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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.
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.
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
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
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
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
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
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
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
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)