Infection Control Audit Report 26/02/2014
Location:
Mill Hill Broadway Surgery 1-6 Station Road Mill Hill London NW7 2JU
Client name:
Demo Surgery
Auditor:
Jennifer Day
Accompanied by:
Kevin Malambo
Additional info:
BUILDING TYPE : Purpose Built
E
Date audited:
AM PL
NUMBER OF : Treatment Rooms : 2 and 1 HCA Room Consulting Rooms : 9 Minor Surgery Room : 0 Dirty Utility / Sluice Room : 1
NUMBER OF : Doctors : 7 Nurses : 4 HCA's : 2 Other Clinical Staff : HV, Clinical Pshycologict and dietician CLINICS : Chronic Disease Management, Zolodex, Testosterone and Depo Injections, Dressings, Spirometry, Child, Adult and Travel Immunisations, Yellow Fever Centre, Ear Syringing, Leg Ulcer, ECG, Phlebotomy, Ante and Post Natal, Six week baby checks, Family Planning.
Section
% Compliance
Governance and Documentary Evidence Staff Records
100 %
EX
Expertise
55 % 86 %
Clinical Environment
81 %
Clinical Practice
85 %
Clinical Equipment
75 %
Hand Hygiene
79 %
Sharps Management
93 %
Waste Management
92 %
Decontamination of Environment
58 %
Vaccine Management including Transport and Storage
85 %
Total
78 %
Corrective actions: Copyright IPC Management (Holdings) Ltd © 2005–2014 Template: Primary Care with Minor Surgery (AT017)
Date Approved:
ICAT Audit Tool Vrs 2.0 27/03/2014
Page 1 of 17
Clinical Practice All ointments, lubricating gels and creams must be used for single patient use only (labelled/dated) or discarded after use.
Disposable plastic aprons should be worn for venepuncture. Clinical Equipment Suitable training must be given to all staff members to ensure they are aware of the 'single use' symbol. Staff must adhere to 'single use' legislation and not re-use any 'single use' medical devices/items. Hand Hygiene
E
Clinical hand wash basins should not be used for decontamination of equipment.
AM PL
Taps on the clinical hand wash basins should not have swan neck fittings and should be considered for replacement. Clinical hand wash basins should not have an overflow.
The dispenser should not be free standing on the work top or the drainer, even if plunger operated and should be wall mounted. Sharps Management
All sharps bins should be temporarily closed when not in use. Waste Management
All waste bins should be fully enclosed and fire retardant. Decontamination of Environment
Chemical cleaning products must be stored in a locked cupboard or room.
All cleaning equipment should be colour coded in line with the National policy (NPSA 2007).
EX
Cleaning/domestic staff should be given training on the importance of storing the mops inverted. Re-usable mop heads are not replaced at least weekly. The designated cleaning cupboard should be free from clutter and be well organised.
Vaccine Management including Transport and Storage Vaccines should not be stored in bottom drawer of the vaccine fridge to minimise temperature fluctuations. The power supply for the vaccine fridge should be switchless so that it cannot be accidently switched off.
Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Primary Care with Minor Surgery (AT017)
Date Approved: 27/03/2014
ICAT Audit Tool Vrs 2.0 Page 3 of 17
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
Environmental cleaning schedules/check lists are available.
Compliant
Expert Guidance
There is a daily cleaning schedule/check list for toys.
Compliant
Expert Guidance
Control of Substances Hazardous to Health (COSHH) data sheets are available for all disinfectants and cleaning agents used.
Non-Compliant
Decontamination of re-usable clinical equipment schedules/check lists are available.
Non-Compliant
Re-usable clinical equipment decontamination schedules are not available
Legislation Control of Substances Hazardous to Health Regulations 2002 Expert Guidance Code of Practice for the prevention and control of infections 2010 Criterion 2; Revised Healthcare Cleaning Manual NPSA 2009; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010
E
COSHH data sheets not available on all products
AM PL
Re-usable clinical equipment decontamination check lists are not available
Non-Compliant
There is a written protocol identifying an area that can be used for patients with communicable diseases.
Compliant
The practice has undertaken a risk assessment of Legionella contamination in accordance with national requirements.
Non-Compliant
EX
Staff are aware of the need for completing a decontamination certificate prior to repair or maintenance of re-usable clinical equipment.
Staff not aware of need for certificate of decontamination.
Expert Guidance
There is a written weekly schedule for running taps/showers.
Non-Compliant
The practice has a regular planned preventative maintenance (PPM) programme for general equipment.
Compliant
No documentary evidence of risk assessment
There are no written schedules for flushing of taps / showers available.
Expert Guidance HTM 04-01 The control of Legionella, hygiene, "safe" hot water, cold water and drinking water systems Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems Approved Code of Practice and Guidance HSE 2000 L8 Expert Guidance HTM 04-01 The control of Legionella, hygiene, "safe" hot water, cold water and drinking water systems Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems Approved Code of Practice and Guidance HSE 2000 L8 Best Practice
Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Primary Care with Minor Surgery (AT017)
Expert Guidance MHRA DB 2003 (05) Management of Medical Devices prior to repair, service or investigation
Date Approved: 27/03/2014
ICAT Audit Tool Vrs 2.0 Page 5 of 17
The clinical/treatment/consulting room is free from clutter and inappropriate items of equipment.
Compliant
Best Practice
A clean storage area is available with sufficient space to store clean and sterile items of clinical equipment off the floor.
Compliant
Expert Guidance
Examination/treatment couches have wipeable surfaces and are in good state of repair with no rips/tears and clean underneath.
Compliant
Expert Guidance
Privacy curtains/screens are clean, in a good state of repair and replaced or laundered every 6 months
Non-Compliant
The reception and public areas are clean and in a good state of repair and appearance.
Compliant
Carpets in non-clinical areas are in a good state of repair and free from extensive staining.
Compliant
Expert Guidance
Chairs and furniture used by service users are wipeable and in a good state of repair.
Compliant
Expert Guidance
Curtains/blinds in non-clinical areas are visibly clean and in a good state of repair.
Compliant
Expert Guidance
Computer keyboards in clinical areas should be clean, covered or wipeable.
Non-Compliant
Toys are clean, in a good state of repair and wipeable
Compliant
Expert Guidance
Toys are stored in designated area in robust, wipeable containers or on wipeable surface.
Compliant
Best Practice
Service user call bells and light pulls are clean and free from debris.
Compliant
Expert Guidance
Toilets are clean and in a good state of repair.
Compliant
Expert Guidance
Toilet and surrounding area is free from extraneous items.
Compliant
Expert Guidance
A dirty utility/sluice area is available.
Compliant
Expert Guidance
Dirty utility/sluice rooms are clean and free from spillages.
Compliant
Expert Guidance
There are no inappropriate items in dirty utility/sluice room.
Non-Compliant
Deep sink is available for the cleaning of clinical equipment.
Compliant
Expert Guidance 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
E
Fabric curtains changed annually. Privacy curtains are not changed 6 monthly.
AM PL
Expert Guidance
EX
Wipeable cover not used for a non washable keyboard.
Dirty utility/sluice room is cluttered.
Expert Guidance HBN 00-09: Infection control in the built environment DH 2013 Expert Guidance
Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Primary Care with Minor Surgery (AT017)
Expert Guidance National specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010
Date Approved: 27/03/2014
ICAT Audit Tool Vrs 2.0 Page 8 of 17
Compliant
Expert Guidance
Waterproof splashbacks are fitted to all clinical hand wash basins and are in a good state of repair.
Compliant
Expert Guidance
All clinical hand wash basins; taps; wall mounted soap and paper towel dispensers are clean, free from limescale build-up and in a good state of repair.
Compliant
Expert Guidance
Clinical hand wash basin and surround is free from inappropriate items.
Compliant
Expert Guidance
Access to clinical hand wash basin is clear and not obstructed by equipment or furniture.
Compliant
Expert Guidance
Wall mounted paper towels are available at all clinical hand wash basins.
Compliant
Expert Guidance
Wall mounted plain liquid soap is available at all clinical hand wash basins from a single-use cartridge dispenser.
Non-Compliant
Antiseptic soap is available for aseptic hand washing if required.
Compliant
Expert Guidance
Alcohol hand rub/gel is available for use in all clinical areas/wherever clinical activity takes place.
Compliant
Expert Guidance
Hand cream is available in wall mounted or pump-operated dispensers in at least one area.
Compliant
Expert Guidance
Clinical staff arms are bare below the elbow during clinical activities and hand washing.
Compliant
Expert Guidance
Clinical staff having direct service user contact are free from wearing wrist watches or stoned rings when performing clinical activities or washing hands.
Compliant
Expert Guidance
Clinical staff are free from long finger nails, false nails, varnish or extensions
Compliant
Expert Guidance
E
There is a hot and cold water supply to every sink and clinical hand wash basin.
Expert Guidance HBN 00-09: Infection control in the built environment DH 2013
EX
AM PL
Plain liquid soap is not wall mounted
Full compliance
Non compliance
Non applicable
Total (%)
15
4
0
79 %
Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Primary Care with Minor Surgery (AT017)
Date Approved: 27/03/2014
ICAT Audit Tool Vrs 2.0 Page 12 of 17