IPPOL09 Decontamination of Medical Equipment V8

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Decontamination of Medical Equipment

Version: V8

Ratified by: Quality & Safety Committee

Date ratified: 17/01/2024

Job Title of author: Specialist Infection Prevention Nurse

Reviewed by Committee or Expert Group Infection Prevention Group

Equality Impact Assessed by: Specialist Infection Prevention Nurse

Related procedural documents

IPPOL17 Aseptic Non-Touch Technique Policy

IPPOL21 Policy on Standard Principles for Infection Prevention

IPPOL03 Hand Hygiene Policy

MMPOL30 Medicines Policy

IPPOL18 Management and Safety of Sharps Policy

CPOL25 Policy for the Administration of Intravenous Drugs in the Community

IPSOP02 Standard Operating Procedure for the Decontamination of Nasendoscopes

EFGUI01 Cleaning Guidelines for Community Hospitals

EPOL02 Annual Deep Cleaning of Community Hospital Wards

Review date: 17/01/2027

It is the responsibility of users to ensure that you are using the most up to date document template – i.e. obtained via the intranet.

In developing/reviewing this policy Provide Community has had regard to the principles of the NHS Constitution.

Version Control Sheet

Version Date Author Status Comment

V2 February 2011 Head of Infection Prevention Ratified Reviewed

V3 June 2013 Head of Infection Prevention Approved Reviewed

V3.1 September 2013 Quality & Safety Administrator No change to review date Updated in line with restructure and organisation name change

V4 September 2015 Head of Infection Prevention & Control 2-year review 2-year review

V5 October 2016 Head of Infection Prevention& control 2-year review Addition of HTM 01-06 (March 2016)

V5.1 April 2017 Head of Infection Prevention& control Addition of cleaning mobile electronic equipment (phones and laptops linking to IGPOL54)

V6 August 2019 Specialist Infection Prevention Nurse Extension 3-month extension agreed at August Quality and Safety

V7 September 2020 Specialist Infection Prevention Nurse Update

V8 October 2023 Specialist Infection Prevention Nurse 2 Year Review Reviewed appendix 10-21 removed and added to NEW SOP Decontamination of Medical Devices in the Community

1. Introduction

This policy has been formulated to cover the cleaning and disinfection of equipment used within Provide and includes selected equipment supplied by Essex Equipment Services. The policy aims to provide an explanation of the process(s) used to ensure safe decontamination of equipment by cleaning, disinfecting and sterilizing in order to prevent the spread of micro-organisms.

Prior to purchasing equipment Provide staff are encouraged to contact the Infection Prevention Team to help ensure that the item can be decontaminated effectively and that the company supplying the equipment offers appropriate instructions on cleaning, disinfection and sterilization methods.

2. Purpose

To promote the safest possible environment for patients through the identification and application of best practice in the decontamination of medical equipment.

3. Definitions

Cleaning

A process, which physically removes contamination but does not necessarily destroy microorganisms. Cleaning removes micro-organisms and the organic material on which they thrive. Cleaning is an essential first stage to ensure effective disinfection or sterilization can then follow the cleaning process if required.

Chlorine Releasing Agent (CRA)

This is a disinfectant. Hypochlorite is a chlorine-based product and is recommended for the safe disinfection of all spillages of blood prior to cleaning. It can also be used for disinfecting items of equipment/environment. The required concentration to destroy blood borne pathogens is 10,000ppm (spillages) and 1,000ppm in water for equipment/environment disinfection.

Contamination

The presence of an undesirable contaminant, e.g. debris, spillage, dust, that contaminates equipment or environmental surfaces increasing the risk of microorganism transmission and potentially, infection.

Decontamination

This is a process which removes or destroys contaminants, so that infectious agents or other harmful substances (chemicals etc.) cannot reach a susceptible site in sufficient quantities to initiate infection or other harmful response. Different levels of decontamination can be used dependent on the device and the procedure involved. Levels of decontamination are:

• Cleaning

• Cleaning followed by disinfection

• Cleaning followed by sterilization

Disinfectant

A chemical agent which is capable of disinfection.

Disinfection

A process used to reduce the number of micro-organisms but not usually of bacterial spores; the process does not necessarily kill or remove all micro-organisms but reduces them to acceptable levels if the process is undertaken properly.

Decontamination Standard Operating Procedures (SOP’s)

These are specific decontamination instructions for items of equipment that are used.

Decontamination Room/Area

This is a designated area for the specific purpose of decontamination of equipment.

Domestic Cleaning

The cleaning that is carried out through a contractual arrangement for an area, with specified guidance on product use and frequency of cleaning of environment surfaces/fixtures and fittings.

High Level Disinfectant

A liquid chemical or vapour (i.e. Hydrogen Peroxide Vapour) agent that can kill bacteria, viruses and spores. It is only sporicidal under certain circumstances. This type of disinfection is commonly used in Automated Endoscope re-processors (AERs).

Integrated Care team (ICT)/Frailty/urgent community response teams

Form part of the healthcare service to the community which is delivered in patients own home as well as residential homes.

Medical Device

Any instrument, apparatus, appliance, material or other articles e.g. commode chairs, drip stands, dressing trolleys, BP cuffs, bedpans, surgical instruments, whether used alone or in combination, and intended by the manufacturer to be used on people/patients.

Microbial Agent

Any micro-organism, cell culture, or human endoparasite, which may cause infection, allergy, toxicity or otherwise create a hazard to human health.

Prions

A form of protein thought to be the causative agent of transmissible spongiform encephalopathy’s (TSE) e.g. Creutzfeldt-Jakob disease (CJD). These cannot be removed by any known decontamination process. Used items of equipment thought to be contaminated must be quarantined and advice sought from the local Health Protection team at UK Health Security Agency (UKHSA)

Packaging

All staff handling medical devices should be aware of these symbols.

Single Patient Use

Some items of equipment are identified as suitable for single patient use i.e. urethral catheters or respiratory nebulisers. A medical device may be used for more than one episode on one patient only; the device may undergo some form of reprocessing/decontamination between each use. Advice must be sought from the manufacturer and the Infection Prevention and Control Team on appropriate decontamination methods. N.B single patient use does not include use of scissors to cut bandages or dressings.

Single Use

Single use refers to items that can be used once only and then must be disposed of e.g. single use scissors.

Single Use

Single Patient Use

All single use items carry the single use logo. Single use medical devices must only be used once.

DO NOT REMOVE STERILISED ITEMS FROM PACKAGING UNTIL IMMEDIATELY BEFORE USE (except into a sterile field).

Single patient use means equipment may be used more than once on one patient only.

The device will require cleaning/ decontamination between each use following the manufacturer’s instructions.

Single-Use Device

Any device deemed unsuitable by the manufacturer for re-processing. Such products will be labelled with the words “single-use” or other synonymous reference, and may have the symbol

N.B. Staff members must not re use any single use devices. Staff who disregard this information and prepare single use products for further use, will transfer legal liability for the safe performance of the product from the manufacturer to themselves, or to Provide CIC.

Sterilization

A process that removes or destroys all micro-organisms including bacterial spores.

4. Duties

The Chief Executive Responsible for:

• Ensuring that Provide has an effective Decontamination of Medical Equipment Policy

• Ensuring sufficient resources to comply with this Policy

Director of Infection Prevention and Control

Responsible for:

• Working directly with the Chief Executive

• Strategic responsibility for decontamination of medical equipment

• Leading on decontamination of serious incidents with joint involvement of the Infection Prevention & Control Team

• Working with Provide Infection Prevention Team on specific prevention policies and guidance related to decontamination

Infection Prevention and Control

Responsible for:

• Assisting where appropriate in investigation of serious incidents involving decontamination

• Advising on matters related to decontamination for new buildings and service changes in conjunction with the Head of Estates & Facilities

• Developing and maintaining Provide Decontamination Policy

Head of Estates & Facilities

Responsible for:

• Ensuring Hospitals and all clinics are cleaned to a high standard by monitoring and liaising with all contracted and subcontracted cleaning services

• Approving plans for year-on-year improvements in Hospital cleanliness

• Ensuring robust systems, processes and adequate resources are identified in order to achieve high levels of cleanliness

• In conjunction with the DIPC agree any purchasing decisions or changes in practice that have decontamination implications providing quarterly cleaning reports to the Infection Prevention Group

Health & Safety, and Compliance

Responsible for:

• Ensuring all COSHH risk assessments are in place for the use of chemicals for cleaning and disinfecting equipment in all services.

• Ensuring all COSHH risk assessments are reviewed annually in all services.

Assistant Directors of Services

Each Assistant Director of Service is responsible for:

• Effective decontamination processes in their area of responsibility. This include any item which passes form one patient to another e.g. mattresses, endoscopes and frequently used items such as drip stands and commodes.

• Ensuring that all decontamination processes are in keeping with current national guidance.

• Ensuring that anyone involved in a decontamination process has been adequately trained, has adequate information and has adequate supervision.

• Providing the Infection Prevention Group with evidence of decontamination and compliance for their service as part of their quarterly report via the Perfect Ward app.

• Ensuring monitoring of planned preventative contracts and programmers relating to decontamination including minor theatres and podiatry theatres and podiatry services.

• Ensuring monitoring of planned preventative maintenance contracts and programmes relating to decontamination.

• Ensuring reporting of all decontamination issues to the executive team and Infection Prevention and Control.

• Ensuring adequate decontamination processes and procedures are being used for all equipment.

• Ensuring monitoring of all inter-service transfer of equipment and its decontamination across Provide sites and returned equipment to external companies.

Department/Ward/Clinical Managers

Each Manager is responsible for:

• Delivering a safe, clean care environment with direct responsibility for ensuring that cleanliness standards are maintained. Ensuring that environmental audits are performed monthly via the Ward app. During an outbreak or period of increased incidence of infection, cleaning and audit frequency must be increased.

• Ensuring that all patient equipment is cleaned between patient use to standards as outlined within the National Standards for Healthcare cleanliness (2021)

• Ensuring that correct documentation is completed to evidence that cleaning has been undertaken. To ensure that monthly auditing are performed via the Tendable audit app.

• All equipment that has not been used and is stored must be cleaned weekly signed, dated and labelled with a green I am clean label.

• Weekly/daily cleaning schedules must be signed and audited.

Ward Manager

Ward Manager is responsible for:

• Delivering a safe, clean care environment with direct responsibility for ensuring that cleanliness standards are maintained. Ensuring that environmental audits are performed monthly via the Ward app. During an outbreak or period of increased incidence of infection, cleaning and audit frequency must be increased.

• Ensuring that all patient equipment is cleaned between patient use to standards as outlined within the National Specifications for Cleanliness (April, 2007).

• Ensuring that correct documentation is completed to evidence that cleaning has been undertaken. All equipment that has not been used and is stored must be cleaned weekly signed, dated and labelled with a green I am clean label.

Infection Prevention Link Practitioners

All link practitioners are responsible for:

• Completion of regular audits of cleaning and decontamination of medical equipment using the ward app.

• Spot checks of working area to ensure all cleaning schedules, signage and posters are displayed and up to date.

• Provide assurance that medical equipment used in their areas is decontaminated after use and in good working order. All faulty is reported and taken out of use.

All Staff

All Staff are responsible for:

• Ensuring they comply with the hygiene code.

• Ensuring all equipment used for patient care is decontaminated prior to use and between each patient and is fit for purpose and labelled with green I am clean label.

• Community Nurses to ensure that all equipment used for patient care is effectively decontaminated prior to use and between each patient. All equipment used that day must be taken to a decontamination facility and cleaned and labelled with an “I am clean green label”

• All equipment that is clean and not in use must be stored in a designated clean storeroom. Equipment must be cleaned weekly and labelled with a “I am clean label” any equipment that has been cleaned longer than a week must be decontaminated again.

• All designated storerooms must be cleaned weekly this must be recorded and audited. This includes shelves, storage boxes and brackets. This must be signed on the cleaning schedule when completed.

• All items with a single use symbol and marked as single use MUST not be reused.

All areas should have:

• COSHH Assessments and documentation for cleaning and disinfection products.

• Copy of a planned preventative maintenance programme for decontamination of all equipment.

• Training record of all staff involved in decontamination.

• A dedicated cupboard for disinfection products with secure storage.

• Instructions for using disinfection products.

• The repairs and maintenance of decontamination of equipment are recorded.

• A procedure of escalating and prioritizing requests for maintenance and repairs to the facilities department within Provide.

• A means of formally recording all incidents through DATIX reporting

5. Consultation and Communication

This policy has been circulated to members of the Infection Prevention group for comments and consultation to approve. Ratification of this policy will be formalised by the Quality and Safety committee.

6. Monitoring

The effectiveness of this policy will be monitored through Infection Prevention group and audit reporting programme. Non-compliance of this policy will be monitored through incidents reported through the incident report system datix, for ‘incidents relating to cleanliness of devices and the environment, and those incidences related to decontamination and outbreaks and where notified, of communicable infectious diseases.

7. Key Principles

The overarching principle for this policy is to ensure that Provide CIC staff are informed and instructed in all aspects of the management of cleaning, disinfection and decontamination of patient equipment and the patients’ environment, thus reducing the risk of transmission of micro-organisms and the potential spread of infection.

Table 1: Infection Risks and Categories (Risk Matrix)

(Classification of infection risk associated with the decontamination of medical devices)

Adapted from Medical Devices Agency, Table 9.1 (2015) now MHRA)

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachm ent_data/file/421028/Managing_medical_devices_-_Apr_2015.pdf

Category Definition

HighRisk Items in contact with a break in the skin or mucous membrane or introduced into a sterile body area/ invasive procedure

Medium Risk Items in contact with intact mucous membranes / body fluids or contaminated with particularly virulent or readily transmissible organisms, or items to be used on highly susceptible patients e.g. immunocompromised patients

Low Risk Items used on healthy intact skin, or not in contact with patient.

Example

Surgical instruments, needles, invasive devices, some endoscopes used in sterile body cavities e.g. bronchoscope, cystoscope etc.

Bedpans, Naso-endoscopes and other endoscopes used in non-sterile body sites e.g. gastro-intestinal tract.

Drip stands, mattresses, BP monitors, children’s toys

Recommendedlevelof Decontamination

Cleaning followed by sterilization; methods include: Automated reprocessing systems inc. ultrasonic washer/disinfector/autoclave OR Disposable – single use only

Cleaning and disinfection and/or sterilization; methods include: Automated reprocessing systems inc. washer/disinfector OR Tristel - wipe process for nasoendoscopes OR Disposable – single use only

Cleaning is usually adequate using detergent & water or detergent wipe.

Combined detergent/disinfectant wipes e.g. universal wipes are a popular alternative

The choice of decontamination method should be related to the infection risk associated with the intended use of the equipment. Factors to be taken into consideration when choosing a method of decontamination to include the nature of the contamination, the heat, pressure, moisture, time and chemical tolerance of the object, the availability of processing equipment and the quality and risks associated with the decontamination method.

All medical devices and equipment used in either a hospital or community environment (clinics, community nursing teams) may become contaminated with micro-organisms (microbes) during their use and may present a risk to patients and staff.

8. Risk Assessment

All staff must categorize medical equipment according to the risk that the particular procedure/use of equipment will pose to patients/clients by assessing the microbial status of the body area being manipulated during the procedure. All equipment that is shared by patients poses a potential risk of transmission of infection.

Cleaning between each patient use is the minimum standard required. Please see Risk Assessment Form, Appendix 1.

Risk Assessment for all New Equipment

If no reprocessing information is provided or is inadequate, seek further assistance from the infection prevention team and the manufacturer.

Manufacturers of medical devices (which includes virtually all patient care equipment) are required to provide instructions for the decontamination of reusable products.

All new equipment purchased should have a copy of instructions attached or available in the area in which the equipment is being used.

9. Method of Decontamination

Cleaning and Drying

Thorough cleaning with detergent and hot water is adequate for most items/surfaces in the healthcare environment. Cleaning is essential before disinfection or sterilisation of any item of equipment / instrument can take place.

Cleaning is a mechanical (physical) process which removes soil, e.g. dust, dirt and organic matter (body fluids), along with a large proportion of micro-organisms. A further reduction will occur on drying as many micro-organisms cannot multiply on a clean, dry surface.

Disinfection

Disinfection by either heat or chemicals will destroy micro-organisms, but not bacterial spores. Chemical disinfection does not necessarily kill all micro-organisms present, but reduces them to a level not harmful to health. Heat treatment should always be chosen in preference to chemical disinfection if the equipment can withstand it. It is important to take methods of disinfection into account when purchasing items of equipment to ensure the manufacturer’s recommended process is locally available for use.

Antiseptic

Antiseptic is the term usually employed to indicate that a particular nontoxic disinfectant may be used on skin or living tissues. An antiseptic solution should not be used to disinfect instruments or the environment.

Sterilisation

Sterilisation is a process which achieves the complete destruction or removal of all micro-organisms, including bacterial spores, but with the exception of prion proteins. Equipment and materials used in procedures involving a break in the skin or mucous membranes should be sterilised, e.g. surgical instruments. Sterilisation procedures should always be automated.

Choosing a Method

The choice of method of disinfection or sterilisation depends on a number of factors, which include:

• risk to patients and healthcare workers from equipment

• micro-organisms involved

• type of material to be disinfected

• level of decontamination required for the procedure

• facilities for decontamination

• manufacturers recommendation

Choice of decontamination method should be undertaken prior to purchase of any new item of equipment and should be informed using manufacturer’s recommendations and seeking additional guidance/support from the IPC team and others, where appropriate. Complex items of equipment should have a Standard Operating Procedure (SOP) to ensure effective decontamination and reprocessing by staff.

When Should Reusable Medical Equipment Be Cleaned?

Cleaning must take place:

• between each patient use

• at regular predefined intervals as part of an equipment cleaning schedule

• immediately after contamination with blood or body fluids

• before disinfection or sterilisation

• before inspection, servicing or repair

• prior to disposal

Cleaning Schedules

Local schedules should be established to indicate:

• Frequency of regular cleaning

• Decontamination process/product to use

• Responsibilities of staff undertaking the cleaning process together with documentation requirements

• Frequency of audit of cleaning schedules

• Clean indicator tape should be applied, signed and dated (where appropriate)

Specialist Equipment/Instruments

• Consideration should be given to the purchase, maintenance, repair and reprocessing of all items of specialist equipment/instruments prior to purchase. A cost benefit analysis may be required to determine whether single use equipment may be more cost-effective.

• Surgical instruments must not be cleaned manually, they must be returned to sterile services for decontamination in the blue rigid containers provided. This includes podiatry instruments and surgical instruments used for any minor surgical procedures.

• Some specialist equipment requires cleaning in accordance with the manufacturer’s instructions and prior to returning to SSD for automated

reprocessing. All on-site cleaning must be compatible with the Sterile Services Department’s decontamination processes and supported by a local SOP.

• Where written instructions are not available the department manager must contact the manufacturer for advice. Equipment must not be used where there is no decontamination instruction/guidance.

• Where necessary a local SOP/guideline should be developed by the clinic/service and approved by the Infection Prevention Group prior to implementation.

• Where guidelines for decontamination have been required, or where the equipment decontamination process is complicated, the unit/department manager must ensure that all staff undertaking the decontamination process have been trained, either by a competent member of staff, or by a representative from the manufacturing company. Record of training must be kept in the department and a robust traceability process must be in practice and evidenced and be in line with national guidance. Where competencies are required, this must be recorded and available for audit from service manager. Examples include the decontamination and reprocessing of Nasendoscopes using the Tristel 3-wipe system.

• It is imperative that cleaning products used are compatible with the equipment. Failure to follow the manufacturer’s instructions may invalidate any warranty or service agreement. In addition, incompatible products can lead to degradation of the item of equipment leading to the risk of failure in use. For support with decision-making, contact infection Prevention before purchasing new equipment.

10.Chemical Disinfectants / Antiseptics and Their Uses

Chlorine-Based Disinfectants

These are available in tablet form for dilution at Ward/ Department level.

Chlorine-based disinfectants are:

• Highly effective against a wide range of bacteria and viruses providing a broad spectrum of activity.

• Rapid acting by the release of available chlorine.

• Available in tablet / solution with tablets being easier to store and prepare as well as having a long shelf-life.

• Also available as granules/powders.

• Unstable once reconstituted/diluted and should be freshly prepared every 24 hours and discarded daily. Reconstitution/dilution date/time must be documented.

• Known to discolour fabrics, carpets and soft furnishings and are corrosive when in contact with metals.

• The product of choice for dealing with spillages of blood at a concentration of 10,000ppm

• Used in conjunction with a detergent cleaner as a combined product and are especially useful for terminal cleaning/isolation room cleans.

• Subject to COSHH regulations and all users should have access to COSHH data sheets and assess use where required to do so. See Health and Safety Manual for more information.

• Caustic to skin/mucosa and appropriate PPE should be worn when mixing, handling and disposing of products. PPE to include disposable nitrile gloves and eye protection (goggles, visors etc.)

Alcohol

The limited action of alcohol does not penetrate well into organic matter, especially protein-based body fluids and should, therefore, be used only on physically clean (not soiled) surfaces. Its chemical activity is short-acting as it has no residual activity unless combined with another product (as below).

Uses

• Can be used as a base for other bactericides, such as chlorhexidine or povidone iodine for pre-operative skin disinfecting e.g. 70% alcohol with 2% chlorhexidine. This combines the benefits of alcohol (quick acting/drying) with the broad spectrum of antimicrobial activity over a prolonged period of time which is required to reduce the level of micro-organisms on the skin and maintain them at safe levels during surgical procedures.

• Hand decontamination – Use of alcohol-based hand sanitiser for hand hygiene should not be used when hands are visibly soiled OR when caring for a patient with potentially infectious diarrhoea. See hand hygiene policy IPPOL03.

Chlorhexidine

Is inactivated by soap, organic matter and by some emollients. Available in both aqueous (detergent) and alcohol-based solutions. It is important to use the correct solution.

Uses

• To be used exclusively as an antiseptic for decontamination of skin and mucous membranes (Hibiscrub, Octenisan)

• Chlorhexidine solutions combined with detergent are used for hand disinfection prior to surgery/high impact invasive procedures (Hibiscrub)

• Combined with alcohol for rapid disinfection of physically clean hands (Spirigel)

2% Chlorhexidine Gluconate & 70% Isopropyl Alcohol

Specifically formulated to be effective against skin microbes:

• Broad spectrum of activity against Gram positive and Gram-negative microorganisms as well as most viruses and fungi.

• Rapid – Good reduction in level of organisms within 30 seconds.

• Has residual effect for 48 hours.

• Can be combined with alcohol for skin disinfection e.g. Sanicloth (70% alcohol & 2% Chlorhexidine)

Uses

• For the decontamination of the skin site prior to the insertion of venous access devices or prior to surgical procedures

• Should be used to clean venous access device insertion site during dressing changes and allowed to air dry.

• An aqueous solution of chlorhexidine gluconate should be used if the manufacturer’s recommendations prohibit the use of alcohol with their products.

• Not licensed for paediatric use.

Iodine and Iodophors

• Inactivated by organic matter.

• May corrode metals.

• Dark colour/staining so used with caution in some circumstances.

Uses

• Alcoholic preparations containing iodine and iodophors can be used for preoperative skin preparation.

• Povidone iodine aqueous (detergent) preparations are suitable for surgical hand-disinfection.

11.General Principles of Cleaning

Cleaning removes grease, soiling, body fluids and if undertaken effectively, the majority of micro-organisms. It is an important method of decontamination and must be undertaken prior to additional methods such as disinfection and sterilisation. Used alone it is an effective method of decontaminating low risk items of equipment such as those coming into contact with intact skin e.g. Sphygmomanometer cuff, PAT slide, slings etc.

General Principles of Cleaning

Please refer to appendices 2, 3, 4 and 5

• Use a designated sink / bowl for cleaning (not a hand wash basin)

• Wear protective clothing as appropriate (see standard infection prevention and control precautions policy and cleaning policy)

• Use disposable cloths and discard after each use

• When using universal wipes (detergent & disinfectant) for cleaning equipment ensure you work from clean to dirty and wipe in an S-shaped pattern, taking care not to go over the same area twice.

• Use a neutral detergent and warm water for general cleaning

• Rinse thoroughly to remove detergent residue

• Dry thoroughly after cleaning (using disposable towels where appropriate)

• Decontaminate cleaning equipment after use and change

• Store cleaning equipment clean and dry

• Use automated cleaning methods where required e.g. surgical instruments

Equipment Cleaning Responsibility Framework

As part of the National Specification for cleanliness in the NHS, provide are following the cleaning frequency by risk category guidance and have adapted cleaning frequencies and schedules for all medical equipment within each service area.

Each member of staff should be clear about their roles and responsibilities for the cleaning of medical equipment. Please refer to the table at Appendix 4 – responsibility for cleaning.

Wards

Staff in each ward area have a responsibility to ensure medical equipment is cleaned after each use. Items that have not been used after a week should be cleaned as part of a weekly cleaning schedule. All equipment that has been cleaned must be signed, dated and labelled with an ‘I am clean’ label. All wards should have an IP link practitioner who is required to undertake a monthly audit of equipment decontamination using the Tendable app.

Community services ICT Bases

All ICT bases should have a designated decontamination area for the cleaning of medical equipment. Please see appendix 9 for location of decontamination areas/rooms. All decontaminated equipment must be stored in a clean designated storeroom. This must have in a place a weekly completed cleaning schedule.

All medical equipment that has been decontaminated must be signed, dated and labelled with an ‘I am clean label’. The stainless-steel trolleys used for the decontamination of equipment must be cleaned after each use and the room cleaned on a weekly basis. A cleaning schedule must be completed. All ICT bases should have an IP link practitioner who is required to undertake a monthly audit of equipment decontamination using the Tendable app.

Clinic Areas

All clinic areas must have cleaning schedules in place. Each clinic room must have a daily cleaning schedule which includes all equipment within the room e.g. BP cuff, examination couch, storage trolleys, desktops, telephones and computers. All clinic areas should have an IP link practitioner who is required to undertake a monthly audit of equipment decontamination using the Tendable app.

Storage of Sterile Equipment and Medical Supplies

All staff have a responsibility to ensure all sterile equipment and medical supplies are stored in original packaging in a secure location away from public access. Stored items are at risk of contamination with dust, moisture etc. and should be stored in covered boxes/containers and off the floor. The room, shelving/racking system and storage boxes should have a weekly cleaning schedule completed.

Cleaning Folders

A cleaning folder has been developed and implemented whereby all cleaning information and records relating to a ward/department/clinic/community team is available. These records are held for twelve months.

The cleaning folder should be easily accessible to all staff working in the ward/clinic/team or department.

12.Decontamination of Equipment Prior to Service or Repair

In order to ensure safe systems of work for the protection of all staff, all reusable medical devices and equipment to be inspected, serviced, repaired, returned to the lending organisations or equipment library, or to be disposed of, must be adequately decontaminated to make the item safe during transit and subsequent handling (MHRA 2015) (please refer to Flow Chart at Appendix 5).

Decontamination should always be carried out in accordance with the manufacturer’s instructions.

A Certificate of Decontamination (see Appendix 6) declaring that a piece of equipment is decontaminated must be attached to the item whilst in storage, awaiting collection, during transit and subsequent handling.

If a piece of equipment cannot be decontaminated prior to repair or service, then complete the appropriate part of the certificate indicating the reason for not decontaminating.

13.Training

All staff will receive training as part of induction and are required to read the appropriate policy/guidance/SOP related to decontamination for their area

An individual’s responsibility relating to decontamination will be outlined in their job description and discussed at appraisal.

14.Auditing

Monitoring the cleanliness and storage of all medical devices/clinical equipment is an integral component of Provide clinical audit programme. This provides assurance of safe standards of patient care in compliance with the Code of Practice for the prevention and control of infections (2022) criterion 2.

Further guidance can be found at Health and Social Care Act 2008: code of practice on the prevention and control of infections - GOV.UK (www.gov.uk)

The results from these audits are presented in the quarterly Infection Prevention Group meeting and exceptions are reported to QSC six-monthly.

15.Incident Reporting

Any issues arising in relation to the use of cleaning solutions, e.g. skin / breathing reactions, should be reported to Medigold Occupational Health Department or General Practitioner for further guidance

Incidents where an inappropriate or incorrect procedure in decontamination of medical devices has occurred will be reported using Datix.

Where an incident has occurred that involves an invasive medical device that has been used on a second patient this will be managed in line with the patient safety incident response policy QSPOL15

16.References

Control of Substances Hazardous to Health Regulations (COSHH) (2002)

Control of substances hazardous to health (COSHH) - health and safety topics in cleaning (hse.gov.uk)

Health and Safety at Work etc. Act (1974)

Health and Safety at Work etc Act 1974 – legislation explained (hse.gov.uk)

Health and Safety Executive (2013) Regulations Sharps instruments in healthcare

The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 (legislation.gov.uk)

Health and Social Care Act (2008): code of practice on the prevention and control of infections and related guidance (2022)

Health and Social Care Act 2008: code of practice on the prevention and control of infections - GOV.UK (www.gov.uk)

Health Technical Memorandum (2016) (HTM) 01-01: management and decontamination of surgical instruments (medical devices) used in acute care.

NHS England » (HTM 01-01) Decontamination of surgical instruments

Health Technical Memorandum (2016) (HTM) 01-04: guidance about decontaminating linen used in health and social care.

NHS England » (HTM 01-04) Decontamination of linen for health and social care

Medicines & Healthcare Regulatory Agency (MHRA) (2021) Managing Medical devices: Guidance for healthcare and social care organisations. Managing medical devices - GOV.UK (www.gov.uk)

National Institute for Health and Clinical Excellence (NICE) (2020) Pathway for the prevention and control of healthcare associated infections in primary and community care. Healthcare-associated infections | Topic | NICE

NHS England & NHS Improvement (2021) National standards of healthcare cleanliness.

B0271-national-standards-of-healthcare-cleanliness-2021.pdf (england.nhs.uk)

Appendix 1: Risk Assessment Form

Appendix 2: Detergents/Disinfectants (Commonly Used)

Product Comments on Usage

1.Cleaning(detergentonly)

e.g. Sani-Cloth detergent or Clinell detergent wipes

Multi-surface wipes

2.Patienthandandfacewipes (e.g. Hygea hand and face wipes)

3.Cleaning(detergent) and/disinfectantwipe: Dualactionwipe (e.g. Clinell universal wipes)

Pre-impregnated detergent/disinfectant wipes

4. Alcoholswabs:

Chlorhexidine0.05%IPA70%

(e.g. Steret H). Steret H are single use items.

Cleaningonly(detergent)

These wipes are for cleaning only– they come in large canister size or small handy packs so very portable.

Please refer to manufacturer’s instructions.

For cleaning patient’s hands before meals and/or using bedpan/commode

Please refer to manufacturer’s instructions.

All-purpose cleaning (detergent) and disinfecting wipe for easeofuse

These are for general use across Provide for cleaning all medical equipment between patient uses. The product is skin safe, suitable for any surface/or equipment, antibacterial, alcohol and chlorine free. All clinics and community hospitals use Universal Clinell wipes (green)

Universal (green) Clinell wipes can also be used for hand decontaminationbystaffincommunityservices.

Please refer to manufacturer’s instructions.

SmallEquipmentDisinfectant

Disinfectant wipes come in sachets – very portable – useful for rapid disinfection of small equipment that is not soiled i.e. stethoscopes

Steret H are 30 x 28 mm swabs which are used for the cleansing of skin prior to a ‘stabbing’ procedure e.g. I/M injections, venepuncture/phlebotomy and finger pricks for BM recording. They contain Chlorhexidine, which is a mild antiseptic and Isopropyl alcohol which is a skin cleanser. The Isopropyl alcohol also helps the solution to dry on the skin.

Please refer to manufacturer’s instructions.

5 ChloraPrep

Chlorhexidine prep 2% chlorhexidine gluconate w/v 70% isopropyl alcohol v/v cutaneous solution

Isopropyl alcohol 70% swabs

6. Alcohol70%and Chlorhexidine2%

(e.g. Sani-Cloth CHG 2% disposable disinfection wipes)

Sachets 200 x 128mm

7 Alcoholhandrubs

(e.g. Deb /Cutan hand/gel/ Purell / Gojo)

Recommended by EPIC 3 Guidelines for rapid skin decontamination – used for insertion of all IV devices (peripheralvenouscannulae).

Theseshouldbestoredinadrylockedcupboard.

Please refer to manufacturer’s instructions.

HubsandConnectionPortsDisinfectant

Sterile disinfectant wipes recommended for the disinfection of hubs and connection ports (EPIC 3 and NICE guidance). Sachets – very portable.

Please refer to manufacturer’s instructions.

HandDisinfectants:AllHealthcareWorkers

Rapid decontamination for hands not visibly soiled (recommended by NPSA-5 Moments of Care, and part of Hand Hygiene Policy).

Comes in different sizes to meet your needs (from 800ml dispensers to individual toggles).

Comes in different sizes to meet your needs (from 1000ml cartridge to individual bottles) – this product is also available as foam.

Please refer to manufacturer’s instructions.

8 SurgicalScrub Minorsurgicalproceduresonly

• Chlorhexidine4%aqueous surgicalscrubsolution

• i.e.Hydrexscrub

• HydrexAlcoholhandrub 70%Alcohol

• PovidoneIodine7.5% surgicalscrubsolution 500ml(Videnescrub)

9. Hard surface disinfectant wipes: IsopropylAlcohol70% (e.g.Sani-cloth70)

Pre-impregnated detergent/disinfectantwipes

10.CHLORINE/PREPARATIONS: disinfectants

Hypochlorite solution 10,000 parts per million available

Chlorine (1%) Actichlor plus tablets

Or Surfactant and disinfectant/chlorinedioxide(I.E TRISTEL)Pleaseseebelow:

Surgicalscrub:handdisinfection

Rapid surgical hand disinfectant: following first surgical scrub

Surgicalscrub:handdisinfection

Please refer to manufacturer’s instructions.

Hardsurfacerapiddisinfectant

Comes in a canister or as individual sachets for easy transport. Can only be used on visibly clean surfaces to disinfect,foruseonnon-invasivemedicaldevicesandnonporoussurfaces – meetsEN1276standardwithafastinitial killoflessthanaminute

Thisisarapiddisinfectantanddoesnotleavearesidue

This can be used on keyboards, computer screens and telephones

Forcleaninganddecontaminatingspillagesofblood/blood stained body fluids (i.e. cleaning and disinfection of leg ulcerbucketandwheelchairequipment).

Used in community hospitals wards/minor surgery/tissue viability and the endoscopy unit to reduce the risk of Healthcare Associated Infection. Environmental decontamination of hard surfaces. Health and Safety law requiresallstaffusingthisproducttobetrainedandCOSHH guidancetobefollowedwhenusingsubstanceshazardous to health. (Manager of department to keep a database recordofallstaffusingthisproduct).

Usedforenvironmentaldecontaminationofhardsurfaces; advisedbytheInfectionPreventionTeamduringoutbreak situations.

Please refer to manufacturer’s instructions. 12. Chlorine dioxide product for cleaning floors and work surfaces

(i.e. Tristel Fuse 50ml base solution – 5% solution of citric acidindemineralisedwater)

(i.e. Tristel Fuse 50ml activator solution – 2.1%sodiumchlorite solutionindemineralisedwater)

ThisproducthassupersededActichlor-plusinmostareas becauseitdoesnotrequiredilutioncalculations.Tristelis bothasurfactantanddisinfectantcombined.

Dilution – 1 sachet to five litres of water. Product is sporicidal, mycobactericidal, bactericidal, fungicidal and virucidal.

Please refer to manufacturer’s instructions &COSHH risk assessmentforuseofPPE. Detergent Detergent/Disinfectant

Disinfectant

Appendix 3: Equipment Cleaning for Clinical Staff

ITEM

Anaesthetic

Equipment

RECOMMENDATION

Airways Disposable – single use only

Ambubag Disposable – single use only

Face Mask Disposable – single use only

Laryngoscope blade and handle (resus trolleys only) (1) Disposable – single use only (2) Re-usable – send to CSSD

Re-breathing bags (resus trolleys only)

Audiology

Equipment

Disposable – single use only

Auroscope Speculae Disposable – single use only

Otolights Disposable – single use only

Otoscope Speculum Disposable – single use only

Otosyringes Disposable – single use only

Tympanometry tips Disposable – single use only

Auroscope Clean handle with 70% Alcohol wipe

Baths

Clean with Tristel or domestic cream cleanser: After each use. It is the responsibility of staff to ensure that the bath is cleaned

BathHoists Clean with detergent /disinfectant wipe (e.g. universal wipe –clinell)

Bathmats Single use only –discard after use

Baby Equipment

Apnoea and enuresis monitors Use detergent/disinfectant wipes (Risk assessment)

Baby baths Use detergent/disinfectant wipes

Baby feeding Disposable – single use only

Baby scales

Bottles and teats

Bottle warmer

Breast pumps

Use detergent/disinfectant wipe between use

Disposable – single use only

Use detergent/disinfectant wipes –after each use and replace water daily

Single patient use

Cardiotocograph machine Use detergent/disinfectant wipes

Bath liner

BedEquipment

Disposable – single use only

Bed cradles Use detergent/disinfectant wipes - before/after each use

Bed end clipboard Use detergent/disinfectant wipes - before/after each use

Bed frames and mattress Use detergent/disinfectant wipes - before/after each use

Bedpans and urinals

Bed pans and urinals

Disinfect bedpan washer/washer/disinfector, which reaches a minimum temperatureof80°Cforatleast1minute.Ifthisisoutofaction,then usedisposableanddiscardinorangebagwastestream –aftereach use

BloodPressureCuff Use detergent/disinfectant wipes – before/after each use

BloodGlucose Meter Use detergent/disinfectant wipes- before/after each use

BloodWarmer Use detergent/disinfectant wipes – before/after each use

Blood warmer ancillary parts

Bowls

Patients’ wash bowls

CardiacEquipment

Cardiac and ECG equipment

Disposable – single use only

Bowls are for single patient use only and disposed of when patient leaves. Use detergent/disinfectant wipes – after each use

If patient contact, use detergent/disinfectant wipes unless disposal is necessary (if single use item)

Cardiograph machine Use detergent/disinfectant wipes – before/after each use

Defibrillator Use detergent/disinfectant wipes – before/after each use

Defibrillator pad

ECG machines

Disposable – single patient use

Use detergent/disinfectant wipes – before/after each use

ECG leads Use detergent/disinfectant wipes –before/ after each

ECG pads

Disposable – single use only

Car storage boxes Use detergent/disinfectant wipes –daily clean and weekly clean

Community services refer to SOP Decontamination for medical devicesinCommunity

CatheterBagStands

Re-usable: Use detergent/disinfectant wipes – i.e. before / after each use

ChartHolder Use detergent/disinfectant wipes – i.e. after each use

Commodes Please use detergent & chlorine-based solution for all commodes cleaning (for example Clorox -wipes). DONOTUSE/MIXWITHOTHER PRODUCTS

If a patient has gastro-intestinal infection, a commode must be allocated to the individual patient. It must be thoroughly cleaned & disinfected by wiping over with a chlorine releasing agent When cleaned –green tape must be place around the lid seat and signedasclean/readyforuse.

COMMODES – steamcleaningasperdomesticcleaningschedules.

Computerscreens& Laptops/hand held electronic screens/mobilework phones.

Curtains

Use Universal cliniell wipe or 70% Isopropyl Alcohol wipes (non-residue)

Disposable curtains: routine change depending on functional risk category of room and in between if visibly soiled/contaminated. Please check date on curtains

Crutches Use detergent/disinfectant wipes –before and after use

DentalEquipment Not used by provide services

Doppler Use detergent/disinfectant wipes - before and after use

Community services refer to SOP Decontamination for medical devicesinCommunity

DressingTrolleys Use detergent/disinfectant wipes - before and after use

DripStands Use detergent/disinfectant wipes – before and after use

Earphones Use detergent/disinfectant wipes -in between each patient use

Earphone Sponges Disposable – single patient use only

Easi-slide Mattresses Use detergent/disinfectant wipes –before and after use

EndoscopesFlexible Decontaminated in Automated Endoscopic Reprocessor (AER).

ExaminationCouches Use detergent/disinfectant wipes – in between patient use. The paper overlay should be changed in between patients.

GlucoseMeters (Glucometer)

Use detergent/disinfectant wipes –after each use

Community services refer to SOP Decontamination for medical devicesinCommunity

GrabRails Use detergent/disinfectant wipes –after each patient use

Hoists Use detergent/disinfectant wipes –after each patient use

HoistSlings

Humidifiers

Intravenous injection tray

Community services refer to SOP Decontamination for medical devicesinCommunity

Use for each patient duration of stay (label for patient) to be single use per patient :

or / Use detergent/disinfectant wipes –in between each patient only if wipeable

Send covers to sunlight laundry after patient discharge or visibly soiled.

For patient with infection Use –single –use slings

Single patient use. Store dry when not in use. When in use, fill with sterile water.

How are these cleaned?

Clean with detergent & disinfectant wipe (clinell): before and after use

Intravenous device ports&hubs

IVPUMPS

IVstands

Infusion Pumps Including Enteral Feeding Pumps, Syringe Drivers and VolumetricPumps

InfusionGivingSets

Jugs for Emptying UrineCatheter Bags

Lifting Aids e.g. Blue Straps, Banana Strap, Patslide

LinenTrolley

Chlorhexidine 2% &alcohol 70% alcohol (Sani-cloth CHG 2%)

Use detergent/disinfectant wipes – i.e. before/after each use

Use detergent/disinfectant wipes – i.e. before/after each use

Use detergent/disinfectant wipes – i.e. before/after each use. Community services refer to SOP Decontamination for medical devices in Community for syringe driver and Renasys negative pressurepump.

Disposable – single patient use only

Disposable – single patient use only

Use detergent/disinfectant wipes – before/after each patient use

Use detergent/disinfectant wipes –after each use

Clean daily and record on cleaning schedules

Mattresses Should be covered with a sealed water-impermeable cover. Use detergent/disinfectant wipes –after each patient use. Do not use alcoholbased wipes as degrades cover causing permeability.

In case of blood/body fluid contamination, use a chlorine-based disinfectant, e.g. Tristel, If cover is torn or porous it must be sent for incineration.

Recordonmattressauditform

Medicinepots Disposable –single use only

MOPS

Change mop header and launder. Clean trolley with Tristel

Nasal Speculae Disposable – single patient use only

NebuliserMasks Disposable – single patient use only

Nebulising Machine

Orthopaedic

Accessories e.g. Abduction Pillows, Beams, Poles, Supports, Wedges, Weights

OxygenMask

Oxygen Saturation Monitors (Portable and Fixed Standing)

PatientTrolleys

Use detergent/disinfectant wipes –before and after use

Use detergent/disinfectant wipes – before after each use

Disposable – single use only

Use detergent/disinfectant wipes – i.e. before/ after each use

Use detergent/disinfectant wipes – i.e. before and after each use

Pillows Should be covered with a sealed water-impermeable cover.

Use detergent/disinfectant wipes – i.e. Universal wipe –Clinell after each patient use and when visibly soiled. In case of blood/body fluid contamination, use a chlorine-based disinfectant, i.e. Tristel

If cover is torn or porous it must be sent for incineration.

Plinths(treatment)

Use detergent/disinfectant wipes – i.e. before / after each use

Pressure Relieving Overlays

Use detergent/disinfectant wipes – i.e. before/ after each use

Pulse Oximeters Use detergent/disinfectant wipes – i.e. before/after each use

Community services refer to SOP Decomtamination for medical devicesinCommunityforhandhelddoppler

Razors Disposable – single patient use only: Discard into sharps bin.

Sand Bags

This item should have a waterproof cover. Use detergent/disinfectant wipes – before/ after each use.

Scales Use detergent/disinfectant wipes – before/ after each use.

Scissors

Sigmoidoscope: Rigid

Community services refer to SOP Decomtamination for medical devicesinCommunityforhandhelddoppler

Disposable – single use only

Disposable – single patient use only

Sphygmomanometer Use detergent/disinfectant wipes – i.e. before/ after each

Spirometer

Mouthpiece

Splint e.g. Arm, Fingersplint

Disposable – single patient use only

Use detergent/disinfectant wipes – i.e. before/ after each use

Splintsandwalking Frames Use detergent/disinfectant wipes – i.e. before/ after each use

Stethoscope Use detergent/disinfectant wipes – i.e. before/ after each use

SuctionApparatus

Suctioncatheter

Suctionjars

Suctiontubing

Disposable – single use only. Preferably do not connect to tubing until required. If necessary to keep connected, ensure it is stored with the packaging cover in place.

A disposable liner or receptacle must be used.

SurgicalInstruments Send to CSSD

Syringes

Disposable – single use only

SyringeDrivers Use detergent/disinfectant wipes – before-after each use, Community services refer to SOP Decomtamination for medical devices in Communityforsyringedriver.

Toys Only use plastic washable toys. Use detergent/disinfectant wipes – i.e. Clinell universal wipe daily (after each clinic when in use) or sooner if visibly soiled.

Trolleys – Dressing

Soft fluffy toys are not easily cleaned and are, therefore, not recommended.

Use detergent/disinfectant wipes – i.e. Clinell universal wipes after each use

Thermometers Use disposable or thermometers with disposable sleeves /covers clean before after patient use: Chlorohexidine 2%& alcohol 70 % wipe For infrared thermometer see Community services refer to SOP DecomtaminationformedicaldevicesinCommunity

UltrasoundMachine

Urinals

Vaginal Speculae

Vaginal Probe

Vomit bowls

Wheelchairs

Work Surfaces (Clinical areas)

Use detergent/disinfectant wipes – i.e. Clinell universal wipes after each use

Wash in a well-maintained bedpan washer/washer/disinfector, which reaches a minimum temperature of 80°C for at least 1 minute

Disposable – single use only

Disposable – single use only

Disposable –single use only

Use detergent/disinfectant wipes – i.e. after each patient use and at the end of the day

Use detergent/disinfectant wipes – i.e. daily unless visibly contaminated

Appendix 4: Responsibility for Cleaning (2021)

Element

1. Overall Appearance

2.OdourControl

3. Commodes, weighing scales, manual handling equipment

4. Medical equipment e.g. intravenous infusion pumps drip stand, pulse oximeters,etc.NOT CONNECTED TO A PATIENT

5. Medical equipment e.g. intravenous infusion pumps drip stand, pulse oximeters, etc. CONNECTED

6. Patient washbowls – single patientuse

7. Bedside oxygen and suction connectors, earpieces for bedside entertainment system

8.Patientfans

9. Bedside alcohol hand wash gel, clipboards and noticeboards

10.Notesanddrugs trolley

11.Patientpersonal items e.g. soft toys and games consoles

12.Linentrolley

13.

33.Chairs

34.Beds

35.Lockers

36.Tables

37.

39.

46. Toilets and bidet 3thoroughcleans

47.Replenishment 3timesdaily 3timesdaily 1timesdaily 1 times daily

48.Sinks

49.Bath

(AdaptedfromNationalSpecificationsforCleaning – MinimumCleaningFrequenciesby RiskCategory)

Nursing/Clinical responsibility for cleaning

Contracted or in-house cleaner responsibility for cleaning

Estates responsibility for cleaning

Window Cleaning Contractors

Appendix 5: Equipment Flowchart

Appendix

Appendix

7:

Dilution Chart for Hypochlorite Solutions:

Dilution Chart for Hypochlorite Solutions decontamination of reusable non invasive care equipment

Appendix 8: HII HCAI Cleaning & Decontamination Audit Tool

Auditor:

Question

Staffcan accesstheDecontaminationpolicy/ Standard Operating Procedure (SOP) for decontamination of clinical equipment

Universalwipesareavailableforthecleaning of equipment

Disposable gloves are worn when decontaminating equipment

Disposable aprons are worn when decontaminating equipment where splashing may occur

Eye protection e.g. goggles are available and worn if there is a riskof splashing to the eyes when decontaminating equipment

Staff are aware that equipment should be decontaminated starting from the top and working downwards – ask staff at random

There is documentary evidence that equipment stored ie not currently in use has been decontaminated e.g. cleaning schedule or I am Clean sticker dated within last 7 days

All equipment is in a good condition/state of repair e.g no rust, label residue or damage which could prevent cleaning

Equipment check:

Check a minimum of 5 items of equipment which MUST include commodes (if used). Items must be free from body fluid stains, dust, dirt, debris etc. List all items checked:

Date of Audit:

Compliant N/C N/A

Comments

Appendix 9: Location of Decontamination Rooms/Areas for Provide CIC

Halstead ICT

Halstead Hospital

78 Hedingham Road

Halstead

Essex

CO9 2DL

Witham ICT

Witham Healthcare Centre

4 Maryland Road

Witham

Essex

CM6 2UX

Maldon ICT

St Peters Hospital

Spital Road

Maldon

Essex

CM9 6EG

Braintree ICT

Tekhnicon House

Springwood Drive

Braintree

Essex

CM7 2YN

Chelmsford ICT

Kestrel House

Hedgerows Business Park

Chelmsford

CM2 5PF

Burnham ICT

Burnham Clinic

Burnham-on-Crouch

CM0 8DX

Crouch Vale Medical Centre

Crouch Vale

South Woodham Ferrers

Chelmsford

CM3 5QP

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Decontamination of Medical Equipment

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Guidance for staff to ensure appropriate decontamination of all equipment is undertaken by Provide staff.

Project/Policy Manager: Specialist Infection Prevention Nurse Date: January 2024

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Positive Review date

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

N/A

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

N/A

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

N/A

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/A

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/A

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

N/A

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age

© MDA 2007 EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’

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