Accompanied By (if applicable) : 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Index
Introduction
How to use this audit tool
Section 1 General
Section 2 Toilet Area
Section 3 Shower Area
Section 4 Sluice Room (Disposal)
Section 5 Domestic Services Room
Section 6 Consulting Room / Treatment Room
Section 7 Local decontamination (contact Infection Control Team for information) Section 8a Kitchens General
Section 8b Kitchens - Refrigerator
Section 8c Kitchens - Cookers / Microwaves
Section 8d Kitchens - Dishwashing
Section 8e Kitchens - Training
Section 9 Handwashing Facilities
Section 10 Waste Disposal
Section 11 Sharps Handling & Disposal
Section 12 Linen Storage, Bagging & Laundering
Section 13 Clinical Practice
Section 14 Cleaning & Disinfection
Section 15 Care of Equipment
Section 16 Staff Facilities
Section 17 Vaccine Storage
Section 18 Minor Surgery
Section 19 Baby Changing Facilities
Scoring Summary
Action Plan
Example Audit Calendars
Recommended Reading 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Introduction
In recent years there has been an increase in concern about the risks to health from receiving treatment and care. The Clinical Standards Board for Scotland published standards for Healthcare Associated Infection (HAI) Infection Control, December 2001 (Ref: ISBN 1-903766-12-5), a copy of which can be obtained from Trust Clinical Standards Facilitator (0141 211 3916). These standards are used by the NHS Quality Improvement Scotland, to assess the quality of Infection Control provided in both the Primary Care and hospital settings throughout Scotland.
As part of the process of ensuring that these standards are met, as well as ensuring that the quality of the infection control practice within the Trust is of a high standard, the Prevention and Control of Infection Team has developed an Infection Control Environmental Audit Tool. This audit tool defines the acceptable standards for a managed environment which minimises the risk of infection to patients, staff and relatives. These standards reflect current legislation, national guidelines and good practice of infection control within a healthcare environment. To ensure that staff at a local level has ownership of the standards, the Head of Department or nominee should demonstrate compliance through self assessment using the audit tool provided.
The Environmental Audit tool is divided into sections containing the relevant standard and criteria, not all sections may be applicable to your area. It is anticipated that the relevant sections of the audit tool are completed at least once a year by staff at local level, As hand washing is the single most important means of preventing the spread of infection, section 9 hand washing facilities should be completed on a monthly basis.
It is advised that the section on how to use this audit tool is read, prior to undertaking the audit.
Further information in relation to the self assessment process or audit tool can be obtained by contacting a member of the Prevention and Control of Infection Team by:
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How to use this audit tool
1. Inpatient areas; Heads of Department or nominated member of staff should identify and complete all sections relevant to their area. Outpatient areas (i.e. Health Centres, Resource Centres) For ease of collation and reporting an identified person within the locality should be responsible for distribution of relevant sections of audit tool to areas and in collating the return of completed action plans and scores to the Infection Control Team (ICT) within the required time frame.
2. Section 9 Handwashing Facilities should be completed on a monthly basis locally, however score and action plan need only be returned to ICT as indicated by timeframe identified by score.
3. Other relevant sections should be completed at least yearly, or as indicated by scoring achieved (see scoring sheet for more details) or by the Infection Control Team in the returned summary report
4. It is suggested that an audit calendar (enclosed) should be completed to chart the relevant sections indicating when re-audit is required
5. To each criterion within the relevant sections, place a cross in the appropriate box (Yes, No or Not Applicable)
6. All criteria which are not fully met require action. However, there are some criteria that require immediate action. These criteria are clearly marked.
7. An action plan, available at the back of the document, should be completed for all actions, indicating realistic timeframes (Immediate actions should be included). To assist in completing your action plan a copy of the Infection Control Team action plan for all sections and criteria is available within the intranet and Public Folder- infection control. For any further advice, contact a member of the Infection Control Team. A Copy of the action plan, score and copies of Infection Control audit reports should be retained at ward/department level as evidence of compliance with these standards, which will be reviewed by the Infection Control Team as part of their planned audit programme.
8. A copy of each completed section score and action plan should be returned via identified person (if applicable) i.e. HAI lead, to the Infection Control Team within given timeframe by email to Sarah.Caulfield@gartnavel,glacomen.scot.nhs.uk, or by post to Sarah Caulfield, Secretary to Risk Management Department, Ward 4, Risk Management department, 1055 Great Western Road, Glasgow, G12 OXH.
9. Your Department will be given a summary report and advice on when to re-audit by the Infection Control Team
10. The ICT will collate a response for overall Primary Care Division Performance to NHS Quality Improvement Scotland (Clinical Standards Board Scotland) Healthcare Associated Infection (HAI) Infection Control, reporting any common themes, challenges, good practice through the Infection Control Committee and Risk Management Advisory Group 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 1 General Standard: The general environment will be maintained appropriately to negate the risk of cross infection
Criteria Yes No N/A Action 1.1 Chairs/tables/trolleys and lockers are clean and in a good state of repair. Immediate 1.2 All floor coverings are clean and in good state of repair. Immediate 1.3 Dust is not present on high horizontal surfaces. 1.4 Low level surfaces are clean and free from dust 1.5 Where extractor fans are in operation, they must be clean and free from dust. 1.6 Curtains and blinds are clean and in good repair 1.7 If toys are available, they are clean, in a good state of repair and capable of being cleaned and withstanding chemical disinfectants. Immediate 1.8 There is a cleaning schedule available within the ward/department Total
Comments
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Section 2 Toilet Area Standard: The toilet area will be maintained appropriately to negate the risk of cross infection.
Criteria Yes No N/A Action 2.1 The toilet area and fixtures are clean and dry Immediate 2.2 The toilet area is free of extraneous items 2.3 The fixtures and fittings are in good repair 2.4 Handwashing sinks are fitted with mixer taps 2.5 Handwashing sink is clean Immediate 2.6 Liquid soap is available at all Handwashing sinks Immediate 2.7 Liquid soap dispensers are clean Immediate 2.8 Disposable paper towels are available in a wall mounted dispenser. 2.9 Waste disposal facilities are appropriate See Section 10 Waste Disposal 2.10 Toilet seats and toilet aids are clean and dry Immediate 2.11 Sanitary disposal is available in female toilets 2.12 There is a cleaning schedule available Total
Comments
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Section 3 Shower Area Standard: The shower area will be maintained appropriately to negate the risk of cross infection.
Criteria Yes No N/A Action 3.1 Shower areas are clean and dry and in good state of repair Immediate 3.2 The area is free of extraneous items i.e. creams, bedpans 3.3 The shower area furnishings/fittings are in good repair e.g. tiles, flooring 3.4 Shower curtains are clean Immediate 3.5 Shower chairs are clean and dry Immediate 3.6 Waste disposal facilities are appropriate i.e. foot operated sack holders with domestic waste sack 3.7 Showers are run daily prior to use 3.8 Anti-slip bath/shower mats are clean and hung dry over the bath rail between use 3.9 There is a cleaning/replacement schedule for shower curtains Total
Comments
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Section 4 Sluice Room (Disposal) Standard: The sluice room will be maintained appropriately to negate the risk of cross infection.
Criteria Yes No N/A Action 4.1 Surfaces and fittings are clean, dry and free from spillages Immediate 4.2 All surfaces and fittings are in good repair and free from extraneous items Immediate 4.3 There is a sink for washing equipment e.g. bedpan shells, suction jars. 4.4 There is a dedicated handwashing sink 4.5 Handwashing sinks are fitted with mixer, elbow/wrist operated taps 4.6 There is a wall mounted antiseptic scrub/liquid soap dispenser Immediate 4.7 Disposable paper towels are available in wall mounted dispenser Immediate 4.8 Waste disposal facilities are appropriate See Section 10 waste disposal 4.9 The macerator is clean and functioning 4.10 Bedpan racks are clean Sub-total
Comments
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Section 4 (contd) Sluice Room (Disposal)
Criteria Yes No N/A Action Sub-total (from previous page) 4.11 Commodes are clean, ready for use and in a good state of repair Immediate 4.12 Bedpan holders and jugs are stored clean, inverted or on racks 4.13 Wash bowls are stored clean and dry and inverted, or patients own are stored in locker Immediate 4.14 Sterile packs/equipment are not stored in the sluice Immediate 4.15 Chemical reagents are kept in a locked cupboard Immediate 4.16 If nurses green sluice mops and buckets are available mop and bucket is correctly colour coded (green). buckets are stored clean, dry and inverted mop heads laundered after each individual use.
Total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 5 Domestic Services Room Standard: The domestic services room will be maintained appropriately to negate the risk of cross infection.
Criteria Yes No N/A Action 5.1 Surfaces and fittings are clean and in good repair Immediate 5.2 The floor is clean, dust free and free from spillages Immediate 5.3 There is a Belfast sink or deep sink available for cleaning equipment 5.4 There is a dedicated handwashing sink 5.5 Handwashing sinks are fitted with mixer, elbow/wrist operated taps 5.6 Liquid soap is available and dispenser is clean Immediate 5.7 Disposable paper hand towels are available in wall mounted dispensers Immediate 5.8 Only items used for the purpose of cleaning are stored in the room 5.9 Protective clothing is available i.e. plastic aprons, gloves 5.10 Cleaning agents are suitably stored in a locked cupboard Immediate 5.11 The equipment used by the Domestic staff is clean, well maintained and stored securely. 5.12 Mopheads are laundered daily Immediate 5.13 Mopheads are stored upright Immediate 5.14 Rubber gloves are stored clean and dry Immediate Sub-total
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Section 5 (cont'd) Domestic Services Room
Criteria Yes No N/A Action Sub-total (from previous page) 5.15 Buckets are stored clean, dry and inverted Immediate 5.16 Colour coded mops, heavy duty gloves, disposable cloths are used appropriately: Red for Toilet Yellow for Kitchen Blue for General
5.17 There is no evidence of used disposable cloths Immediate 5.18 Spray cleaners are stored clean, empty and dry Immediate 5.19 Cleaning schedule is available Total
Comments
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Section 6 Consulting Room / Treatment Room Standard: The consulting room/treatment room will be maintained appropriately to negate the risk of cross infection.
Criteria Yes No N/A Action 6.1 Surfaces/fixtures are visibly clean, dry and in good repair Immediate 6.2 Room is free from extraneous items 6.3 Sterile packs, dressings etc are stored off the floor in closed cupboards 6.4 Items are stored above floor level Immediate 6.5 There is an effective stock rotation system 6.6 Items of sterile equipment are in date (randomly select 2 items and check date) 6.7 There is a dedicated handwashing sink Immediate 6.8 Handwashing sinks are fitted with mixer, wrist/elbow operated taps Immediate 6.9 There is a wall mounted antiseptic soap/ liquid soap dispenser Immediate 6.10 An alcohol hand rub is available for use when recommended by Infection Control Staff Sub-total
Comments
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Criteria Yes No N/A Action Sub-total (from previous page) 6.11 Waste disposal facilities are appropriate. See section 10 Waste Disposal 6.12 Sharps container is available and stored safely Immediate 6.13 Equipment is stored clean and dry Immediate 6.14 Medicine trolleys are clean Immediate 6.15 Dressing trolleys are cleaned with detergent and water before each session and whenever contaminated Immediate 6.16 Dressing trolleys are wiped with 70% alcohol or detergent wipes between cases 6.17 Examination couch is clean, surface intact with wipeable surfaces Immediate 6.18 Disposable paper towel is used to protect the couch and changed between patients Immediate 6.19 Cover blankets are laundered weekly or after contamination 6.20 Drug fridge is clean, free of extraneous items and is defrosted regularly Immediate Sub-total
Comments
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Criteria Yes No N/A Action Sub-total (from previous page) 6.21 Drug fridge temperature is recorded daily and is within safe zone (2-8C) Immediate 6.22 Suitable protective clothing is available i.e. plastic aprons, disposable gloves, protective eyewear Immediate 6.23 Lotions in lotion cupboard are stored appropriately and identified for individual patient use when required Immediate 6.24 NHS Greater Glasgow Management of needlestick injuries flipchart is available Immediate 6.25 Specimens are stored in suitable washable container before transporting to the lab. Immediate Total
Comments
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Section 7 Local Decontamination Contact Infection Control Team. Standard: Re usable instruments are effectively and safely decontaminated after each use to negate the risk of cross infection
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Section 8a Kitchens General Standard: The kitchen will be maintained appropriately to negate the risk of cross infection.
Criteria Yes No N/A Action 8a.1 An identified handwashing sinks, liquid bactericidal soap and paper towels are available. Immediate 8a.2 All work surfaces are clean, intact and impervious Immediate 8a.3 All work surfaces are cleaned after each meal with bactericidal detergent and hot water and dried Immediate 8a.4 A bactericidal detergent is used for cleaning the kitchen surfaces and crockery Immediate 8a.5 A disposable cloth is used for cleaning the kitchen surfaces and crockery and is discarded after use. Immediate 8a.6 Hands are washed and a clean plastic apron is worn to serve patient meals/beverages Immediate 8a.7 Kitchen surfaces (walls, ceilings, work surfaces and floors) are intact and washable. 8a.8 Inappropriate items are not stored on the work surfaces Immediate 8a.9 Disposable paper towelling is used to dry surface areas after cleaning. Immediate 8a.10 Dishes are left to air dry or dried with disposable paper towels Immediate 8a.11 Correct cleaning materials used in the kitchen are stored separately from other ward cleaning equipment, and away from food. Immediate 8a.12 All opened food (e.g. cereals) is stored in pest proof containers or packets are appropriately sealed. Immediate Sub-total
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Section 8a (contd) Kitchens General
Criteria Yes No N/A Action Sub-total (from previous page) 8a.13 All food waste is removed from the kitchen after each meal e.g. via food disposal unit within the sink or double black bags. Immediate 8a.14 Extractor fans are clean and in good working order. Immediate 8a.15 Open windows must have a mesh screen or Insecta flash, to prevent insects entering the kitchen. 8a.16 Bread is stored in a clean bread bin or covered container Immediate 8a.17 Stocks of any foods are within date and there is a system of stock rotation Immediate 8a.18 Access to the kitchen should be restricted and not used as a thoroughfare. Immediate 8a.19 There are no inappropriate items or equipment in the kitchen e.g. staff hand bag/personal belongings. Immediate 8a.20 There is no evidence of infestation or animals in the kitchen. Immediate 8a.21 Wooden boards, spoons and rolling pins are only used in rehabilitation departments under supervision. Immediate 8a.22 Notices within the kitchen are kept to a minimum, laminated and are in date. Immediate 8a.23 Colour coded yellow mops, rubber gloves etc are used Immediate 8a 24 There is a clean, functioning foot operated waste bin Total
Comments
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Section 8b Kitchens Refrigerator
Criteria Yes No N/A Action 8b.1 The temperature of the refrigerator is recorded daily and is between 0 4C Immediate 8b.2 Freezer temperature is recorded daily and is below minus 18C Immediate 8b.3 Patient food in the fridge is labelled with name/date as per Trust/local policy. Immediate 8b.4 Items stored in the refrigerator are covered Immediate 8b.5 Food is properly stored and marked with use by date Immediate 8b.6 There is no food past the expiry date in the fridge. Immediate 8b.7 Milk is stored under refrigerated conditions, with outer polythene wrapping removed Immediate 8b.8 All dairy products are refrigerated and within expiry date Immediate 8b.9 Raw food is absent from ward refrigerator e.g. eggs, meat or fish Immediate 8b.10 Where indicated on the label, sauces and preserves are stored in the refrigerator after opening. Immediate 8b.11 Non food items are absent from the refrigerator i.e. drugs or specimens Immediate 8b.12 All refrigerators are externally clean and door seals intact. Immediate 8b.13 Refrigerator is clean internally and defrosted weekly Immediate Total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 8c Kitchens Cookers / Microwaves
Criteria Yes No N/A Action 8c.1 The cooker is clean and free from food stuffs Immediate 8c.2 Microwave ovens, if present, are clean and used for staff food only Immediate 8c.3 Microwave ovens, if present, interior and exterior is clean and free from spillages Immediate Total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 8d Kitchens Dishwashing
Criteria Yes No N/A Action 8d.1 All crockery and cutlery is thermally disinfected or washed with bactericidal detergent Immediate 8d.2 There is a functioning dishwasher or double sink designated to wash crockery and cutlery. Immediate 8d.3 Dishwasher is clean, appropriate solutions are used and the machine reaches 80C or above for the final rinse Immediate 8d.4 A disposable cloth is used for washing dishes only and disposed of after use. 8d.5 Green scourers are not used Total
Comments
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Section 8e Kitchens Training
Criteria Yes No N/A Action 8e.1 All staff designated as food handlers have received food hygiene training. Immediate 8e.2 Patients are supervised when involved in the preparation of food. Immediate 8e.3 If used, food temperature probes are maintained and cleaned in between uses with approved bactericidal wipes. Immediate Total
Comments
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Section 9 Handwashing Facilities Standard: Handwashing facilities should be appropriate to negate the risk of cross infection.
Criteria Yes No N/A Action 9.1 Wash hand basins are fitted with mixer taps with single pillar and no plug Immediate 9.2 Wash hand basins are fitted with wrist/elbow operated taps Immediate 9.3 Basins are suitably situated to encourage use 9.4 Basins are clean and intact Immediate 9.5 Liquid soap is available Immediate 9.6 Liquid soap dispensers are available at all wash hand basins Immediate 9.7 Liquid soap dispensers are clean and dry Immediate 9.8 Paper towel dispensers and towels are available at all sinks Immediate Sub-total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 9 (contd) Handwashing Facilities
Criteria Yes No N/A Action Sub-total (from previous page) 9.9 Foot operated waste bins with appropriate liner is provided for paper waste. See section 10 Waste Disposal Immediate 9.10 Handcream, if it is available, is in pump dispenser Immediate 9.11 No fabric towels are seen at handwashing sinks Immediate 9.12 The sinks are free from used equipment e.g. medicine pots Immediate 9.13 Alcohol hand gel is available for use when specified by the Infection Control Staff 9.14 Laminated posters demonstrating a good handwashing technique are available at sinks 9.15 Hands are washed/decontaminated as hand hygiene technique described in the Prevention and Control of Infection Manual (observe 2 members of staff)
Total
Comments
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Section 10 Waste Disposal Standard: Waste is disposed of safely without the risk of contamination or injury.
Criteria Yes No N/A Action 10.1 Black bags are available for the disposal of domestic waste Immediate 10.2 Yellow bags are available for the disposal of clinical waste Immediate 10.3 Waste is segregated according to Waste Policy Immediate 10.4 An adequate number of bins are available for use 10.5 Pedal operated bins are in use Immediate 10.6 Pedal operated bins are functioning 10.7 Pedal operated bins are clean Immediate 10.8 Bags are sealed securely Immediate 10.9 Bags are no more than 3/4 full Immediate 10.10 Identification tape and label are available and in use Immediate 10.11 Waste is stored in a suitable designated area prior to uplift Immediate 10.12 The storage area is kept clean Immediate 10.13 Waste bags are stored safely from the public Immediate 10.14 The disposal area is locked and inaccessible to unauthorised persons Immediate Sub-total
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Section 10 (contd) Waste Disposal
Criteria Yes No N/A Action Sub-total (from previous page) 10.15 Clinical and domestic waste is stored separately Immediate 10.16 All staff who handle waste bags and containers have received appropriate training Immediate 10.17 Cytotoxic waste is disposed through the approved channel (ask 2 staff) Immediate Total
Comments
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Section 11 Sharps Handling & Disposal Standard: Sharps will be handled safely to negate the risk of sharps injury.
Criteria Yes No N/A Action 11.1 Sharps containers in use comply with BS7320/UN3291 Immediate 11.2 Sharps containers are assembled correctly. Immediate 11.3 Sharps containers are labelled and dated following Waste policy. Immediate 11.4 Sharps containers are less than 2/3rds full. Immediate 11.5 Sharps container is free from protruding sharps. Immediate 11.6 Sharps are disposed of directly into a sharps box. Immediate 11.7 When administrating medication via injection, a sharps container (of suitable size) is taken to the point of administration (ask two members of staff). Immediate 11.8 Needles are discarded without being re-sheathed Immediate 11.9 NHS Greater Glasgow Management of needlestick injury flipchart is available and accessible. 11.10 Sharps containers are safely stored and do not present a risk to patients. Immediate 11.11 Sharps containers are safely stored in a designated area prior to uplift. Immediate Total
Comments
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Section 12 Linen Storage, Bagging & Laundering Standard: Linen is handled appropriately to prevent cross infection.
Criteria Yes No N/A Action 12.1 Clean linen is suitably stored, above floor level in a clean area, protected from contamination Immediate 12.2 White laundry bags are available for used linen Immediate 12.3 Red alginate bags are available for fouled/infected linen Immediate 12.4 Blue laundry bags are available for personalised clothing Immediate 12.5 Used linen is segregated according to Laundry Policy.(Ask 2 members of staff) Immediate 12.6 Linen bags are less than 2/3rds full and capable of being secured Immediate 12.7 Linen buggies are available and in use 12.8 Used linen is stored in a designated area Immediate 12.9 Used linen is regularly uplifted 12.10 Staff wear disposable plastic aprons and gloves when handling soiled/infected linen Immediate Sub-total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Criteria Yes No N/A Action Sub-total (from previous page) 12.11 If laundry facilities at ward level; washing machine is situated in a designated area and guidance for use is complied with
12.12 There is evidence that washing machine is maintained and serviced 12.13 Handwashing Facilities are available in the laundry room Immediate Total
Comments
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Section 13 Clinical Practice Standard: Clinical Practice will reflect Infection Control guidelines and negate the risks of cross infection to patients whilst providing appropriate protection to staff
Criteria Yes No N/A Action 13.1 Staff can locate the Prevention and Control of Infection Manual. Immediate 13.2 Powder free non-sterile gloves are available. Immediate 13.3 Powder free sterile gloves are available if required. Immediate 13.4 Disposable plastic aprons are available. Immediate 13.5 Eye protection is available (shatter proof may be required in some areas). Immediate 13.6 Specimens are collected following Standard Precautions 13.7 Specimens are well secured in re-sealable clear plastic bags 13.8 Specimens and form are clearly labelled 13.9 Specimens are stored in a secure separate designated washable container 13.10 Waterproof plasters are available for use to cover cuts and abrasions Immediate Sub-total
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Section 13 (contd) Clinical Practice
Criteria Yes No N/A Action Sub-total (from previous page) 13.11 Non sterile gloves are worn for emptying urinary catheter bags. Immediate 13.12 A disposable receptacle is used for emptying urinary catheter bags. Immediate 13.13 Catheter stands are in use, there are no catheters/bags touching the floor. Immediate Total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 14 Cleaning & Disinfection Standard: Disinfectants are available and used correctly to prevent cross infection.
Criteria Yes No N/A Action 14.1 General purpose neutral detergent is available Immediate 14.2 Chlorine releasing disinfectants are available e.g. chlorine spillage kit, Titan Sanitizer, Actichlor Immediate 14.3 Disinfectants are used in accordance with manufacturers instructions 14.4 Impervious flooring such as vinyl is used whenever body fluid spillage is frequent and predictable 14.5 Carpets are impervious and bleach resistant 14.6 All furniture/equipment is capable of being cleaned/ decontaminated 14.7 Cleaning and disinfectant agents are stored appropriately Immediate 14.8 Spillages of blood and other body fluids are appropriately cleaned and disinfected (ask two staff members)
14.9 Medical devices marked as single use are not re-used Immediate 14.10 Single patient use devices are used only for individual patient and destroyed on completion of treatment
Sub-total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 14 (contd) Cleaning & Disinfection
Criteria Yes No N/A Action Sub-total (from previous page) 14.11 Decontamination guidelines are available and staff are able to resource this information (Ask two staff) Immediate 14.12 COSHH Data sheets are available for disinfectants/detergents Immediate 14.13 Non sterile gloves are available when disinfectants are used Immediate 14.14 Disposable waterproof aprons and eye protection are available when there is risk of splashing Immediate 14.15 Staff are aware that a decontamination certificate should be completed prior to sending equipment for maintenance and repair Immediate Total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 15 Care of Equipment Standard: Equipment is cleaned/ decontaminated/ stored correctly to negate the risk of infection.
Criteria Yes No N/A Action 15.1 Re-usable equipment is decontaminated as manufacturers instructions 15.2 Suction equipment is clean and dry with a bacterial/viral hydrophobic filter in situ. Immediate 15.3 Suction tubing and catheters are kept within plastic bags. Immediate 15.4 Thermometers are stored dry. Immediate 15.5 Mattresses and wipeable duvets are cleaned between patients with detergent and water and dried (Ask two staff members) Immediate 15.6 All surfaces such as mattresses and pillows are protected from body fluids contamination with wipeable or disposable waterproof covers
15.7 Oxygen cylinders are clean. Masks are available, but not open to contamination by dust or condensation. Immediate 15.8 Nebulisers are stored clean and dry after individual patient use following therapeutic use of humidifiers and nebulisers Immediate 15.9 Treatment trolleys are routinely cleaned, and are free from extraneous items. 15.10 Lifting aids undergo a suitable decontamination procedure between patients (Ask two members of staff) Immediate Total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 16 Staff Facilities Standard: Staff facilities are maintained appropriately to negate the risk of cross infection.
Criteria Yes No N/A Action 16.1 There are facilities available for staff to change. 16.2 There are clean wash/shower areas available for staff to use. 16.3 Staff have a designated toilet See section 2 Toilet area 16.4 If cooking facilities are available, the area where the facilities are situated must be clean and all surfaces intact. Immediate 16.5 If a fridge is in use, it must be clean and food stored in a container and labelled. Immediate 16.6 The fridge must have a thermometer present and a daily record of temperature is kept (temperature range 0 4C). Immediate 16.7 If a freezer is in use, the temperature must be recorded daily (temperature below minus 18C). Immediate 16.8 There is a designated sink/dishwasher for staff to wash their cutlery and crockery. Immediate 16.9 There is a designated handwashing sink within the area. Immediate 16.10 Liquid soap is available. Immediate Total
Comments
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Section 16 Staff Facilities
Criteria Yes No N/A Action Sub-total (from previous page) 16.11 Disposable paper towels are available. Immediate 16.12 There is a pedal operated domestic waste bin within the area. See section 10 Waste Disposal 16.13 When a microwave is in use, it must be kept clean. Immediate Total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 17 Vaccine Storage Standard: Vaccines are stored safely to ensure efficacy of the drug.
Criteria Yes No N/A Action 17.1 Vaccines are stored in a designated, lockable drug fridge Immediate 17.2 Vaccine/drug fridges temperatures are recorded daily or before starting a vaccine session (must be between 2 8C) Immediate 17.3 Vaccines are not stored in the fridge door Immediate 17.4 Vaccines are rotated to avoid accidental usage of expired vaccines Immediate 17.5 Vaccine/drug fridges are not overstocked Immediate 17.6 Vaccine/drug fridge is fitted with a minimum / maximum thermometer Immediate 17.7 Vaccines are placed in the vaccine/drug fridge immediately following delivery Immediate Total
Comments
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Section 18 Minor Surgery Standard: The environment is maintained appropriately to negate the risk of cross infection.
Criteria Yes No N/A Action 18.1 There is a room designated for minor surgery 18.2 The floor covering is intact, washable, non-slip with coved edges 18.3 The walls have smooth, washable surfaces ( no ceramic tiles) 18.4 The walls can withstand chemical disinfectants 18.5 The ceiling have smooth washable surfaces, able to withstand chemical disinfection 18.6 The window is fully closed during surgical procedures Immediate 18.7 The window ensures privacy with opaque glass (no curtains) Immediate 18.8 The ceiling light is covered 18.9 There is an anglepoise lamp 18.10 There is adequate ventilation by natural or mechanical means Sub-total
Comments
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Section 18 (contd) Minor Surgery
Criteria Yes No N/A Action Sub-total (from previous page) 18.11 The work surfaces are smooth, intact, impervious and able to withstand chemical disinfectants 18.12 The work surfaces have a coved edge 18.13 The work surfaces are free from extraneous items 18.14 Storage cupboards are lockable for chemicals 18.15 There is no open shelving in the room 18.16 The treatment couch is intact with a washable, impervious surface 18.17 The treatment couch is regularly maintained, height adjustable and accessible from both sides 18.18 The couch is protected with disposable paper towel, changed between patients. Immediate 18.19 The electric sockets are accessible and sufficient for requirements 18.20 There are splash proof sockets, placed approx. 1 m from the floor 18.21 Curtain screens are ceiling mounted on rails Sub-total
Comments
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Section 18 (contd) Minor Surgery
Criteria Yes No N/A Action Sub-total (from previous page) 18.22 Curtains should be laundered at least 6 monthly and when visibly soiled 18.23 There is a designated hand washing basin with elbow /wrist operated mixer taps with single pillar and no plug See section 9 Immediate 18.24 There is a wall mounted disposable paper hand towels and liquid soap dispenser Immediate 18.25 There are single use disposable nail brushes available (if used) Immediate 18.26 There is an antiseptic skin cleanser Immediate 18.27 There are detergent skin preparations available i.e. chlorhexidine, iodine Immediate 18.28 There is the necessary personal protective equipment. See section 13. Immediate 18.29 There are disposable sterile drapes available Sub-total
Comments
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Section 18 (contd) Minor Surgery
Criteria Yes No N/A Action Sub-total (from previous page) 18.30 There is a designated procedure trolley 18.31 There is a foot operated clinical waste bin, with yellow bag See section 10 Immediate 18.32 There is a foot operated domestic waste bin. See section 10 Immediate 18.33 There is a sharps container which conforms to BS 7320, securely stored Immediate 18.34 There is an up to date Prevention and Control of Infection Manual 18.35 There is a protocol for spillages of blood /body fluids Immediate 18.36 There is a domestic cleaning schedule which is sufficient to prevent the accumulation of dust or debris on horizontal surfaces
18.37 Staff have received Hepatitis B vaccination 18.38 Single use items are disposed of after individual use immediate 18.39 Re-usable instruments are sterilised at CSSD Immediate 18.40 Re-usable instruments being decontaminated on site Immediate- Contract Infection Control Team for standards 18.41 If, available on site steriliser conforms to HTM2010, Immediate
Comments
02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Section 19 Baby Changing Facilities
Standard: Baby changing facilities are maintained appropriately to negate the risk of cross infection
Criteria Yes No N/A Action 19.1 The environment is clean 19.2 There are appropriate handwashing facilities. See Section 9 19.3 There are appropriate waste disposal facilities. See Section 10 19.4 There is a flat surface for baby changing which is smooth, intact, impervious and able to withstand chemical disinfectants
19.5 The baby changing surface is clean and intact Total
Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Scoring Summary
To complete the scoring for each section
1 Points for every Yes 0 Points for every No
This will give a Total Score for that section Possible Score = (Number of questions) [D] Maximum Score [E] = Possible Score [D] minus Total Not Applicable Score [C] Percentage =Total Yes Score divided by Maximum Score x 100
It is recommended that section 9 Handwashing is audited monthly. The timescales for the other sections relevant to your area will be dependant on the percentage received. It is recommended that if a score of 60% or less is obtained, an audit of the section is repeated in 3 months time; if between 60-75% re-audit in 6 months; if greater than 75% re-audit in 1 year. 02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Scoring Summary
Section Total Yes [A] Total No [B] Total N/A [C] Possible Score [D] Max Score [E] = [D] [C] % Score [A] / [E] x 100 1 8 2 12 3 9 4 16 5 19 6 25 7 Contact ICT for advice 0 8a 24 8b 13 8c
3
8d
5
8e
3
Sub Total ()
137
02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Scoring Summary (contd)
Section Total Yes [A] Total No [B] Total N/A [C] Possible Score [D] Max Score [E] = [D] [C] % Score [A] / [E] x 100 Sub Total () 137 9 15 10 17 11 11 12 13 13 13 14 15 15 10 16 13 17 7 18 41 19 5 Total
301
02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Action Plan
Section Problem(s) Identified Recommendations Action Taken
02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Action Plan
Section Problem(s) Identified Recommendations Action Taken
02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Action Plan
Section Problem(s) Identified Recommendations Action Taken
02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Sample Audit Calendar 1
Sample audit calendar if all sections are relevant and greater than 75 % is achieved for all sections i.e. each section re-audited yearly. Please note, section 9 Hand washing should be audited locally monthly and results kept at a local level. A copy of score and action plan should only be returned to ICT as indicated by time frame determined by the score i.e. within 3, 6 or 12 months
January February March April
9. Handwashing Facilities 2.Toliet area 3 Shower area 19 Baby changing. 9. Handwashing Facilities 1 General 6 Consulting/treatment room
9. Handwashing Facilities 12 linen storage 13 Clinical practice 9. Handwashing Facilities 14 Cleaning and disinfection
September October November December
9. Handwashing Facilities 16 Staff facilities 9. Handwashing Facilities 18 Minor Surgery 9. Handwashing Facilities 15 Care of equipment 9. Handwashing Facilities 10 Waste disposal 17 Vaccine storage
02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Blank Audit Calendar
Please note, section 9 Hand washing should be audited locally monthly and results kept at a local level. A copy of score and action plan should only be returned to ICT as indicated by time frame determined by the score i.e. within 3, 6 or 12 months
02/04/2008 Version 2 Revised may2004 Review Date: April 2006
Recommended Reading
Ayliffe G., Fraise A., Geddes A. and Mitchell K. (2000) Control of Hospital Infection 4 th Edition Arnold
Pratt R. et al (2001) The Epic Project: Developing National Evidence- based Guidelines for Preventing Healthcare associated Infections Journal of Hospital Infection 47 (supplement S3-S4)
Greater Glasgow Primary Care NHS Trust Prevention and Control of Infection Manual
NHS Estates (2001) Infection Control in the Built Environment
Royal College of Nursing (2001) Good Practice in Infection Control; Guidance for nurses working in general practice
NHSScotland Property and Environmental Forum (2002) Scottish Health Facilities Note 30 Infection Control in the built environment
Scottish Consultants in Public Health Medicine (Communicable Disease/Environmental Health) Working Party (June 1995) Infection Control: A Purchasers Guide Specification Manual and Monitoring Protocol
West Midlands ICNA (1995) Infection Control Audit Tool 1 st Edition
Wilson J. (2000). Infection Control in Clinical Practice Bailliere Tindall