NHS Stoke on Trent Stoke on Trent Community Healthcare Service. Hand Hygiene Policy

Transcription

1 NHS Stoke on Trent Stoke on Trent Community Healthcare Service Hand Hygiene Policy Policy Number / Version: 7.03v2 Ratified by: Stoke On Trent Trust Board Date ratified: 24 th vember 2009 Name of originator/author: Infection Prevention and Control Clinical Nurse Specialists Name of responsible committee/individual: Director of Infection Prevention and Control Date issued: Review date: vember 2011 Date of first issue vember 2008 Target audience: All PCT employees and those working on behalf of the Trust. Page 1 of 20

2 CONSULTATION AND RATIFICATION SCHEDULE 7.3v2 Hand Hygiene Policy Name and Title of Individual Date Consulted Kim Gunn Head of Infection Prevention and 6 th October 2009 Control (IPC) Carol Lawton IPC Nurse 6 th October 2009 Anne Gething IPC Nurse 6 th October 2009 Name of Committee Date of Committee Infection Control Committee 23 rd vember 2009 Integrated Governance Committee 29 th October 2009 Trust Board 24 th vember 2009 Stoke on Trent Community Healthcare Board 13 th January 2010 VERSION CONTROL Policy Name: Hand Hygiene Policy Version V1 V2 Valid From vember 2008 vember 2009 Valid To vember 2010 vember 2011 Document Path/Name N:\SHARED_RESOURCES\Policies_Guidelines_Plans_&_Strategies\ Stoke_on_Trent_PCT_Policies\Folder_7_Infection_Control\ 7.3v2_Hand_Policy Page 2 of 20

3 Contents 1 Introduction 5 2 Scope 5 3 Responsibilities 5 4 Training 7 5 Monitoring Implementation through Audit 7 6 Terminology associated with hand washing facilities within the Trust 7 7 Hand Hygiene sinks 7 8 Waste bins 8 9 Soap products 8 10 Domiciliary care 8 11 Support Service Staff 8 12 Equality and Diversity 8 13 Terminology associated with cleaning hands 8 14 What are your hands carrying 9 15 The aim of hand hygiene 9 Five Moments Poster Alcohol rub The use of personal tottles COSHH Incident reporting Hand washing Procedure Nail brushes Clostridium difficile and viral gastritis Hand wipes Hand care 13 Page 3 of 20

4 26 Jewellery and wrist watches Skin irritation and soft tissue infection Respiratory etiquette Involving patients and carers 14 References 15 Appendix I Six stage good hand washing technique 16 Appendix II Areas commonly missed 17 Appendix III Hand hygiene audit tool 18 Appendix IV Hand Hygiene Observation Tool (HHOT) 19 Equality Impact Assessment Tool 20 Page 4 of 20

5 1 Introduction The Health Act (Department of Health 2008) requires NHS organisations to have up to date policies and procedures which minimise the risk of healthcare associated infection (HCAI). This includes evidence based hand hygiene guidelines which promote timely and effective hand decontamination. Hand hygiene forms part of Standard Precautions, consequently this policy should be read in conjunction with other key policy documents located in the Trust infection control policy manual. 2 Scope This policy applies to all Trust employees and staff working for and on behalf of the Trust including contractors, voluntary workers, students, locum and agency staff. 3 The Trust s Responsibilities The Trust will - Provide a Hand Hygiene Policy. Present an introduction to infection prevention including hand hygiene in the Trust Corporate Induction Programme. Deliver an ongoing programme of updates for all staff through the Big 4 Training programme, work place trainers and dedicated infection prevention and control sessions. Ensure that there is adequate provision of suitable and well maintained hand hygiene facilities and equipment in all areas. Monitor the implementation of infection control policies through regular audit using standard audit tools. (Department of Health 2008). 3.1 Responsibilities of the Director of Infection Prevention and Control (DIPC) The DIPC should Oversee the implementation and impact of this policy and make recommendations for change. Challenge poor hygiene standards. Report on the state of healthcare associated infection within the organisation. 3.2 Responsibilities of the Infection Prevention and Control Nurses (IPCNs) The IPCNs will Provide specialist advice on hand hygiene practice and facilities. Contribute to Trust training programmes including Corporate Induction and the Big 4 Training Programme. Undertake random hand hygiene audits. 3.3 Staff Responsibilities Infection prevention and control is the responsibility of everyone within the Trust and should be reflected in job descriptions, personal appraisal and development plans. All staff must ensure that they Are aware of the location, how to access and be able to demonstrate an understanding of Trust policies on infection prevention and control. Page 5 of 20

6 Take appropriate measures to minimise the risk of healthcare associated infection at all times and be seen to apply the policy in the area of practice. Take personal responsibility for ensuring that they receive as a minimum an annual update in infection prevention and control including hand hygiene. Are able to demonstrate the recommended six stage hand hygiene technique (Appendix 1). Nails are short (no longer than the end of the finger) and all wrist and hand jewellery is removed apart from a plain wedding type band before a shift begins. Artificial nails and/or nail varnish must not be worn by clinical and allied staff whilst on duty. Ensure that any faults, repairs or issues associated with hand hygiene facilities are reported immediately to the Estates Department or support services staff as appropriate. Report any infectious illness to the Occupational Health Department and not provide direct care whilst infectious. 3.4 Responsibilities of Service leads and managers Service leads and managers must ensure that The Infection Control Induction Checklist is used with all new members of staff within the first twenty four hours of commencing duty in a new area of clinical practice. Staff are released to attend training and regular updates on infection prevention and control including hand hygiene training. Managers will ensure that non attendees are re-booked and are aware of possible consequences of non attendance at statutory and mandatory training events, such as Infection prevention and Control All staff have access to information on hand hygiene including posters and leaflets illustrating the recommended six stage technique. Patients, relatives and visitors are encouraged to undertake hand washing prior to assisting with, or engaging in personal care of the patient they are visiting. 3.5 Responsibilities of the Estates Department The risk of infection can be minimised through the application of evidence based design and the provision of facilities which support good infection control practice. Minimising the risk of infection should be considered at all stages of refurbishment, redevelopment and new build projects. The project lead should ensure that the IPCNs are involved at all stages of the process. The Estates Department must ensure that hand washing basins are of the correct specification for the service provided. Hand washing basins used by clinical staff should conform with Health Technical Memorandum 64 (Department of Health 2006). Repairs or maintenance relating to the operational aspects of hand hygiene facilities must be afforded highest priority. 4 Training Page 6 of 20

7 4.1 All staff employed on a permanent basis will receive basic Infection Prevention and Control and Hand Hygiene training as part of induction and will attend up dates at least yearly. Those staff on fixed term contract will receive training on induction. Please read this section in conjunction with Stoke on Trent Community Health service Training and Education policy. 4.2 Training records containing staff signatures must be retained and made available for inspection at short notice. All trainers will ask attendees to complete attendance sheet. The trainer may keep a copy, but the original will be sent to the training and education department. 4.3 The training and education department will record all attendance on the Oricle Learning Management system. 4.4 In the case of non attendance at statutory and mandatory training events, the employee s line manager will be informed by letter. Attendance at Infection Prevention and Control training events and the individuals application to practice will form part of the appraisal process. 4.5 The Education and Training department will supply the Infection Prevention and Control group with quarterly attendance figures. 5 Monitoring the implementation and effectiveness of policy and practice through audit Matrons, ward managers, or team leaders will monitor the implementation and effectiveness of this policy through quarterly environmental hand hygiene audits and hand hygiene observational audits using standardised audit tools. This may include Infection Prevention Society 2004 and 2005 tools (Previously known as the Infection Control Nurses Association), Essential Steps to Safe Clean Care and National Patient Safety 2008 Hand Hygiene Observation Tool (HHOT). 5.1 All clinical areas will achieve a consistent 95% compliance of observed hand hygiene practice. All Hand Hygiene audit results will be submitted to the appropriate modern matron. 5.2 Any area which does not achieve a consistent 95% will complete audits on a weekly basis until 95% has been achieved for 4 consecutive weeks, at which point the audits may reduce in frequency to fortnightly. When the target of 95% has been consistently achieved for further 4 weeks, audits may be reduced to 4 weekly with the agreement of the Matron and IPCN. The IPCN will carry out spot hand hygiene observation audits at any time. 5.2 The results of Hand Hygiene observation audit will be a standing agenda item for reporting to Stoke on Trent Community Health Service Infection Control Group. The minutes of the group will be reported at the NHS Stoke on Trent PCT infection Control Committee. 6 Terminology associated with staff hand washing facilities within the Trust For the purpose of this document hand washing facilities of an appropriate specification for clinical staff are referred to as hand hygiene sinks. 6.1 Facilities used to clean equipment such as those found in a dirty utility are referred to as deep sinks. 7 Hand Hygiene Sinks Hand hygiene sinks should be of the correct specification, appropriately located, well maintained and equipped with liquid soap in disposable cartridges and paper towels both delivered from wall mounted dispensers. Supplies of paper towels and other hand hygiene products should be stored in a clean dry area prior to use. Page 7 of 20

8 7.1 Hand hygiene sinks must be dedicated for that purpose and kept free from equipment and inappropriate items, for example instruments or re-usable medicine pots. 7.2 Hand hygiene sinks should have mixer taps or thermostatic mixer valves to provide the correct water temperature. 7.3 The faucet should hit the basin and not expel directly into the drain to avoid a contaminated aerosol splash back. 7.4 Clinical hand hygiene sinks should not have a plug or overflow. 7.5 Hands free tap systems are crucial in preventing re-contamination of hands, consequently, wrist, elbow, foot or motion sensor controlled taps should be provided. 7.6 Uneven damaged surfaces may harbour micro-organisms, consequently any chipped, cracked or damaged hand wash basins should be reported to the Estates Department immediately. 8 Waste bins Must be of a design which supports thorough cleaning, are foot operated and constructed in such a way that the operator is unable to lift the lid using their hands. 9 Soap Products All soap products used for routine hand washing within the NHS must meet the standards of the NHS procurement contract. Clinical staff should not use bar soap. 10 Domiciliary care Staff undertaking domiciliary visits or care may have to carry their own hand hygiene products. 11 Support services staff Support Services staff must ensure that hand washing facilities are cleaned in accordance with The National Specifications for Cleanliness in the NHS (NPSA 2007). 12 Equality and Diversity The Trust aims to promote equality and diversity and value the benefits this brings. The organisation aims to ensure that all staff feel valued and have a fair and equitable quality of working life. 13 Terminology associated with cleaning hands A number of terms may be use to describe the process of cleaning hands including hand washing, hand hygiene and hand decontamination Hand decontamination This process reduces the bacterial count on hands by performing hand washing and using antiseptic hand rub (CDC 2002). The process refers to the physical removal of blood, body fluids, secretions, excretions and the removal or destruction of microorganisms from the hands. (epic2 2007). Hand decontamination therefore refers to a number of processes which will successfully remove transient microorganisms and reduce resident microorganisms Hand hygiene Page 8 of 20

9 Refers to the combination of processes including hand washing, the use of alcohol hand rub, drying, caring for the skin and nails (CDC 2002) Hand washing Refers to conventional methods using warm running water, liquid soap and disposable papers towels. Hand washing will remove transient microorganisms and render the hands socially clean, however, evidence suggests that this process is poorly performed (Epic2 2007) Areas commonly missed Areas most commonly missed include the backs of hands, thumbs, fingertips, areas between the fingers and under nails and rings. (Epic2 2007) 14 What are your hands carrying? Micro-organisms found on the hands may be resident or transient Resident micro-organisms are: Deep seated Difficult to remove Part of the body s natural defence mechanism Associated with infection following surgery or invasive procedures 14.2 Transient micro-organisms are: Superficial Transferred easily to and from the hands A prominent cause of cross infection Easily removed with good hand hygiene 15 The aim of hand hygiene Hand hygiene is considered to be the single most important measure in preventing the spread of infection The Point of Care as the crucial moment for hand hygiene The point of care refers to the patient s immediate environment in which healthcare staff to patient contact or treatment is taking place. This may be the treatment room, bed, chair, or patient s home. This time represents the point when the risk of transfer of micro-organisms is greatest. To assist healthcare staff The World Health Organisation has identified five moments for hand hygiene 1. Clean your hands before touching a patient. 2. Clean your hands after touching a patient and the immediate surroundings. 3. Clean your hands immediately before an aseptic technique. 4. Clean your hands immediately after an exposure risk to body fluids (and after glove removal). 5. Clean your hands after touching any object or furniture in the patients immediate surrounding when leaving even if the patient has not been touched. (National Patient Safety Agency 2008) Page 9 of 20

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11 16 Alcohol Handrub 16.1 Alcohol handrub is the recommended product in all patient care situations except when - Hands are visibly or potentially soiled The patient is experiencing vomiting and/or diarrhoea There is direct hand contact with bodily fluids i.e. if gloves have not been worn There patient has diarrhoeal illness attributed to an infectious cause. In the above instances hands should always be washed with liquid soap and water (NPSA 2008) Alcohol handrub products Alcohol based products are proven to be the most effective and acceptable for hand decontamination, however, alcohol handrub products purchased for use at the point of care must adhere to the European Committee for Standardisation (CEN) standards (EN 1500). (NPSA 2008), 16.3 Only products approved by the Trust Infection Control Committee and available through NHS Logistics should be used by staff working for or on behalf of the Trust. Alcohol hand rub should be available in staff areas, for example, clean and dirty utility rooms, treatment rooms or staff toilets and may be delivered via wall mounted dispensers, pump dispensers or tottles Alcohol hand rub must be available at the point of care in all healthcare facilities. Unless hands are visibly soiled it must be used to decontaminate hands between caring for different patients and between different care activities for the same patient The NPSA (2008) however, have reported adverse incidents associated with alcohol hand rub consequently this product must not be accessible to patients or members of the public in entrance areas or corridors. Visitors should be encouraged to wash their hands prior entering a clinical area. 17 The use of personal dispensers (tottles) A risk assessment will determine the most appropriate way of delivering alcohol handrub depending upon the location and needs of the client group. Consideration should be given to the risk of fire or ingestion The use of personal dispensers (tottles) is considered the best practice when caring for children, mental health patients or the confused older person. The container should be a flip top with short clip (to avoid the item being used as a spray or ligature point) Hand rub containers and nozzles should be kept clean and free from congealed gel Tottles and alcohol hand rub containers should not be topped up and reused Using alcohol hand rub Place enough of the product in your palm to thoroughly cover the hands. The solution must come into contact with all surfaces of the hand by rubbing together vigorously using the recommended six stage technique (Appendix A), paying particular attention to the finger tips, the thumbs and the areas between the fingers. The solution will evaporate consequently there is no need for rinsing or drying. Where hand washing facilities are not available or inaccessible, alcohol hand rub must be used Minimising the risk of fire and ingestion - Storage of alcohol hand rub products In addition to in use alcohol hand rub, only minimum quantities should be stored in the clinical area and no more than five litres should be held on storage. (NHS Estates Alert NHSE 2005) Page 11 of 20

12 17.6 Ingestion and eye exposure Accidental splashes in the eye should be irrigated with water. If significant ingestions occurs contact the National Poisons Information Service via the twenty four hour telephone service on Tel or TOXBASE 18 Control of Substances Hazardous to Health (COSHH) COSHH and product data sheets should be referred to in order to promote the safe use of hand hygiene products 19 Incident Reporting Any incidents where failures in hand hygiene have occurred or where there are issues associated with the supply or use of products associated with hand hygiene should be reported through the Trust incident reporting system. 20 Hand Washing Hand washing with liquid soap and water will render the hands socially clean Hands must be washed using the recommended six stage hand washing technique when hands are visibly or potentially contaminated with dirt or organic material. This process is sufficient for general social contact Clinical staff must ensure that they are implementing the bare below the elbows dress code outlined in the Trust Dress and Appearance Policy (Clinical Policy Folder 3). 21 Procedure Ensure that the wrists and forearms are exposed by removing any items of clothing that many hinder thorough hand hygiene Effective hand washing involves three stages: Preparation requires wetting hands under warm running water before applying liquid soap. The solution must come into contact with all surfaces of the hand Washing using soap and water and applying the recommended six stage technique Rinsing under warm clean running water Drying with good quality disposable paper towels 21.2 Hands should be washed by systematically rubbing all parts of the hands and wrists being particularly careful to include the areas of the hand which are most frequently missed i.e. the finger tips, finger webs and thumbs (Appendix II). Turn on the taps using elbows if possible. Wet hands before applying liquid soap. Wash hands thoroughly with liquid soap and running water, following the recommended six-stage technique (Appendix I). The solution must come into contact with all surfaces of the hand. Rinse hands under running water, holding the hands down. Page 12 of 20

13 Turn off the taps using the elbows. If elbow operated taps are not available, use a paper towel to turn off the tap. Dry hands thoroughly using a good quality paper towel (cotton hand towels may harbour bacteria and should not be used). Correct hand drying is essential to aid the removal of transient microorganisms and to protect the integrity of the skin. Hands not dried properly may become dry and cracked leading to an increased risk of harbouring microorganisms. Dispose of towels in a footoperated bin (never lift the bin lid by hand to avoid re-contamination of hands). Community staff working in the patient s home may wish to use kitchen roll. 22 Nail brushes should not be used for routine hand washing. Nail brushes can damage the skin leading to an increased risk of harbouring microorganisms or dispersing skin scales. If a nail brush is necessary it must be single-use and disposed of immediately after use. 23 Clostridium difficile and viral gastroenteritis When caring for symptomatic cases associated with a spore forming organism such as Clostridium difficile and viral gastroenteritis hands must be washed with liquid soap and water. Alcohol hand rub may only be used to compliment hand washing. 24 Hand wipes Impregnated hand wipes are not as effective as hand washing or the use of alcohol hand rub and should not be used as a substitute. 25 Hand Care Hand hygiene products may cause skin irritation, the risk can be minimised by observing the following - Always wet hands before applying soap. Rinse hands thoroughly after washing to remove all traces of soap. Use good quality paper towels to dry hands thoroughly, including the area between the fingers. Regularly use aqueous based hand creams to keep the skin moist and supple. Do not wear gloves for any longer than is necessary for the task. Always wash hands thoroughly after removing gloves. Always wear gloves when handling blood, body fluids, secretions and excretions, or chemicals Nails Nails and nail polish can harbour potentially harmful bacteria, therefore nails should be kept short (no longer than the end of the fingers) and clean. Nail polish, nail extensions, false nails or nail jewellery must not be worn by staff working within or supporting clinical teams. 26 Jewellery & Wrist Watches Jewellery and wrist watches may become contaminated with and harbour microorganisms, consequently staff providing care should ensure that prior to commencing a shift all wrist and hand jewellery is removed apart from a plain band. 27 Skin irritation and soft tissue infections An intact skin is a natural barrier to infection consequently all staff need to be aware of the potentially damaging effects of alcohol hand rub. Staff should protect and maintain skin integrity through the Page 13 of 20

14 regular use of hand creams particularly, for example, before a break, prior to going off duty and when off duty. Before commencing duty, cuts, abrasions or breaks in the skin of the hands or arms must be covered with a waterproof dressing and any skin conditions such as boils, abscesses, eczema or psoriasis reported to the Occupational Health Department. (Office Block 1, Crown Business Park, Fenton. Tel ) 28 Respiratory hygiene/ Cough etiquette Hand hygiene is an important part of respiratory hygiene and cough etiquette. The following measures will assist good practice When coughing, sneezing, wiping or blowing the nose, cover the nose and mouth with disposable single use tissues. Dispose of used tissues immediately into the appropriate waste stream. Wash hands after coughing, sneezing wiping or blowing the nose, or after contact with respiratory secretions. Patients, particularly the immobile, confused, older person may need assistance with the disposal of used tissues and hand hygiene. 29 Involving Patients and Carers Patients must be offered the opportunity to wash their hands before eating, at meal times and after using the toilet, commode or bedpan Patients, relatives and carers should be Educated on the importance of hand hygiene and encouraged to adopt the Trust recommended six stage technique. Sure that staff have decontaminated their hands prior to patient contact and are encouraged to report breaches of policy to the matron, ward manager, the IPCNs, or the Patient Advice and Liaison Service. Advised to wash their hands prior to entering and leaving a side room when the patient is isolated due to a suspected or identified infection. Please ensure that you are able to provide patients, relatives or carers with information, advice and a demonstration of the correct six stage hand hygiene technique. References Page 14 of 20

15 Centre for Disease Control (CDC) 2002 Guideline for Hand Hygiene in Health Care Settings. Recommendations of the Healthcare Infection Control Practice Advisory Committee and the HICPAC/SHEA/APIC/IDSA Healthcare Hygiene Task Force. Prepared by John M Boyce and Didier Pittet. Department of Health 2007 Improving Cleanliness and Infection Control. From the Chief Nursing Officer and Director General of NHS Finance, Performance and Operations. PL/CNO/2007/6 Department of Health 2008 The Health Act 2006: Code of Practice for the Prevention and Control of Health Care Associated Infections. Revised in January Department of Health 2006 Health Technical Memorandum 64: Sanitary assemblies. DH Estates and Facilities Division. The Stationery Office. London. Department of Health 2003 Winning Ways Working Together to Reduce Healthcare-associated Infection in England Infection Control Nurses Association 2005 Audit Tools for Monitoring Infection Control Guidelines within the community (The ICNA changed the name of the organisation to the Infection Prevention Society in 2007). National Patient Safety Agency The national specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes. National Patient Safety Agency 2008 Clean Hands Save Lives. Patient Safety Alert. Second Edition 2 September 2008 Pratt R.J. Pellowe C.M. Wilson J.A Loveday H.P., Harper P.J., Jones S.R.L.J, Mc Dougal C., Wilcox M.H epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection (2007) 65(Supplement): S1-64 Six Stage Good Hand-Hygiene Technique Appendix I Page 15 of 20

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17 Appendix II Areas commonly missed Page 17 of 20

18 Appendix III Hand hygiene Audit Tool Standard: Hands will be decontaminated correctly and in a timely manner using a cleansing agent, at the facilities available to reduce the risk of cross infection Date... Ward... Auditor... 1 Liquid soap is available at all hand washing sinks 2 Liquid soap must be single use cartridge dispensers 3 Dispenser nozzles are visibly clean Yes N/A Comments Soft absorbent paper towels are available at all hand washing sinks Wall mounted or pump dispenser hand cream is available for use Antibacterial solutions/scrubs are not used for social hand washing Antibacterial solutions are used for invasive procedures and surgical scrubs There are no nail brushes on hand wash sinks in clinical areas The hand wash sinks are free from used equipment and inappropriate items 10 Hand wash sinks are dedicated for that purpose Hand wash sinks conform to HBN 95. Check that they do not have plugs, overflows or that the water jet does not flow directly into the plughole There are sufficient numbers of hand wash sinks available in accordance with national and local guidance (e.g. one sink per four beds in acute care settings) 13 Access to hand wash sinks is clear Hand washing facilities are clean and intact. (Check sinks, taps, splash backs) There is appropriate temperature control to provide suitable hand wash water at all sinks Elbow operated or automated taps are available in hand wash sinks in clinical areas Page 18 of 20

19 Appendix IV Hand Hygiene Observation Tool. (HHOT) Observer Date Doctor Opportunity Soap Alcohol action Unknown Nurse/HCW Opportunity Soap Alcohol action Unknown Other professionals Before low risk contact After low risk contact Before high risk contact After high risk contact Before unobserved contact After unobserved contact Opportunity Soap Alcohol action Unknown Hospital Calculating hand Hygiene compliance 1soap + 2 hand rub x 100 = 3x100=60 1soap + 2 hand rub x 100 = 3x100=60 Ward hand rub x100 = 3 x 100 =60% + 3 no action 5 Opportunities for hand hygiene are defined by the WHO 5 moments for hand hygiene. Page 19 of 20

20 Equality Impact Assessment Tool 7.3v2 Hand Hygiene To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Yes/ Comments Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? 8. Has the Mental Capacity Act been considered in the development of the policy? If you have identified a potential discriminatory impact of this procedural document, please refer it to the Equality and Diversity Manager, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Equality and Diversity Manager. N/A N/A Yes Page 20 of 20