infection control audit report - thaxted surgery · infection control audit report section %...

West Essex (NCB Essex LAT)

Thaxted SurgeryMargaret Street .Thaxted CM6 2QN

Infection Control Audit Report

Section % Compliance

Governance and Documentary Evidence 44 %

Staff Records 67 %

Expertise 57 %

Clinical Environment 35 %

Clinical Practice 82 %

Clinical Equipment 67 %

Hand Hygiene 69 %

Sharps Management 67 %

Waste Management 100 %

Decontamination of Environment 67 %

Vaccine Management including Transport and Storage 69 %

Minor Surgery N/A

Total 63 %

Date audited: 20/06/2013

Location:

Client name:

Jennifer Day. Auditor:

Sara CarruthersAccompanied by:

Corrective actions:

BUILDING TYPE : Purpose Built 1983 NUMBER OF : Treatment Rooms : 2 Consulting Rooms : 5 Minor Surgery Room : 1 NUMBER OF : Doctors : 7 Nurses : 2 HCA's : 2 CLINICS : Chronic Disease Management, Zolodex and Depo Injections, Dressings, Spirometry, Child, Adult and Travel Immunisations, Yellow Fever Centre, Ear Syringing, ECG, Phlebotomy, Ante and Post Natal, Six week baby checks, Family Planning. TREATMENTS: Removal of In-growing Toenails (no scalpel used), Joint Injections, Removal of Skin Tags, Removal of Warts and Moles, Coil Insertion and Removal, Implanons.

Additional info:

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Copyright IPC Management (Holdings) Ltd © 2005–2013 ICAT Audit Tool Vrs 2.0

Template: Primary Care with Minor Surgery (AT017)

10/07/2013Date Approved:

Governance and Documentary Evidence

There should be a local risk assessment to establish which policies, procedures and protocols are required for the regulated activities provided.

The manual should contain policies, procedures and protocols required by the local risk assessment.

Environmental cleaning check lists should be kept to provide documentary evidence of monitoring that all environmental surfaces have been routinely and thoroughly cleaned.

Toy cleaning check lists should be kept to provide documentary evidence of monitoring that all toys have been routinely and thoroughly cleaned.

All disinfectant and cleaning products must have a COSHH data sheet.

Re-usable clinical equipment decontamination check lists should be kept to provide documentary evidence of monitoring that all re-usable clinical equipment has been routinely and appropriately decontaminated.

Decontamination certificate should be available and accompany all equipment sent for service or repair.

Staff should be aware of the need to complete a certificate of decontamination for all re-usable clinical equipment, prior to sending for repair or service.

Ensure that the practice has a written protocol indentifying a designated waiting area for service users with communicable diseases.

All owners/occupiers must conduct a risk assessment of hot & cold water supplies for legionella contamination.

Written schedules for flushing of taps / showers should be available to provide information on location of taps and frequency of flushing.

Staff Records

All staff should have regular 12 monthly updates on infection control training.

All staff should have regular 12 monthly updates on hand hygiene training as part of their infection prevention and control training.

Expertise

Staff should be aware of how to contact local Infection prevention and control support for advice.

Local arrangements should be in place for staff to have access to Occupational Health services and advice.

The practice should have access to the appropriate Competent Persons for vaccine fridges and Legionella management.

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Clinical Environment

Consultation / examination rooms should ONLY be used for low risk clinical procedures and clean tasks only.

Ensure walls have no defects which reduce effectiveness of cleaning. Repair/refurbish damaged areas so that surfaces are impervious and washable.

Flooring in clinical areas should be heat sealed at seams/edges to prevent the accumulation of dust and dirt and facilitate cleaning.

In clinical areas and associated corridors, there should be a continuous return between the floor and the wall e.g. a coved skirting with a minimum height of 100mm.

Carpet is not appropriate in clinical areas and should be replaced with a washable, impermeable floor surface e.g. vinyl material, which is continuous, non-slip and where possible joint-less.

Clinical room work surfaces joints and seams must be sealed to avoid build up of debris and facilitate cleaning.

Environmental cleaning schedules should include low surfaces.

Environmental cleaning schedules should include high surfaces.

All inappropriate items and clutter should be cleared away and stored in appropriate storage spaces, to leave surfaces clear for effective cleaning.

Consumables and small items should be stored in covered boxes or storage containers.

Examination/treatment couch should be kept clean and dust free at all times and be included in the daily cleaning schedule.

Privacy curtains should be changed 6 monthly.

Disposable curtains should be changed by their due date.

All chairs/furniture used service users should be covered in an impermeable material and be wipeable.

Chairs/furniture coverings should be wipeable and able to withstand regular cleaning.

Non washable keyboards should be provided with a wipeable cover which remains insitu during service user treatment.

Clinical Practice

Eye protection must be available i.e. full-face visor, goggles or mask with integral visor.

Disposable gloves should be worn for venepuncture.

Disposable plastic aprons should be worn for venepuncture.

Disposable plastic aprons should be worn for urine analysis.

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Clinical Equipment

Staff must adhere to 'single use' legislation and not re-process any 'single use' medical devices/items.

Single use medical devices/items opened for a procedure and not used must be discarded.

Warm water and a liquid detergent should be used for cleaning medical devices/clinical equipment. Detergent wipes can also be used.

Warm water and liquid detergent should be used for cleaning dressing trolleys/procedure trays. Detergent wipes can also be used.

Hand Hygiene

Taps on the clinical hand wash basins should not have swan neck fittings and should be considered for replacement.

Clinical hand wash basins should not have an overflow.

Clinical hand wash basins should not have a sink plug.

Splashback should be free from damage and in a good state of repair to enable adequate cleaning to be performed.

The dispenser should not be free standing on the work top or the drainer, even if plunger operated and should be wall mounted.

Clinical staff arms should be bare below the elbow during clinical activities and hand washing.

Sharps Management

Sharps bins should be labelled prior to use with the location, date and name of individual assembling the sharps bin.

Purple lidded sharps bin should be available for the disposal of sharps contaminated with cytotoxic or cytostatic drugs.

Sharps bins should be replaced when two thirds full or fill line has been reached.

Sharps bins should be labelled with date of closure and signed, when sealed/locked.

Decontamination of Environment

All cleaning equipment should be colour coded and staff made aware of their responsibilities for compliance.

Cleaning/domestic staff should be given training on the importance of storing the mops inverted.

The designated cleaning cupboard should be free from clutter and be well organised.

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West Essex (NCB Essex LAT) Thaxted Surgery

Governance and Documentary Evidence

Governance documents should be accessible to staff and available for inspection

Question Compliance Comments Rationale

Infection prevention and control policy statement is available which outlines compliance with the Code of Practice (2010).

Compliant Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criteria 1

A local risk assessment has been undertaken to determine which infection prevention and control policies, procedures and protocols are required for the regulated activities provided.

Non-Compliant Local risk assessment for infection prevention and control policies, procedures and protocols is not available

Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criterion 9

Infection prevention and control policy manual is available in compliance with the Code of Practice and local risk assessment.

Non-Compliant The manual does not contain policies, procedures and protocols required by the local risk assessment.

Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criterion 9 and table 3

Local protocol for vaccine management (cold chain) available

Compliant Expert GuidanceImmunisation Against Infectious Disease – ‘The Green Book’ - Storage, distribution and disposal of vaccines Ch.3 DH 2011

Staff can locate/access the infection prevention and control policy manual.

Compliant Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criterion 9

The infection prevention and control policy manual is clearly marked with a review date and has not expired.


Vaccine Management including Transport and Storage

Specimens should not be stored in the vaccine fridge.

The vaccine fridge should or the room in which it is sited should be capable of being locked when not in use or unattended.

Records should be kept of when the vaccine fridge is de-frosted.

Records should be kept of when the vaccine fridge is cleaned.

Vaccines should not be stored in bottom drawer of the vaccine fridge to minimise temperature fluctuations.

Vaccines should not be stored near the freezer plate in a vaccine fridge to minimise temperature fluctuations.

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There is a programme in place that defines the infection prevention and control assurance framework/infrastructure.


Public information is available for: the practice's approach to infection prevention and control; staff roles and responsibilities; who to contact, and up-to-date information on current infection control issues.


There is a policy and/or poster outlining the process for management of inoculation injury/splash incident including up-to-date contact phone numbers for A&E/Occupational Health.

Compliant Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criterion 10.3, Hepatitis B infection in healthcare workers.

Environmental cleaning schedules/check lists are available.

Non-Compliant Cleaning check lists are not available

Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criterion 2; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

There is a daily cleaning schedule/check list for toys.

Non-Compliant Cleaning check lists for toys are not available

Expert GuidanceNational specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

Control of Substances Hazardous to Health (COSHH) data sheets are available for all disinfectants and cleaning agents used.

Non-Compliant COSHH data sheets not available on all products

LegislationControl of Substances Hazardous to Health Regulations 2002

Decontamination of re-usable clinical equipment schedules/check lists are available.

Non-Compliant Re-usable clinical equipment decontamination check lists are not available

Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criterion 2; Revised Healthcare Cleaning Manual NPSA 2009; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

Staff are aware of the need for completing a decontamination certificate prior to sending re-usable clinical equipment for repair or maintenance.

Non-Compliant Decontamination certificate not available.Staff not aware of need for certificate of decontamination.

Expert GuidanceMHRA DB 2003 (05) Management of Medical Devices prior to repair, service or investigation

There is a written protocol identifying an area that can be used for patients with communicable diseases.

Non-Compliant There is no written protocol for segregating service users.

Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criteria 7 and 9

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The practice has undertaken a risk assessment of Legionella contamination in accordance with national requirements.

Non-Compliant No documentary evidence of risk assessment

Expert GuidanceHTM 04-01 The control of Legionella, hygiene, "safe" hot water, cold water and drinking water systems Ch5.12. Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems Approved Code of Practice and Guidance HSE L8 2000

There is a written weekly schedule for running taps/showers.

Non-Compliant There are no written schedules for flushing of taps / showers available.

Expert GuidanceHTM 04-01 The control of Legionella, hygiene, "safe" hot water, cold water and drinking water systems Ch5.12. Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems Approved Code of Practice and Guidance HSE L8 2000

The practice has a regular planned preventative maintenance (PPM) programme for general equipment.

Compliant Best Practice

Full compliance Non compliance Non applicable Total (%)

8 10 0 44 %


Staff Records

-


There is documentary evidence that staff having direct/indirect service user contact have received infection prevention and control training including hand hygiene training within the last 12 months.

Non-Compliant Not all staff have had infection control training within the past 12 months.Not all staff have had hand hygiene training within the past 12 months.

Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criteria 1, 5, 6 and 10

Staff have appropriate immunisations in line with local risk assessment.

Compliant Expert GuidanceImmunisation of healthcare & laboratory staff Ch. 12 'The Green Book' DH 2006, Code of Practice for the prevention and control of infections 2010 Criterion 10.1

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All staff involved in handling/management of vaccines are trained in vaccine management and the cold chain.

Compliant Expert GuidanceImmunisation Against Infectious Disease Ch. 3 Management of Vaccines DH 2011


2 1 0 67 %


Expertise

Staff roles and responsibilities, Competent Persons


Infection prevention and control support is available.

Non-Compliant Staff not aware who to contact.

Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criteria 1, 5, 8 and table 2

There is a nominated lead for environmental cleaning.


There is a nominated lead for Infection prevention and control (IPC Lead).


There is a nominated lead for decontamination of re-usable clinical equipment/devices (Decontamination Lead).


Staff should have access to Occupational Health for services and advice.

Non-Compliant Local arrangements not in place for Occupational Health.

Expert GuidanceCode of practice for the prevention and control of infections 2010 Criteria 10

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All re-usable invasive devices are reprocessed in a compliant SSD/decontamination unit.

Not applicable LegislationMDD 93/42/EEC; Stat Instr SI 2002 No 618 Medical Devices Regulations 2002; Gateway 8199 2007 Clarification policy summary Decon of re-usable medical devices DH 2007; Code of Practice Criteria 2 and 9; HTM01-01 Decontam Medical Devices

The practice has access to the appropriate Competent Person for vaccine fridges and Legionella management.

Non-Compliant There is no access to the appropriate Competent Person.

Expert GuidanceImmunisation Against Infectious Disease Ch. 3 Management of Vaccines DH 2011; HTM 04-01 Ch 6.13. Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems Approved Code of Practice and Guidance HSE L8 2000

There is a designated person and deputy for vaccine management.



4 3 1 57 %


Clinical Environment

The clinical environment will be maintained appropriately in order to reduce the risk of cross infection

Wooden drawer fronts and skirting boards.


Consultation/examination room is ONLY used for low risk clinical procedures.

Non-Compliant Medium risk invasive clinical procedures are performed in the consultation / examination room.

Expert GuidanceHBN 00-03: Clinical and clinical support spaces DH 2010; Facilities for primary and community care services: Planning and design manual 1183:0.8:England DH 2011

A designated clinical treatment room is available for medium risk invasive clinical procedures.

Compliant Expert GuidanceHBN 00-03: Clinical and clinical support spaces DH 2010; Facilities for primary and community care services: Planning and design manual 1183:0.8:England DH 2011

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Walls are washable, impervious and in a good state of repair.

Non-Compliant Walls have defects e.g. cracks,gaps,exposed plaster/brickwork, etc.

Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011 (element 2)

Flooring in clinical areas is washable, impermeable, undamaged with sealed seams and coved skirting.

Non-Compliant Flooring in clinical areas is not heat sealed at seams/edges.Flooring in clinical areas not coved up into skirting/wall.Floor in clinical area is carpeted

Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011 (element 1)

Clinical room work surfaces are washable, sealed and in a good state of repair

Non-Compliant Holes in work surface for cablesClinical room work surfaces joints and seams are not sealed.

Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003

All clinical areas are clean and dust free.

Non-Compliant Dust noted on low surfaces.Dust noted on high surfaces.

Expert GuidanceRevised Healthcare Cleaning Manual NPSA 2009; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

The clinical/treatment/consulting room is free from clutter and inappropriate items of equipment.

Non-Compliant Surfaces are cluttered. Best Practice

A clean storage area is available with sufficient space to store clean and sterile items of clinical equipment off the floor.

Non-Compliant Consumables and small items not stored covered.


Examination/treatment couches have wipeable surfaces and are in good state of repair with no rips/tears and clean underneath.

Non-Compliant Dust noted under examination/treatment couch

Expert GuidanceNational specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010

Privacy curtains/screens are clean, in a good state of repair and replaced or laundered every 6 months

Non-Compliant Privacy curtains are not changed 6 monthly.Disposable curtains have exceeded their due date for change


Chairs and furniture used by service users are wipeable and in a good state of repair.

Non-Compliant Chairs/furniture are upholstered in porous materials.Chairs/furniture are upholstered in a non-wipeable material.


Computer keyboards in clinical areas should be clean, covered or wipeable.

Non-Compliant Wipeable cover not used for a non washable keyboard.


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Toys are clean, in a good state of repair and wipeable

Compliant Expert GuidanceNational specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010

Toys are stored in designated area in robust, wipeable containers or on wipeable surface.


A dirty utility/sluice area is available.

Compliant Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003; HBN00-03 Clinical & clinical support spaces DH 2010

Dirty utility/sluice area is clean, free from spillages and extraneous items.

Compliant Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003; Revised Healthcare Cleaning Manual NPSA 2009

Clinical hand wash basin is available in the dirty utility/sluice area and is accessible.

Compliant Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011


6 11 0 35 %


Clinical Practice

Clinical practice will ensure the risk of cross infection is minimised


Ointments and creams, including lubricating gel, are single patient use.

Compliant LegislationGeneral Product Safety Regulations 2005

Disposable paper is used to protect the examination/treatment couch and changed between each service user.


Specimens awaiting transfer to the laboratory are in appropriate containers in a designated area away from public areas and rest rooms.

Compliant Expert GuidanceHealth & Safety Executive: Infectious substances and diagnostic specimens; UN classification UN3373 Diagnostic Specimens

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Single use, powder-free, non-sterile gloves are available in all clinical areas and in all sizes required by staff.

Compliant LegislationNICE (2012) Prevention and control of healthcare associated infections in primary and community care; Personal Protective Equipment at Work Regulations 2005

Plastic gloves must not be used. Compliant LegislationNICE (2012) Prevention and control of healthcare associated infections in primary and community care; Personal Protective Equipment at Work Regulations 2005

Disposable gloves are single use only.

Compliant Expert GuidanceEPIC2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007

Single use, disposable plastic aprons are available when required.

Compliant LegislationNICE (2012) Prevention and control of healthcare associated infections in primary and community care; Personal Protective Equipment at Work Regulations 2005

Plastic apron dispensers are wall mounted


Full facial protection is available for staff when splashing of blood, body fluids or chemicals is anticipated.

Non-Compliant Eye protection is not available.

LegislationNICE (2012) Prevention and control of healthcare associated infections in primary and community care; Personal Protective Equipment at Work Regulations 2005

Re-usable facial protection is decontaminated after each use.

Not applicable Expert GuidanceNational specifications for cleaning in the NHS; primary care medical and dental premises NPSA 2010.

Gloves and aprons (PPE) are worn for urinalysis and blood collection.

Non-Compliant Disposable gloves are not worn for venepuncture.Disposable plastic aprons are not worn for venepunctureDisposable plastic aprons are not worn for urinalysis.

Expert GuidanceEPIC2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007; NICE (2012) Prevention and control of healthcare associated infections in primary and community care.

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Urine specimens are disposed of in a safe and appropriate manner.

Compliant Expert GuidanceHFN 30 Infection control in the built environment DH 2003


9 2 1 82 %


Clinical Equipment

Clinical equipment will be managed appropriately to reduce the risk of cross infection


All staff are familiar with the symbol for 'single use'.

Compliant LegislationMHRA Single use medical devices: Implications and consequences for re-use MDA DB 2006(04) v2.0 DH 2011; The Medical Devices Regulations 2002

There is no evidence of single use equipment being re-used.

Non-Compliant Treatment room 1 - forceps, scissors and Jobson's horne probe, dressings in a dressings bag.Evidence seen of reuse of 'single use' medical devices/items.Staff admit to reuse of 'single use' medical devices/items.Single use medical devices/items opened for a procedure and not used are not discarded.

LegislationCode of Practice for the prevention and control of infections 2010 Criterion 9; MHRA Single use medical devices: Implications and consequences for re-use MDA DB 2006(04) v2.0 DH 2011; The Medical Devices Regulations 2002

Single use sterile medical devices/items are in date and packaging is intact.

Compliant Expert GuidanceMHRA Safety Notice 1999(32) Storage of sterile medical devices

Nebuliser/oxygen masks/peak flow mouth pieces are single use.

Compliant Expert GuidanceMHRA Single use medical devices: Implications and consequences for re-use MDA DB 2006(04) v2.0 DH 2011

Medical devices (non-surgical)/clinical equipment in use are visibly clean, dust free and in a good state of repair.


Staff are decontaminating reusable medical devices/clinical equipment by cleaning.

Non-Compliant Warm water and detergent are not used for cleaning medical devices/clinical equipment.


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Dressing trolleys/procedure trays are clean and in a good state of repair.

Compliant Expert GuidanceNational specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

Dressing trolleys/procedure trays are cleaned with detergent and water daily, at the beginning of session, between cases and if contaminated.

Non-Compliant 70% alcohol wipe/spray used to clean contaminated dressing trolleys/procedure trays.


All pillows are protected by a wipeable/waterproof cover.



6 3 0 67 %


Hand Hygiene

Hands will be washed correctly using an appropriate cleansing agent. Handwashing facilities will be adequate to ensure hand hygiene can be carried out effectively.Dual sink for dirty and clean in all treatment rooms.

Taps showing evidence of limescale build up.


A poster demonstrating a good hand washing technique is available by at least one clinical hand wash basin.

Compliant Expert GuidanceWorld Health Organisation Guidelines on hand hygiene in healthcare 2009

Clinical hand wash basins are available in any room where clinical activity takes place.

Compliant Expert GuidanceHFN30 Infection Control in the Built Environment DH 2003, HBN00-03: Clinical & clinical support spaces 2010

Clinical hand wash basins in clinical/treatment/consulting rooms are designated for that purpose alone.

Compliant Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003

Clinical hand wash basins have wall-mounted lever action/sensor operated mixer taps offset from drainage outlet.

Non-Compliant Swan necked fittings on taps are present on clinical hand wash basin.

Expert GuidanceHBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011

Clinical hand wash basins should be medium/large with no plug or overflow

Non-Compliant Clinical hand wash basins have an overflow.

Clinical hand wash basins have a sink plug.

Expert GuidanceHFN30 Infection Control in the Built Environment DH 2003, HBN00-03: Clinical & clinical support spaces DH 2010

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There is a hot and cold water supply to every sink and clinical hand wash basin.

Compliant Expert GuidanceHTM 04-01 The control of Legionella, hygiene, "safe" hot water, cold water and drinking water systems Ch5.12. Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems Approved Code of Practice and Guidance HSE L8 2000

Waterproof splashbacks are fitted to all clinical hand wash basins and are in a good state of repair.

Non-Compliant Splashback is damaged, not in a good state of repair.


Clinical hand wash basin and surround is free from inappropriate items.


Access to clinical hand wash basin is clear and not obstructed by equipment or furniture.


Wall mounted paper towels are available at all clinical hand wash basins.


Wall mounted plain liquid soap is available at all clinical hand wash basins from a single-use cartridge dispenser.

Non-Compliant Plain liquid soap is not wall mounted


Antiseptic soap is available for aseptic hand washing if required. The dispenser is wall mounted and operated by a plunger or infra-red sensor.

Not applicable Expert GuidanceNICE (2012) Prevention and control of healthcare associated infections in primary and community care

Alcohol hand rub/gel is available for use in all clinical areas/wherever clinical activity takes place.

Compliant Expert GuidanceWater sources and potential for Psuedomonas Aeruginosa infection from taps and water systems DH 2012, HFN30 Infection control in the built environment.

Hand cream is available in wall mounted or dispensers in at least one area.


Clinical staff arms are bare below the elbow during clinical activities and hand washing.

Non-Compliant Clinical staff are wearing long sleeves when performing clinical activities and hand washing.

Expert GuidanceUniforms and Workwear: Guidance on Uniforms and Workwear Policy for NHS Employers DH 2010

Clinical staff having direct service user contact are free from wearing wrist watches or stoned rings when performing clinical activities or washing hands.


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Clinical staff are free from long finger nails, false nails, varnish or extensions

Compliant Expert GuidanceUniforms and Workwear: Guidance on Uniforms and Workwear Policy for NHS Employers DH 2010


11 5 1 69 %


Sharps Management

Sharps will be managed appropriately to reduce the risk of accidental inoculation injury

Staff accepting service user's sharps bin return's should ensure that the bins are completely sealed before accepting them. The sharps bins should also be labelled with service user details.


Sharps bins are available for use and conform to relevant standards (BS 7320 and UN 3291)

Compliant Expert GuidanceSafe Management of Healthcare Waste DH 2011

All sharps bins in use are assembled correctly.


All sharps bins in use are labelled correctly prior to use and are disposed of every 3 months even if not full.

Non-Compliant Sharps bin not labelled before use

Expert GuidanceSafe Management of Healthcare Waste DH 2011, Prevention & control of healthcare associated infections in primary and community care (NICE) March 2012

There are appropriately coloured lidded sharps bins available for the procedures that take place.

Non-Compliant Purple lidded sharps bin are not available but required.

Expert GuidanceSafe Management of Healthcare Waste DH 2011

Sharps bins are appropriately situated between waist and shoulder height.


All sharps bins in use are less than two thirds full (or fill line has not been reached) and free from protruding sharps.

Non-Compliant Sharps bins are overfilled.


Sharps bins are free from inappropriate items.


Sharps are disposed of directly into a sharps bin at the point of care.

Compliant Expert GuidanceCouncil Directive 2010/32/EU Framework agreement on prevention from sharps injuries in the hospital and healthcare sector EU 2010

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Disposable syringes and needles are disposed of as one unit and not disassembled.

Compliant Expert GuidanceEPIC2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007

Used sharps such as needles are not manually resheathed prior to disposal.

Compliant Expert GuidanceCouncil Directive 2010/32/EU Framework agreement on prevention from sharps injuries in the hospital and healthcare sector EU 2010

The temporary closure is used when the sharps bin is being transported between locations/travelling.

Not applicable Expert GuidanceSafe Management of Healthcare Waste DH 2011

Sharps bins are labelled and securely sealed closed with the integral locking mechanism when two thirds full or the fill line is reached.

Non-Compliant Sharps bins are not labelled when closed


Sealed and locked sharps bins are stored in a locked room, cupboard or container away from public access.



8 4 1 67 %


Waste Management

Waste is disposed of safely without risk of contamination or injury and in accordance with national legislation and regulations


Waste bags are not attached to cupboard/trolley, etc.


All waste bins are fully enclosed, fire retardant, lidded, foot operated, clean and in good working order.

Compliant Expert GuidanceSafe Management of Healthcare Waste DH 2011; Operational provisions manuals - Part F: Arson prevention in NHS premises 2062:0.7:England DH 2011

Waste bins are labelled clinical/domestic waste, etc or colour coded as appropriate.


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Orange/yellow bags are used for the disposal of clinical/infectious waste, wherever clinical activity takes place.


Domestic waste is placed in black bags.


Clinical waste bags are labelled. Compliant Expert GuidanceSafe Management of Healthcare Waste DH 2011

All waste bags (clinical/domestic) are less than two thirds full and securely tied.


There is a designated storage area for clinical waste bags awaiting collection.


The clinical waste bag storage area is lockable and inaccessible to unauthorised persons and animals.


Clinical/domestic waste bags are segregated whilst awaiting collection.


The waste storage area is clean. Compliant Expert GuidanceSafe Management of Healthcare Waste DH 2011


11 0 0 100 %


Decontamination of Environment

Ensure that the environment is decontaminated using appropriate chemicals and appropriate concentrations


Environmental surfaces used for clinical tasks are cleaned between service users.


Chlorine-releasing agents e.g. sodium hypochlorite or NaDCC (eg Presept, Actichlor, Haztabs) are available to deal with body fluid spillages.

Compliant Expert GuidanceRevised Healthcare Cleaning Manual NPSA 2009

The correct dilution of chlorine-releasing agent is used for body fluid spillages and any unused solution is discarded not stored.


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All staff are aware of the correct procedure for dealing with blood/body fluid spillage.


Cleaning equipment/products (mops, buckets, cloths, gloves etc.) are colour-coded or designated for specific areas and staff are familiar with/aware of the system in use.

Non-Compliant Colour coding in use but evidence of non-compliance.

Expert GuidanceRevised Healthcare Cleaning Manual NPSA 2009; Safer Practice Notice Colour Coding for Hospital cleaning materials and equipment NPSA 2007

Cleaning equipment is stored clean, dry, and mops are stored inverted.

Non-Compliant Mops are not stored inverted.

Expert GuidanceRevised Healthcare Cleaning Manual NPSA 2009

Mop heads are replaced/laundered regularly or are disposable.


There is a designated, locked area for cleaning products (chemicals).

Compliant LegislationRevised Healthcare Cleaning Manual NPSA 2009; Control of Substances Hazardous to Health Regulations 2002

The designated cleaning cupboard is free of inappropriate items.

Non-Compliant Cleaning cupboard is cluttered/disorganised.

Expert GuidanceRevised Healthcare Cleaning Manual NPSA 2009


6 3 0 67 %


Vaccine Management including Transport and Storage

Vaccines will be managed appropriately in accordance with current recommended practice to maintain the integrity of the vaccine to prevent cross contamination


Vaccines are stored in a vaccine fridge immediately after delivery.


Vaccines are stored in specialist pharmaceutical refrigerators.

Non-Compliant Specimens are in the vaccine fridge.

Expert GuidanceImmunisation Against Infectious Disease Ch. 3 Management of Vaccines DH 2011

The vaccine fridge is situated away from a heat source e.g. radiator and air is able to circulate freely.


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The vaccine fridge is lockable. Non-Compliant Vaccine fridge or room in which it is sited is not lockable when not in use or unattended.


Vaccine fridge has an integral maximum/minimum thermometer.


Records of vaccine fridge temperatures are kept and are up-to-date.


Records of vaccine fridge defrosting and cleaning are kept and are up-to-date.

Non-Compliant Vaccine fridge is de-frosted but records are not kept.Vaccine fridge cleaning records are not kept.


All vaccines are stored in their original packaging.


Vaccines are not stored near the freezer plate, in the door or bottom drawers and the fridge is not over-stocked.

Non-Compliant Vaccines are stored in bottom drawer of vaccine fridge.Vaccines are stored near the freezer plate.


A system is in place for the management of breakdowns, repairs and servicing of the vaccine fridge.


There is an alternative approved cool box or pharmaceutical refrigerator available to store vaccines in case of breakdown or maintenance.


A system is in place for the safe disposal of expired, surplus or damaged vaccines.

Compliant Expert GuidanceSafe Management of Healthcare Waste DH 2011; Immunisation Against Infectious Disease Ch. 3 Management of Vaccines DH 2011

The vaccine fridge has an uninterrupted electrical supply.


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9 4 0 69 %


Minor Surgery

The environment will be maintained appropriately to negate the risk of cross infection.


There is a checklist for all minor surgical procedures

Not applicable Expert GuidanceWorld Health Organisation Guidelines for Safe Surgery 2009 and Surgical Safety Checklists 2009; Guidelines on the facilities required for minor surgical procedures and minimal access interventions: Journal of Hospital Infection 80 (2012) 103-109

There is a room designated for minor surgical procedures.

Not applicable Expert GuidanceFacilities for primary and community care services: Planning and design manual 1183:0.8:England DH 2011; Guidelines on the facilities required for minor surgical procedures and minimal access interventions:Journal Hospital Infection 80 (2012) 103-109

The designated treatment room used for minor surgery meets local or published (expert) specifications.

Not applicable Expert GuidanceGuidelines on the facilities required for minor surgical procedures and minimal access interventions: Journal of Hospital Infection 80 (2012) 103 - 109; HBN 00-03: Clinical and clinical support spaces DH 2010

The minor surgery room has a domestic cleaning schedule and check list that documents twice daily cleaning.

Not applicable Expert GuidanceRevised Healthcare Cleaning Manual NPSA 2009, National specification for cleanliness in primary care medical & dental premises 2010

The minor surgery room is cleaned at the beginning and end of each minor surgery session with an appropriate detergent.

Not applicable Expert GuidanceRevised Healthcare Cleaning Manual NPSA 2009

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Decontamination of re-usable clinical equipment schedules/check lists are available for clinical equipment in the minor surgery room.

Not applicable Expert GuidanceCode of Practice for the prevention and control of infections 2010 Criterion 2: Revised Healthcare Cleaning Manual NPSA 2009; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

There are schedules/check lists available for the replacement/cleaning of privacy curtain/screens.

Not applicable Expert GuidanceNational specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010

Walls in the minor surgery room are smooth, impermeable surfaces with no seams/joints/tiles.

Not applicable Expert GuidanceHFN 30 DH 2003; HBN 00-10 DH 2011; Guidelines on the facilities required for minor surgical procedures and minimal access interventions: Journal of Hospital Infection 80 (2012) 103-109

Flooring in the minor surgery room is non-slip, washable, impermeable, undamaged with sealed seams and coved skirting.


The ceiling in the minor surgery room has a smooth, non-porous, impermeable surface.


The windows in the minor surgery room ensure privacy with opaque glass; blinds installed between double glazed units or disposable curtains.

Not applicable Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003

Opening windows in the minor surgery room are fitted with a fly screen

Not applicable Expert GuidanceGuidelines on the facilities required for minor surgical procedures and minimal access interventions: Journal of Hospital Infection 80 (2012) 103-109

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Lighting in the minor surgery room is fully enclosed and clean.

Not applicable Expert GuidanceHFN 30 Infection Control in the Built Environment DH 2003; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011 - Lighting Guide 2: Hospitals and healthcare buildings CIBSE 2008

The heat source in the minor surgery room e.g. the radiator and pipework is enclosed in a smooth-surfaced washable box.


Electric fans are not in use in the minor surgery room during surgical procedures.

Not applicable Expert GuidanceStandards and recommendations for surgery in primary care AfPP 2008

Mechanical ventilation is monitored via a control panel in the minor surgery room.


Mechanical ventilation in the minor surgery room undergoes routine cleaning.

Not applicable Expert GuidanceHTM 03-01 Specialised Ventilation for Healthcare Premises DH 2007

Minor surgery room work surfaces are washable, sealed and in a good state of repair


Treatment couches have wipeable surfaces, are in a good state of repair with no rips/tears and are clean.


Disposable paper is used to protect the treatment couch and is changed between each service user.

Not applicable Best Practice

Operator's chairs or step stools furniture in the minor surgery room are wipeable, impervious and in a good state of repair.

Not applicable Expert GuidanceHFN 30 Infection control in the Built Environment DH 2003; National specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010

All pillows are protected by a wipeable/waterproof cover.

Not applicable Best Practice

The minor surgery room has a designated free standing stainless steel or aluminium procedure trolley.


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Procedure trolley are cleaned with detergent and water daily/at the beginning of session, between cases and if contaminated.

Not applicable Expert GuidanceNational specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

Computer keyboards in the minor surgery room are clean, covered or washable.


There are adequate storage systems for sterile instruments/equipment which are enclosed, easy to clean and off the floor.

Not applicable Expert GuidanceMHRA Safety Notice 1999(32) Storage of sterile medical devices; HFN 30 Infection Control in the Built Environment DH 2003

All single use devices and sterile instruments packs are intact and in date

Not applicable Expert GuidanceMHRA Safety Notice 1999(32) Storage of sterile medical devices

The minor surgery room has disposable sterile drapes available if required.

Not applicable Expert GuidanceStandards and Recommendations for Safe Perioperative Practice AfPP 2008

All re-usable invasive devices are reprocessed in a compliant SSD/decontamination unit.

Not applicable LegislationMDD 93/42/EEC; Stat Instr SI 2002 No 618 Medical Devices Regulations 2002; Gateway 8199 2007 Clarification policy summary Decon of re-usable medical devices DH 2007; Code of Practice Criteria 2 and 9; HTM01-01 Decontam Medical Devices

A tracking system is in place to ensure traceability of all surgical instruments through the decontamination process.

Not applicable Expert GuidanceStandards and recommendations for surgery in primary care AfPP 2008; Health Service Circular 2000/032 DH 2000

There is a dedicated secure storage area/container for the storage of used re-usable instruments awaiting collection from the minor surgery room.


Clinical hand wash basins have wall-mounted lever action/sensor operated mixer taps offset from drainage outlet.

Not applicable Expert GuidanceHBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011

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Clinical hand wash basins should be medium/large with no plug

Not applicable Expert GuidanceHBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011, HBN00-03: Clinical & clinical support spaces DH 2010

Wall mounted paper towels are available at all clinical hand wash basins.


Wall mounted plain liquid soap is available at all clinical hand wash basins from a single-use cartridge dispenser.


Antiseptic soap is available for aseptic hand washing if required. The dispenser is wall mounted and operated by a plunger or infra-red.

Not applicable Expert GuidanceStandards and Recommendations for Safe Perioperative Practice AfPP 2008

An aseptic hand wash technique is employed prior to donning sterile gloves before minor surgical procedures.

Not applicable Expert GuidanceStandards and recommendations for safe perioperative practice AfPP 2008

Wall mounted alcohol hand rub/gel is available via pump/sensor operated dispenser.

Not applicable Expert GuidanceGuidelines on the facilities required for minor surgical procedures and minimal access interventions: Journal of Hospital Infection 80 (2012) 103-109.

Disposable nail picks are available to clean nails, if required.


Single use, powder-free sterile surgeons gloves are available

Not applicable Expert GuidanceEPIC2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007

Personal protective equipment is available when splashing of blood/body fluids is anticipated.

Not applicable LegislationPersonal Protective Equipment at Work Regulations 1992; Guidelines on the facilities required for minor surgical procedures and minimal access interventions: Journal of Hospital Infection 80 (2012) 103-109

The minor surgery room has a securely positioned sharps bin.

Not applicable Expert GuidanceSafe Management of Healthcare Waste 2011

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A sterile sharps disposal device is available for use in the sterile field.


The minor surgery room has a fully enclosed, fire retardant, foot operated, lidded clinical waste bin with orange/yellow bag.

Not applicable Expert GuidanceSafe Management of Healthcare Waste DH 2011; Operational provisions manuals - Part F: Arson prevention in NHS premises 2062:0.7:England DH 2011; Standards and recommendations for surgery in primary care AfPP 2008

The minor surgery room has access to an adjacent dirty utility area.

Not applicable Expert GuidanceHBN00-03 Clinical & clinical support spaces DH 2010, Guidelines on the facilities required for minor surgical procedures and minimal access interventions: Journal of Hospital Infection 80 (2012) 103-109


0 0 45 0 %

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infection control audit report - thaxted surgery · infection control audit report section %...

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