Audit report by Karen Foulis

Infection Control Audit Report

DRAFT

16/12/2013

Location:

Mill Hill Demo Clinic 1-6 Station Road Mill Hill Broadway London NW7 2JU

Client name:

Mill Hill Demo Clinic

Auditor:

Jennifer Day.

Accompanied by:

Kevin Malambo

Additional info:

There are two Consultants and one Physiologist in the clinic. Present for the audit:

Section

AM PL E

Date audited:

% Compliance

Governance and Documentary Evidence

27 %

Staff Records

50 %

Clinical Practice

60 %

Clinical Equipment

50 %

Hand Hygiene

25 %

Sharps Management

79 %

Waste Management

62 %

Decontamination of Environment

23 %

Minor Surgery

N/A

ADL Patient Assessment Area (bedroom/bathroom)

N/A

Clinical Environment

Total

46 %

Corrective actions:

Governance and Documentary Evidence An Infection Control Manual containing the appropriate Infection Control Policies & Protocols must be available in compliance with the Hygiene Code of Practice. Local sharps policy must include contact details of GP/A&E/Occupational health provider to ensure that staff have prompt access to risk assessment following a sharps injury. Local policy on prevention of occupational exposure to blood borne viruses must include guidance on which staff groups are defined as at risk of exposure to blood & body fluids and the means by which they can seek immunisation and advice. Staff should be aware of how to contact the local ICN for advice. There should be written schedules for cleaning clinical equipment.

ICAT Audit Tool Vrs 2.0 Date Approved:

Page 1 of 16

Mill Hill Demo Clinic Governance and Documentary Evidence Governance documents should be accessible to staff and available for inspection Question

Compliance

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Non-Compliant

The Infection control policy manual is updated every 2 years.

Compliant

Staff can locate/access the infection control policy manual.

Compliant

Key policy elements are available for staff to refer to.

Non-Compliant

ICN/ICD advice available.

Non-Compliant

There are written equipment cleaning schedules/check lists for clinical equipment.

Non-Compliant

Environmental cleaning schedules/check lists available.

Non-Compliant

Data sheets are available for all disinfectants and cleaning agents used.

Non-Compliant

Staff are aware of the need for completing a decontamination certificate prior to sending equipment for repair or maintenance.

Non-Compliant

The facility has a regular planned preventative maintenance (PPM) programme for general equipment.

Compliant

There is a written weekly schedule for running taps/showers.

Non-Compliant

Comments

Rationale

Not all policies are available.

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Very new still setting up policies.

Legislation Expert Guidance Best Practice

EX AM PL E

No documentary evidence of local telephone numbers for sharps injury assessment. No documentary evidence that at risk staff are offered hepatitis B immunisation. Staff not aware who to contact. Cleaner comes in three times and is responsible for cleaning treatment couches. There are no written schedules available. There are no cleaning check lists available. Clinic staff conduct an audit post cleaner and document any areas which have been missed. Cleaning schedules not available Cleaning check lists not available

Data sheets not available on any products Staff not aware of certificate

Expert Guidance

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Legislation

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Best Practice

No written schedule for weekly flushing of taps/showers.

Best Practice

Full compliance

Non compliance

Non applicable

Total (%)

27 %

Date Approved:

ICAT Audit Tool Vrs 2.0 Page 4 of 16

0LOO +LOO 'HPR &OLQLF Staff Records Compliance

There is documentary evidence that staff having direct/indirect service user contact have received infection control training within the last 12 months.

Non-Compliant

There is documentary evidence that staff having direct/indirect service user contact have received hand hygiene training within the previous 12 months.

Non-Compliant

Documentary records should be kept of all sharps injuries.

Non-Compliant

Comments Staff have not had infection control training.

Staff have not had hand hygiene training.

No documentary evidence of staff inoculation injuries.

Rationale Expert Guidance

Expert Guidance

Legislation

EX AM PL E

Question

Full compliance

Non compliance

Non applicable

Total (%)

Clinical Environment

The clinical environment will be maintained appropriately in order to reduce the risk of cross infection

Question

Compliance

Comments

Toys are clean,in a good state of repair and are stored in a designated enclosed box, off the floor.

Not applicable

Expert Guidance

Walls are washable, impervious and in a good state of repair.

Compliant

Expert Guidance

Waterproof splashback to sinks/basins/drainers.

Non-Compliant

Floors in clinical areas are waterproof and non-porous and in good state of repair.

Non-Compliant

All clinical areas are clean and dust free. Check for high and low level dust. Check floors and work surfaces for cleanliness.

Non-Compliant

No waterproof splashback fitted. Wooden laminated flooring throughout clinic, there are large gaps (in a few areas) between the laminate boards and these are not sealed. Flooring in clinical areas is not waterproof /non porous. Flooring in clinical areas is not heat sealed at seams/edges. Dust noted under treatment couches and on top of curtain rails. Dust noted on low surfaces. Dust noted on high surfaces.

Date Approved:

Rationale

Expert Guidance Expert Guidance

Expert Guidance

ICAT Audit Tool Vrs 2.0 Page 5 of 16

Clinical/treatment/consulting rooms are free from the build up of clinical waste.

Compliant

The clinical / treatment / consulting room is free from clutter and inappropriate items of equipment.

Non-Compliant

There is sufficient storage space in the clinical room for clean and sterile items of clinical equipment.

Compliant

Expert Guidance

Chairs and furniture are washable and in a good state of repair.

Compliant

Best Practice

Examination/treatment couches have wipeable surfaces and are in good state of repair.

Non-Compliant

Disposable paper is used to protect the examination/treatment couch and changed between each service user.

Compliant

A dirty utility/sluice is available.

Not applicable

Best Practice

Dirty utility/sluice areas are clean, free from spillages and uncluttered.

Not applicable

Best Practice

Hand wash facilities are available in the dirty utility / sluice area.

Not applicable

Best Practice

There are no inappropriate items in dirty utility / sluice area.

Not applicable

Best Practice

The treatment / clinical room contains inappropriate items

Dust noted under examination / treatment couch

Best Practice

Expert Guidance

EX AM PL E

Best Practice

Full compliance

Non compliance

Non applicable

Total (%)

50 %

Clinical Practice

Clinical practice will ensure the risk of cross infection is minimised Question

Compliance

Comments

Ointments and creams, including lubricating gel, are single patient use.

Compliant

Single use, plastic aprons are available when required.

Non-Compliant

Plastic apron dispensers are wall mounted

Not applicable

Single use, powder-free nonsterile gloves available

Compliant

Plastic gloves must not be used.

Compliant

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Single use, powder-free sterile surgeons gloves available if required.

Not applicable

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Gloves worn for all clinical procedures.

Compliant

Best Practice

Disposable gloves are single use only.

Compliant

Expert Guidance

No plastic aprons available.

Legislation

Best Practice

There are no vinyl gloves available.

Rationale

Date Approved:

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ICAT Audit Tool Vrs 2.0 Page 6 of 16

Thermometers are decontaminated appropriately after each use (i.e. wiped with 70% alcohol if mercury) or disposable covers are used.

Not applicable

Expert Guidance

Auroscope ear pieces are washed in neutral detergent and hot water, dried, then wiped with 70% alcohol after each use or are disposable.

Not applicable

Expert Guidance

Automated Pro-pulse ear syringing equipment is decontaminated appropriately.

Not applicable

Expert Guidance

Single use disposable mouthpieces are used for peak flow, respiratory recordings.

Not applicable

Expert Guidance

Disposable suction liners are available and used.

Not applicable

Expert Guidance

Clinical equipment in use is visibly clean

Non-Compliant

Tread mill dusty, ECG electrode sticky pads are single use but the leads are not wiped. Clinical equipment is not clean.

EX AM PL E

Expert Guidance

Dressing trolleys / procedure trays are clean and in a good state of repair.

Non-Compliant

Dressing trolleys are cleaned with detergent and water before each session and with detergent and water or 70% alcohol between uses.

Non-Compliant

Staff are using hot water and detergent for the manual cleaning of low risk equipment (non surgical reusable medical devices).

Compliant

Staff have access to appropriate PPE for cleaning clinical equipment

Non-Compliant

Blood pressure cuffs cleaned between uses.

Compliant

Best Practice

Dressing trolleys not clean.

The trolley is not cleaned between uses.

Expert Guidance

Not all PPE available disposable apron, vinyl gloves, facial protection.

Legislation

Best Practice

Full compliance

Non compliance

Non applicable

Total (%)

50 %

Date Approved:

ICAT Audit Tool Vrs 2.0 Page 8 of 16

0LOO +LOO Clinic Hand Hygiene Hands will be washed correctly using an appropriate cleansing agent. Handwashing facilities will be adequate to ensure hand hygiene can be carried out effectively. Question

Non-Compliant

Comments No sink in consulting room although separate toilet area attached, which is used as a store cupboard so access to sink is limited. The clinical room uses the sink in the office/kitchen area, but this sink is used for making tea, etc. Designated hand wash basins not available in all rooms where clinical activity takes place. The office/kitchen area sink is used to make tea and coffee. Hand wash basins used for disposal of waste water

Rationale Expert Guidance

EX AM PL E

Clinical hand wash basins are available in any room where clinical activity takes place.

Compliance

Clinical hand wash basins in clinical / treatment rooms only, are designated for that purpose alone.

Non-Compliant

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Non-Compliant

Clinical hand wash basin and surround is free from inappropriate items.

Non-Compliant

Access to hand washing facilities is clear and not obstructed by equipment or furniture.

Non-Compliant

A poster demonstrating a good hand washing technique is available by at least one clinical hand wash basin.

Non-Compliant

No poster available

Expert Guidance

Wall mounted liquid soap is available at all clinical hand wash basins.

Non-Compliant

Soap not wall mounted

Expert Guidance

Wall mounted paper towels are available at all hand wash basins.

Non-Compliant

Hand cream is available in wall mounted containers in at least one clinical area, e.g. clinical room.

Not applicable

Alcohol hand rub is available for use in all clinical areas and dispensed via a plunger which is wall mounted

Non-Compliant

Hands are washed after the removal of gloves.

Compliant

Expert Guidance

Staff having clinical contact are free from wearing wrist watches or stoned rings when performing clinical activities or washing hands.

Compliant

Expert Guidance

Taps not elbow operated or automatic Some basins have an overflow Some basins have a sink plug Swan necked fittings on taps present on hand wash basin

Inappropriate items around or in hand wash basin Route to hand washing facilities obstructed

Not in the office/kitchen area sink. Towels not available at all hand wash basins Individual tubes used.

Alcohol hand rub not dispensed by plunger wall mounted

Date Approved:

Expert Guidance

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Expert Guidance

Best Practice

Expert Guidance

ICAT Audit Tool Vrs 2.0 Page 9 of 16

Clinical staff are free from long finger nails, false nails, varnish or extensions

Compliant

Best Practice

An aseptic hand wash is employed prior to donning sterile gloves before minor surgical procedures

Not applicable

Expert Guidance

Skin antiseptics (e.g. Chlorhexidine, Betadine) are available for aseptic hand washing if required. Antiseptics are wall mounted and dispensed by a plunger or infra-red

Not applicable

Best Practice

Non compliance

Non applicable

Total (%)

25 %

EX AM PL E

Full compliance

Sharps Management

Sharps will be managed appropriately to reduce the risk of accidental inoculation injury Question

Compliance

Comments

Sharps bins are available for use and conform to relevant standards (BS 7320 and UN 3291)

Compliant

Expert Guidance

All sharps bins in use are assembled correctly.

Compliant

Expert Guidance

All sharps bins in use are labelled correctly prior to use.

Non-Compliant

There are appropriately coloured lidded bins for the procedures that take place and their waste streams together with a local protocol for use.

Compliant

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Sharps bins are clean and free from contamination/soil on the outside.

Compliant

Best Practice

Sharps bins are appropriately situated between waist and shoulder height.

Non-Compliant

The temporary closure is used when the bin is being transported.

Not applicable

Expert Guidance

All sharps bins in use are less than two thirds full (or fill line has not been reached) and free from protruding sharps.

Compliant

Expert Guidance

Sharps are disposed of directly into a sharps bin at the point of care.

Compliant

Best Practice

Disposable syringes and needles are disposed of as one unit and not disassembled.

Compliant

Expert Guidance

Sharps bins are free from inappropriate items i.e. gloves, paper

Compliant

Expert Guidance

A sharps bin is located with all near service user testing equipment.

Compliant

Best Practice

Sharps bin not labelled before use

On low level shelf of monitoring equipment trolley. Sharps bins not situated between waist and shoulder height

Date Approved:

Rationale

Expert Guidance

ICAT Audit Tool Vrs 2.0 Page 10 of 16

Waste bags (clinical/domestic) are less than two thirds full and securely tied.

Compliant

Expert Guidance

Full compliance

Non compliance

Non applicable

Total (%)

62 %

ronment

EX AM PL E

Ensure that the environment is decontaminated using appropriate chemicals and appropriate concentrations Question

Compliance

Comments

Appropriate cleaning agents are available for the cleaning of the environment.

Compliant

Chlorine-releasing agents eg. sodium hypochlorite or NaDCC (eg Presept, Actichlor, Haztabs) are available to deal with blood spillages

Non-Compliant

The correct dilution of liquid or tablet chlorine-releasing, is used for blood spillages and dilution charts are available

Not applicable

Expert Guidance

Liquid or tablet preparations of chlorine-releasing agents e.g. sodium hypochlorite or NaDCC, are freshly prepared daily and discarded if not used.

Not applicable

Expert Guidance

Staff must be aware of procedure for dealing with blood spills.

Non-Compliant

Environmental surfaces used for clinical tasks are cleaned between service users.

Non-Compliant

Cleaning equipment/products (mops, buckets, cloths, etc.) are colour-coded or designated for specific areas.

Non-Compliant

Cleaning equipment/products stored clean, dry, and mops stored inverted

Non-Compliant

There is a designated, locked area for cleaning products (chemicals).

Non-Compliant

No inappropriate items are stored in the designated cleaning cupboard.The cupboard is only used to store cleaning equipment and materials.

Non-Compliant

Machines used for floor cleaning are clean and dry.

Not applicable

Mop heads are laundered regularly or are disposable.

Non-Compliant

Personal protective clothing is available for staff.

Non-Compliant

Expert Guidance

Chlorine-releasing agent eg. sodium hypochlorite or NaDCC not available

Staff not aware of correct procedure.

Surfaces not cleaned between service users.

Equipment not colour coded Colour coding in use but mixed cloths in bucket.

Mops not stored inverted Equipment not stored clean Area not locked

Cleaning cupboard cluttered/disorganised.

Expert Guidance

Best Practice

Expert Guidance Expert Guidance

Expert Guidance

Legislation

Best Practice

Expert Guidance

Mop heads are not laundered/replaced at least weekly. Personal protective clothing is not available.

Rationale

Date Approved:

Expert Guidance

Legislation

ICAT Audit Tool Vrs 2.0 Page 12 of 16

Not applicable

Expert Guidance

The minor surgery room has a wall mounted dispenser containing disposable paper hand towels and a liquid soap dispenser.

Not applicable

Best Practice

The minor surgery room's clinical hand wash basin is free from reusable nail brushes.

Not applicable

Expert Guidance

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Not applicable

Best Practice

Antiseptic aqueous based skin preparations available i.e. Chlorhexidine, iodine.

Not applicable

Best Practice

Single use, powder-free sterile surgeons gloves available if required.

Not applicable

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The following are available when splashing of body fluids is anticipated: Plastic goggles OR, Fluid repellent face mask/goggles/visor.

Not applicable

Best Practice

The minor surgery room has disposable sterile drapes available.

Not applicable

Best Practice

The minor surgery room has a designated stainless steel procedure trolley.

Not applicable

Expert Guidance

Dressing trolleys in the minor surgery room are cleaned with detergent and water before each session and with detergent and water or 70% alcohol between cases.

Not applicable

Expert Guidance

Dressing trolleys are wiped with 70% alcohol between cases.

Not applicable

Best Practice

Sterile instrument packs are reprocessed and supplied by SSD

Not applicable

Best Practice

The minor surgery room has access to an adjacent dirty utility area.

Not applicable

Best Practice

The minor surgery room has a foot operated, lidded clinical waste bin with yellow/orange bag.

Not applicable

Best Practice

The minor surgery room has a securely positioned sharps container which conforms to BS7320/UN3291.

Not applicable

Best Practice

Mechanical extract/ventilation in the minor surgery undergoes routine cleaning.

Not applicable

Best Practice

Waste bags are not attached to cupboard/trolley etc.

Not applicable

Best Practice

EX AM PL E

Date Approved:

ICAT Audit Tool Vrs 2.0 Page 14 of 16

Not applicable

Best Practice

Clinical areas in the minor surgery room are cleaned at the beginning and end of each minor surgery clinic with an appropriate detergent.

Not applicable

Expert Guidance

The minor surgery room has a domestic cleaning schedule that documents twice daily cleaning.

Not applicable

Best Practice

Following minor surgery, service users should return within two weeks for a follow up appointment following a minor surgical procedure.

Not applicable

Best Practice

The minor surgery clinic has a surveillance system for post operative wound infection.

Not applicable

Best Practice

EX AM PL E

The minor surgery environment is uncluttered with adequate storage space.

Full compliance

Non compliance

Non applicable

Total (%)

0LOO +LOO 'HPR Clinic

ADL Patient Assessment Area (bedroom/bathroom) .

Question

Compliance

Comments

Carpets cleaned and unstained

Not applicable

Best Practice

Spot cleaning schedule for carpets

Not applicable

Best Practice

All furniture i.e. chairs, tables beds and lockers are washable/wipeable and in a good state of repair.

Not applicable

Best Practice

All furniture and surfaces in ADL room clean

Not applicable

Best Practice

Environmental cleaning schedules/check lists available.

Not applicable

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No inappropriate items in ADL room

Not applicable

Best Practice

Bed linen changed between patients.

Not applicable

Best Practice

Bed linen changed weekly

Not applicable

Best Practice

There is a written schedule for bed linen replacement

Not applicable

Best Practice

Bed linen stored in secured terylene bag and collected regularly

Not applicable

Best Practice

Shower heads are visibly free from lime-scale

Not applicable

Best Practice

There is a written weekly schedule for running taps/showers.

Not applicable

Best Practice

Date Approved:

Rationale

ICAT Audit Tool Vrs 2.0 Page 15 of 16