Hospice audit report

Infection Control Audit Report 06/06/2013

Location:

Demo Hospice Mill Hill Mill Hill Broadway London NW7 2JU

Client name:

Demonstration Hospice

Auditor:

Kevin Malambo

Accompanied by:

Jennifer Day

Additional info:

This is a children's hospice with a mixture of respite and care beds in addition to day care services.

E

Date audited:

% Compliance

Governance and Documentary Evidence Staff Records Kitchen - Servery Clinical Environment Clinical Practice Clinical Equipment

91 %

100 % 85 % 87 %

100 %

AM

Hand Hygiene

PL

Section

94 % 86 %

Sharps Management

82 %

Waste Management

94 %

Decontamination of Environment

86 %

Linen Management

100 %

Enteral Feeding

100 %

Pressure Sore Management and Chronic Wound Care

71 % 100 %

Urinary Catheter Management

100 %

EX

Respiratory Care

Peripheral Venous Cannula (PVC) Line Insertion

N/A

Peripheral Venous Cannula (PVC) Line On-going

N/A

Paediatric Equipment

88 %

Milk Kitchen

79 %

Total

90 %

Corrective actions:

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

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

Date Approved:

ICAT Audit Tool Vrs 2.0 07/06/2013

Page 1 of 36

Kitchen - Servery The hand hygiene sink must only be used for handwashing Paper towels should be provided in wall-mounted dispensers to avoid contamination from wet hands when one is removed.

Food items supplied from a commercial source and stored in the fridge must be labelled with contents and display a 'use by' or 'best before' date.

Consider maintenance or replacement of freezer to ensure correct temperature is maintained below minus 18 deg C. Clinical Environment

E

Carpets should be in a good state of repair to aid cleaning and avoid injury to service users from slip / trip / fall hazard.

PL

All chairs/furniture used by service users should be damage and abrasion free to facilitate cleaning. Replace damaged furniture with vinyl furniture or re-upholster in non-porous wipeable materials.

Damaged examination/treatment couches should be replaced or repaired with a wipeable cover.

A simple log of the cleaning for each commode should be kept (a daily tick sheet or similar).

AM

A washer-disinfector should be installed for the thermal disinfection of re-usable: bed pans; bed pan holders; commode pans; urinals; suction bottles; jugs, etc.

Clinical Equipment

Warm water and a liquid detergent should be used for cleaning medical devices/clinical equipment. Detergent wipes can also be used.

Hand Hygiene

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

EX

None of the hand wash basins should have an overflow or a sink plug, and the spout must not be directly in line with the drain.

The faucet on the hand wash basin should not be in line with the drain.

Antiseptic soap should be available for aseptic hand washing.

Sharps Management

Sharps bins should be situated on a secure surface between waist and shoulder height ideally in a wall-mounted bracket.

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

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

Date Approved: 07/06/2013

ICAT Audit Tool Vrs 2.0 Page 2 of 36

Compliant

Expert Guidance Code of Practice for the prevention and control of infections 2010 Criteria 1, 5, 8 and table 2

Key policy elements are available for staff to refer to.

Compliant

Expert Guidance Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criteria 9 and 10

Environmental cleaning schedules/check lists are available.

Compliant

Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 2; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

Decontamination of re-usable clinical equipment schedules / check-lists are available.

Compliant

E

Infection prevention and control support is available

AM

PL

Expert Guidance Code of practice for the prevention and control of infections 2010 Criterion 2; Revised Healthcare Cleaning Manual NPSA 2009; The national specifications for cleanliness:Guidance on setting and measuring performance outcomes in care homes NPSA 2010

Compliant

Staff are aware of the need for completing a decontamination certificate prior to repair or maintenance of re-usable clinical equipment.

Non-Compliant

The facility has a regular planned preventative maintenance (PPM) programme for general equipment.

Compliant

Staff not aware of need for certificate of decontamination.

EX

Control of Substances Hazardous to Health (COSHH) data sheets are available for all disinfectants and cleaning agents used.

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

Date Approved: 07/06/2013

Legislation Control of Substances Hazardous to Health Regulations 2002 Expert Guidance MHRA DB 2003 (05) Management of Medical Devices prior to repair, service or investigation Expert Guidance CFPP 01-04 Decontamination of linen for health and social care: Engineering, equipment and validation manual DH 2012; CFPP 0101Management and decon. of surgical instruments (medical devices) used in acute care. Part D – Washer-disinfectors DH 2012

ICAT Audit Tool Vrs 2.0 Page 4 of 36

Compliant

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes; Food Standards Act 1990

Stocks of any foodstuff are within date, the packaging is clean and not damaged (i.e. vacuum packs are not punctured or swollen, cans are not badly dented or bottles / jars have broken seals).

Compliant

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes; Food Standards Act 1990

Crockery, cutlery, and utensils are cleaned in a dishwasher or by hand washing in a double sink with drainer.

Compliant

Legislation HFN 30 Infection Control in the Built Environment DH 2003; Food Standards Agency Guidance for Caterers / Supplement for Care Homes; Food Standards Act 1990

A procedure is available for handwashing of crockery and cutlery.

Compliant

Microwaves if used for heating residents food are clean, with a written procedure for use and are cleaned and monitored regularly.

Compliant

Evidence of cleaning schedules for kitchen environment and documentary evidence of cleaning performed.

Compliant

The food temperature probe is cleaned after each use and stored to prevent re-contamination.

Compliant

E

The kitchen/servery is free from infestation.

PL

Best Practice

AM

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes and Food Standards Act 1990

Legislation HFN 30 Infection Control in the Built Environment DH 2003 and Revised Healthcare Cleaning Manual NPSA 2009

Legislation Food Standards Act 1990

Non compliance

Non applicable

Total (%)

22

4

0

85 %

EX

Full compliance

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

Date Approved: 07/06/2013

ICAT Audit Tool Vrs 2.0 Page 8 of 36

Compliant

Expert Guidance EPIC2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007; NICE (2012) Prevention and control of healthcare associated infections in primary and community care.

Full facial protection is available for staff when splashing of blood, body fluids or chemicals is anticipated.

Compliant

Legislation NICE clinical guideline 139 Infection Prevention and control of healthcare associated infections in primary and community care NICE 2012; Personal Protective Equipment at Work Regulations 2005

Re-usable facial protection is decontaminated after each use.

Compliant

After use all Personal Protective Equipment (PPE) is discarded into a clinical waste bag.

Compliant

Specimens awaiting transfer to the laboratory are in appropriate containers in a designated area away from public areas and rest rooms.

Not applicable

There is a dedicated (separate) specimen fridge that does not contain drugs, vaccines, food or drink e.g. milk.

Not applicable

E

Gloves and aprons (PPE) are worn for urinalysis and blood collection.

PL

Expert Guidance National specifications for cleaning in the NHS; primary care medical and dental premises NPSA 2010.

Expert Guidance

AM

Specimens taken directly to the lab

Expert Guidance Health & Safety Executive: Infectious substances and diagnostic specimens; UN classification UN3373 Diagnostic Specimens Best Practice

Non compliance

Non applicable

Total (%)

11

0

2

100 %

EX

Full compliance

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

Date Approved: 07/06/2013

ICAT Audit Tool Vrs 2.0 Page 14 of 36

Tuffie wipes are in use, which contain disinfectant agents.

Warm water and detergent are not used for cleaning medical devices/clinical equipment.

Staff are decontaminating reusable medical devices/clinical equipment by cleaning.

Non-Compliant

Pillows are clean, in a good state of repair and protected by a wipeable/waterproof cover or are single patient use.

Compliant

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009; The national specifications for cleanliness: Guidance on setting and measuring performance outcomes in care homes NPSA 2010

Bed frames, wheels and accessories are clean, free from excessive dust and in a good state of repair.

Compliant

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009; The national specifications for cleanliness: Guidance on setting and measuring performance outcomes in care homes NPSA 2010

All mattresses are protected by waterproof covers or are single patient use.

Compliant

Mattress filling is visibly clean, dry, intact and free from noxious smells. Covers are intact (undamaged).

Compliant

Mattresses visually inspected routinely.

Compliant

Expert Guidance Code of practice for the prevention and control of infections 2010 Criteria 2

Staff have access to appropriate PPE for cleaning clinical equipment

Compliant

Legislation Management of Health & Safety at Work Regulations 1999 and HSE Approved Code of Practice

Manual handling equipment is clean, free from evidence of staining or contamination, dust free and in a good state of repair.

Compliant

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009; The national specifications for cleanliness: Guidance on setting and measuring performance outcomes in care homes NPSA 2010

Wheelchairs are clean and ready for use.

Compliant

PL

E

Expert Guidance National specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010

EX

AM

Best Practice Code of practice for the prevention and control of infections 2010 Criteria 2

Expert Guidance Code of practice for the prevention and control of infections 2010 Criteria 2

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

Expert Guidance Code of practice for the prevention and control of infections 2010 Criteria 2

Date Approved: 07/06/2013

ICAT Audit Tool Vrs 2.0 Page 16 of 36

Compliant

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009; The National Specifications for Cleanliness Guidance on setting and measuring performance outcomes in care homes NPSA 2010; Prevention and control of infection in care homes DH/HPA 2013

Chlorine-releasing agents e.g. sodium hypochlorite or NaDCC (eg Presept, Actichlor, Haztabs) are available to deal with body fluid spillages.

Compliant

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009

Liquid or tablet preparations of chlorine-releasing agents e.g. sodium hypochlorite or NaDCC, are freshly prepared daily and discarded if not used.

Compliant

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009

The correct dilution of chlorinereleasing agent is used for body fluid spillages and any unused solution is discarded not stored.

Compliant

All staff are aware of the correct procedure for dealing with blood/body fluid spillage.

Compliant

E

Detergent based cleaning agents are available for the cleaning of the environment.

AM

PL

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

Compliant

There is a designated, locked area for chemical cleaning products.

Non-Compliant

EX

Cleaning equipment/products (mops, buckets, cloths, gloves etc.) are colour-coded or designated for specific areas and staff are familiar with/aware of the system in use.

Area is not locked.

Expert Guidance National specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010 Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009; Safer Practice Notice Colour Coding for Hospital cleaning materials and equipment NPSA 2007 Legislation Revised Healthcare Cleaning Manual NPSA 2009; Control of Substances Hazardous to Health Regulations 2002

No inappropriate items are stored in the designated cleaning cupboard.The cupboard is only used to store cleaning equipment and materials.

Compliant

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009

Machines used for floor cleaning are clean and dry.

Compliant

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009

Cleaning equipment is stored clean, dry, and mops are stored inverted.

Non-Compliant

Mop heads are replaced regularly and either laundered or discarded.

Compliant

Kitchen cleaning mops not stored inverted Mops are not stored inverted.

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009

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

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009

Date Approved: 07/06/2013

ICAT Audit Tool Vrs 2.0 Page 22 of 36

Compliant

Expert Guidance HFN 30 Infection Control in the Built Environment DH 2003 and Revised Healthcare Cleaning Manual NPSA 2009

Red alginate or water soluble bags are available and used for transporting infected linen.

Compliant

Expert Guidance CFPP 01-04 Decontamination of linen for health and social care: Social care manual DH 2012; Prevention and control of infection in care homes – an information resource DH/HPA 2013

There is no manual sluicing of soiled laundry

Compliant

Legislation Control of Substances Hazardous to Health Regulations 2002

Used linen bags are stored in a designated area prior to collection

Compliant

Linen baskets are labelled with a service user's name and are easily cleaned.

Compliant

Washing machines/tumble dryers are situated in a designated laundry area.

Compliant

E

There is a written schedule in place for the routine laundering of curtains.

PL

Expert Guidance Hospital Laundry Arrangements for used and infected linen DH 1995

AM

Best Practice

Expert Guidance Prevention and control of infection in care homes – an information resource DH/HPA 2013

Compliant

Best Practice

Staff wear aprons and gloves for handling all used linen.

Compliant

Legislation Personal Protective Equipment at Work Regulations 1992; CFPP 0104 Decontamination of linen for health and social care: Social care manual DH 2012; Prevention and control of infection in care homes – an information resource DH/HPA 2013

EX

A tumble dryer is used where clothing is laundered in the ward area.

Hand washing facilities are available in the laundry room.

Compliant

Expert Guidance HFN 30 Infection Control in the Built Environment DH 2003; CFPP 01-04 Decontamination of linen for health and social care: Social care manual DH 2012; Prevention and control of infection in care homes – an information resource DH/HPA 2013

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

Date Approved: 07/06/2013

ICAT Audit Tool Vrs 2.0 Page 24 of 36

There is documented evidence of risk assessments carried out on all service users at admission and at regular intervals.

Non-Compliant

All service users who are at high risk of pressures sores have a pressure relieving mattress.

Compliant

A validated pressure sore grading assessment tool is used for documenting pressure sores.

Compliant

All wounds are accurately assessed and documented in nursing care plan.

Compliant

Not all service users have been routinely assessed on admission with documentary evidence

E

Expert Guidance 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

AM

PL

Expert Guidance NICE Clinical Guidelines 29 Pressure ulcers - The management of pressure ulcers in primary and secondary care NICE 2005

Compliant

EX

There is a wound irrigation protocol stating solution to be used.

Antiseptic dressings are not used routinely.

Expert Guidance 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

Compliant

Expert Guidance NICE Clinical Guidelines 29 Pressure ulcers - The management of pressure ulcers in primary and secondary care NICE 2005; RCN Clinical practice guidelines – The nursing management of patients with venous leg ulcers – Recommendations RCN 2006

Expert Guidance RCN Clinical practice guidelines – The nursing management of patients with venous leg ulcers – Recommendations RCN 2006

Best Practice

Full compliance

Non compliance

Non applicable

Total (%)

5

2

0

71 %

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

Date Approved: 07/06/2013

ICAT Audit Tool Vrs 2.0 Page 28 of 36

Compliant

Expert Guidance NICE Clinical Guidelines 139 Infection - Prevention and control of healthcare associated infections in primary and community care NICE 2012; Prevention and control of infection in care homes - an information resource DH/HPA 2013

Hands are decontaminated prior to donning gloves and any manipulation of the urinary drainage system.

Compliant

Best Practice

Catheter is connected to a closed drainage system or catheter valve

Compliant

Expert Guidance NICE Clinical Guidelines 139 Infection - Prevention and control of healthcare associated infections in primary and community care NICE 2012; Prevention and control of infection in care homes - an information resource DH/HPA 2013

Day bags have integral sampling port

Not applicable

Bags are labelled with change date (next/last)

Compliant

PL

E

Non-sterile, disposable gloves are worn for all manipulation of the urinary drainage system.

This aspect could not be assessed as service users bring their own day bags with them

Best Practice

AM

Best Practice

Compliant

Expert Guidance NICE Clinical Guidelines 139 Infection - Prevention and control of healthcare associated infections in primary and community care NICE 2012

Catheter specimens of urine (CSU's) are obtained from an integral sampling port.

Not applicable

Expert Guidance NICE Clinical Guidelines 139 Infection - Prevention and control of healthcare associated infections in primary and community care NICE 2012

EX

Urinary drainage bags are changed in line with manufacturers recommendations and change is documented

Urine drainage bags are hung on a specific catheter drainage stand

Compliant

Expert Guidance NICE Clinical Guidelines 139 Infection - Prevention and control of healthcare associated infections in primary and community care NICE 2012; Prevention and control of infection in care homes - an information resource DH/HPA 2013

Urine drainage ports are dried after emptying

Compliant

Best Practice

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

Date Approved: 07/06/2013

ICAT Audit Tool Vrs 2.0 Page 31 of 36