Social audit report

Date audited:

03/09/2012

Location:

Hill Top Care 12 Green Lane Mill Hill London NW7 1AA

Client name:

Demonstration 1

Auditor:

Mike Garfield

Accompanied by:

Care Manager

Additional info:

18 bedded unit, refurbished in 2009.

% Compliance

Governance and Documentary Evidence Staff Records Ward Kitchen Clinical Environment Clinical Practice Clinical Equipment

55 %

100 %

AM

Hand Hygiene

PL

Section

DRAFT

E

Infection Control Audit Report

82 % 74 % 75 % 62 % 83 %

Sharps Management

91 %

Waste Management

53 %

Decontamination of Environment

40 %

Linen Management

47 %

Enteral Feeding

61 %

Pressure Sore Management and Chronic Wound Care

86 %

Respiratory Care

100 % 65 %

EX

Urinary Catheter Management

Peripheral Venous Cannula (PVC) Line Insertion

N/A

Peripheral Venous Cannula (PVC) Line On-going

N/A

Total

69 %

Corrective actions:

Governance and Documentary Evidence 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.

Staff should be able to access the infection control policy manual at any time during the shifts/working day.

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Residential Care Home with Nursing

Date Approved:

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

Staff should be aware of the need to complete a certificate of decontamination for all re-usable clinical equipment, prior to sending for repair or service.

Written schedules for flushing of taps / showers should be available to provide information on location of taps and frequency of flushing.

Ward Kitchen

There should be a thermometer in the fridge with a digital readout.

PL

Freezer temperatures should be recorded daily.

E

Ensure the correct colour coding is in use for all kitchen cleaning materials and equipment, which comply with local policy or national guidelines.

The temperature probe must be stored in a clean container to prevent re-contamination.

Clinical Environment

There must be a schedule for spot-cleaning of spillages from carpets

AM

The storage area should have enough space to store clinical equipment in cupboards or on enclosed shelving when not in use.

Equipment and other items should have their own storage areas, and should be removed from bathrooms.

Shower heads must be kept free of limescale and should be de-scaled regularly.

A simple log of the cleaning for each commode should be kept (a daily tick sheet or similar).

A dirty utility / sluice room should be available per floor / area.

EX

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

There should be a separate washer-disinfector available per floor.

Washer-disinfector should be free from limescale.

Clinical Practice

Apron dispensers should be available and wall-mounted to avoid contamination of aprons during storage.

Facial protection must be available i.e. full-face visor, goggles and mask or mask with integral visor.

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Residential Care Home with Nursing

Date Approved:

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An assessment of the need for urinary catheterisation should be undertaken and the rationale for insertion documented 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.

Indwelling urinary catheters must be connected to a sterile, closed drainage system or catheter valve to minimise the risk of infection Day bags should have an integral sampling port to enable urine collection without disconnecting the bag from the catheter

E

CSUs should be obtained using the sampling port on the day bag which ensures the closed drainage system is not breached

Governance and Documentary Evidence

PL

Demonstration 1 Hill Top Care

Governance documents should be accessible to staff and available for inspection Compliance

Comments

Appropriate Infection Control Policies & Protocols must be available in compliance with the Code of Practice (2010).

Non-Compliant

Staff can locate/access the infection prevention and control policy manual.

Non-Compliant

The Infection control policy manual is clearly marked with a review date and has not expired.

Non-Compliant

Not all policies are available.

AM

Question

Staff cannot access the manual

EX

Manual review date has expired.

Rationale

Legislation Code of practice for the prevention and control of infections 2010 Criteria 9 Legislation Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criterion 9 Legislation Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criterion 9

ICN and ICD advice available.

Compliant

Legislation Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criteria 1 and 5

Key policy elements are available for staff to refer to.

Compliant

Expert Guidance Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criteria 9 and 10

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Residential Care Home with Nursing

Date Approved:

ICAT Audit Tool Vrs 2.0 Page 5 of 30

Compliant

Legislation Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criterion 2 and Revised Healthcare Cleaning Manual NPSA 2009.

Decontamination of re-usable clinical equipment schedules / check-lists are available.

Compliant

Legislation Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criterion 2 and Revised Healthcare Cleaning Manual NPSA 2009.

Data sheets are available for all disinfectants and cleaning agents used.

Compliant

Legislation Control of Substances Hazardous to Health Regulations 2002

Staff are aware of the need for completing a decontamination certificate prior to sending reusable clinical equipment for repair or maintenance.

Non-Compliant

The facility has a regular planned preventative maintenance (PPM) programme for general equipment.

Compliant

There is a written weekly schedule for running taps/showers.

Non-Compliant

Expert Guidance MHRA DB 2003 (05) Management of Medical Devices prior to repair, service or investigation

PL

Staff not aware of certificate

E

Environmental cleaning schedules / check-lists are available.

Best Practice

AM

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 Ch5.12.

Part B Operational management and The Control of Legionella Bacteria in Water Systems Approved Code of Practice and Guidance HSE L8 (2000)

Non compliance

Non applicable

Total (%)

6

5

0

55 %

EX

Full compliance

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Residential Care Home with Nursing

Date Approved:

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Wall mounted liquid soap and paper towels are available next to the handwash basin

Compliant

Legislation HFN 30 Infection Control in the Built Environment DH 2003 and Food Standards Act 1990

Disposable paper towelling is used for cleaning and drying equipment and surfaces.

Compliant

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes and Food Standards Act 1990

Cleaning materials used in the kitchen are stored separate to other environmental cleaning equipment and away from food.

Compliant

Legislation HFN 30 Infection Control in the Built Environment DH 2003 and Food Standards Act 1990

Cleaning materials are colour coded and the correct colour is in use.

Non-Compliant

All opened foodstuffs (e.g. cereals, buscuits) are stored in clean, labelled, pest proof containers.

Compliant

All food items stored in the fridge which are supplied from a noncommercial source (i.e. homemade or prepared in in-house kitchen) are wrapped, labelled with date of storage and are discarded if not consumed within 24 hours.

Compliant

All service user food items stored in the fridge are discarded if not consumed within 24 hours if it does not display a commercial 'use by' or 'best before' label.

Compliant

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes and Food Standards Act 1990

Food in the fridge displays an expiry date and the food is within the expiry period

Compliant

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes and Food Standards Act 1990

EX

AM

PL

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes and Food Standards Act 1990

Milk is stored under refrigerated conditions.

Compliant

Sauces and preserves are stored in the refrigerator after opening.

Not applicable

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes and Food Standards Act 1990

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes and Food Standards Act 1990 Single use sachets

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Residential Care Home with Nursing

Expert Guidance Revised Healthcare Cleaning Manual NPSA 2009

E

The wrong colour cleaning equipment is in use.

Date Approved:

Legislation Food Standards Agency Guidance for Caterers / Supplement for Care Homes and Food Standards Act 1990

ICAT Audit Tool Vrs 2.0 Page 8 of 30

Full compliance

Non compliance

Non applicable

Total (%)

18

4

1

82 %

Demonstration 1 Hill Top Care Clinical Environment The clinical environment will be maintained appropriately in order to reduce the risk of cross infection

Compliant

Flooring in clinical areas (bathrooms, toilets, treatment rooms) are waterproof, nonporous and in a good state of repair.

Compliant

Rationale Expert Guidance HFN 30 Infection Control in the Built Environment DH 2003 (4,226), HBN 0010 Performance requirements for building elements used in health care facilities DH 2011 (element 2)

E

Walls are washable, impervious and in a good state of repair.

Comments

PL

Compliance

AM

Question

Expert Guidance HFN 30 Infection Control in the Built Environment DH 2003 (4.206-4,123), HBN 00-10 Performance requirements for building elements used in health care facilities DH 2011 (element 1, 9032))

Compliant

Expert Guidance HFN 30 Infection Control in the Built Environment DH 2003

Carpets in non-clinical areas are in a good state of repair.

Compliant

Expert Guidance HFN 30 Infection Control in the Built Environment DH 2003 (4.214 - 4.129), HBN 00-10 Performance requirements for building elements used in health care facilities DH 2011 (element 1, 9032)

EX

Floors in clinical areas are free from carpet.

There is a schedule for spotcleaning of spillages from carpets

Non-Compliant

Chairs and furniture used by residents or service users are wipeable and in a good state of repair.

Compliant

No cleaning schedule for spot-cleaning carpets.

Expert Guidance HFN 30 Infection Control in the Built Environment DH 2003 (4.235), Health and Social Care Act 2008 Code of practice for the prevention and control of infections 2010 Criterion 2

Copyright IPC Management (Holdings) Ltd Š 2005–2012 Template: Residential Care Home with Nursing

Expert Guidance HFN 30 Infection Control in the Built Environment DH 2003

Date Approved:

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