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
0%
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
EX
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.
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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 (%)
3
8
0
27 %
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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 (%)
0
3
0
0%
c
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.
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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
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 (%)
5
5
5
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
Expert Guidance
No plastic aprons available.
Legislation
Best Practice
There are no vinyl gloves available.
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Rationale
Date Approved:
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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
Expert Guidance
Not all PPE available disposable apron, vinyl gloves, facial protection.
Legislation
Best Practice
Full compliance
Non compliance
Non applicable
Total (%)
5
5
7
50 %
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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
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Date Approved:
Expert Guidance
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Expert Guidance
Expert Guidance
Expert Guidance
Best Practice
Expert Guidance
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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 (%)
3
9
3
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
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Rationale
Expert Guidance
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 (%)
8
5
1
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.
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Rationale
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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
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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 (%)
0
0
35
0%
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
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Date Approved:
Rationale
ICAT Audit Tool Vrs 2.0 Page 15 of 16