Infection Control Audit Report 14/10/2013
Location:
Atlantic Hendon Road Mill Hill London NW8
Client name:
Demonstration 1
Auditor:
Mike Garfield
Accompanied by:
Jason P
Additional info:
Atlantic is an 8 bedded unit comprising single rooms with en-suite facilities. The client group is working age adult ...... and ....
E
Date audited:
% Compliance
PL
Section Governance and Documentary Evidence Staff Records Expertise Kitchen - Servery Kitchen - Therapy
67 % 40 % 81 % N/A N/A
AM
Kitchen - Bistro/Beverage Area
46 %
52 %
Clinical Practice
43 %
Clinical Equipment
50 %
Hand Hygiene
78 %
Sharps Management
80 %
Waste Management
58 %
Decontamination of Environment
40 %
Linen Management
78 %
EX
Clinical Environment
Total
62 %
Corrective actions:
Governance and Documentary Evidence The manual should contain all the policies, procedures and protocols for the standard infection prevention and control precautions. The Infection prevention and control policy manual should be clearly marked with a review date.
Kitchen cleaning schedules should be available to provide information on the type and frequency of cleaning.
Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)
Date Approved: 05/11/2013
ICAT Audit Tool Vrs 2.0 Page 1 of 34
Environmental cleaning schedules should be available to provide information on the type and frequency of cleaning. All disinfectant and cleaning products must have a COSHH data sheet. Decontamination certificate should be available and accompany all equipment for service or repair.
Written schedules for flushing of taps / showers should be available to provide information on location of taps and frequency of flushing.
Staff Records
E
Documentary evidence of infection prevention and control training should be kept up-to-date. Expertise
There should be a designated named person as the infection prevention and control lead.
PL
There should be a designated, named person as the environmental cleaning lead.
There should be a named lead for the decontamination of clinical equipment/devices. Kitchen - Servery
Walls should be repaired and coated with a washable surface.
AM
Kitchen/servery work surfaces must be in a good state of repair to facilitate effective cleaning. Damaged work surfaces should be replaced/repaired. Fridges must be cleaned with warm water and detergent following any leaks or spills. Microwave must be cleaned with warm water and detergent following any leaks or spills.
Temperature probe must be thoroughly decontaminated after each use with a commercial probe wipe and stored in an enclosed container. Water boiler dispenser nozzle should be kept free from limescale build-up.
EX
Water boiler collection tray should be kept free from limescale build-up and mildew. Clinical Environment
A designated clinical treatment room should be available for minimally invasive clinical procedures and clean tasks. Wallpaper should be removed and replaced with washable/impervious surface. Carpet is not appropriate in clinical areas and should be replaced with a washable, impermeable floor surface e.g. vinyl material, which is continuous, non-slip and where possible joint-less. The clinical treatment room should be tidied up and all inappropriate items removed to facilitate cleaning and minimise the risk of contamination. Chairs/furniture in the general purpose / therapy room(s) should be undamaged.
Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)
Date Approved: 05/11/2013
ICAT Audit Tool Vrs 2.0 Page 2 of 34
Disposable cloths must be discarded daily and replaced Linen Management Clean linen should be free from stains. Staff should wear aprons for handling used linen.
Demonstration 1 Atlantic Governance and Documentary Evidence Governance documents should be accessible to staff and available for inspection
Compliance
Comments
Infection prevention and control policy manual is available in compliance with the Code of Practice.
Non-Compliant
Staff can locate/access the infection prevention and control policy manual.
Compliant
The infection prevention and control policy manual is clearly marked with a review date and has not expired.
Non-Compliant
Service user and visitor information is available for: the facilities approach to infection prevention and control; staff roles and responsibilities; who to contact, up-to-date current infection control issues and visiting access.
Compliant
Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 3
There is a policy and/or poster outlining the process for management of inoculation injury/splash incident including up-to-date contact phone numbers for A&E/Occupational Health.
Compliant
Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 10
Staff are aware of the action to be taken in the event of an inoculation injury. (ask staff members at random).
Compliant
Expert Guidance EPIC2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007
There is a policy regarding service user and visitor access to the kitchens.
Compliant
Best Practice
A written local policy and safe working procedure for the operation of all washing machines and tumble dryers is available to staff and service users.
Not applicable
Expert Guidance CFPP 01-04 Decontamination of linen for health and social care: Social care DH 2013
Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 9 and table 3
PL
The manual does not contain all policies, procedures and protocols for the standard infection prevention and control precautions.
Expert Guidance Code of practice for the prevention and control of infections 2010 Criterion 9
EX
AM
Infection prevention and control policy manual is not clearly marked with a review date.
Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)
Rationale
E
Question
Date Approved: 05/11/2013
Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 9
ICAT Audit Tool Vrs 2.0 Page 5 of 34
Non-Compliant
There is a designated, named lead for environmental cleaning.
Non-Compliant
There is a named lead for decontamination of re-usable clinical equipment/devices.
Non-Compliant
Staff should have access to Occupational Health for services and advice.
Compliant
There is no named infection prevention and control lead.
Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 1
There is no designated, named environmental cleaning lead.
Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 2
There is no named lead for the decontamination of clinical equipment/devices.
Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 1 and 2; The National Specifications for Cleanliness in NHS a framework for setting and measuring performance outcomes NPSA 2007
E
There is a nominated lead for infection prevention and control (IPC Lead).
PL
Expert Guidance Code of practice for the prevention and control of infections 2010 Criteria 10
Non compliance
Non applicable
Total (%)
2
3
0
40 %
AM
Full compliance
Demonstration 1 Atlantic Kitchen - Servery
The kitchen/servery will be maintained so as to reduce the risks of cross-infection, cross-contamination and hence food borne illness Question
Non-Compliant
Comments
The walls are not washable or have cracked/peeling surface
EX
The fabric of the room, including fixtures and fittings, walls, floors, splashbacks, etc, is in a good state of repair.
Compliance
The floor is free from dust, grit, litter, marks, water or other fluids.
Compliant
Legislation Food Standards Act 1990; HBN 00-09: Infection control in the built environment DH 2013; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011
Expert Guidance Code of practice for the prevention and control of infections 2010 Criteria 2; HBN 00-09 Infection control in the built environment DH 2013
Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)
Rationale
Date Approved: 05/11/2013
ICAT Audit Tool Vrs 2.0 Page 8 of 34
Computer keyboards in clinical areas should be clean, covered or wipeable.
Non-Compliant
Bathrooms, shower rooms and bathroom equipment are clean and ready for the next service user.
Compliant
Expert Guidance HBN 00-09: Infection control in the built environment DH 2013; Revised Healthcare Cleaning Manual NPSA 2009; The National Specifications for Cleanliness in NHS a framework for setting and measuring performance outcomes NPSA 2007
Bathrooms/shower rooms are not used to store inappropriate items / equipment.
Compliant
Expert Guidance HBN 00-09: Infection control in the built environment DH 2013
Shower curtains/screens are visibly clean.
Non-Compliant
Shower heads are clean and visibly free from lime-scale
Non-Compliant
Service user call bells and light pulls are clean and free from debris.
Compliant
Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009
Toilets and seat raisers are clean, ready for the next service user and in a good state of repair.
Compliant
Expert Guidance HBN 00-09: Infection control in the built environment DH 2013; Revised Healthcare Cleaning Manual NPSA 2009; The National Specifications for Cleanliness in NHS a framework for setting and measuring performance outcomes NPSA 2007
Toilet and surrounding area is free from extraneous items.
Compliant
Expert Guidance HBN 00-09: Infection control in the built environment DH 2013; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011
PL
Shower screens have evidence of lime-scale build up.
EX
AM
Lime scale is visible on shower heads.
Expert Guidance The Control of Legionella Bacteria in Water Systems Code of Practice HSE 2000 L8; HBN 00-09: Infection control in the built environment DH 2013; Revised Healthcare Cleaning Manual NPSA 2009
Expert Guidance HBN 00-09: Infection control in the built environment DH 2013
Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)
Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009
E
The keyboard/mouse/screen is not clean, e.g. visible signs of debris and dirty keys, dusty screen
Date Approved: 05/11/2013
ICAT Audit Tool Vrs 2.0 Page 19 of 34
Single use, powder-free sterile surgeons gloves available if required.
Compliant
Expert Guidance HSE Guidance on regulations for PPE at Work Regulations 1992 (2005); COSHH Regulations 2002; EPIC2 National Evidence Based Guidelines for Preventing Health Care Associated Infections in NHS Hospitals in England 2007
Plastic gloves (i.e. polythene) must not be used.
Compliant
Legislation Personal Protective Equipment at Work Regulations 2005
Staff wear gloves during all procedures where there is a risk of exposure to blood, body fluids, secretions and excretions; chemicals, etc and when handling sharp instruments or decontaminating clinical equipment.
Non-Compliant
Single use, disposable plastic aprons must be available when required.
Non-Compliant
Legislation Code of practice for the prevention and control of infections 2010 Criterion 9; HSE Guidance on regulations for Personal Protective Equipment at Work Regulations 1992 (2005); COSHH Regulations 2002
PL
E
Gloves not worn for all procedures.
AM
Single use, disposable plastic aprons are not available.
Not applicable
Staff wear a disposable plastic apron during all procedures where there is a risk of exposure to blood, body fluids, secretions and excretions; or when a service user has a known infection.
Non-Compliant
EX
Plastic aprons are stored in covered containers or are in wall mounted dispensers.
Full facial protection is available for staff when splashing of blood, body fluids or chemicals is anticipated.
Non-Compliant
Re-usable facial protection is decontaminated after each use.
Not applicable
Disposable plastic aprons are not worn where there is a risk of exposure.
Appropriate facial protection is not available for staff.
Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)
Date Approved: 05/11/2013
Legislation Code of practice for the prevention and control of infections 2010 Criterion 9; Personal Protective Equipment (EC Directive Regulations) 1992; Control of Substances Hazardous to Health Regulations 2002 Expert Guidance HBN 00-09: Infection control in the built environment DH 2013 Expert Guidance EPIC2 National Evidence Based Guidelines for Preventing HCAI in NHS Hospitals in England Final 2007 Expert Guidance EPIC2 National Evidence Based Guidelines for Preventing HCAI in NHS Hospitals in England Final 2007 Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009; The National Specifications for Cleanliness in NHS a framework for setting and measuring performance outcomes NPSA 2007
ICAT Audit Tool Vrs 2.0 Page 22 of 34