Date audited:
03/09/2012
Location:
Hill Top Care 12 Green Lane Mill Hill London NW7 1AA
Client name:
Demonstration 1
Notes: Corrective actions: Other Corrective Actions Governance and Documentary Evidence
DRAFT
PL E
Infection Control Action Plan
Reference
An Infection Control Manual containing the appropriate Infection Control Policies & Protocols must be available in compliance with the Code of practice for the prevention and control of infections 2010 Criterion 9.
Code of practice for the prevention and control of infections 2010 Criteria 9
Staff should be able to access the infection control policy manual at any time during the shifts/working day.
Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criterion 9
Infection control guidelines should be reviewed regularly (at least every 2 years) to ensure that all policies are kept up to date and complete.
Health and Social Care Act 2008 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 2005–2012 Template: Residential Care Home with Nursing
Responsibility
Due Date
Report Version 0.0.1 Date Approved:
Page 1 of 10
Washer-disinfector should be free from limescale.
HFN 30 Infection Control in the Built Environment DH 2003; HTM 01-01 Decontamination of Reusable Medical Devices DH 2007
Clinical Practice Reference
Apron dispensers should be available and wall-mounted to avoid contamination of aprons during storage.
Infection Control Guidance for Care Homes DH 2006
Facial protection must be available i.e. full-face visor, goggles and mask or mask with integral visor.
Health and Social Care Act 2008 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); CCOSHH,
M
Clinical Equipment
Evidence of Compliance
Reference
Strict stock rotation will ensure sterile medical devices / items are used within their expiry date.
Safety Notice Storage of sterile medical devices MDA SN 1999(32)
Dressing trolleys / procedure trays which are used for clinical tasks (e.g. dressings, invasive procedures), should not be uses for other tasks.
Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criteria 2 and 9; EPIC2 National Evidence Based Guidelines for Preventing Health Care Associated Infections in NHS Hospitals in England 2007; HTM 01-01 Criterion 2 and 9.3j; SP4, SP5; 2.2
A local protocol should be devised that indicates the frequency of mattress inspection e.g. weekly.
Code of practice for the prevention and control of infections 2010 Criteria 2
Evidence of Compliance
EX A
Corrective Action
Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Residential Care Home with Nursing
Responsibility
Due Date
Responsibility
Due Date
PL E
Corrective Action
Report Version 0.0.1 Date Approved:
Page 4 of 10
Date audited:
03/09/2012
Location:
Hill Top Care 12 Green Lane Mill Hill London NW7 1AA
Client name:
Demonstration 1
Notes: Corrective actions: Other Corrective Actions Governance and Documentary Evidence
DRAFT
PL E
Infection Control Action Plan
Reference
An Infection Control Manual containing the appropriate Infection Control Policies & Protocols must be available in compliance with the Code of practice for the prevention and control of infections 2010 Criterion 9.
Code of practice for the prevention and control of infections 2010 Criteria 9
Staff should be able to access the infection control policy manual at any time during the shifts/working day.
Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criterion 9
Infection control guidelines should be reviewed regularly (at least every 2 years) to ensure that all policies are kept up to date and complete.
Health and Social Care Act 2008 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 2005–2012 Template: Residential Care Home with Nursing
Responsibility
Due Date
Report Version 0.0.1 Date Approved:
Page 1 of 10
Ensure there is a written protocol for enteral feed preparation/administration.
NICE(2003) Prevention of HCAIs
Pressure Sore Management and Chronic Wound Care Reference
All residents must be routinely assessed on admission for pressure sore risk with documentary evidence of assessment Urinary Catheter Management Corrective Action
Reference
Urine jugs must be labelled with the patients name and the next due date for change
Evidence of Compliance
1.Saving Lives & 2.NICE(2003) Prevention of HCAIs
The clinical need for catheterisation should be reviewed weekly and documented in the service users care plan. Urinary catheters should be removed as soon as possible.
NICE(2003) Prevention of HCAIs
Indwelling urinary catheters must be connected to a sterile, closed drainage system or catheter valve to minimise the risk of infection
NICE(2003) Prevention of HCAIs
EX A
An assessment of the need for urinary catheterisation should be undertaken and the rationale for insertion documented
Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Residential Care Home with Nursing
Responsibility
Responsibility
Due Date
Due Date
M
Urinary catheter bags should be labelled with last / next change date to ensure they are changed when necessary
Evidence of Compliance
PL E
Corrective Action
Report Version 0.0.1 Date Approved:
Page 9 of 10