liase directly with the infection control team to assist in
the assessment and management of occupational risks associated with contact with
pathogens and infectious diseases.
Occupational Health will liase directly with the infection control team in assessing and
managing any risk associated with an infected heallth care worker involved in
provision of services to patients.
The importance of confidentiality will be respected throughout activities and will
protect the interests of patients and employees at all times.

Contract Manager Domestic – Domestic and Portering Services


The Contract Manager Domestic and Portering Services is responsible for ensuring
that all practices and procedures are carried out in line with the requirements of this
policy.Any proposed changes to cleaning products or practices will be discussed with
the infection control team, prior to implementation.

All Staff
All staff are responsible for following policies, procedures and guidance ( written or
verbal) relating to the prevention and control of infection , at all times. Staff are
responsible for ensuring that they understand the risk of infection associated with

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their activity and that they adopt safe practice for their own safety and that of others.
Any member of staff who has concerns about infection risk,suspicions of an outbreak
of infection will discuss their concerns (as a matter of urgency) with the infection
control team. In addtion staff have a responsibility to provide appropriate and
sensitive information to patients and visitors so that they are aware of the risks and
implications of health care associated infections and understand the contribution that
they can make to prevention.

Clinical Care Protocols


Tameside Hospital NHS Foundation Trust will provide, maintain and monitor policies,
protocols and procedures to ensure that all staff provide high quality, clean, safe care
to patients. Standard precautions for the prevention and control of health care
associated infections are applied by all employees and contractors according to
assessment of likely direct or indirect contact with body substances. Standard
precautions are taken by all clinical staff, working in or visiting a clinical area, for
every patient and during every intervention. Standard precautions include:

Hand hyiene (incorporating bare below the elbows)


Protective clothing and equipment
Aseptic non touch technique
Isolation
Safe handling and disposal of sharps
Handling and disposal of used linen
Handling and disposal of clinical and hazardous waste
Decontamination of equipemtn and the environment
Prudent antibiotic prescribing

Bare below the elbows

All staff entering the clinical area that have responsibility for direct patient contact will
adopt the ‘bare below the elbows’ dress code.The ‘bare below the elbows’ initiative is
part of the government’s Clean Safe Care strategy which aims to reduce infection
risks by improving hand hygiene
All clinical staff must now wear short sleeves or sleeves rolled up and NO hand or
wrist jewellery (other than a plain metal wedding band).Allied to this is the avoidance
of wearing ties when carrying out clinical activity.

Key changes for the Trust on uniform


• A’ bare below the elbows’ approach will be adopted at all times,by all staff in
the clinical area..

• Any staff who wear their own clothes in the clinical area, must adhere to the
‘bare below the elbows’initiative for the facilitation of hand washing.
• Clothing worn by all staff must be clean and fit for purpose and hands washed
before before and after patient contact.
• Coats etc can either be left in the ward ‘rest room’ or carried , as long as they
are removed whilst hand washing takes place.

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This guidance ensures good hand washing and wrist washing,as staff that are bare
below the elbows are not impeded by shirt cuffs or jewellery.

Hand Hygiene
Effective decontamination of the hands is the single most effective way of preventing
the spread of infection in the healthcare setting. Hands must be decontaminated
immediately before each and every episode of direct patient contact/care and after
activity or contact that potentially results in hands becoming contaminated(EPIC2).
Hands should be decontaminated between caring for different patients or between
different care activities for the same patient.
Effective hand hygiene depends on a technique that enables all the surfaces of the
hands to be cleaned and dried thoroughly.

Alcohol handrub/gel
Rubbing the hands with an alcohol handrub or gel is an effective alternative to soap
and water washing. This method should be used whenever the hands are visibly
clean and have not been contaminated by body substances.Alcohol hand rub
should be used by all staff before and after all ‘hands on’ patient contact.
To be effective the alcohol product must come into contact with all the skin surfaces
and the hand should be rubbed together vigorously until the alcohol has evaporated
completely and the hands are dry.
It should be noted that following five applications of alcohol product the hands
will require a soap and water wash.

Soap and water (handwashing)


Liquid soap and water must be used to clean hands thoroughly following any contact
with body substances.Hands that are visibly soiled or potentially grossly
contaminated with dirt or organic material must be washed with liquid soap and
water.This procedure must be undertaken immediately after the contact and before
contact with another patient or handling equipment.

Handcreams
Regular use of handcream can help to protect the skin on thehands and prevent
cracking and chaffing. It is important that staff have access to good quality hand
cream but this must be in the form of a wall mounted dispenser providing a cream
manufactured to complement soap and alcohol products selected for use within the
Trust.

Finger Nails and Jewellery.


In clinical practice finger nails must be kept short and neat. The use of nail varnish ,
polish, extensions, or false nails is not acceptable in the clinical area.Hand jewellery
(with the exception of plain band ‘wedding’ rings only) should not be worn whilst on
duty. These are inhibitive to effective hand hygiene. Where the plain band ‘wedding’

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ring can not be removed , the wearer will ensure that the ring and the skin beneath
are thoroughly cleaned and dried during hand decontamination.

Personal Protective Equipment (PPE)


Personal protective equipment (PPE) includes the use of aprons, gloves, eye
protection and facemasks.
PPE must be worn whenever there is assessed risk of contact with body
substances.The level of protective clothing selected will reflect the nature of that
contact. In wearing appropriate protective clothing healthcare staff will safeguard
patients, the environment and themselves.

Gloves
Gloves should be worn in accordance with the Trust’s Policy for the selection and
use of gloves.Gloves must be worn as single use items.

Disposable (plastic) aprons


A disposable apron should be worn whenever there is an assessed risk of contact
with body substances or contaminated equipment Plastic aprons are single use,
disposables intended to be used for one procedure or episode of care ,and then
discarded and disposed of as clinical waste.

Masks and Eye Protection


Mask and eye protection must be available to and used by all staff whose activities
may expose them to the risk of body substances splashing into the eyes and
face.When activities expose staff to direct contact with secretions from a patients
respiratory tract e.g. pharyngeal suction, appropriate protection for the eyes, mouth
and nose must be worn.

Aseptic Non Touch Technique (ANTT)


ANTT
Clinical staff involved in invasive procedures must be trained and assessed to be
competent to carry out ANTT procedures. Clinical staff involved in such procedures
must demonstrate consistently high standards of practice by ensuring that the setting
selected for each procedure is appropriately prepared, that all appropriate sterile
supplies items are available and that manipulation of the affected site is minimised.
(DOH 2003). The ANTT clinical guideline is available on the Trusts intranet and
managers must ensure that the guideline is clearly understood by all clinical staff in
their area of responsibility.

Isolation of Patients
It is appropriate in some circumstances to nurse patients in single room isolation. In
such circumstances clinical staff will implement the Isolation Policy under the
guidance and direction of the infection prevention and control team.
The Isolation Policy identifies two distinct types of isolation as follows:
• Source Isolation – the isolation of a patient who may pose a risk of infection to
others

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• Protective Isolation – the isolation of a patient who is assessed to be


particularly susceptible to infection

Single room accommodation will be allocated by bed managers on the assessment


of clinical need and giving priority to patients requiring isolation. Any patient admitted
to the hospital with undiagnosed diarrhoea and or vomiting, will be isolated until the
cause of symptoms is established.

Safe Handling and Disposal of Sharps

Avoiding sharps injuries is everybody’s responsibility.


Sharp instruments can cause injury to patients, visitors and staff if not appropriately
managed.Such injuries are a major route of transmission for blood borne viral
infection.All sharps must be discarded into a sharps container (conforming to UN
3291 and BS 7320 standards) at the point of use by the carer. This is the
responsibility of the user.Sharps bins will be labelled, handled, transported and
disposed of in accordance with current waste regulations and with the Trust’s policy
for the management of Clinical Waste.

Inoculation Injuries
All staff must be familiar with the procedure to be followed in the event of an
inoculation injury as per policy-Management of Inoculation Injuries.An inoculation
injury includes needlestick and sharps injuries,bites scratches and splashes (body
substances) onto broken skin or mucous membranes membranes.
Following an inoculation injury all staff must attend Accident and Emergency for the
HIV risk assessment on the source to be undertaken. In accordance with the Trust
Policy for all staff attending Accident and Emergency must then attend Occupational
Health to allow for the appropriate follow –up treatment and documentation to be
completed.
All inoculation injuries must be reported to the line manager on duty and through the
incident reporting system to Risk Management.

Waste Management (clinical and hazardous waste)


All waste generated as a result of direct patient care activity will be manageged in
accordance with the Trust waste and as such will be bagged in British Standard
yellow waste sacks.When bags are three quarters full they must be securely fastened
and labelled as to source before being placed carefully inside a designated clinical
waste bin to await collection for incineration. All such bins should be kept locked. All
staff must comply with the requirements of the Trust’s Waste Management Policy at
all times. All staff whose role involves the generation and /or handling of clinical
waste must be trained to ensure that they are equipped to manage waste safely.

Linen
Clean Linen

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Clean linen must be stored in a dedicated cupboard and protected from


contamination. It is not appropriate to carry quantities of linen around the ward on an
open trolley. Linen should therefore be collected as required for individual use.

Soiled(dirty but not ‘fouled’ linen)


Soiled linen must be placed into a white linen bag at the bedside. The bag should be
tied when three quarters full, labelled as to the source and removed to await
collection by the portering staff.

Fouled Linen (contaminated with body substances) and “Infected” Linen (from
a known infected patient)
All foul anf imfected linen is placed into red aliginate (hot water soluble) bags inside
red laundry bags and removed from the ward immediately.

Spillage of Body Substances


Responsibility for clearing up spillages rests with the member of staff finding such a
spill. All spillage of body substances will be cleared away promptly with due regard
for personal and public safety.

Outbreak of Infection
For the purpose of this policy an outbreak has been defined as two or more cases of
infection which are or appear to be associated in time and place. It should be
acknowledged that in some very special circumstances , a single case of infection
may prompt the implementation of outbreak controls.

Recognition / Suspicion of an Outbreak


The infection control team must be notified immediately if staff have reason to
suspect an outbreak of infection. Staff should not wait for laboratory confirmation of
their suspicions before contacting the infection control team.

Outbreak Investigation
The infection control team are responsible for the investigation of any suspected or
confirmed outbreak of infection and will liase with colleagues in other agencies as
appropriate. On confirmation of suspected outbreak the infection prevention and
control team will implement the Outbreak of Infection Plan

Outbreak Control
All staff will be required to follow the instruction of the infection control team and to
implement such control measures as may be necessary for the protection of
patients,visitors ,staff and the wider community.

Antibiotic Therapy
The contribution of antibiotics in the treatment of serious infections cannot be
underestimated; however the unrestricted administration of antibiotics can lead to the
selection of antibiotic-resistant organisms and can increase the patient’s risk of
Clostridium difficile associated diarrhoea. Such organisms are sometimes associated
with increased morbidity and mortality. It is important to ensure that antibiotics are
prescribed in a way which minimises the risk. Local antibiotic guidelines are provided

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and have been designed to enable clinicians to treat common infections effectively
and with the minimum risk of healthcare-associated infections. All prescriptions for
antibiotic therapy must be reviewed after 72 hours to ensure that the prescription is
necessary and appropriate.

Health Care Workers


Tameside Hospital NHS Foundation Trust will ensure that staff are appropriately
supervised and are trained to recognise and adress the risks of infection associated
with health care activities and the health care environment.

Responsibilities for the prevention and control of health care associated infection will
be clearly identified in the job description for all health care workers. Training needs
accountabilities and objectives in relation to infection prevention and control
activities will be identified and discussed during personal development meetings and
will be documented in personal development plans for all employees.

Occupational Health Services


Tameside Hospital NHS Foundation Trust provides access to occupational health
services for all staff and has implemented policies to manage the risk of infection and
communicable disease in the workplace. Where appropriate staff are offered
immunisation, guidance and support.

POLICY DEVELOPMENT & CONSULTATION


The policy was developed in conjunction and in consultation with the infection control
team, using the best available evidence. The authorising bodies will be the Infection
Control Committee..

DEFINITIONS
Health Care Associated Infection (HCAI) - infection that is acquired as a result of
contact with the health care system.
Hospital acquired infections - infections that develop in patients 48 hours or more
after admission to hospital.
Community acquired infections - any infection from which the patient was suffering
when they came into hospital or occurs within 48 hours of admission (i.e. acquired in
the community).
Invasive procedures – procedures involving a break in the skin, contact with mucous
membranes, or a body cavity
Body Substances - all secretions produced by the body (especially blood and blood
stained fluids, but also serous fluids, such as pleural or cerebrospinal fluids, and genital
and oral secretions, faeces, sputum etc.) which may contain potentially harmful
organisms.

IMPLEMENTATION
The policy will be displayed on the intranet and within Volume 1 of the Infection
Prevention and Control Manual issued to all wards and departments. The policy will
also form an integral part of the existing Infection Prevention / Control training for all

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staff and will by issued to contractors as appropriate.

MONITORING
Compliance with this policy will be monitored by the infection prevention and control
team on behalf of the Infection Prevention and Control Committee. Annual
environmental and practice audits will be undertaken by the Infection Control team
and formal reports will be issued to all managers, clinical leads and departmental
heads. Departmental managers will be required to submit, implement and monitor
remedial action plans where necessary. Clinical divisions report complance via
Clinical Governance Framework reporting structures.

REFERENCES
Department of Health (2006).The Health Act .Code Of Practice For The Prevention
and Control of Healthcare Associated Infections. The Stationary Office .

Pratt,R.J.,Pellowe,C.M.,Wilson,J.A.,
Loveday,H.P.,Harper,P.,Jones,S.R.J.J.,McDougall,C.,Wilcox,M.H.(2007). EPIC2
National Evidence Based Guidelines For Preventing Health Care Associated
Infections in NHS Hospitals In England.
.
APPENDICES
Appendix 1 Equality Impact Assessment Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval.

Yes/No Comments
1. Does the policy/guidance affect one group
less or more favourably than another on the
basis of:

• Race No

• Ethnic origins (including gypsies and No


travellers)

• Nationality No

• Gender No

• Culture No

• Religion or belief No

• Sexual orientation including lesbian, gay No


and bisexual people

• Age No

• Disability - learning disabilities, physical No


disability, sensory impairment and mental

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Yes/No Comments
health problems
2. Is there any evidence that some groups are No
affected differently?
3. If you have identified potential No There is no discrimination in
discrimination, are any exceptions valid, this guidance
legal and/or justifiable?
4. Is the impact of the policy/guidance likely to No
be negative?
5. If so can the impact be avoided? N/a
6. What alternatives are there to achieving the N/a
policy/guidance without the impact?
7. Can we reduce the impact by taking N/a
different action?

Appendix 2

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REVIEW
This policy will be formally reviewed in January 2010 or earlier depending on the
results of monitoring, or as a result of incidents or recommendations from recognised
National bodies or the introduction/review of legislation.

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