16/12/2013
Location:
Mill Hill Demo Clinic 1-6 Station Road Mill Hill Broadway London NW7 2JU
Client name:
EX AM PL
Date audited:
E
Infection Control Action Plan
Mill Hill Demo Clinic
Corrective actions:
Other Corrective Actions
Governance and Documentary Evidence
Corrective Action An Infection Control Manual containing the Local sharps policy must include contact Local policy on prevention of occupational Staff should be aware of how to contact the There should be written schedules for Check lists provide documentary evidence, Cleaning schedules for the environment Cleaning check lists should be kept routinely All disinfectants and cleaning products must Staff should be aware of the need to There should be a written schedule for Staff Records
Reference Hygiene Code of Practice (2010). Hygiene Code of Practice 2010 Hygiene Code of Practice 2010
Corrective Action Staff should have regular updates on Staff should have regular updates on hand
Reference Hygiene Code of Practice (2010) Criterion 10 Hygiene Code of Practice (2010) Criterion 10
Evidence of Compliance
Responsibility
Due Date
Evidence of Compliance
Responsibility
Due Date
Hygiene Code of Practice 2010, NPSA Hygiene Code of Practice 2010, NPSA Hygiene Code of Practice 2010 Hygiene Code of Practice 2010 COSHH Regulations 2002 HSG (93) 26 Decontamination of Equipment
Copyright Š Infection Control Solutions Ltd Template: Out Patient Clinic
Date Approved: 19/01/2011
Report Version 0.0.1 Page 1 of 3
Accurate records should be kept of Clinical Environment
RIDDOR/Health & Safety at Work Act
Corrective Action Waterproof splashback should be fitted to Flooring in clinical areas should be of a Flooring in clinical areas should be heat Cleaning schedules should include low Cleaning schedules should include high The treatment /clinical room should be Examination / treatment couch should be Clinical Practice
Reference HFN 30 HFN 30 HFN 30 NPSA Revised Cleaning Manual (2009) NPSA Revised Cleaning Manual (2009)
Corrective Action Aprons should be available when there is a Disposable PPE (gloves and aprons) should Facial protection must be available to all Specimens awaiting transfer should be Clinical Equipment
Reference
Evidence of Compliance
Responsibility
Due Date
Corrective Action Reference Suitable training should be given to all staff Ensure clinical equipment is visibly clean Ensure dressing trolleys are clean and ready Ensure the trolley is cleaned with detergent A full range of PPE - disposable plastic Hand Hygiene
Evidence of Compliance
Responsibility
Due Date
Corrective Action Hand wash basins must be made available in Hand wash basins should not be used for Taps should be automatic or elbow operated None of the hand wash basins should have Taps on clinical hand wash basins should not All extraneous items should be permanently Staff should ensure that there is good Handwashing poster should be available and
Evidence of Compliance
Responsibility
Due Date
EX AM PL Reference HFN30
Responsibility
Due Date
E
Evidence of Compliance
HTM64 HTM64 HTM64
Copyright Š Infection Control Solutions Ltd Template: Out Patient Clinic
Date Approved: 19/01/2011
Report Version 0.0.1 Page 2 of 3
The dispenser should not be free standing Ensure paper towels are available at all Alcohol hand rub should be dispensed by Sharps Management Reference HTM 07-01 HTM 07-01 HTM 07-01
Evidence of Compliance
Responsibility
Corrective Action Appropriate clothing (disposable gloves and Large yellow waste bins should be lockable. Clinical waste bags should be labelled with Ensure that the waste storage areas are Other items stored in the waste storage Decontamination of Environment
Reference HTM 07-01 HTM 07-01 HTM 07-01 HTM 07-01 HTM 07-01
Evidence of Compliance
Responsibility
Due Date
Corrective Action Chlorine-releasing agent eg. sodium All staff must be aware of the correct Surfaces used for clinical tasks should be Ensure all cleaning equipment is colour Ensure all cleaning equipment and supplies Cleaning/domestic staff must be given Cleaning/domestic staff must be given Cleaning products (chemicals) should be Ensure cleaning cupboard is free from Ensure mop heads are changed at least Personal protective clothing (disposable Computer keyboards in the clinical area
Reference
Evidence of Compliance
Responsibility
Due Date
EX AM PL
E
Corrective Action Sharps bins must be labelled prior to use Sharps bins should be situated between All sharps bins should be labelled with date Waste Management
Due Date
NPSA (2007) Colour Coding NPSA (2007) Colour Coding NPSA Revised Cleaning Manual (2009) NPSA Revised Cleaning Manual (2009) COSHH Regulations 2002 NPSA Revised Cleaning Manual (2009)
Copyright Š Infection Control Solutions Ltd Template: Out Patient Clinic
Date Approved: 19/01/2011
Report Version 0.0.1 Page 3 of 3