Hospice action plan

Date audited:

06/06/2013

Location:

Demo Hospice Mill Hill Broadway Mill Hill London NW7 2JU

Client name:

Demonstration Hospice

Notes: Corrective actions: Other Corrective Actions Governance and Documentary Evidence

PL E

Infection Control Action Plan

Reference

Staff should be aware of the need to complete a certificate of decontamination for all re-usable clinical equipment, prior to repair or service.

MHRA DB 2003 ( 05) Management of Medical Devices prior to repair, service or investigation

Evidence of Compliance

Responsibility

Due Date

Evidence of Compliance

Responsibility

Due Date

EX A

M

Corrective Action

Kitchen - Servery Corrective Action

Reference

The hand hygiene sink must only be used for handwashing

HFN 30 Infection Control in the Built Environment DH 2003; Food Standards Act 1990

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Hospice Adult / Paediatric

Report Version 0.0.1 Date Approved:

07/06/2013

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A washer-disinfector should be installed HFN30 Infection Control in the built for the thermal disinfection of re-usable: environment DH 2003 bed pans; bed pan holders; commode pans; urinals; suction bottles; jugs, etc.

Clinical Equipment Reference

Evidence of Compliance

Responsibility

Due Date

Evidence of Compliance

Responsibility

Due Date

PL E

Corrective Action

Warm water and a liquid detergent should National specifications for cleaning in the be used for cleaning medical NHS: primary care medical and dental devices/clinical equipment. Detergent premises NPSA 2010 wipes can also be used.

Hand Hygiene Reference

Taps should be elbow/foot operated or automatic in clinical hand wash basins.

HBN 00-10 Performance Requirements for building elements used in healthcare facilities 2011

M

Corrective Action

None of the hand wash basins should have HBN 00-10 Performance Requirements for an overflow or a sink plug, and the spout building elements used in healthcare must not be directly in line with the facilities 2011 drain.

EX A

The faucet on the hand wash basin should HBN 00-10 Performance Requirements for not be in line with the drain. building elements used in healthcare facilities 2011 Antiseptic soap should be available for aseptic hand washing.

NICE Clinical Guideline 139 Infection Prevention and control of healthcare associated infections in primary and community care NICE 2012

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Hospice Adult / Paediatric

Report Version 0.0.1 Date Approved: 07/06/2013

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Sharps Management Corrective Action

Reference

Evidence of Compliance

Responsibility

Due Date

All sharps bins should be temporarily closed when not in use.

PL E

Sharps bins should be situated on a secure Safe Management of Healthcare Waste DH surface between waist and shoulder 2012 height ideally in a wall-mounted bracket.

Safe Management of Healthcare Waste DH 2012

Waste Management Corrective Action

Reference

All domestic waste should be placed into black bags for final disposal.

Safe Management of Healthcare Waste DH 2012

Decontamination of Environment Reference

Chemical cleaning products must be stored in a locked cupboard or room.

Revised Healthcare Cleaning Manual NPSA 2009; Control of Substances Hazardous to Health Regulations 2002

Cleaning/domestic staff should be given training on the importance of storing the mops inverted.

Revised Healthcare Cleaning Manual NPSA 2009

Responsibility

Due Date

Evidence of Compliance

Responsibility

Due Date

Evidence of Compliance

Responsibility

Due Date

EX A

M

Corrective Action

Evidence of Compliance

Pressure Sore Management and Chronic Wound Care Corrective Action

Reference

There should be a validated risk NICE Clinical Guidelines 7 - The use of assessment tool in use for service users at pressure relieving devices (beds, risk of developing pressure sores. mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care NICE 2003

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Hospice Adult / Paediatric

Report Version 0.0.1 Date Approved: 07/06/2013

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All service users should be routinely assessed on admission for pressure sore risk with documentary evidence of assessment

NICE Clinical Guidelines 7 - The use of pressure relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care NICE 2003

Corrective Action

PL E

Paediatric Equipment Reference

Toys and play equipment should be clean.

Sleep mats should be cleaned after each use.

Milk Kitchen

Milk feeds should be prepared in an appropriate area which is easy to clean, not shared with other activities and where all equipment is close at hand including: fridge, dish-washer, sink, microwave, etc.

Due Date

Evidence of Compliance

Responsibility

Due Date

EX A

Gloves should be worn for milk feed preparation to prevent contamination.

Reference

Responsibility

M

Corrective Action

Evidence of Compliance

There should be a system in place to take action if the milk feed fridge temperatures are out of limits.

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Hospice Adult / Paediatric

Report Version 0.0.1 Date Approved: 07/06/2013

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