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
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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
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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
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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
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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
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Date Approved: 07/06/2013
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