Infection Prevention and Control Team Broad Lea House Bradley Business Park Dyson Wood Way Bradley Huddersfield HD2 1GZ Tel: 01484 464 428 01484 464509 2012
Dear RE:
Infection Prevention Audit for Care Homes
Thank you for your assistance with the recent Infection Prevention Audit undertaken on the ……. . I have enclosed a copy of the score sheet, completed audit tool and action plan, identifying the actions required to improve practice. The audit tool continues to be updated in accordance with new legislation and best practice. The scoring system for 2012/13 is as follows: Red 80% or below, Amber 81 – 89%, Green 90% or above. Please sign off the actions on the action plan and return the completed sheet to me before the ……… If action plans are not returned, the IPCN will visit unannounced to review progress. If you require any additional information, please do not hesitate to contact me. Yours sincerely
Enc:
RAG Score Sheet, Audit & Action Plan
Copies to: NHS Wakefield Quality Assurance Team NHS Safeguarding Team LA Contracting Team
NHS Kirklees Terry Service (Assistant Director of Corporate Services and Risk Management) LA Contracting
1
INFECTION PREVENTION AND CONTROL AUDIT CARE HOMES Date: Time: Name of home:
Address:
Client/Service User Group: Telephone Number: E-mail: Corporate Organisation: Head office e-mail address/contact details: Number of beds: Number of “residents” at time of audit: Number of staff: Nurses:
Care Assistants:
Domestic housekeeping: Cooks:
Laundry: Handy worker:
Agency Staff: Staffing ratio (12 hour shifts) Mornings:
Evenings:
Afternoons:
Nights:
Number of “residents” with invasive devices: Indwelling catheters (tick below): Known MRSA (tick below): Urethral
Suprapubic
Current
Previous
Other:
Known C. Difficile (tick):
Peg feeds:
Current:
Leg Ulcers:
Previous:
Pressure Sores:
Double rooms:
Number of single rooms:
If no, do all have hand wash basins in room
Yes / No
2
All en suite
Yes / No
Do staff have access to Occupational Health?
Yes / No
Care Home Representative: Designation: Name of Manager: Preferred method to receive report:
Email Post Password given
3
CONTENTS INFECTION PREVENTION AND CONTROL AUDIT CARE HOMES
1.0
There is a system to manage and monitor the prevention and control of infection using risk assessments
2.0
A clean and appropriate environment is provided and maintained to facilitate the prevention and control of infection
3.0
Suitable and accurate information on infections is available to service users and their visitors
4.0
Suitable and accurate information on infections is provided in a timely manner to others who provide support or care to the client
5.0
People who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people
6.0
All staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection
7.0
Adequate isolation facilities are provided
8.0
Adequate access to laboratory support is secured – Not applicable to Care Home
9.0
Policies are available, that will help to prevent and control infections
10.0
As far as is reasonably practicable, care workers are free of and are protected from exposure to infections that can be caught at work, and all staff are suitably educated in the prevention and control of infection
*
Indicates current legislation
4
1
Standard One:
There is a system to manage and monitor the prevention and control of infection using risk assessments. (Outcome 6, Regulation 24) Y
1 2 3 4 5
6
7
8 9 10
11
*There is an identified infection control lead (1, 2) *There is an identified individual who leads on decontamination of equipment (2) *The lead is of sufficient seniority to challenge inappropriate practice (2) *The lead is able to advise how infection control issues are escalated within the organisation (2) *The lead manager is able to correctly identify when a member of staff who has had diarrhoea and vomiting will be allowed to return to work (2) *Evidence that infection prevention and control information has been discussed/updated with staff (1, 2) *There is a written infection prevention and control programme which details objectives and priorities for action (2) *There is a written annual statement which is publicly available regarding compliance with good practice (2) *There is evidence that the statement has been reviewed and acted upon Have you ever used NHS Kirklees Infection Prevention and Control Internet - http://www.kirklees.nhs.uk/yourhealth/infection-prevention-and-control/ *There is a programme of audit which monitors compliance with infection control e.g. environmental standards/ cleaning (2, 3)
N
NA
Comments Include full name Include full name
What information was required? Was the information found?
1
Y
N
NA
Comments
12
There is evidence that cleaning standards are monitored 13 *Essential Steps assessments are being undertaken and seen by IPC Nurse (2, 3) ● Control of infection ● Catheter insertion ● Continuing catheter care ● PEG feeding ● Wound care 14 IP&C Nurse to record number of assessments : number of staff 15 IP&C Nurse to record areas identified for development from assessments 16 Mattresses are checked monthly for staining etc 17 Staff are aware of the emergency procedure to follow out of hours to obtain treatment, following an exposure incident (involving sharps injury or bite/splash) (4) Comments
1
Standard Two:
A clean and appropriate environment is provided and maintained to facilitate the prevention and control of infection. (Outcome 10, regulation 15)
Y N Communal areas (eg, reception / lounge / dining room) 18 All communal areas are clean, free from clutter and in a good state of repair (1, 5) 19 Furnishings, fixtures and fittings are clean and in a good state of repair (6, 7) 20 The floor is clean and in a good state of repair (6, 7, 8) 21 There is adequate odour control 22 Alcohol gel is available in communal areas or close by “Residents� bedroom (General) (Check 10% of rooms) Bedroom Number: Environment 23 Bedroom is clean and in a good state of repair (1, 5) 24 Bedroom furnishings, fixtures and fittings are clean and in a good state of repair (6, 7) 25 The floor is clean and in a good state of repair (6, 7, 8) 26 There is adequate odour control Hand washing facilities 27 *There is a designated handwash basin available (en 28 29 30 31 32
NA
Comments
suite/not) (2, 9, 10) The handwash basin is clean and in a good state of repair (5, 6) Liquid soap is available for staff use (not topped up) (9, 10) Paper towels are available from an enclosed dispenser (9, 10) Alcohol gel is available at the point of care If room is en suite, is it clean and in a good state of repair and free from clutter (1, 5)
2
Y
N
NA
Comments
Comments for previous sheet
Client Equipment 33 Commode/urinal is clean and in a good state of repair (8) 34 Staff correctly advise how to clean commode/urinal 35 Mattress has impervious cover 36 Member of staff correctly demonstrates mattress checks 37 Mattress and cover is visibly clean and in a good state of repair 38 Bed frame is visibly clean and in a good state of repair (1, 5) 39 Washbowls are clean and stored dry (1, 5) 40 *Manual handling equipment is clean and in a good state of repair (2) Comments
(is not required for every bedroom checked)
3
Y
N
NA
Comments
Communal Bathroom / Shower Rooms 41 Bathroom is clean and free from clutter and in a good state of repair (1, 5) 42 Furnishings, fixtures and fittings are clean and in a good state of repair (6, 7) 43 The floor is clean and in a good state of repair (6, 7, 8) 44 There is adequate odour control 45 *There is a designated handwash basin (2, 9, 10) 46 The handwash basin is clean and in a good state of repair (5, 6) 47 Liquid soap is available for staff use (not topped up) (9, 10) 48 Paper towels are available from an enclosed dispenser (9, 10) 49 Cleaning equipment is appropriately stored and managed when not in use 50 Alcohol gel is available at the point of care (10) 51 If room is en suite, is it clean and in a good state of repair and free from clutter (1, 5) 52 There are no bars of soap available 53 There are no communal flannels, towels etc 54 A wipeable handwash poster is available demonstrating correct technique (10) 55 Shower chair is clean and in a good state of repair (6, 7) 56 Hoist(s) is clean and in a good state of repair (6, 7) 57 Staff advise hoists are cleaned after each use 58 Bath is visibly clean 59 Staff advise bath is cleaned after each use with appropriate cleaning product 60 Staff are able to locate appropriate cleaning materials
4
Y
N
NA
Comments
easily 61 Shower curtains are visibly clean (7, 8) 62 Anti-slip mats are clean and in a good condition (7, 8) Comments for previous sheet
Clinical/ Medicines Room is available 63 Area is clean, free from clutter and in a good state of repair (1, 5) 64 Furnishings, fixtures and fittings are clean and in a good state of repair (6, 7) 65 The floor is clean and in a good state of repair (6, 7, 8) 66 Alcohol gel is available 67 *There is a designated handwash basin (2, 9, 10) 68 69 70 71 72 73 74 75 76
The handwash basin is clean, in a good state of repair and in compliance with HTM 64 (5, 6) Liquid soap is available for staff use (not topped up) (9, 10) Paper towels are available from an enclosed dispenser (9, 10) A wipeable handwash poster is available demonstrating correct technique (10) Medicine pots are cleaned appropriately If dressing trolley available, it is clean and in a good condition All products are stored above floor level Sharps boxes are less than 2/3 full (8) Sharps boxes are safely stored (4)
5
Y
N
NA
Comments
77 78
Devices including razors are not re-sheathed Sharps are segregated in correct colour sharps boxes (11) 79 An approved container to transport specimens is available (11) Comments
Toilet 80 The toilet is clean, free from clutter and in a good state of repair (1, 5) 81 There is a designated handwash basin (2, 9, 10) 82 The handwash basin is clean and in a good state of repair (5, 6) 83 Furnishings, fixtures and fittings are clean and in a good state of repair (6, 7) 84 Liquid soap is available for staff use (not topped up) (9,10) 85 The floor is clean and in a good state of repair (6, 7, 8) 86 Paper towels are available from an enclosed dispenser (9, 10) 87 No bars of soap are available for staff use 88 Toilet brushes and holders are visibly clean (7, 8) 89 Raised toilet seats are visibly clean, in a good condition and stored off the floor (8) Comments
6
Y
N
NA
Comments
House Keepers / Cleaners Room 90 There is a dedicated room / cupboard for storage of cleaning equipment 91 The room is clean, free from clutter and in a good state of repair (1, 5) 92 Fixtures and fittings are clean and in a good state of repair (6, 7) 93 The floor is clean and in a good state of repair (6, 7, 8) 94 *There is a designated handwash basin (2, 9, 10) 95 The handwash basin is clean and in a good state of repair (5, 6) 96 Liquid soap is available (not topped up) (9, 10) 97 Paper towels are available in an enclosed dispenser (9, 10) 98 A wipeable hand hygiene poster is displayed (10) 99 There is a low level facility for staff to fill buckets with water for cleaning 100 Dirty water is disposed of into an appropriate place 101 A cleaning schedule is available (6, 7) 102 A carpet shampooer is available 103 Home representative is able to identify when a steam cleaner would be used 104 A colour coding system is in use for cleaning equipment (6, 7, 9, 15) 105 A wipeable poster is displayed confirming colour coded equipment (6, 7, 9) 106 Cleaning equipment is appropriately stored when not
7
Y
N
NA
Comments
in use (6, 7) 107 Staff can describe which products should be used for routine cleaning 108 Hypochlorite disinfectant is available for environmental/equipment disinfection 109 Separate colour code is used for cleaning equipment during an outbreak (7, 15)) 110 Mop heads are disposed of/laundered when appropriate (6) Comments
Sluice Room / Dirty Utility 111 There is dedicated room to dispose of body fluid and clean soiled equipment 112 The room is clean, free from clutter and is in a good state of repair (1, 5) 113 Fixtures and fittings are clean and in a good state of repair (6, 7) 114 The floor is clean and in a good state of repair (6, 7, 8) 115 *There is a designated handwash basin (2, 9, 10) 116 The handwash basin is clean and in a good state of repair (5, 6) 117 Liquid soap is available (not topped up) (9, 10) 118 Paper towels are available in an enclosed dispenser
8
Y
N
NA
Comments
(9, 10) 119 A wipeable hand hygiene poster is displayed (10) 120 There is a disposal unit available for disposal of body fluids 121 A washer disinfector/macerator is available (Nursing Home only) and in working order 122 Staff are aware of the correct procedure to deal with spillages of body fluid 123 Spill kits for blood spillages are available 124 PPE is readily available in the sluice area and correctly stored 125 Bedpans/urinals/commode pans are clean, stored correctly and in a good state of repair 126 The storage racks for equipment are clean 127 Measuring jugs are disposable or processed through a washer disinfector Comments
Laundry Facilities 128 There is a dedicated room to provide laundry facilities. 129 The room is clean, free from clutter and in a good state of repair (1, 5) 130 Fixtures and fittings are clean and in a good state of repair (6, 7) 131 The floor is clean and in a good state of repair
9
Y
N
NA
Comments
(6, 7, 8) 132 *There is a designated handwash basin (2, 9, 10) 133 The handwash basin is clean and in a good state of repair (5, 6) 134 Liquid soap is available (not topped up) (9, 10) 135 Paper towels are available in an enclosed dispenser (9, 10) 136 A wipeable hand hygiene poster is displayed (10) 137 Water soluble bags are available for soiled linen (12) 138 Soiled laundry is not “manually sluiced� (12) 139 Clean linen is sorted away from dirty linen (12) 140 Soiled/infected linen is stored safely whilst awaiting laundering 141 Standards for managing laundry are satisfactory (12) Comments
Management of Equipment 142 *All equipment is identified on a cleaning schedule (2, 7) 143 There is a system to confirm equipment is cleaned and ready to use (tagging) 144 Clean mattresses in storage are labelled and stored appropriately 145 Soiled mattresses awaiting disposal are safely managed 146 Decontamination forms are available and there is evidence of their use 147 Staff are able to explain when decontamination forms
10
Y
N
NA
Comments
are used 148 Records of cleaning of equipment are available (7) 149 *Medical equipment is clean and in a good condition (e.g. Sphyg, nebuliser, blood glucose monitoring, suction machine) (2, 13) Comments
Waste Management 150 Domestic waste (black bags) are in use (11) 151 Offensive waste (tiger striped)are in use (11) 152 Infectious waste (orange bags) are in use / available if needed (11) 153 All waste bins are foot operated, clean and in good working order (11) 154 Evidence of correct segregation of waste available (11) 155 *Internal storage of full waste bags is satisfactory (2, 11) 156 Outside storage area is clean and tidy Comments
11
Y
Standard Three:
N
NA
Comments
Suitable and accurate information on infections is available to service users, staff and visitors. (Outcome 1, Regulation 17) Y
N
NA
Comments
Written information is available: 157 To promote the need for good hand hygiene (10) 158 *On outbreak management and how everyone can help (2) 159 On roles and responsibilities to manage IP&C 160 On how to report concerns regarding IPC practices for hygiene 161 On norovirus 162 On MRSA 163 On the application of suppression treatment 164 On Clostridium Difficile 165 On vaccinations 166 Scabies Comments
12
Y
N
NA
Comments
13
Standard Four:
Suitable and accurate information on infections is provided in a timely manner to others who provide support or care to the client (Outcome 6 and Regulations 24) Y
167 There is a written system detailing how clients are risk assessed regarding their infectious status 168 There is evidence of this risk assessment being documented in a client’s records 169 There is a written plan of care to advise how a client with an infection should be safely cared for 170 There is evidence that the care plan is being followed 171 A system of risk assessment is available to inform staff of the client’s infectious status on transfer to other care providers 172 Methods of communication with relevant others (D/N’s, Podiatry etc) are satisfactory regarding IP&C. Comments
N
NA
Comments
Describe
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Standard Five:
People who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people. Y
173 Staff are able to correctly advise on how outbreaks are reported within office hours 174 Staff are able to advise who to report outbreaks to out of office hours 175 Information to document outbreak is available 176 Specimen pots and forms are available 177 Staff know how to contact the PCT infection prevention team 178 Care pathway to manage diarrhoea and vomiting is available 179 Care pathway to manage scabies is available Comments
N
NA
Comments HPA Duty desk 0113 386 0300 Public Health on-call 01484 342000/01844 8118110
01484 464 428/01924 317672
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Standard Six:
All staff and those employed to provide care in all settings are fully involved in the process of preventing controlling infection Y
N
NA
Comments
180 There is evidence that outside agencies (e.g. podiatry) comply with health professional’s registration. 181 Mechanisms are in place to monitor all staff employed independently in the home to ensure that basic infection prevention and control standards are adhered to. To include: ● Bare below the elbows ● Use of PPE ● Hand hygiene/alcohol gel ● Waste management 182 Manager is able to explain actions to be taken if independent staff fail to comply. 183 IP&C induction training is undertaken and records are available (1) 184 *There is an annual IP&C education programme for staff which is recorded (2) 185 *Is there a process to ensure non attendees are followed up (2) Comments
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Standard Seven:
Adequate isolation facilities are provided Y
N
NA
Comments
186 Mechanisms are available to isolate clients to minimise the spread of infection 187 Staff correctly identify when and how a client should be isolated 188 If unable to isolate, evidence of risk assessment is available Comments
17
Standard Eight:
Adequate access to laboratory support is secured – not applicable to care home services Y
N
NA
Comments
Comments
18
Standard Nine:
Policies are available, and adhered to that will help to prevent and control infections (Outcome 11, Regulation 16 and Outcome 10, Regulation 15)
Y N NA Comments 189 The home representative is able to confirm that the following policies are available 190 Standard Precautions (including hand decontamination: use of PPE, management and transportation of specimens) (2) 191 Safe handling and disposal of sharps, prevention of occupational exposure to blood borne viruses and management of exposure incidents (2,4) 192 Safe handling and disposal of waste (11) 193 Care of deceased persons (2) 194 Use and care of invasive devices (catheters, feeding systems etc) (2) 195 Uniform and dress code (2) The following policy information exists – NURSING HOMES ONLY (if residential do not complete) 196 Aseptic technique (2) 197 Management of communicable infections including outbreaks, isolation and communication to others (2) 198 Cleaning/disinfection of the environment and equipment including single use (13) 199 Management of residents with specific alert organisms – MRSA, respiratory illness, diarrhoeal illness, C difficile (2) 200 *Policies identify the author (2) 201 *Policies identify the date for revision (2) 202 *Policies are current (2) 203 *Policies are easily accessible and staff know where to find them (2) 204 *Staff are aware of where to find policies 205 *There is a signed sheet to confirm that staff are aware of policies
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Y The following policy information exists – ALL HOMES Practices related to preventing infection: 206 CE marked gloves are readily available in appropriate areas (1, 8) 207 Non latex gloves are readily available 208 Disposable aprons are readily available in appropriate areas (1, 8) 209 PPE is appropriately stored 210 Eye protection is readily available (8) 211 Face masks are readily available (8) 212 Staff correctly advise when they would wear eye protection and face masks (8) 213 Catheter bags are emptied safely (8) 214 Receptacles for emptying catheter bags are disinfected / disposed of after each use (8) Staff are observed to be bare below the elbows. Identify which: 215 Free of stoned rings 216 Free from nail polish 217 Free from false nails / gel overlays 218 Free from watches and bracelets 219 Free from long sleeves / cardigan Comments
N
NA
Comments
Nursing homes only
Describe
20
Standard Ten:
As far as is reasonably practicable, care workers are free of and are protected from exposure to infections that can be caught at work and all staff are suitably educated in the prevention and control of infection. Y
N
NA
Comments
Homes have systems to: 220 *Ensure staff complete of a confidential health assessment after a conditional offer of employment (overseas residence), previous and current illness, immunisations (2) 221 *Ensure health screening for communicable diseases (2) 222 *Identify how exposure to infections will be managed (2) 223 *Identify how staff are risk assessed to receive appropriate immunisations (2) 224 *Identify how staff are offered immunisations in line with current national guidance and records are kept (2, 14) 225 Responsibilities of staff to report episodes of illness. 226 *Identify circumstances when staff may need to be excluded from work (2) 227 *Where advice for staff health is obtained from (2) 228 The responsibilities for infection prevention and control are reflected in job descriptions (JD information seen) 229 The responsibilities for infection prevention and control are reflected in personal development plans/appraisals (documentation seen) Comments
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1
Department of Health (2000) Infection Control Guidance for Care Home. London: Department of Health.
2
Department of Health (2008) The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance: Revised December 2010.
3
Department of Health (2006) Essential Steps to safe, clean care. Reducing healthcare associated infections (HCAI) in primary care trusts, mental health trusts, learning disability organisations, independent healthcare facilities, care homes, hospices, GP practices and ambulance services. London: Department of Health.
4
Department of Health (1998) Guidance for healthcare workers: protection against infection with blood borne virus. Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis.
5
Department of Health (2006) Health Technical memorandum 64 (HTM 64): Sanitary assemblies. London: TSO.
6
The national specifications for cleanliness in the NHS: A framework for setting and measuring performance outcomes April 2007. www.nrls.npsa.nhs.uk/rescources/?EntryId45=59818.
7
The NHS cleaning manual: NPSA 2009.
8
Pratt RJ, Pellowe C, Wilson Loveday HP, Harper PJ, Jones SRLJ, McDougall CM, Wilcox MH (2007). Epic2: National Evidence Based Guidelines for preventing Healthcare Associated Infection in NHS Hospitals in England. Journal of Hospital Infection. 65 (1) Supplement (1).
9
HTM’s superseded by HBN 00-10 – Built environment 2.011
10
World Health Organisation (2009) Guidelines on hand hygiene in health care. Geneva, Switzerland: World Health Organisation.
11
Department of Health (2011) Health technical Memorandum 07-01: Safe management of healthcare waste. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_073328.pdf.
12
Department of Health NHS Executive (1995) Guidelines. Hospital Laundry Arrangements for Used and Infected Linen. HSG (95) 18. Department of Health. www.dh.gov.uk/en/publicationsandstatistics/lettersandcirculars/healthserviceguidelines/dh_4017865.
22
13
Department of Health (2007) Health Technology Memorandum 01-01. Decontamination of re-useable medical devices Part A. London. The Strategy Office.
14
Department of Health (2006) “Immunisation against Infectious Disease” – “The Green Book” Department of Health TSO London.
15
NPSA (2007) Safer Practice Notice 15. Colour Coding of Hospital Cleaning Materials and Equipment, London. www.hospitalcaterers.org.
23