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:
ICAT Audit Tool Vrs 2.0 Page 1 of 30
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:
ICAT Audit Tool Vrs 2.0 Page 2 of 30
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:
ICAT Audit Tool Vrs 2.0 Page 6 of 30
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:
ICAT Audit Tool Vrs 2.0 Page 10 of 30