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Infection Prevention and ControlWoodkirk House
Halifax RoadDewsbury
WF13 4HS
Tel:01924 512079Fax: 01924 816078
2010
Dear,
RE: Infection Prevention Audit for Care Homes
Thank you for your assistance with the recent Infection Prevention Audit undertaken…….. I have enclosed a copy of the score sheet, completed audit tool and action plan identifying the actions required to improve practice.
Please sign off the actions on the action plan and return the completed sheet to me before ……… If you require any additional information, please do not hesitate to contact me.
Yours sincerely
Enc RAG Score Sheet, Audit & Action PlanCC Quality Improvement Team
LA Contracting Team NHS Contracting TeamHPA West Yorkshire Unit
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 1
INFECTION PREVENTION AND CONTROL AUDIT CARE HOMESDate: Time:
Name of Home: Address:
Telephone Number:
Fax Number:
Number of beds: Number of residents at time of audit:
Number of staff:
Nurses: Care Assistants:
Domestic housekeeping:
Laundry:
Cooks: Handy worker:
Staffing ratio (12 hour shifts)
Mornings: Evenings:
Afternoons: Nights:
Number of residents who have:
Indwelling catheters
Leg ulcers/Pressure sores
Peg feeds Infected/colonised Identify organism
Number of single rooms:
Double rooms:
All en suite Yes / No
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 2
Do staff have access to Occupational Health? Yes / No
Does this include: Latex Allergy information:
Immunisations including:
Influenza:
Hepatitis B
Care Home Representative:
Designation:
Name of Manager:
Agency staff:
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 3
POLICY STATEMENT
Tackling HCAI (Healthcare Associated Infections) is a key priority for the NHS. The Health and Social Care Act 2008: Code of Practice for healthcare and adult social care on the prevention and control of healthcare associated infection and related guidance (known as The Code) reinforces this with statutory legislation.
All commissioners must ensure their providers comply with the Health Act ensuring that they provide a clean and safe environment for patients, visitors and staff, care homes are legally required to register with the Care Quality Commission (CQC).
This information will be available to the public.
The inspection will focus around cleanliness, infection control, safety and suitability of equipment and premises, as well as the fitness of workers. (All these standards are identified within The Code.)
The criteria standards for this audit tool have been developed using the ten criterion within The Code of Practice. Environmental audits of care homes will form part of a rolling programme for infection prevention & control, to work in partnership with nursing and residential homes in order to improve standards for patients, staff and visitors.
The infection prevention and control team will undertake an unannounced visit if there are concerns regarding standards within the home. If the standards within the criterion are not met then the Local Authority and NHS Kirklees’ contracting teams and risk and governance teams will be advised.
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 4
CONTENTS
INFECTION PREVENTION AND CONTROL AUDIT CARE HOMES
1.0 There is a system to manage and monitor the prevention and control of infection using risk assessments
2.0 A clean and appropriate environment is provided and maintained to facilitate the prevention and control of infection
3.0 Suitable and accurate information on infections is available to service users and their visitors
4.0 Suitable and accurate information on infections is provided in a timely manner to others who provide support or care to the client
5.0 People who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people
6.0 All staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection
7.0 Adequate isolation facilities are provided
8.0 Adequate access to laboratory support is secured – Not applicable to Care Home
9.0 Policies are available, that will help to prevent and control infections
10.0 As far as is reasonably practicable, care workers are free of and are protected from exposure to infections that can be caught at work, and all staff are suitably educated in the prevention and control of infection
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 5
Standard One: There is a system to manage and monitor the prevention and control of infection using risk assessments
Y N NA Comments1 There is an identified infection
control lead2 The lead is of sufficient seniority to
challenge inappropriate practice3 There are sufficient resources to
ensure safe infection prevention and control practice
4 The Lead is able to advise how infection control issues are escalated within the organisation
5 The Lead is able to correctly identify when a member of staff who has had diarrhoea and vomiting will be allowed to return to work
6 Staff receive suitable and sufficient information to prevent and control infection
7 There is a written infection prevention and control programme which details objectives and priorities for action
8 There is a written annual statement which is publicly available regarding compliance with good practice
9 There is evidence that the statement has been reviewed and acted upon if necessary
10 There is a programme of audit which monitor compliance with infection control policies and practices
11 There is an identified individual who leads on decontamination of equipment
12 Essential Steps assessment tools are in use (identify which ones)
13 Staff are able to advise correct action to take following exposure incident
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 6
Findings:
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 7
Standard Two: A clean and appropriate environment is provided and maintained to facilitate the prevention and control of infection.
Y N NA Comments14 There is an identified lead to
ensure the environment is clean and appropriately maintained
15 All parts of the premises are clean, suitable for purpose and in a good state of repair
16 There is a cleaning schedule / plan readily available
17 Staff are aware of how to safely manage spillages of blood and body fluid
18 A hypochlorite solution is available for managing blood spillages
19 There is evidence that cleaning standards are monitored
20 There are sufficient resources to adequately manage cleaning in the home
21 Medicine pots are cleaned appropriately
22 Cleaning equipment is appropriately stored and managed when not in use
23 A hand wash poster demonstrating correct technique is available
There is adequate provision of suitable hand wash basins available within:24 Bedrooms25 Bathrooms26 Treatment Rooms27 Sluice28 Laundry29 Toilet30 Cleaners RoomThere is liquid soap available (not refilled) in:31 Bedrooms32 Bathrooms33 Treatment Rooms34 Sluice35 Laundry36 Toilet37 Cleaners RoomThere are wall mounted paper towels available in:38 Bedrooms39 Bathrooms
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 8
Y N NA Comments40 Treatment Rooms41 Sluice42 Laundry43 Toilet44 Cleaners Room45 There are no bars of soap
available for staff use46 There is alcohol rub available at
the point of client contact47 Hoists and commodes are cleaned
each time they are used. 48 Clinical procedures are carried out
in a manner that maintains the principles of asepsis (NH only)
Nursing home only
49 Random check identifies that hoist is clean
50 Commode pans / urinals / bedpans are cleaned each time they are used
Describe method used:
51 Random check identifies commode/ bedpan/ urinals are clean
52 Appropriate methods are used to clean / dispose of commode pans / urinals / bedpans
53 Mattresses are checked monthly for staining etc.
54 Random check identifies satisfactory standard for mattresses (10% checked, plus one air type mattress)
55 Equipment is cleaned in an appropriate facility/ area
56 A system to record cleaning of equipment is available and in use
57 The storage of equipment for cleaning is satisfactory
58 Cleaning equipment is colour coded
59 Mop heads are disposable / laundered weekly
60 Dirty water is disposed of in an appropriate place
61 Cleaning products in use are appropriate
62 There are adequate supplies of laundry
63 Water soluble bags for soiled linen are available
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 9
Y N NA Comments64 Clean linen is stored away from
dirty linen65 Soiled laundry is not “manually
sluiced”66 Linen is in a good condition when
checked67 Standards for managing laundry
are satisfactory68 Furnishings are clean and in a
good state of repair69 There is adequate odour control
within the homeWaste is segregated appropriately:70 Domestic waste is in a black bag71 Offensive waste is in a tiger-stripe
bag72 Hazardous waste is in an orange
bag73 Waste bins are foot operatedFindings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 10
Standard Three: Suitable and accurate information on infections is available to service users and their visitors.
Y N NA CommentsWritten Information is available: 74 To advise visitors how they can
play a part in supporting the home to manage an outbreak of infection
75 To remind everyone of the need for good hand hygiene
76 On norovirus77 On MRSA78 On the application of suppression
treatment79 On Clostridium DifficileFindings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 11
Standard Four: Suitable and accurate information on infections is provided in a timely manner to others who provide support or care to the client
Y N NA Comments80 There is a written system detailing
how clients are risk assessed regarding their infectious status
81 There is evidence of this risk assessment being documented in a client’s records
82 There is a written plan of care to advise how a client with an infection should be safely cared for
83 There is evidence that the care plan is being followed
84 There is written information to advise staff when and how to inform relevant others of a client’s infectious status
85 The risk assessment stickers are available for use to inform staff of the client’s infectious status on transfer to other care providers
86 There is evidence that the stickers are in use
Findings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 12
Standard Five: People who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.
Y N NA Comments87 Staff are able to correctly advise
on how outbreaks are reported within office hours
88 Staff are able to advise who to report outbreaks to out of office hours
Public Health on-call 01484 342000
89 Staff know how to contact the PCT infection prevention team
90 Staff know how to contact the HPA West Yorkshire unit to notify an outbreak of infection
HPA 0113 2840606
Findings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 13
Standard Six: All staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection
Y N NA Comments91 There is evidence that outside
agencies (e.g podiatry) comply with health professional’s registration.
92 Mechanisms are in place to monitor all staff employed independently in the home to ensure that basic infection prevention and control standards are adhered to. To include:● Bare below the elbows● Use of PPE● Hand hygiene/alcohol gel● Waste management
93 Induction training is available for all staff including agency workers
94 There is a record that new staff have completed induction training
95 There is an annual programme of ongoing education for all staff
96 There is a record of staff who have received annual training
Findings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 14
Standard Seven: Adequate isolation facilities are provided
Y N NA Comments97 Facilities are available to
physically separate clients from other residents in an appropriate manner to minimise the spread of infection
98 Staff correctly identify when a client should be isolated
99 Staff are able to appropriately advise what isolation precautions are implemented when a client is suspected/ known to have a transmissible infection
100 Information is available on when and how a client should be ‘isolated’
101 Evidence to demonstrate compliance to the above is available
Findings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 15
Standard Eight: Adequate access to laboratory support is secured – Not applicable to Care Home Services
Y N NA Comments
Findings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 16
Standard Nine: Policies are available, and adhered to that will help to prevent and control infections
Y N NA Comments102 Policies identify the author103 Policies identify the date for
revision104 Policies are current105 Policies are easily accessible106 Staff are aware of where to find
policies107 There is a signed sheet to confirm
that staff have read and understood the policies
Findings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 17
Y N NA CommentsThe following policies exist – ALL HOMES108 Standard Precautions (including
hand decontamination: use of PPE, management of specimens)
109 Safe handling and disposal of sharps
110 Prevention of occupational exposure to blood borne viruses including management of sharps (includes use of PPE, handling sharps and advice re management of injury both in and out of hours)
111 Management of occupational exposure to blood borne viruses
112 Single use medical devices113 Safe handling and disposal of waste114 Care of deceased persons115 Use and care of invasive devices
(catheters, feeding systems etc)116 Uniform and dress codeThe following policies exist – NURSING HOMES ONLY117 Aseptic technique118 Outbreak of communicable
infections (includes recognising symptoms, when to inform HPA, closure of facilities and cleaning)
119 Isolation of service users with an infection
120 Closure of rooms / home to new admissions / transfers
121 Disinfection122 Decontamination of reusable
medical devices123 Control of outbreaks and infections
associated with specific alert organisms – MRSA, respiratory illness, diarrhoeal illness, C difficile
124 Packaging, handling and delivery of laboratory specimens
125 Purchase, cleaning, decontamination, maintenance and disposal of equipment (to include management of mattresses, commodes and hoists)
126 Surveillance and data collection127 Dissemination of information128 Isolation facilities
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 18
Y N NA Comments129 There is a written statement
confirming that there is a system for clients to receive appropriate immunisations
Practices related to preventing infection:130 Latex gloves are readily available131 Nitrile gloves are readily available132 Disposable aprons are readily
available133 Eye protection is readily available134 Face masks are readily available Nursing homes only135 Catheter bags are emptied safely Describe
136 Receptacles for emptying catheter bags are disinfected / disposed of after each use
Identify cleaning procedure
137 Urinary catheter night bags are changed each night
138 Sharps boxes are less than 2/3 full139 Sharps boxes are safely stored140 Devices (including razors) are not re-
sheathed141 Specimens are stored appropriately142 Staff are observed to be bare below
the elbows. Identify which:143 free of stoned rings144 free from nail polish145 free from false nails / gel overlays146 free from watches and bracelets147 long sleeves / cardiganFindings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 19
Standard Ten: As far as is reasonably practicable, care workers are free of and are protected from exposure to infections that can be caught at work, and all staff are suitably educated in the prevention and control of infection.
Y N NA Comments148 There is a written policy for staff
protectionThis includes:149 pre employment questionnaire for
screening staff150 information regarding infection
when staff should not work151 how staff are assessed to receive
appropriate immunisations152 where advice for staff health is
obtained from153 a record of staff immunisations is
available154 The responsibilities for infection
prevention and control are reflected in job descriptions (JD information seen)
155 The responsibilities for infection prevention and control are reflected in personal development plans/appraisals (documentation seen)
156 Staff are aware of the emergency procedure to follow out of hours to obtain treatment, following an exposure incident (involving sharps injury or bite / splash)
Findings
© Kirklees Primary Care Trust Chairman: Rob NapierChief Executive: Mike Potts
Page 20