Infection Control Audit Report Date audited:
17/06/2016
Location:
Gordon House 1-6 Station Road Mill Hill London NW7 2JU
Client name:
Demonstration
Auditor:
Kevin Malambo
Accompanied by:
Jennifer Day
Additional info:
.
Section
% Compliance
Governance and Documentary Evidence
100 %
Staff Records
33 % 100 %
e
Kitchen - Servery Clinical Environment
pl
Clinical Practice Clinical Equipment Hand Hygiene
Waste Management
m
Sharps Management
100 % 91 % 100 % 100 % 100 % 100 % 100 %
Linen Management
100 %
Sa
Decontamination of Environment
Enteral Feeding
100 %
Pressure Sore Management and Chronic Wound Care
100 %
Respiratory Care
100 %
Urinary Catheter Management
100 %
Peripheral Venous Cannula (PVC) Line Insertion
100 %
Peripheral Venous Cannula (PVC) Line On-going
100 %
Paediatric Equipment
100 %
Milk Kitchen
100 %
Total
99 %
Corrective actions: Staff Records Staff should have regular updates on hand hygiene every 12 months. Accurate records should be kept of inoculation injuries to staff including date; time; location; who was involved; reported to; action taken and outcome.
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric
Date Approved: 17/06/2016
ICAT Audit Tool Vrs 2.0 Page 1 of 21
Demonstration Gordon House Staff Records Documentary evidence of staff immunisations and training
Question
Compliance
There is documentary evidence that staff having direct/indirect service user contact have received infection control training within the last 12 months.
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/inoculation injuries.
Non-Compliant
All staff handling or serving food to service users have undertaken basic food hygiene training.
Not applicable
Comments
Rationale Legislation
Staff have not had hand hygiene training.
No documentary evidence of staff inoculation injuries.
Expert Guidance Code of practice for the prevention and control of infections 2010 Criteria 1,5,6 and 10 Legislation RIDDOR Regulations 1995
e
Legislation
Non compliance
Non applicable
Total (%)
1
2
1
33 %
Kitchen - Servery
m
Demonstration Gordon House
pl
Full compliance
Question
Sa
The kitchen/servery will be maintained so as to reduce the risks of cross-infection, cross-contamination and hence food borne illness Compliance
Comments
Rationale
The fabric of the room, including fixtures and fittings, walls, floors, splashbacks, etc, is in a good state of repair.
Compliant
Legislation
All kitchen/servery work surfaces are clean and in a good state of repair.
Compliant
Legislation
Designated hand wash facilities are available for staff
Compliant
Legislation
Wall mounted liquid soap and paper towels are available next to the hand wash basin
Compliant
Legislation
Wall mounted disposable paper toweling is used for cleaning and drying equipment and surfaces.
Compliant
Legislation
Cleaning materials used in the kitchen are stored separately to other environmental cleaning equipment and away from food.
Compliant
Legislation
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric
Date Approved: 17/06/2016
ICAT Audit Tool Vrs 2.0 Page 3 of 21
The macerator is clean, working and in a good state of repair.
Compliant
Expert Guidance
A macerator is installed for the disposal of single use cellulose pulp: bed pans and urinals plus their contents.
Compliant
Expert Guidance
Full compliance
Non compliance
Non applicable
Total (%)
40
0
0
100 %
Demonstration Gordon House Clinical Practice Clinical practice will ensure the risk of cross infection is minimised
Compliance
Comments
Ointments and creams, including lubricating gel, are single patient use.
Compliant
Legislation
Single use, disposable plastic aprons must be available when required.
Compliant
Legislation
Plastic apron dispensers are wall mounted
Compliant
Single use, powder-free, nonsterile gloves are available in all clinical areas and in all sizes required by staff.
Compliant
Single use, powder-free sterile surgeons gloves available if required.
Compliant
Expert Guidance
Plastic gloves must not be used.
Compliant
Legislation
Disposable gloves are single use only.
Compliant
Expert Guidance
Gloves and aprons (PPE) are worn for urinalysis and blood collection.
Compliant
Expert Guidance
Full facial protection is available for staff when splashing of blood, body fluids or chemicals is anticipated.
Compliant
Legislation
Re-usable facial protection is decontaminated after each use.
Compliant
Expert Guidance
After use all Personal Protective Equipment (PPE) is discarded into a clinical waste bag.
Non-Compliant
Specimens awaiting transfer to the laboratory are in appropriate containers in a designated area away from public areas and rest rooms.
Not applicable
pl
Best Practice
Sa
m
Legislation
Gloves and/or aprons are discarded into domestic waste bags.
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric
Rationale
e
Question
Date Approved: 17/06/2016
Expert Guidance
Expert Guidance
ICAT Audit Tool Vrs 2.0 Page 7 of 21
Demonstration Gordon House Respiratory Care .
Compliance
Comments
Rationale
Single patient use nebulisers are provided.
Compliant
Expert Guidance
Nebulisers are washed and dried after each use
Compliant
Expert Guidance
Nebuliser mask and tubing are changed according to manufacturer's instructions.
Compliant
Best Practice
Suction equipment is decontaminated between uses and is stored clean and dry.
Compliant
Expert Guidance
Disposable suction liners are used and changed daily
Compliant
Expert Guidance
Suction tubing is changed daily
Compliant
Expert Guidance
Respiratory suction catheters are single use only and are discarded after single use.
Compliant
Expert Guidance
Oxygen masks and nasal cannulae are kept clean and dry at all times.
Compliant
Best Practice
Oxygen masks and nasal cannulae are single patient use items only.
Compliant
e
Question
pl
Best Practice
Non compliance
9
0
Non applicable
m
Full compliance
0
Total (%) 100 %
Sa
Demonstration 1 Gordon House Urinary Catheter Management .
Question
Compliance
Comments
Rationale
Urine jugs are washed after each use or a single use receptacle is used.
Compliant
Expert Guidance
Urine jugs are single patient only and labelled with name.
Compliant
Expert Guidance
All details of catheter insertion are documented in care plan.
Compliant
Expert Guidance
All service users have received an assessment prior to catheterisation which has been documented.
Compliant
Expert Guidance
Ongoing assessment of need for catheter is undertaken.
Compliant
Expert Guidance
Catheters are changed only when clinically indicated.
Compliant
Expert Guidance
Sterile, single use lubricant or anaesthetic gel is used for catheter insertion.
Compliant
Expert Guidance
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric
Date Approved: 17/06/2016
ICAT Audit Tool Vrs 2.0 Page 16 of 21
Date audited:
17/06/2016
Location:
Gordon House 1-6 Station Road Mill Hill London NW7 2JU
Client name:
Demonstration
Notes:
.
e
Infection Control Action Plan
Corrective actions:
pl
Other Corrective Actions Staff Records Reference
Evidence of Compliance
Responsibility
Due Date
Responsibility
Due Date
m
Corrective Action
Staff should have regular updates on hand Code of practice for the prevention and hygiene every 12 months. control of infections 2010 Criteria 1,5,6 and 10
Clinical Practice Corrective Action
RIDDOR Regulations 1995
Sa
Accurate records should be kept of inoculation injuries to staff including date; time; location; who was involved; reported to; action taken and outcome.
Reference
Evidence of Compliance
Gloves and/or aprons should be discarded into clinical waste bags following use.
Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric
Report Version 0.0.1 Date Approved: 17/06/2016
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