Infection Control Audit Report 02/08/2016
Location:
Gordon House 1-6 Station Road Mill Hill London NW7 2JU
Client name:
Gordon House
Auditor:
Kevin Malambo
Accompanied by:
Jennifer
Additional info:
.
pl e
Date audited:
Section
% Compliance
Hand Hygiene 01
79 %
Hand Hygiene 10
100 %
Total
90 %
Corrective actions: Hand Hygiene 01
Staff hands should be decontaminated before an aseptic non touch technique/clean task.
m
Staff hands should be decontaminated after exposure to blood and body fluids. Staff hands should be decontaminated after service user contact.
Sa
Effective decontamination of hands should be performed using alcohol hand gel/rub.
Gordon House
Hand Hygiene 01
Effective decontamination of staff hands is performed to minimise the risk of transmission of infection. Question
Compliance
Comments
Staff having direct/indirect service user contact have received hand hygiene training.
Compliant
Expert Guidance
Staff can locate/access the hand hygiene policy.
Compliant
Expert Guidance
A poster demonstrating a good hand hygiene technique is available for guidance for staff when performing hand decontamination.
Compliant
Expert Guidance
Staff hands are decontaminated before service user contact.
Compliant
Expert Guidance
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hand Hygiene Audit (ATJ003)
Date Approved: 02/08/2016
Rationale
ICAT Audit Tool Vrs 2.0 Page 1 of 4
Effective decontamination of hands is performed using alcohol hand gel/rub.
Non-Compliant
Alcohol hand gel/rub is available at the point of care.
Compliant
Expert Guidance
Alcohol hand gel/rub is not used during outbreaks or when dealing with service users with diarrhoeal illness.
Compliant
Expert Guidance
Staff are bare below the elbow when performing hand hygiene.
Compliant
Expert Guidance
Staff are free from wearing wrist and hand jewellery.
Compliant
Expert Guidance
Staff fingernails are short, clean and free from false nails and nail polish.
Compliant
Expert Guidance
Cuts and abrasions on staff hands are covered with waterproof dressings.
Compliant
Expert Guidance
Hand cream is used by staff at regular intervals.
Compliant
Expert Guidance
Gordon House
Expert Guidance NICE clinical guideline 139 Infection Prevention and control of healthcare associated infections in primary and community care NICE 2012; EPIC3 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2014
pl e
Non compliance
Non applicable
m
Full compliance 15
Effective decontamination of hands is not performed using alcohol hand gel/rub.
4
2
Total (%) 79 %
Hand Hygiene 10
Sa
Effective decontamination of staff hands is performed to minimise the risk of transmission of infection.
Question
Compliance
Comments
Staff having direct/indirect service user contact have received hand hygiene training.
Compliant
Expert Guidance
Staff can locate/access the hand hygiene policy.
Compliant
Expert Guidance
A poster demonstrating a good hand hygiene technique is available for guidance for staff when performing hand decontamination.
Compliant
Expert Guidance
Staff hands are decontaminated before service user contact.
Compliant
Expert Guidance
Staff hands are decontaminated before an aseptic non touch technique/clean task.
Compliant
Expert Guidance
Staff hands are decontaminated after exposure to blood and body fluids.
Compliant
Expert Guidance
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hand Hygiene Audit (ATJ003)
Date Approved: 02/08/2016
Rationale
ICAT Audit Tool Vrs 2.0 Page 3 of 4
Compliant
Expert Guidance
Staff hands are decontaminated after contact with service user surroundings.
Compliant
Expert Guidance
Staff hands are decontaminated after the removal of gloves.
Compliant
Expert Guidance
Hand hygiene technique is used for decontamination of hands using soap and water or applying alcohol hand gel/rub.
Compliant
Expert Guidance
Effective hand washing is performed using soap and water.
Compliant
Expert Guidance
Hands are thoroughly rinsed after hand washing is performed.
Compliant
Expert Guidance
Hands are thoroughly dried after hand washing is performed.
Compliant
Expert Guidance
Effective decontamination of hands is performed using alcohol hand gel/rub.
Compliant
Expert Guidance
Alcohol hand gel/rub is available at the point of care.
Compliant
Expert Guidance
Alcohol hand gel/rub is not used during outbreaks or when dealing with service users with diarrhoeal illness.
Compliant
Expert Guidance
Staff are bare below the elbow when performing hand hygiene.
Compliant
Expert Guidance
Staff are free from wearing wrist and hand jewellery.
Compliant
Expert Guidance
Staff fingernails are short, clean and free from false nails and nail polish.
Compliant
Expert Guidance
Cuts and abrasions on staff hands are covered with waterproof dressings.
Not applicable
Expert Guidance
m
pl e
Staff hands are decontaminated after service user contact.
Hand cream is used by staff at regular intervals.
Compliant
Expert Guidance
Non compliance
Non applicable
Total (%)
20
0
1
100 %
Sa
Full compliance
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hand Hygiene Audit (ATJ003)
Date Approved: 02/08/2016
ICAT Audit Tool Vrs 2.0 Page 4 of 4
Date audited:
02/08/2016
Location:
Gordon House 1-6 Station Road Mill Hill London NW7 2JU
Client name:
Gordon House
Notes:
Demo Audit
Corrective actions: Other Corrective Actions Hand Hygiene 01
pl e
Infection Control Action Plan
Reference
Staff hands should be decontaminated before an aseptic non touch technique/clean task.
NICE clinical guideline 139 Infection Prevention and control of healthcare associated infections in primary and community care NICE 2012; EPIC3 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2014; World Health Organisation Guidelines on hand hygiene in healthcare 2009
Evidence of Compliance
Sa
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hand Hygiene Audit (ATJ003)
Responsibility
Due Date
m
Corrective Action
Report Version 0.0.1 Date Approved: 02/08/2016
Page 1 of 2
NICE clinical guideline 139 Infection Prevention and control of healthcare associated infections in primary and community care NICE 2012; EPIC3 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2014; World Health Organisation Guidelines on hand hygiene in healthcare 2009
Staff hands should be decontaminated after service user contact.
NICE clinical guideline 139 Infection Prevention and control of healthcare associated infections in primary and community care NICE 2012; EPIC3 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2014; World Health Organisation Guidelines on hand hygiene in healthcare 2009
Effective decontamination of hands should be performed using alcohol hand gel/rub.
NICE clinical guideline 139 Infection Prevention and control of healthcare associated infections in primary and community care NICE 2012; EPIC3 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2014
Sa
m
pl e
Staff hands should be decontaminated after exposure to blood and body fluids.
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hand Hygiene Audit (ATJ003)
Report Version 0.0.1 Date Approved: 02/08/2016
Page 2 of 2