Mental health action plans

Date audited:

14/10/2013

Location:

Atlantic Hendon Road Mill Hill London NW8

Client name:

Demonstration 1

PL E

Infection Control Action Plan

Notes: Corrective actions: CFPP01-04 Essential Quality Requirements

M

Linen Management Reference

Staff should wear aprons for handling used linen.

Personal Protective Equipment at Work Regulations 1992; CFPP 01-04 Decontamination of linen for health and social care: Social care DH 2013; Prevention and control of infection in care homes – an information resource DH/HPA 2013

EX A

Corrective Action

Evidence of Compliance

Responsibility

Due Date

Evidence of Compliance

Responsibility

Due Date

Other Corrective Actions

Governance and Documentary Evidence Corrective Action

Reference

The manual should contain all the Code of Practice for the prevention and policies, procedures and protocols for the control of infections 2010 Criterion 9 and standard infection prevention and control table 3 precautions.

Copyright IPC Management (Holdings) Ltd © 2005–2013 Template: Mental Health In-Patient (AT039)

Report Version 0.0.1 Date Approved: 05/11/2013

Page 1 of 11

Kitchen/servery work surfaces must be in Food Standards Act 1990; HBN 00-09: a good state of repair to facilitate Infection control in the built environment effective cleaning. Damaged work DH 2013; HBN 00-10 Performance surfaces should be replaced/repaired. requirements for building elements used in healthcare facilities DH 2011

PL E

Fridges must be cleaned with warm water Food Standards Agency Guidance for and detergent following any leaks or Caterers / Supplement for Care Homes; spills.

Food Standards Act 1990 Food Standards Agency Guidance for Caterers / Supplement for Care Homes; Food Standards Act 1990

Temperature probe must be thoroughly decontaminated after each use with a commercial probe wipe and stored in an enclosed container.

Food Standards Agency Guidance for Caterers / Supplement for Care Homes; Food Standards Act 1990

Water boiler dispenser nozzle should be kept free from limescale build-up.

HBN 00-09: Infection control in the built environment DH 2013; Revised Healthcare Cleaning Manual NPSA 2009; The National Specifications for Cleanliness in NHS a framework for setting and measuring performance outcomes NPSA 2007

Water boiler collection tray should be kept free from limescale build-up and mildew.

HBN 00-09: Infection control in the built environment DH 2013; Revised Healthcare Cleaning Manual NPSA 2009; The National Specifications for Cleanliness in NHS a framework for setting and measuring performance outcomes NPSA 2007

EX A

M

Microwave must be cleaned with warm water and detergent following any leaks or spills.

Clinical Environment Corrective Action

Reference

Evidence of Compliance

Responsibility

Due Date

A designated clinical treatment room HBN 00-03 Clinical and Clinical Support should be available for minimally invasive Spaces DH 2010 clinical procedures and clean tasks.

Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)

Report Version 0.0.1 Date Approved: 05/11/2013

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Code of practice for the prevention and control of infections 2010 Criterion 9; Personal Protective Equipment (EC Directive Regulations) 1992; Control of Substances Hazardous to Health Regulations 2002

PL E

Single use, disposable plastic aprons must be available when there is a risk of contamination of clothing with blood, body fluids, secretions, excretions, chemicals or when handling waste bags or dirty linen, etc.

Staff should wear a disposable plastic EPIC2 National Evidence Based Guidelines apron during all procedures where there for Preventing HCAI in NHS Hospitals in is a risk of exposure to blood, body fluids, England Final 2007 secretions and excretions; or when a service user has a known infection.

Facial protection must be available i.e. EPIC2 National Evidence Based Guidelines full-face visor, goggles and mask or mask for Preventing HCAI in NHS Hospitals in with integral visor.

England Final 2007

EPIC2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007

Disposable plastic aprons should be worn for urine analysis.

EPIC2 National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007

Discard urine samples into a slop-hopper or toilet, not into hand wash basins or sinks.

HBN 00-09: Infection control in the built environment DH 2013; HBN 00-03: Clinical and clinical support spaces DH 2010; HTM 07-01 Safe management of healthcare waste DH 2013

EX A

M

Disposable plastic aprons should be worn for venepuncture.

Clinical Equipment Corrective Action

Reference

Evidence of Compliance

Responsibility

Due Date

Suitable training must be given to all staff MHRA Single use medical devices: members to ensure they are aware of the Implications and consequences for re-use 'single use' symbol.

MDA DB 2006(04) v2.0 DH 2011; The Medical Devices Regulations 2002 Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)

Report Version 0.0.1 Date Approved: 05/11/2013

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Waste Management Corrective Action

Reference

Evidence of Compliance

Responsibility

Due Date

PL E

All waste bins should be fire retardant. If HTM 07-01 Safe management of healthcare plastic, these must be heavy duty and waste DH 2013; HBN 00-09: Infection labelled fire retardant. control in the built environment DH 2013; Firecode HTM 05-03: Operational Provisions Part F: The prevention and control of arson in NHS healthcare premises DH 2013 Offensive/hygiene waste should be HTM 07-01 Safe management of healthcare disposed of in tiger striped (yellow/black) waste DH 2013 bags.

HTM 07-01 Safe management of healthcare waste DH 2013

All waste bags (clinical/domestic) should be securely tied to prevent the risk of spillage during transit.

HTM 07-01 Safe management of healthcare waste DH 2013

The waste storage area should only contain waste items for collection.

HTM 07-01 Safe management of healthcare waste DH 2013; HBN 00-09: Infection control in the built environment DH 2013

EX A

M

Orange/yellow waste bags should be labelled with source (i.e. location/department, etc) using a label, numbered tag or an indelible pen.

Decontamination of Environment Corrective Action

Reference

Blood and body fluid spillage kit should be available.

Revised Healthcare Cleaning Manual NPSA 2009

Chlorine-releasing agent eg. sodium hypochlorite or NaDCC (or equivalent spillage kit) should be available for blood/body fluid spillages.

Revised Healthcare Cleaning Manual NPSA 2009

Evidence of Compliance

Copyright IPC Management (Holdings) Ltd Š 2005–2013 Template: Mental Health In-Patient (AT039)

Responsibility

Due Date

Report Version 0.0.1 Date Approved: 05/11/2013

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