Primaryaction plan

Date audited:

26/02/2014

Location:

Mill Hill Surgery 1-6 Station Road Mill Hill Broadway London NW7 2JU

Client name:

Demo Surgery

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

PL E

Infection Control Action Plan

Reference

There should be a local risk assessment to establish which policies, procedures and protocols are required for the regulated activities provided.

Code of Practice for the prevention and control of infections 2010 Criterion 9

The manual should contain all the policies, procedures and protocols for the standard infection prevention and control precautions.

Code of Practice for the prevention and control of infections 2010 Criterion 9 and table 3

Infection prevention and control policy manual should be reviewed regularly (at least every 2 years) to ensure that all policies are kept up to date and complete.

Code of Practice for the prevention and control of infections 2010 Criterion 9

Evidence of Compliance

EX A

M

Corrective Action

Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Primary Care with Minor Surgery (AT017)

Responsibility

Due Date

Report Version 0.0.1 Date Approved:

27/03/2014

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Expertise Reference

Evidence of Compliance

The practice should have access to the appropriate Competent Persons for vaccine fridges and Legionella management.

Immunisation Against Infectious Disease Ch. 3 Management of Vaccines DH 2011; HTM 04-01 Ch 6.13. Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems Approved Code of Practice and Guidance HSE L8 2000

Responsibility

PL E

Corrective Action

Clinical Environment Reference

Evidence of Compliance

Ensure walls have no defects which reduce effectiveness of cleaning.

Repair/refurbish damaged areas so that surfaces are impervious and washable.

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 (element 2); HBN 00-10 Part B: Walls and ceilings DH 2013

Privacy curtains should be changed 6 monthly.

HBN 00-09: Infection control in the built environment DH 2013; Revised Healthcare Cleaning Manual NPSA 2009; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

Responsibility

Due Date

EX A

M

Corrective Action

Due Date

Non washable keyboards should be provided with a wipeable cover which remains insitu during service user treatment.

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

The dirty utility/sluice room should be free of extraneous items to allow easy access and to encourage thorough cleaning.

HBN 00-09: Infection control in the built environment DH 2013

Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Primary Care with Minor Surgery (AT017)

Report Version 0.0.1 Date Approved: 27/03/2014

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Decontamination of Environment Reference

Evidence of Compliance

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

All cleaning equipment should be colour coded in line with the National policy (NPSA 2007).

Revised Healthcare Cleaning Manual NPSA 2009

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

Revised Healthcare Cleaning Manual NPSA 2009

Responsibility

Due Date

PL E

Corrective Action

Re-usable mop heads are not replaced at Revised Healthcare Cleaning Manual NPSA least weekly.

2009

M

The designated cleaning cupboard should Revised Healthcare Cleaning Manual NPSA be free from clutter and be well 2009 organised.

Vaccine Management including Transport and Storage Reference

Vaccines should not be stored in bottom drawer of the vaccine fridge to minimise temperature fluctuations.

Immunisation Against Infectious Disease Ch. 3 Management of Vaccines DH 2011

The power supply for the vaccine fridge should be switchless so that it cannot be accidently switched off.

Immunisation Against Infectious Disease Ch. 3 Management of Vaccines DH 2011

Evidence of Compliance

EX A

Corrective Action

Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Primary Care with Minor Surgery (AT017)

Responsibility

Due Date

Report Version 0.0.1 Date Approved: 27/03/2014

Page 6 of 6