Bad news spreads fast and nothing spreads faster in the childcare sector than the news that an infection has caused serious illness in children at a nursery. This was evident during the recent outbreaks of the deadly E.coli 0157 bug.
Television footage of early years inspectors and medical officials entering a setting or contract cleaners leaving with bags of waste, can shake parents' confidence, even when the bug has originated from outside the premises and the staff have made great efforts to limit its spread.
'Parents want to know that infection control is taken seriously,' says Laura Henry of Childcare Consultancy. 'They want to know t their children are being looked after properly. If an infection does spread through a nursery inevitably it is bad for the reputation of that setting.
'When I conduct pre-Ofsted inspection visits I look at the nursery's cleanliness, health, safety and hygiene and how they manage their infection control policies and procedures. I tend to come across quite high standards of cleanliness, but, in general, their priority seems to be to make sure that they have got the curriculum in place.'
'Infections are very common in childhood and are responsible for 80 per cent of illness in the under-fives,' according to the Infection Control Guidelines for daycare facilities issued by the Worcestershire Health Protection Team and Early Years and Childcare Service. 'Susceptibility to infection in this group is increased because immune defences are not fully developed and so infants and young children lack prior exposure to virtually all infecting agents.'
Some diseases are infectious before or without signs of the illness being present, so children and staff can unwittingly bring an infection into nursery with them.
Childcare practitioners must adopt strict infection-control policies to prevent infections, to avoid them entering their setting and to contain their spread if an outbreak occurs. The need to be rigorous is underlined by a survey from the Childcare Recruitment Company in Manchester last year which says eight out of 10 parents admit to sending their child to nursery when he or she is unwell.
* 28 per cent of parents confessed they had deliberately disguised the signs of a child's contagious ear or eye infection.
* Others admitted to administering a dose of Calpol before dropping a child off to 'perk them up'.
* Other parents had failed to divulge that a child had diarrhoea.
The single most effective strategy in the prevention and spread of infections is proper hand washing, says early years consultant Laura Henry.
'I went on a hand washing course, which might sound ridiculous, as everyone thinks they know how to wash their hands. They asked us to wash our hands as we would normally. Then we put our hands under a special lamp and you could see the dirt still there, which was a real shock.'
Hand washing
* Hands should be washed under running, warm water.
* Use liquid soap.
* Rub hands together vigorously, ensuring that soap and water are applied to the whole of your hands - between the fingers, under fingernails, around the tips of the fingers, and the palms and back of the hands.
* Rinse hands under running water.
* Dry hands on disposable paper towels.
* Nail brushes can harbour germs, ensure nails are kept short and clean.
* Cuts and abrasions on hands must be covered with a waterproof dressing, sealed at all edges.
Practitioners should wash their hands:
Before
* Starting work
* Undertaking a care procedure
* Preparing/serving food and eating
* Moving groups
* Taking a break/going home
After
* Preparing food and feeding a child
* Giving medicine to a child
* Using/supervising children using the toilet
* Nappy changing
* Cleaning a child's nose/mouth
* Handling pets
* Messy play and using the sand pit
* All cleaning procedures
* Caring for sick children
* Handling soiled clothing, linen
* Dealing with waste Staff must emphasise the importance of effective hand washing to the children and see that it becomes part of their normal routine.
Children must wash their hands
Before and after
* Eating
* Playing in shared water tray
After
* Using the toilet or potty
* Engaging in messy activities
* Sand play
* Handling pets
* Contact with bodily fluids
Cleaning
Managers need to set a daily cleaning programme. The regime should be planned so that clean areas (kitchen and playrooms) are cleaned before dirty areas (nappy changing room), according to the Infection Control Guidelines for Day Care Facilities issued by Worcestershire County Council.
It advises:
* General cleaning of surfaces and furniture should be undertaken using a detergent solution and a disposable cleaning cloth followed by drying.
* One cloth should not be used to clean everywhere. Cleaning should involve the use of separate colour-coded cloths.
* Disinfectants are not recommended for general cleaning as they can be toxic.
* Equipment must be cleaned regularly and immediately if visibly soiled.
Kitchen hygiene
Under food hygiene laws all staff responsible for food handling and preparation must undergo basic food hygiene training.
David Ritchie, managing director of Armadillo Training, says, 'Floors, walls, work tops and equipment have to be kept clean. You need to prevent cross-contamination - the transfer of bacteria from one place to another.
This is why you should use colour-coded chopping boards and knives and take care to clean and store them separately.
'Wash and disinfect cleaning cloths. They should only be in two places - either in a container of sanitize solution or in your hand being used. They should not be kept behind taps, in sinks, on work surfaces or drying on radiators.'
The four key points to remember for good kitchen hygiene are:
* Cross-contamination
* Cleaning
* Chilling
* Cooking
Staff handling food should be strict about their personal hygiene and about ensuring that all surfaces, chopping boards and equipment are clean before they are used and cleaned after use. The same rigour should be applied to baby formula and baby feeding equipment.
Playrooms
'The playroom should be cleaned regularly', says early years consultant Ann Langston. 'All toys, materials and equipment, especially anything that is mouthed or sucked by children should be cleaned thoroughly on a regular basis.
'Routines should include the use of and disposal of paper hankies for runny noses, correct cleaning and disposal of body fluids and the use of disposable aprons and gloves when 'accidents' happen, and encouraging children to cover their mouths when they cough.'
Outdoor play
* Paddling pools should be emptied and cleaned daily.
* Sandpits must be kept covered and pest-proof when not in use.
* Use suitable sand such as silver sand and change every three months.
* Between changes sieve the sand for foreign bodies and clean weekly.
Pet hygiene
Pets should be healthy and free from parasites. Children and staff must wash their hands after handling pets.
* Pets should not be housed or fed in food preparation/consumption areas.
* Bedding and housing must be clean.
* Feeding bowls, litter trays and other equipment must be kept out of reach of children.
Managing spillages of bodily fluids
* Spillages of bodily fluids must be dealt with quickly. Other persons must be kept away from the spillage until it has been effectively dealt with.
* The person carrying out the cleaning must ensure all cuts are fully covered with a waterproof plaster. They must always wear disposable gloves.
* The spillage must be covered with absorbent paper. The paper and spillage must then be cleared away and disposed of in a yellow waste incineration bag.
* The area must then be washed with a strong solution of detergent and wiped dry using disposable paper.
* Disposable gloves and other materials used must be disposed of in a yellow waste incineration bag.
* Hands must always be washed after handling bodily fluids.
Bathrooms
'In nursery bathrooms the need for vigilance is increased,' says Ann Langston, 'because urine and faeces often have to be cleaned from potties and the toilets.
* Toilets/potties to be cleaned after every use and at the end of the day.
* Hand basins and taps, toilet seats, flush handles, must be cleaned and wiped with disposable cloths after use - clean basins before cleaning the toilets.
* Floors washed when soiled and as part of daily routine.
'If settings use flannels for washing faces, they should be used only once and then dropped into a laundry bucket for a thorough hot wash before re-use,' says Laura Henry. 'Never use a towel for more than one child; think of infections like impetigo and conjunctivitis.'
Nappy changing
'People say wearing gloves is quite impersonal and childcare is meant to be like the home environment,' says Laura Henry. 'But gloves protect the staff and children. At home you know what illnesses your child might have. but in nursery you don't.'
The Cedar House procedure on nappy changing and handling excreta says:
* Changing mats must always be used.
* Changing mats must be covered with disposable paper sheets, which must be disposed of in a yellow waste incineration bag after each nappy change.
* After use, the mat must be cleansed with antibacterial/viral spray and dried with disposable paper. Changing mats with torn plastic covers must be discarded immediately.
* Disposable nappies must be placed in a nappy bag and then in the nappy bin, lined with a yellow waste incineration bag along with disposable plastic gloves that must be worn and disposed of after changing each nappy.
* All yellow waste incineration bags must be tied, labelled and placed in the designated dustbin at the end of each day.
* Thorough hand-washing must follow all nappy changes.
Sick child policy
'A sick child policy must operate consistently,' says Laura Henry. 'Don't be pressurised by a parent into accepting a child who has been sick back into nursery until the child has been symptom-free for the period stated in your policy. It is unfair on other children, parents and staff. The Health Protection Agency issues guidance on exclusion times.'
If a child becomes ill during the day:
* Staff must notify the duty manager.
* Take and record the child's temperature, the time it was taken and measures taken to reduce it. Also note when the parents were contacted and the child collected.
* If a parent takes the child to the GP/hospital, ask to be informed of the outcome as soon as possible.
If a child develops diarrhoea:
* Contact the parents/carers and ask them to collect the child.
* Step up your hygiene measures, particularly if staff are having to keep changing the child.
* Keep the child away from the others and warm and comfortable and record how often staff are changing the child.
* Communicate that information to parents, so they can tell the doctor.
If the public health teams gets involved it is important to have records of what happened.
The Cedar House unwell child policy
If a child is unwell, the nursery must be informed and the child must be completely recovered before they return.
Children who are unwell will not be admitted to nursery because: 1 The relatively confined area can cause infection to spread rapidly.
2 Staffing levels are set to care for well children only and adequate care cannot be given to a child who arrives at the nursery unwell.
Parents/carers who arrive at the nursery with children who are unwell will be required to take them home.
When an outbreak occurs
Nursery managers need to recognise potential outbreaks promptly so they can introduce control measures to prevent further cases, say the Worcestershire Infection Control Guidelines.
There is no statutory requirement for nurseries to notify the health protection team about an outbreak. That is the duty of the doctor diagnosing the illness. But it is helpful if nursery managers contact their local team.
An outbreak may be defined as two or more cases of an infection occurring around the same time in children or their carers. However, a single case of a serious disease such as meningitis or hepatitis would count as an outbreak.
In the event of an outbreak, the manager should contact the Consultant in Communicable Disease Control at the local health protection team (see box).
The manager should:
* Review hygiene practices.
* Give specific instructions on control measures to staff.
* Watch for new cases and if suspected or confirmed initiate control measures.
* Inform and advise parents.
In the event of an outbreak of gastrointestinal infection the health protection team and local environmental health officers may undertake a review of hygiene procedures and inspect the setting's food hygiene arrangements.
* Additional cleaning and disinfection will be necessary.
* Activities such as cooking, sand and water play may need to be suspended.
* Affected food handlers should seek advice from the environmental health team before returning to work.
Rules and regulations
Food Hygiene
From January 2006 new food hygiene regulations came into effect in support of the Food Safety Act 1990.
You must be able to show what you do to make the food you serve safe to eat and that you follow written procedures which are reviewed if you change what you produce or how you work.
This new rule requires kitchen staff to put in place food safety management procedures on the principles of Hazard Analysis Critical Control Points.
For further information visit the Food Standards Agency website: www.food.gov.uk or Chartered Institute of Environmental Health website www.cieh.org.uk
National Day Care Standards - Standard 7 Health - requires that, 'The registered person promotes the good health of children and takes positive steps to prevent the spread of infection and appropriate measures when they are ill.'
Ofsted's guidance on this standard advises, 'High standards of hygiene and the prevention of the spread of infection are essential to maintaining good health. Where the registered person and staff have a secure knowledge of the setting's policies and arrangements for health and hygiene and a commitment to adhering to their agreed procedures, they are likely to promote children's good health.'
The Ofsted guidance covers all areas of good hygiene practice.
* Visit www.ofsted.gov.uk.
The Early Years Foundation Stage consultation on a single quality framework for services for children from birth to five, Section 4, 'Meeting the Welfare Requirements,' says providers must be aware of their responsibilities under food hygiene legislation and ensure that those responsible for the preparation and handling of food are competent.
Providers must notify Ofsted about cases of food poisoning and serious disease and have arrangements for:
* Contacting parents if their child is ill
* Situations when the parents cannot be contacted to collect a child
* The care of a sick child while awaiting collection
* Informing parents of occurrences of infection
* Confidentiality
* How to make parents aware of the need to inform the setting about the child's illness or condition.
* Visit www.surestart.gov.uk
Guidance on infection control in nurseries is available at:
* www.wiredforhealth.gov.uk
An up to date list of diseases which are notifiable is on the Health Protection Agency website, along with local team contact details:
* www.hpa.org.uk .
Case study: Cedar House Day Nursery
Parents using the 69-place Cedar House day nursery at London's Maudsley Hospital work in healthcare, so they understand its high hygiene standards.
'It is a strict regime, but it is second nature to us,' says manager Symone Pearce. 'If you are going to change a child's nappy, you automatically reach for the disposable apron, gloves and the antibacterial spray.
'Infections don't spread through our nursery. We have had two cases of measles in the past six weeks, while there has been an epidemic in south London.
'We notify the hospital infection control team if a child does get an infection and they advise us on any extra measures to take and notify the public health team if we have more than one case.
'If we have children off with sickness and diarrhoea, the staff very rarely get it, which is a relief. Obviously, it is unpleasant for staff if they are constantly picking up infections. I couldn't manage if my staff were always ill.
'The hospital's infection control department keeps us up to date on infection-control policies. They recently advised us to extend from 24 hours to 48 hours the time a child with sickness and diarrheoa must be symptom free before being allowed back into nursery.
'The hospital has infection-control policies and if something changes the managers of the Trust's nurseries write it into their policies in conjunction with their staff. You need to have the staff input. If they are not 100per cent behind a policy, it won't work.
'All staff have a full induction which covers the health and safety and hygiene aspects of our work, such as how we change nappies and why it is important to wear aprons and gloves.'
