Hospice Adult Audit Report

Infection Control Audit Report Date audited:

17/06/2016

Location:

Gordon House 1-6 Station Road Mill Hill London NW7 2JU

Client name:

Demonstration

Auditor:

Kevin Malambo

Accompanied by:

Jennifer Day

Additional info:

.

Section

% Compliance

Governance and Documentary Evidence

100 %

Staff Records

33 % 100 %

e

Kitchen - Servery Clinical Environment

pl

Clinical Practice Clinical Equipment Hand Hygiene

Waste Management

m

Sharps Management

100 % 91 % 100 % 100 % 100 % 100 % 100 %

Linen Management

100 %

Sa

Decontamination of Environment

Enteral Feeding

100 %

Pressure Sore Management and Chronic Wound Care

100 %

Respiratory Care

100 %

Urinary Catheter Management

100 %

Peripheral Venous Cannula (PVC) Line Insertion

100 %

Peripheral Venous Cannula (PVC) Line On-going

100 %

Paediatric Equipment

100 %

Milk Kitchen

100 %

Total

99 %

Corrective actions: Staff Records Staff should have regular updates on hand hygiene every 12 months.

Accurate records should be kept of inoculation injuries to staff including date; time; location; who was involved; reported to; action taken and outcome.

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric

Date Approved: 17/06/2016

ICAT Audit Tool Vrs 2.0 Page 1 of 21

Demonstration Gordon House Staff Records Documentary evidence of staff immunisations and training

Question

Compliance

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

Compliant

There is documentary evidence that staff having direct/indirect service user contact have received hand hygiene training within the previous 12 months.

Non-Compliant

Documentary records should be kept of all sharps/inoculation injuries.

Non-Compliant

All staff handling or serving food to service users have undertaken basic food hygiene training.

Not applicable

Comments

Rationale Legislation

Staff have not had hand hygiene training.

No documentary evidence of staff inoculation injuries.

Expert Guidance Code of practice for the prevention and control of infections 2010 Criteria 1,5,6 and 10 Legislation RIDDOR Regulations 1995

e

Legislation

Non compliance

Non applicable

Total (%)

1

2

1

33 %

Kitchen - Servery

m

Demonstration Gordon House

pl

Full compliance

Question

Sa

The kitchen/servery will be maintained so as to reduce the risks of cross-infection, cross-contamination and hence food borne illness Compliance

Comments

Rationale

The fabric of the room, including fixtures and fittings, walls, floors, splashbacks, etc, is in a good state of repair.

Compliant

Legislation

All kitchen/servery work surfaces are clean and in a good state of repair.

Compliant

Legislation

Designated hand wash facilities are available for staff

Compliant

Legislation

Wall mounted liquid soap and paper towels are available next to the hand wash basin

Compliant

Legislation

Wall mounted disposable paper toweling is used for cleaning and drying equipment and surfaces.

Compliant

Legislation

Cleaning materials used in the kitchen are stored separately to other environmental cleaning equipment and away from food.

Compliant

Legislation

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric

Date Approved: 17/06/2016

ICAT Audit Tool Vrs 2.0 Page 3 of 21

The macerator is clean, working and in a good state of repair.

Compliant

Expert Guidance

A macerator is installed for the disposal of single use cellulose pulp: bed pans and urinals plus their contents.

Compliant

Expert Guidance

Full compliance

Non compliance

Non applicable

Total (%)

40

0

0

100 %

Demonstration Gordon House Clinical Practice Clinical practice will ensure the risk of cross infection is minimised

Compliance

Comments

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

Compliant

Legislation

Single use, disposable plastic aprons must be available when required.

Compliant

Legislation

Plastic apron dispensers are wall mounted

Compliant

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

Compliant

Single use, powder-free sterile surgeons gloves available if required.

Compliant

Expert Guidance

Plastic gloves must not be used.

Compliant

Legislation

Disposable gloves are single use only.

Compliant

Expert Guidance

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

Compliant

Expert Guidance

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

Compliant

Legislation

Re-usable facial protection is decontaminated after each use.

Compliant

Expert Guidance

After use all Personal Protective Equipment (PPE) is discarded into a clinical waste bag.

Non-Compliant

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

Not applicable

pl

Best Practice

Sa

m

Legislation

Gloves and/or aprons are discarded into domestic waste bags.

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric

Rationale

e

Question

Date Approved: 17/06/2016

Expert Guidance

Expert Guidance

ICAT Audit Tool Vrs 2.0 Page 7 of 21

Demonstration Gordon House Respiratory Care .

Compliance

Comments

Rationale

Single patient use nebulisers are provided.

Compliant

Expert Guidance

Nebulisers are washed and dried after each use

Compliant

Expert Guidance

Nebuliser mask and tubing are changed according to manufacturer's instructions.

Compliant

Best Practice

Suction equipment is decontaminated between uses and is stored clean and dry.

Compliant

Expert Guidance

Disposable suction liners are used and changed daily

Compliant

Expert Guidance

Suction tubing is changed daily

Compliant

Expert Guidance

Respiratory suction catheters are single use only and are discarded after single use.

Compliant

Expert Guidance

Oxygen masks and nasal cannulae are kept clean and dry at all times.

Compliant

Best Practice

Oxygen masks and nasal cannulae are single patient use items only.

Compliant

e

Question

pl

Best Practice

Non compliance

9

0

Non applicable

m

Full compliance

0

Total (%) 100 %

Sa

Demonstration 1 Gordon House Urinary Catheter Management .

Question

Compliance

Comments

Rationale

Urine jugs are washed after each use or a single use receptacle is used.

Compliant

Expert Guidance

Urine jugs are single patient only and labelled with name.

Compliant

Expert Guidance

All details of catheter insertion are documented in care plan.

Compliant

Expert Guidance

All service users have received an assessment prior to catheterisation which has been documented.

Compliant

Expert Guidance

Ongoing assessment of need for catheter is undertaken.

Compliant

Expert Guidance

Catheters are changed only when clinically indicated.

Compliant

Expert Guidance

Sterile, single use lubricant or anaesthetic gel is used for catheter insertion.

Compliant

Expert Guidance

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric

Date Approved: 17/06/2016

ICAT Audit Tool Vrs 2.0 Page 16 of 21

Date audited:

17/06/2016

Location:

Gordon House 1-6 Station Road Mill Hill London NW7 2JU

Client name:

Demonstration

Notes:

.

e

Infection Control Action Plan

Corrective actions:

pl

Other Corrective Actions Staff Records Reference

Evidence of Compliance

Responsibility

Due Date

Responsibility

Due Date

m

Corrective Action

Staff should have regular updates on hand Code of practice for the prevention and hygiene every 12 months. control of infections 2010 Criteria 1,5,6 and 10

Clinical Practice Corrective Action

RIDDOR Regulations 1995

Sa

Accurate records should be kept of inoculation injuries to staff including date; time; location; who was involved; reported to; action taken and outcome.

Reference

Evidence of Compliance

Gloves and/or aprons should be discarded into clinical waste bags following use.

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Hospice Adult / Paediatric

Report Version 0.0.1 Date Approved: 17/06/2016

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