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02/04/2008

Version 2 Revised may2004 Review Date: April 2006

Primary Care Division

Infection Control Audit Tool

Site : Location :

Speciality : Head of Department (or nominee):

Audit Date : Completed By :

Accompanied By (if applicable) :

02/04/2008


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


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:

Email [email protected]

Lesley [email protected]

[email protected]

[email protected]

[email protected]

Telephone 0141 211 3568

02/04/2008


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


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.


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.


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.


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

02/04/2008


Section 4 (cont’d) Sluice Room (Disposal)


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


Section 5 Domestic Services Room

Standard: The domestic services room will be maintained appropriately to negate the risk of cross infection.


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

02/04/2008


Section 5 (cont'd) Domestic Services Room



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

02/04/2008


Section 6 Consulting Room / Treatment Room

Standard: The consulting room/treatment room will be maintained appropriately to negate the risk of cross infection.


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

02/04/2008


Section 6 (cont'd) Consulting Room / Treatment Room



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

02/04/2008


Section 6 (cont'd) Consulting Room / Treatment Room



6.21 Drug fridge temperature is recorded daily and is within safe zone (2-8°C) 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

02/04/2008


Section 8a Kitchens – General

Standard: The kitchen will be maintained appropriately to negate the risk of cross infection.


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

02/04/2008


Section 8a (cont’d) Kitchens – General



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

02/04/2008


Section 8b Kitchens – Refrigerator


8b.1 The temperature of the refrigerator is recorded daily and is between 0 – 4ºC Immediate

8b.2 Freezer temperature is recorded daily and is below minus 18ºC 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


Section 8c Kitchens – Cookers / Microwaves


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


Section 8d Kitchens – Dishwashing


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 80°C 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

02/04/2008


Section 8e Kitchens – Training


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

02/04/2008


Section 9 Handwashing Facilities

Standard: Handwashing facilities should be appropriate to negate the risk of cross infection.


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


Section 9 (cont’d) Handwashing Facilities



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

02/04/2008


Section 10 Waste Disposal

Standard: Waste is disposed of safely without the risk of contamination or injury.


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

02/04/2008


Section 10 (cont’d) Waste Disposal



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

02/04/2008


Section 11 Sharps Handling & Disposal

Standard: Sharps will be handled safely to negate the risk of sharps injury.


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

02/04/2008


Section 12 Linen Storage, Bagging & Laundering

Standard: Linen is handled appropriately to prevent cross infection.


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


Section 12 (cont’d) Linen Storage, Bagging & Laundering



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

02/04/2008


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


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

Comments

02/04/2008


Section 13 (cont’d) Clinical Practice



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


Section 14 Cleaning & Disinfection

Standard: Disinfectants are available and used correctly to prevent cross infection.


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


Section 14 (cont’d) Cleaning & Disinfection



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


Section 15 Care of Equipment

Standard: Equipment is cleaned/ decontaminated/ stored correctly to negate the risk of infection.


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


Section 16 Staff Facilities

Standard: Staff facilities are maintained appropriately to negate the risk of cross infection.


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 – 4ºC).

Immediate

16.7 If a freezer is in use, the temperature must be recorded daily (temperature below minus 18ºC). 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

02/04/2008


Section 16 Staff Facilities



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


Section 17 Vaccine Storage

Standard: Vaccines are stored safely to ensure efficacy of the drug.


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 – 8ºC)

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

02/04/2008


Section 18 Minor Surgery

Standard: The environment is maintained appropriately to negate the risk of cross infection.


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

02/04/2008


Section 18 (cont’d) Minor Surgery



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

02/04/2008





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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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

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Section 19 Baby Changing Facilities

Standard: Baby changing facilities are maintained appropriately to negate the risk of cross infection


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

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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.

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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

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Scoring Summary (cont’d)

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

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Action Plan

Section Problem(s) Identified Recommendations Action Taken

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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 4.Sluice 5 DSR

9. Handwashing Facilities 7. local decontamination

May June July August

9. Handwashing Facilities 8 Kitchens

9. Handwashing Facilities 11 Sharps handling

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

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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

January February March April


9. Handwashing Facilities 9. Handwashing Facilities 9. Handwashing Facilities

May June July August



September October November December



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Recommended Reading

Ayliffe G., Fraise A., Geddes A. and Mitchell K. (2000) Control of Hospital Infection 4th 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

environmental audit tool - nhsggclibrary.nhsggc.org.uk/mediaassets/infection control/microsoft...

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