hospital hygiene audit tool 24 jun 10.pdf

8/12/2019 Hospital Hygiene Audit Tool 24 jun 10.pdf

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Audit Tool version 8.0

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Hospital Hygiene Unannounced Inspection

Audit Tool

Organisation: ...........................................................................................................................

Ward/Area: ................................................ Speciality:..................................................

Date: ................................................ Inspector/Reviewer:...................................

Guidance

The tool is based on the Infection control Nurse Association (ICNA) Audit tools for monitoringinfection control standards 2004 and the RQIA Hygiene Inspection of Health and Social Care 2008and the Hospital Cleanliness Spot Check, Direct Observation Audit Tool (Healthcare InspectorateWales).

Inspectors/reviewers will be aware of and follow the RQIA's Inspection Protocol.

Inspectors/reviewers may use digital cameras provided to capture images of particular concern orto highlight examples of good practice. These images should only be taken of the organisationsward/area's environment and should at no time include images of Patients, their relatives or staff.Where appropriate these images will be embedded into the inspection report.

If the inspector/reviewer identifies any serious concerns during the review, they should bring this tothe attention of the Team Leader in the first instance. Any area of serious concern which requiresimmediate action will be brought to the attention of the person in charge and Senior Managementbefore the team leave the premises. These concerns will be reported to the RQIA's SeniorManagement Team.

The inspections are not intended to be paper based, they will seek information from observationsin functional areas as defined in 'Cleanliness Matters, a regional strategy for improving thestandard of environmental cleanliness in HSS Trusts, 2005 - 2008' and supplemented bydocumentary and photographic evidence where appropriate. Some areas of direct questioningand observation of clinical practice have been included.

For the purposes of this inspection, the team will concentrate on two of the functional areasdefined in 'Cleanliness Matters' these areas will be specified to the team at the time of theinspection.

Scoring

All criteria should be marked either yes/no or non-applicable.


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It is not acceptableto enter a non-applicable response where an improvement in a standard maybe achieved. For example where a national standard is not being met, a non-applicable must notbe used:

Hand Hygiene Yes No N/A Issues Identified/Good Practice4 Soft absorbent paper

towels are available atall hand washing sinks

In the example above it is not appropriate to mark non-applicable where soft absorbent towels arenot in use as the national standard is to use them. Therefore if they are not in use a no scoremust be allocated. The action plan will then reflect the change in practice required.

Whereas if a standard is not achievable because a facility is absent or a practice not undertaken,the use of non-applicable is acceptable. For example in a clinical area, which does not haveisolation facilities the following standard would be not applicable:

(a) Hand Hygiene Yes No N/A Issues Identi fied/Good Practice34 All staff use the correct

procedure fordecontaminating hands

Comments should be written on the form for each of the criteria at the time of the audit clearlyidentifying any issues of concern and areas of good practice. These comments can then beincorporated into the final report.

Manual scoring can be carried out as fol lows:

Add the total number of yes answers and divide by the total number of questions answered(including all yes and no answers) excluding the non-applicable; multiply by 100 to get thepercentage.

FormulaTotal number of yes answers x 100 = %Total number of yes and no responses

Hand Hygiene Yes No N/A Issues Identified/Good Practice1 Liquid soap is available

at all hand washingsinks

2 Liquid soap is providedas single use cartridgedispensers

3 Dispensers and nozzlesare visibly clean

Dispenser nozzles were blocked with soap residue.

The score for the above table would be calculated as follows:2 x 100 = 66.6 = 67%3


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Level of Compliance

Percentage scores can be allocated a level of compliance using the compliance categories below.The categories are allocated as follows:

Compliant 85% or above

Partial compliance 76 to 84%Minimal compliance 75% or below

Weighting Criteria

Millward et al (1993) reported that weighting of the criteria did not significantly influence overallscores. Therefore weighting of criteria has not been attempted.

Feedback of information and report findings

It is advised that the inspection team should verbally report any areas of concern and of good

practice to the person in charge of the area being inspected prior to leaving. The person in chargeshould be invited to the feedback session. At the feedback session outline issues, do not give outscores or compliance rates as audits need to be fully checked. A list of preliminary findings will beformatted and agreed by each team and then forwarded to be checked within ten working days ofthe inspection.

A written report will be developed by the RQIA and should be given to the Trust for action. Thereport will clearly identify areas requiring action. The Trust is responsible for developing an actionplan to address the issues identified within a given timescale.

The team may decide to re-audit a functional area if there are concerns or a minimal compliancerating is observed to ensure that areas noted in the Quality Improvement Plan have beenaddressed.


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ENVIRONMENTAudit Tool version 8.0

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INFECTION CONTROL AUDIT TOOL

ENVIRONMENT - The environment will be maintained appropriately to reduce the risk ofcross infection.

Yes No N/A Issues Identif ied/Good Practice

General Environment1 The external

entrance/reception to thefacility is clean, tidy, and ingood decorative order

2 The corridors leading to theward/department are clean,clutter free, fresh smellingand in good decorativeorder

3 The ward/department areais clutter free and freshsmelling (first impression)

The following are free of splashes, soil, film, dust, fingerprints and spillage and are in a good stateof repair

4 Lockers

5 Chairs and stools

6 Tables (including bedsidetables/trolleys)

7 Bed frames

8 Patient trolleys

9 All chairs and stools inclinical areas are coveredin an impermeable materialeg vinyl

10 Floors including edges andcorners are free of dustand grit

11 All high and low surfacesare free from dust andcobwebs

12 Curtains and blinds arefree from stains, dust andcobwebs


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Yes No N/A Issues Identified/Good Practice

13 Fans are clean and freefrom dust

14 Air vents are clean andfree from excessive dust

15 Patient equipment such ascall bells, audio visual andwall mounted lamps arevisibly clean.

16 In clinical areas workstations are neat and tidy,equipment is visibly clean,phones, computerkeyboards

17 Radiators interiors andexteriors are clean andfree from dust and debris

General

18 All walls are clean and ingood decorative order

19 All doors are clean and ingood decorative order

20 All light switches and pullcords are clean

21 All windows includingframes are clean and ingood decorative order

Bathrooms/Washrooms

22 Bathrooms/washrooms areclean (high and lowsurfaces and wall tiles and

accessories such as soapdispensers, toweldispenser, radiators etc)

23 Floors including edges andcorners are free of dustand grit

24 Bathrooms/washrooms arein good decorative order

25 Bathrooms are free from

communal items egcreams, talcum powderand shampoos etc


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26 Bathrooms are free frominappropriate equipmenteg hoists, sparemattresses, linen,incontinence products etc

27 Appropriate cleaningmaterials are available forstaff to clean the bath/showers between use askstaff what is the practiceobserve during visit

28 Baths, sinks, showers andaccessories are clean andfree from mould (shower

curtains/bath mats)

29 A foot operated wastedisposal bin is available todispose of used papertowels

30 The bin is clean, free fromspillages inside and outand in a good state ofrepair

31 Baths, showers and sinksout of use have a plannedprovision for running waterweekly (see evidence)

Toilets

32 Toilets are in gooddecorative order

33 The toilet, hand washsink, handrails andsurrounding area is cleanand free from extraneousitems

34 Floors including edgesand corners are free ofdust and grit

35 Hand washing facilitiesare available includingliquid soap and papertowels


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36 A foot operated wastedisposal bin is available todispose of used papertowels

37 The bin is clean, free fromspillages inside and outand in a good state ofrepair

38 There is a facility forsanitary waste disposal

39 Toilet seats are clean andready for use (checkunderneath)

Clinical Room40 There is an identified area

for the storage of cleanand sterile equipment

41 The area is clean, freefrom dust and spillage(check floor, edges andcorners) and in gooddecorative order

42 Shelves bench tops and

cupboards are cleaninside and out and free ofdust, spills and paperlabels

43 All equipment includingmedicine fridge is cleanand free from dust, spillsetc

44 Check for temperaturerecords of medicine fridgei.e. when storing vaccines,insulin, etc

45 The drugs trolley is cleanand free from dust, spillsetc

46 The clinical room is freefrom inappropriate itemsof equipment


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47 Hand washing facilitiesare available includingliquid soap and papertowels

48 A foot operated wastedisposal bin is available todispose of used papertowels. Check clinical andgeneral waste aresegregated correctly

49 All products are storedabove floor level

50 There is an effective stock

rotation system

51 Sterile equipment itemsare in date (randomlyselect items, check date)

Clean Store

52 There is an identified areafor the storage of cleanand sterile equipment

53 The area is clean (check

floor (edges and corners)and in good decorativeorder

54 Shelves, bench tops andcupboards are cleaninside and out and free ofdust, spills and paperlabels

55 The clean store is freefrom inappropriate itemsof equipment

56 All products are storedabove floor level

57 There is an effective stockrotation system

58 Sterile equipment itemsare in date (randomlyselect items, check date)


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Dirty Utility

59 A dirty utility is available

60 The area is kept in gooddecorative order

61 The integrity of fixturesand fittings are intact

62 A separate sink isavailable fordecontamination ofpatient equipment

63 A sluice hopper isavailable for the disposal

of body fluids

64 Separate hand washingfacilities are availableincluding soap and papertowels

65 A foot operated wastedisposal bin is available todispose of used papertowels, it is clean and ingood repair

66 The room is clean andfree from inappropriateitems

67 The floor is clean and freefrom spillage


69 Macerators and bed panwashers are clean and inworking order (washer/disinfectors are regularlytested)

70 Shelves and cupboardsare clean inside and outand free of dust, litter orstains

71 Equipment used by staff

is clean and wellmaintained


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72 Commodes are clean andready for use (checkunderside)

73 A triggering system isavailable to identify thatcommodes have beencleaned and are ready foruse

74 Commodes are in a goodstate of repair

75 Bedpans are clean andstored appropriately (onracks)

76 Bedpan liners areavailable for use withMaceraters

77 If re-useable jugs are inuse for emptying catheterbags, appropriatewashing and disinfectionfacilities are available

78 Catheter stands are

available, clean and in agood state of repair

Domestic's Room

79 A domestics store isavailable for equipmentand cleaning products

80 The room is in a goodstate of repair

81 Information on the colourcoding system in use isavailable in the domesticsroom

82 Cleaning equipment iscolour coded in line withNational Colour CodingGuidelines

83 A good supply of colourcoded equipment and

materials is available


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84 Mops and buckets arestored inverted

85 Mop heads are laundereddaily or are disposable(single use)


87 Equipment used by thedomestic staff is clean,well maintained andstored in a locked area

88 Machines used for floorcleaning are clean anddry

89 Chemicals used bydomestic staff are storedin accordance withCOSHH regulations (in alocked area

90 Products used forcleaning and disinfection

comply with policy andare used at the correctdilution

91 Diluted products arediscarded after 24 hours

92 No inappropriatematerials or equipmentare stored in domestic'sroom

93 Personal protectiveclothing is available andappropriately used ( Maybe available fromdispensers throughoutward or department )

94 Hand hygiene facilitiesincluding liquid soap andpaper towels are availablefor domestic use


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95 A sluice is available

96 A waste bin is availablefor paper towels

Direct Questioning

97 A written policy for pre-planned curtain changesis available

98 Ear phones are single useand changed betweenpatients

99 Re-useable ear phones

are cleaned betweenpatients

100 Environmental audits areundertaken (see evidenceand note frequency ,responsibility and followup)

101 Staff changing facilitiesare available

TOTAL SCORES

PERCENTAGEACHIEVED


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HANDLING AND DISPOSAL OF LINENAudit Tool version 8.0

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HANDLING AND DISPOSAL OF LINEN - Linen is managed and handled appropriately toprevent cross in fection


Clean linen is:1 Stored in a designated

area (not in sluice orbathroom or on thefloor)

2 Free from stains and ina good state of repair(Randomly check linen)

The clean linen store is:

3 Clean and free fromdust

4 Free from inappropriateitems

5 In a good state of repair(wooden shelves aresealed)

Used linen is:

6 Segregated in

appropriate colourcoded bags according topolicy(poster displayed)

7 Put in linen bags thatare less that 2/3 full andcapable of beingsecured

8 Soiled linen bags arestored in an appropriateholding area prior todisposal

Direct Questioning

9 Facilities for launderingstaff uniforms areavailable or a homelaundering policy hasbeen issued

10 Staff are supplied with asufficient supply of

uniforms to facilitate useof laundering facility


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Observational

11 Linen skips and theappropriate bags aretaken to bedside/bay(Staff are not carryingsoiled linen or leaving iton the floor)

12 Staff uniforms are visiblyclean

13 Gloves and apron areworn when handlingcontaminated linen

14 Aprons are worn when

handling used linen

Ward Based Mini Laundries (staff launder patients cloth ing/bed linen/towels or mops and cloths)

15 Ward based washingmachines are only usedwith the agreement ofthe Infection ControlTeam and comply withHSG 95(18)

16 A washing machine ifused is situated in an

appropriate designatedarea

17 If a washing machine isin use a tumble dryer isalso available which isexternally exhausted

18 There is evidence thatthe washing machine andtumble dryer are on apre-planned maintenanceprogramme

19 Hand washing facilitiesincluding liquid soap andtowels are available inthe laundry room

20 A foot operated wastedisposal bin is availableto dispose of used papertowels


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21 Written guidanceregarding the use of thewashing machine isavailable

22 There is evidence thatthese guidelines arebeing adhered to(question staff andobserve use)

TOTAL SCORES

PERCENTAGEACHIEVED


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DEPARTMENT WASTE HANDLING AND DISPOSALAudit Tool version 8.0

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DEPARTMENTAL WASTE HANDLING AND DISPOSAL - Waste is disposed of safely withoutthe risk of contamination or injury


Waste Handling1 Waste posters on

household and clinicalwaste segregation aredisplayed. Generalwaste policy is available

2 All waste bags are tiedand clinical waste bagsfastext tagged andsecured before leaving

the place of generation(e.g. ward)

3 All waste bins areenclosed to minimize therisk of injury

4 Various bins areavailable i.e. clinical,household, glass andaerosol and labeled andused correctly (visibly

check bin contents)

5 All waste bins in the areaare foot operated, liddedand in good workingorder

6 All waste bins are visiblyclean and in a goodstate of repair

7 Bins are not more than

2/3 full

8 Bags are not observed incorridors or public areas

9 Bags are stored in anappropriate internal holdarea


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DEPARTMENT WASTE HANDLING AND DISPOSALAudit Tool version 8.0

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10 All prescription onlymedicines must bedisposed of ashazardous/special wasteand the bin labeledaccordingly

11 Answer yes if:- wastebags are not tied ontocontainers/trolleys

12 Suction waste must bedisposed of in a mannerwhich prevents spillage,e.g. canisters/liners aredisposed of into rigid

leak-proof containers orsuction waste has beensolidified with a gellingagent

13 Approved rigid burnbins are available fordisposable of bodyparts, equipment etc

14 Internal storage area isinaccessible to the

public or locked

Direct Questioning

15 Waste bags areremoved at least daily.If not observed ask staff

16 Answer yes if:- there isno transfer of clinicalwaste from one bag toanother

17 Staff have attended atraining session whichincludes the correct andsafe disposal of clinicalwaste (timescale andsee records)

TOTAL SCORES

PERCENTAGE

ACHIEVED


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SAFE HANDLING AND DISPOSAL OF SHARPSAudit Tool version 8.0

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SAFE HANDLING AND DISPOSAL OF SHARPS - Sharps will be handled safely to preventthe risk of needle stick injury


Check all sharps bins to ensure they:1 The bins in use comply

with national standards(UN 3291.BS 7320)

2 Have not been filledabove the fill line

3 Are free from protrudingsharps

4 Have been assembledcorrectly

5 Are stored safely(consider when not inuse, full and away fromthe public)

Sharp bins:

6 All sharp bins arelabeled and signedaccording to hospital

policy

7 Sharps bins are storedappropriately off the floor

8 Sharp bins are used inaccordance withergonomic manualhandling principles i.e.using brackets

9 The temporary closuremechanism is usedwhen bins are not in use(this criteria has beenchecked - it is currentlygood practice and shouldbe applied)

10 Once full the binaperture is locked

11 Sealed, tagged andlocked bins are stored ina locked room, cupboardor container, away frompublic access


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SAFE HANDLING AND DISPOSAL OF SHARPSAudit Tool version 8.0

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12 An empty sharps bin isavailable on the cardiacarrest trolley

13 The sharps bin on thecardiac arrest trolley isstored safely

14 Sharps trays withintegral sharps areavailable for use

15 Sharps trays arecompatible with thesharps bins in use

16 Sharps trays in use are

visibly clean

17 Needles and syringesare discarded into asharps bin as one unit

Observational

18 Sharps are disposed ofdirectly into a sharps binat the point of use

19 Answer yes if:-

inappropriate re-sheathing of needlesdoes not occur.Observe or question amember of staff

20 Is there a poster for themanagement of aninoculation injury

Direct Questioning

21 Staff have receivedtraining which includesthe safe handling anddisposal of sharps(timescale and seerecords)

22 Staff are aware of theaction required followingan inoculation injury

TOTAL SCORES

PERCENTAGEACHIEVED


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PATIENT EQUIPMENT (GENERAL)Audit Tool version 8.0

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PATIENT EQUIPMENT (GENERAL) - There is a system in place that ensures as far asreasonably practicable that all re-useable equipment is properly decontaminated prior touse and that the risks associated with decontaminating facilities and processes areadequately managed. All decontamination must be undertaken in accordance with local

policy and manufacturer's instructions.


The following general equipment is v isibly c lean and free from dust and body fluids (check):

1 The responsibility for thecleaning of dedicated patientequipment is clearly definedeg bed frames, IV standards,commodes (Good practice-check for triggering systemsto indicate equipment is

clean and ready for use)

2 IV Stands

3 Vital signs monitoring trolley

4 IV pumps/syringe drivers

5 Cardiac monitors

6 Near patient testingequipment e.g. blood gasmachines

7 Dressing trolleys

8 Blood pressure cuffs

9 Pillows

10 Mattresses check if an auditof mattresses has beenundertaken (see evidence).If possible spot checkmattress with a zip

11 Bed rails

12 Wheelchairs and cushions


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13 Oxygen saturation probes

14 Patient wash bowls aredecontaminatedappropriately betweenpatients and are storedclean, dry and inverted

15 Disposable paper towels oncouches/trolleys is changedbetween patient use

Manual handling equipment is visib ly clean ( managed according to local policy)

16 Hoists

17 Pat slides

18 Easy slides

19 Hoist slings

20 Stand aids

21 Handling belts

Resuscitation equipment

22 Items on the resuscitationtrolley/resuscitaire are indate and visibly clean (freefrom dust and body fluids)

23 Single use ambu bags areused or filters to ambu bags

are changed between patientuse

24 Laryngoscope blades arestill in sterile packaging

25 Laryngoscope handles andblades if not disposable aredecontaminated followingeach use


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Oxygen and suction equipment

26 Suction equipment is clean,free from dust and dry(including canister)

27 Answer yes if:- catheter isnot attached (clean coveracceptable in someemergency situations)

28 Disposable suction liners areused and changed betweenpatient use

Respiratory equipment is changed accord ing to local policy and manufacturers instructions, check

29 Oxygen masks/nasal

cannulae

30 Wall humidifiers

31 Nebulisers

Ventilator equipment is visibly clean and free from dust and body fluids

32 Humidifiers are managedaccording to manufacturersinstructions and local policy,

33 Ventilator tubing is protectedby filters - expiratory

34 Ventilator is protected by afilter - inspiratory

35 Ventilator equipment is on apre-planned maintenanceprogramme

36 Ventilator equipment isvisibly clean and tubingchanged weekly

Decontamination and Disinfecting Knowledge

37 Is a written comprehensivedecontamination policy,approved by the IPCT/ICC,available to all staff?


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38 Staff are aware to contactIPCT for advice whenpurchasing new equipment(check with person incharge)

39 Manufacturers' instructionsare available for thedecontamination of newlypurchased equipment (checkwith person in charge)

40 Used instruments are safelystored in an appropriatecontainer prior to collectionfor decontamination in CSSD

(rigid container)

41 Answer yes if:- localdecontamination of reusablesurgical instruments is notundertaken in clinical areas(check for bench topautoclaves)

42 Staff can describe thesymbol used to indicatesingle use items

43 Appropriate disinfectantsand dilution charts areavailable to deal with bloodspillages and disinfection ofisolation rooms

44 Correct dilutions ofdisinfectants are used forblood spillages anddecontamination of isolationrooms

45 Chemical disinfection is onlyused for heat-labileequipment e.g. fibroscopes

46 Appropriate measures forcompliance with COSHH arein place when usingdisinfectants e.g. lockedcupboards


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47 Data sheets are available fordisinfectants used by nursingstaff (COSHH)

48 Staff can state the procedurefor decontamination ofcommonly used patient careequipment e.g. commodes,mattresses, IV stand

49 Staff are aware of the needfor decontamination and acertificate before equipmentis maintained/serviced/repaired within the area ortransferred from the area

50 A Disinfection Policy is inplace and known by staff

TOTAL SCORES

PERCENTAGEACHIEVED


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HAND HYGIENEAudit Tool version 8.0

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HAND HYGIENE - Hands wi ll be decontaminated correctly and in a timely manner using acleansing agent, at the facilities available to reduce the risk of cross infection


1 Liquid soap is availableat all hand washingsinks

2 Liquid soap is providedas single use cartridgedispensers

3 Dispensers and nozzlesare visibly clean

4 Soft absorbent papertowels are available atall hand washing sinks

5 Paper towel dispensersare visibly clean, dustfree and in a good stateof repair

6 A foot operated wastedisposal bin is availableto dispose of used paper

towels. Is clean and in agood state of repair

7 Wall mounted or pumpdispenser hand cream isavailable for use in atleast one location

Hand wash sinks:

8 Are free fromnailbrushes in clinicalareas

9 Are free from usedequipment andinappropriate items

10 Are dedicated for thatpurpose


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11 Conform to HTM 64.Check that they do nothave plugs, overflows orthat the water jet doesnot flow directly into theplughole. (In patientareas a plug isacceptable so thatpatients can wash)

12 Are sufficient numbersin accordance withnational and localguidance (e.g. one sinkper four beds in acutecare settings)

13 Sinks are accessible(not blocked byequipment or furnitureetc)

14 Hand washing facilitiesare clean and intact.(Check sinks, taps,splash backs)

15 Have appropriate

temperature control toprovide suitable handwash water

16 Have elbow operated orautomated taps inclinical areas

Alcohol hand rub is available for use throughout c linical cares, check:

17 Entrance/exits to wardsand departments

18 Directly accessible atthe point of care (eg onedispenser per bed/perfour beds as per localand national standards)

19 Posters promoting handdecontamination areavailable and displayedin areas visible to staffbefore and after patient

contact


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20 Clinical staffs' nails areshort and free from nailvarnish

21 Staff working in clinicalareas have long hair tiedback and off the collar

22 Non uniform clinical staffdo not wear unsecuredties or draped scarves

23 All staff wear shortsleeves or roll sleeves toelbow length

24 Alcohol hand rub isportable for clinicalprocedures

25 No wrist watches/stonerings or other wristjewellery are worn bystaff carrying out patientcare (plain band ringacceptable)

Direct Question ing Staff

26 Patients are offeredhand hygiene facilitiesafter using thetoilet/commode/bedpane.g. hand wipes

27 Staff have receivedtraining in hand hygieneprocedures within thelast year (Ask a memberof medical, nursing,ancillary and AHP staff).

Observational

28 Antibacterialsolutions/scrubs are notused for social handwashing

29 Antibacterial solutionsare used for invasiveprocedures and surgicalscrubs


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Observational and Direct Questioning for patients

30 Patients are offered handhygiene facilities afterusing thetoilet/commode/bedpaneg hand wipe

31 Patients are offered handhygiene facilitiesprior to meals

32 Do staff wash ordecontaminate hands(before, during, aftercontact)?

Observation of Hand Hygiene Practices33 All staff can indicate

when it is appropriate touse alcohol rub (ask 2staff)

34 All staff use the correctprocedure fordecontaminating hands

Hand Hygiene is performed in the following circumstances (observe practices)

35 Following patient contact

36 After removal of gloves

37 Prior to clinicalprocedures

38 After a clinical procedure

39 Prior to handling food

40 After handlingcontaminated items

41 After leaving an isolationroom

TOTAL SCORES

PERCENTAGEACHIEVED


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WARD/DEPARTMENT KITCHENSAudit Tool version 8.0

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WARD/DEPARTMENT KITCHENS - Kitchens wil l be maintained to reduce the risk of crossinfection in accordance with legislation


1 The floor is free ofdust, grit, litter, marks,water or other liquids

2 Inaccessible areas(edges, corners andaround furniture) arefree of dust, grit, lintand spots

3 Answer yes if:- there

are no inappropriateitems or equipment inthe kitchen

4 Answer yes if:- there isno evidence ofinfestation or animalsin the kitchen. If bateboxes are in place,look for date or dust todetermine if still active

5 Fly screens are inplace where required

6 Insectacutor is cleanand well maintained(serviced every year)

7 Fans, expel airs andextraction units areclean and free fromdust and grease

8 Cleaning materialsused in the kitchen areidentifiable (e.g. colourcoded) and are storedseparately to otherward cleaningequipment and awayfrom food(includeschemicals)

9 Hand wash sink, liquid

soap and disposablepaper towels areavailable


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10 Waste bins are footoperated and in goodworking order

11 Waste bins are cleanand labeled for'general waste'

12 Fixtures are in goodstate of repair andsurfaces andappliances are free ofgrease, dirt, dust,deposits, marks, stainsand cobwebs

13 Shelves, cupboardsand drawers are cleaninside and out and arefree from damage,dust, litter or stains andin a good state ofrepair

14 Kitchen trolleys areclean and in a goodstate of repair

15 Refrigerators/freezersare clean and free ofice build up

16 There is athermometer in thefridge and freezer

17 There is evidence thatdaily temperatures arerecorded andappropriate action istaken if standards arenot met (refrigeratortemperature must beless than 8C or aslocal policy. Freezertemperature - 18C)

18 Patient and staff foodin the fridge is labeledwith name and dateand stored

appropriately (raw andcooked)


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19 Hot and cold food isheld in appropriatestorage prior to service

20 The fridge is free fromdrugs/blood fortransfusion orpathology specimens

21 Microwaves are visiblyclean inside and out

22 Where local policyallows a microwave tobe used to heat patientfood a temperature

probe is used toensure the correcttemperature has beenreached (check forprobe and calibrationrecords)

23 Water coolers arevisibly clean and on apre-plannedmaintenanceprogramme

24 Water coolers and icemachines for patientuse are mains supplied

25 Ice machines arevisibly clean and on apre-plannedmaintenanceprogramme andcleaning schedule is inplace

26 Scoop used for ice isstored outside of themachine in a liddedcontainer

27 Toasters are visiblyclean

28 Bread is stored in aclean bread bin or

suitable segregatedarea (fridge in hotweather)


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29 Milk coolers are visiblyclean

30 Milk is stored underrefrigerator conditions

31 All food products arewithin their expiry date

32 All opened food iscovered or stored incontainers

33 There is a satisfactorysystem for cleaningcrockery and cutlery

such as central wash-up dishwasher,achieving disinfectiontemperaturesevidenced by amaintenanceprogramme(a dailyrecord of wash andrinse cycles isavailable)

34 Disposable paper roll

is available for dryingequipment andsurfaces

Direct Questioning of Staff

35 There is a policyregarding patient andvisitor access to theward kitchen

Observational

36 Hands aredecontaminated and aclean plastic apron isworn to serve patientmeals and drinks

37 Cleaning schedulesare available

TOTAL SCORES

PERCENTAGE ACHIEVED


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CLINICAL PRACTICEAudit Tool version 8.0

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CLINICAL PRACTICE- Clinical practices will be based on best practice and reflect infectioncontrol guidance. The following criteria are areas which can be reviewed. They do not cover allaspects of care but can give some indication that appropriate infection control measures are inplace.


Personal Protective Equipment

1 Sterile and non-sterilegloves are available

2 Eye protection isavailable (shatterproofmay be required in someareas)

3 Sterile and non-sterilegloves (powder free)conforming to EuropeanCommunity (EC)standards are fit forpurpose (not splittingetc)and are available inall clinical areas

4 Alternatives to naturalrubber latex (NRL)gloves are available for

use by practitioners andpatients with NRLsensitivity

5 Disposable plasticaprons are available inwall mounted containers

Gloves are observed to be worn for:

6 Invasive procedures

7 Contact with sterile sites

8 Contact with mucousmembranes

9 All activities that havebeen assessed ascarrying a risk ofexposure to body fluids

10 Gloves are worn assingle use items


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11 Gloves are wornimmediately before anepisode of patientcontact or treatment,when appropriate, andremoved as soon as theactivity is completed

12 Hands aredecontaminatedfollowing the removal ofgloves

Disposable plastic aprons are observed to be worn for

13 Disposable plasticaprons are worn when

there is a risk thatclothing or uniform maybecome exposed tobody fluids or becomewet

14 Plastic aprons are wornas single use items foreach clinical procedureor episode of patientcare

15 Full body, fluid repellentgowns are worn wherethere is a risk ofextensive splashing ofbody fluids onto the skinof health carepractitioners

Other PPE

16 Facemasks and eyeprotection are wornwhere there is a risk ofany body fluidssplashing into the faceand eyes

17 Respiratory protectiveequipment is availablefor use when clinicallyindicated e.g. particulatefiltration masks for openpulmonary tuberculosis


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Catheter care

18 All catheters must beconnected to a sterileclosed drainage systemor valve

19 Non-sterile gloves areworn for emptyingurinary catheter bags

20 A disposable receptacleor heat disinfected jug isused for emptyingurinary catheter bags

21 Catheter stands are in

use, there are nocatheters bags touchingthe floor(bags are belowbladder level)

22 Protocols are in placefor catheter hygiene

Enteral Feeding

23 Feeds are replaced atappropriate timeintervals according to

local recommendationse.g. 4 hourly

24 Aseptic technique isused during allprocedures affecting thefeed

Peripheral int ravenous lines

25 Transparent steriledressings are used to

cover intravenouscannulae sites(check ifdated)

26 Evidence of regular siteinspection is available(at least daily)

27 2% Chlorhexidinegluconate in 70%Isopropol alcohol isavailable for cleaning

insertion site or forcannulla access


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28 Replacement protocol inplace for administrationsites and cannulla

Isolation

29 Isolation facilities areavailable i.e. identifynumber of single rooms

30 Any infected patientpresently on the ward isbeing nursed with theappropriate isolationprecautions andaccording to hospitalpolicy

31 Clear instructions forstaff and visitors are inplace when a patient isin isolation (e.g.confidential notice ondoor)

32 There are informationleaflets available forpatients for commoninfections i.e. MRSA, C-

difficile

33 Separate colour codedcleaning equipment is inuse for isolation facilities

General Questioning

34 Staff can state theprocedure when dealingwith specimens frompatients with knowninfections

35 Staff can state theprocedure whenhandling deceasedpatients who have had aknown infectivecondition, e.g. HIV,Hepatitis B

36 Staff can locate theInfection Control Policy

Manual


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37 Staff are aware of theon-line RegionalInfection Control Manual

38 Staff can name theirICLN and Link Nurses

39 Infection control is partof the staff inductionprogramme

40 Staff have attendedmandatory training(random staff includingnurses, doctors, supportstaff)(timescale)

41 Staff have access to thee-learning infectioncontrol programme

42 Housekeeping staff areaware of the local policyand procedures forcleaning isolation rooms

43 A rapid responsecleaning service is in

place

TOTAL SCORES

PERCENTAGEACHIEVED

hospital hygiene audit tool 24 jun 10.pdf

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