Actionplan

16/12/2013

Location:

Mill Hill Demo Clinic 1-6 Station Road Mill Hill Broadway London NW7 2JU

Client name:

EX AM PL

Date audited:

E

Infection Control Action Plan

Mill Hill Demo Clinic

Corrective actions:

Other Corrective Actions

Governance and Documentary Evidence

Corrective Action An Infection Control Manual containing the Local sharps policy must include contact Local policy on prevention of occupational Staff should be aware of how to contact the There should be written schedules for Check lists provide documentary evidence, Cleaning schedules for the environment Cleaning check lists should be kept routinely All disinfectants and cleaning products must Staff should be aware of the need to There should be a written schedule for Staff Records

Reference Hygiene Code of Practice (2010).

Hygiene Code of Practice 2010 Hygiene Code of Practice 2010

Corrective Action Staff should have regular updates on Staff should have regular updates on hand

Reference Hygiene Code of Practice (2010) Criterion 10 Hygiene Code of Practice (2010) Criterion 10

Evidence of Compliance

Responsibility

Due Date

Evidence of Compliance

Responsibility

Due Date

Hygiene Code of Practice 2010, NPSA Hygiene Code of Practice 2010, NPSA Hygiene Code of Practice 2010 Hygiene Code of Practice 2010 COSHH Regulations 2002 HSG (93) 26 Decontamination of Equipment

Copyright Š Infection Control Solutions Ltd Template: Out Patient Clinic

Date Approved: 19/01/2011

Report Version 0.0.1 Page 1 of 3

Accurate records should be kept of Clinical Environment

RIDDOR/Health & Safety at Work Act

Corrective Action Waterproof splashback should be fitted to Flooring in clinical areas should be of a Flooring in clinical areas should be heat Cleaning schedules should include low Cleaning schedules should include high The treatment /clinical room should be Examination / treatment couch should be Clinical Practice

Reference HFN 30 HFN 30 HFN 30 NPSA Revised Cleaning Manual (2009) NPSA Revised Cleaning Manual (2009)

Corrective Action Aprons should be available when there is a Disposable PPE (gloves and aprons) should Facial protection must be available to all Specimens awaiting transfer should be Clinical Equipment

Reference

Evidence of Compliance

Responsibility

Due Date

Corrective Action Reference Suitable training should be given to all staff Ensure clinical equipment is visibly clean Ensure dressing trolleys are clean and ready Ensure the trolley is cleaned with detergent A full range of PPE - disposable plastic Hand Hygiene

Evidence of Compliance

Responsibility

Due Date

Corrective Action Hand wash basins must be made available in Hand wash basins should not be used for Taps should be automatic or elbow operated None of the hand wash basins should have Taps on clinical hand wash basins should not All extraneous items should be permanently Staff should ensure that there is good Handwashing poster should be available and

Evidence of Compliance

Responsibility

Due Date

EX AM PL Reference HFN30

Responsibility

Due Date

E

Evidence of Compliance

HTM64 HTM64 HTM64

Copyright Š Infection Control Solutions Ltd Template: Out Patient Clinic

Date Approved: 19/01/2011

Report Version 0.0.1 Page 2 of 3

The dispenser should not be free standing Ensure paper towels are available at all Alcohol hand rub should be dispensed by Sharps Management Reference HTM 07-01 HTM 07-01 HTM 07-01

Evidence of Compliance

Responsibility

Corrective Action Appropriate clothing (disposable gloves and Large yellow waste bins should be lockable.

Clinical waste bags should be labelled with Ensure that the waste storage areas are Other items stored in the waste storage Decontamination of Environment

Reference HTM 07-01 HTM 07-01 HTM 07-01 HTM 07-01 HTM 07-01

Evidence of Compliance

Responsibility

Due Date

Corrective Action Chlorine-releasing agent eg. sodium All staff must be aware of the correct Surfaces used for clinical tasks should be Ensure all cleaning equipment is colour Ensure all cleaning equipment and supplies Cleaning/domestic staff must be given Cleaning/domestic staff must be given Cleaning products (chemicals) should be Ensure cleaning cupboard is free from Ensure mop heads are changed at least Personal protective clothing (disposable Computer keyboards in the clinical area

Reference

Evidence of Compliance

Responsibility

Due Date

EX AM PL

E

Corrective Action Sharps bins must be labelled prior to use Sharps bins should be situated between All sharps bins should be labelled with date Waste Management

Due Date

NPSA (2007) Colour Coding NPSA (2007) Colour Coding NPSA Revised Cleaning Manual (2009) NPSA Revised Cleaning Manual (2009) COSHH Regulations 2002 NPSA Revised Cleaning Manual (2009)

Copyright Š Infection Control Solutions Ltd Template: Out Patient Clinic

Date Approved: 19/01/2011

Report Version 0.0.1 Page 3 of 3