Care_hom

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

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


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:


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.


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


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


Findings:


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


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


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


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


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


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


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


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


Standard Eight: Adequate access to laboratory support is secured – Not applicable to Care Home Services

Y N NA Comments

Findings


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


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


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


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


Care_hom

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