Social action plan

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