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YAS Director of Infection Prevention and Control Annual Report 2009-2010 of 21

Director of Infection Prevention and Control

Annual Report 2009-10

Version: 1.0 Owner: Medical Director/Director of Infection Prevention and

Control Lead: Infection Prevention and Control Nurse Approved By: Strategic Infection Prevention and Control Committee

(IPCC) Date of Approval: Ratified By: Not required Date Ratified: Review Date: May 2011 Target Audience: All staff and stakeholders as identified Policy ID: Issued by Corporate Communications


Contents Section Page 1. Executive Summary 3

2. Description of Infection Prevention and Control (IPC) Arrangements 4

3. DIPC Reports to Trust Board 6

4. Budget Allocation for IPC Activities 7

5. Root Cause Analysis and Incidents Reported 8

6. Hand Hygiene 9

7. Decontamination Arrangements 10

8. Cleaning Services 12

9. Audit 14

10. Targets and Outcomes 15

11. Training Activity 15

Appendices Appendix A Deep Clean Monitoring form

Appendix B Deep Clean Audit form

Appendix C Station Cleaning Audit form

Appendix D Estates General Cleaning Audit form


1 Executive Summary - Overview of Infection Prevention and Control (IPC) Activities in the Trust

1.1 Organisation

Yorkshire Ambulance Service NHS Trust covers almost 6,000 square miles of varied terrain from isolated moors and dales to urban areas, coastline to inner cities. We employ over 3,900 staff, have over 2100 volunteers and provide 24-hour emergency and healthcare services to a population of more than five million.

This is the annual report produced by the Medical Director (Director with responsibility for IPC (DIPC)) for YAS. The Medical Director is a voting member of the Yorkshire Ambulance Service (YAS) Trust Board and is separately accountable to the Chief Executive in this role. YAS has developed its IPC procedures over the past year and this report documents progress over that time.

Progress has been measured against the Board approved action plan for compliance and the requirements of the Health and Social Care Act (2008). In order to provide assurance during 2009-10 there have been three Public Trust Board reports.

The IPC Committee has met on a regular basis during the year.

Recognising the importance of IPC issues in the delivery of effective and professional healthcare, YAS has developed a bid for further resources to support its IPC work relating to IPC units at acute hospital emergency departments. This bid is currently with the Bradford and Airedale PCT and further evidence will be provided to them in the year 2010-2011.

1.2 Activities

YAS IPC activities are planned to meet the following: • Board-approved action plan • National Health Service Litigation Authority level 1 application • Risk Management Scheme for Trusts (RMST) audit • Care Quality Commission (CQC) Healthcare Associated Infections

(HCAI) registration process to obtain a licence to practise for 2010-2011


1.3 Infection Prevention and Control Action Plan for the Year

The action plan was established for a 12 month period and was created to adopt the Health & Social Care Act (2008) relating to IPC. In April 2009 the level of compliance with the Act was 94% and remained and remained at this level until the revision of the Health & Social Care Act (2008) in December 2009 which incorporated additional measures for ambulance trusts.

Compliance against this approved plan has been monitored by the Board through the IP&C Board reports throughout the year. In addition to the Board reports, assurance has been provided following the YAS Annual Business Plan, where appropriate, as below:

Reporting Period

Action

Monthly • Progress update from Directors • Report to the Executive Team • Dash Board Report • Dash Board Report to Board members

Bi-monthly • Detailed report to Integrated Governance Committee

• Exception Report to Trust Board

The coming 12 months will see a further review of this compliance level due to changes within the Health & Social Care Act (2008) relating to IPC.

2 Description of IPC Arrangements 2.1 IPC Team

The IPC team within YAS includes a centralised team and many YAS staff leading IPC initiatives within their own areas.

The work of the central IPC team is owned by the Executive Directors, who ensure that IPC issues are managed appropriately in their respective areas. The principal role in the team is taken by the Director of Infection prevention and Control (DIPC). The role of the DIPC (fulfilled in YAS by the Trust Medical Director), involves but is not restricted to; • overseeing local control of infection policies and their

implementation; • holding responsibility for the Infection Prevention and Control Team

within the healthcare organisation; • reporting directly to the Chief Executive and the Board and not

through any other officer;


• having the authority to challenge inappropriate clinical hygiene practice as well as antibiotic prescribing decisions;

• assessing the impact of all existing and new policies and plans on infection and make recommendations for change;

• being an integral member of the organisation’s clinical governance and patient safety teams and structures;

• producing an annual report on the state of healthcare associated infection in the organisation(s) for which he/she is responsible and release it publicly.

Policy/guidance development and procedures have been delivered by the Infection Prevention and Control Nurse (IPCN) via the Strategic IPC Committee. The IPCN was responsible to the Assistant Director – Health, Safety & Risk in April 2009 and due to re-organisation is now responsible to the Assistant Director – Risk and Assurance. The Health & Safety team and the Risk & Assurance team provide local support for the implementation of IPC initiatives via the Safety Systems Managers/Administrators who work in conjunction with Staff-side colleagues.

The central IPC team has also worked with colleagues in A&E Operations, Patient Transport Service, Estates and Fleet, Organisation Development and Human Resources (OD&HR), training schools and Occupational Health providers. We have high level support from the Health Protection Agency (HPA) for Strategic IPC Committee meetings and from the SHA with specific funding for IPC initiatives.

There has also been invaluable input from over 100 YAS “cleanyourhands” champions and 10 WTE NVQ level 2 trained cleaners in IP&C.

2.2 Strategic IPC Committee (IPCC)

The Trust has a formally constituted IPCC which meets five times a year. The IPCC has been in existence since the formation of YAS in 2006.

The members of this Committee as at April 2009 were:

Medical Director – DIPC (Chair) Assistant Director – Health, Safety & Risk Infection Prevention & Control Nurse Occupational Health Adviser Health Protection Agency Consultant in Public Health Assistant Director – A&E Operations or their representative Assistant Director – Estates and Supplies or appropriate representative Assistant Director – Fleet and Equipment or appropriate representative Assistant Director – Organisation Development (Workforce) or appropriate representative Assistant Director – PTS Operations or appropriate representative


Staffside representatives – four representatives entitled to attend Cleaning Services Manager Medical Equipment Manager Due to organisational restructuring, there was a change in the Chair and additional members were added which included: Director of Operations Patient Transport Services Director of Standards and Compliance Assistant Director of Risk and Assurance From June 2008 The Health Protection Agency Consultant in Public Health retired and YAS is awaiting a replacement. From January 2010 the Chair of the IPCC changed from the DIPC to the Director of Operations Patient Transport Services.

The purpose of the IPCC has been focused on developing policies, guidance and initiatives to meet the requirements of the Board-approved plan. It has also considered data from IPC reported incidents and sought resolution for the issues encountered.

The IPCC minutes have been presented to the YAS Integrated Governance Committee as part of the YAS assurance process.

2.3 Reporting Line to the Trust Board

Regular reports are presented to the YAS Board three times a year. In addition the minutes from the IPCC are presented to the Integrated Governance Committee for discussion and approval.

2.4 Links to Clinical Governance/Risk Management/Patient Safety

Until October 2009 the Assistant Director Health, Safety and Risk was the organisation’s lead for risk management and ensured that appropriate issues were captured at the IPCC meetings, or at the Strategic Health, Safety & Risk meetings where there is any overlap of responsibility. From October 2009 the Assistant Director Health and Safety and the Assistant Director Risk and Assurance both ensure that appropriate issues are captured at the IPCC meetings or at the Strategic Health & Safety or Risk & Assurance meetings where there is any overlap of responsibility.

The Assistant Director Health and Safety is a member of the Clinical Governance Committee and is the nominated YAS link to the National Patient Safety Agency (NPSA) Patient Safety Alerts issued via the NHS Central Alerting System


The IPCN acts as a link to local meetings via the Supplies Consumables and the Clinical Standardisation Groups. The IPCN coordinates the NPSA National ‘cleanyourhands’ campaign and responds to draft documentation published by the agency.

.

3 DIPC Reports to the Trust Board – Summary 3.1 Annual Action Plan and Board Decisions

Reports to the Trust Board in 2009-10 included updates of compliance against the Health & Social Care Act (2008) as well as key updates on initiatives.

Significant IPC items presented to the 2008-09 Board meetings are shown in the table below.

Board Meeting Date

Key Issues Reported Health Act Compliance Level

July 2009 • Healthcare Commission findings update • Compliance with the Health & Social Care

Act (2008) • Care Quality Commission registration

94%

November 2009

• Care Quality Commission registration update

• Compliance with the Health & Social Care Act (2008)

94%

March 2010

• Compliance with the Health & Social Care Act (2008) Updated Department of Health version

88%

The compliance figure has reduced from 94% in November 2009 to 88% in March 2010. The primary reason for this drop in compliance is due to an additional requirement within the Health and Social Care Act 2008, relating to antimicrobial prescribing. A secondary reason relates to an internal review of IP&C audits requirements and the development of a workplan.

4 Budget Allocation to IPC Activities 4.1 Staff

The Medical Director/DIPC has corporate lead responsibility for IPC issues.. The Director of Standards & Compliance has operational lead responsibility for IPC issues and is supported by the Assistant Director Health & Safety and Assistant Director Risk & Assurance. YAS also has a full-time IPCN post.


4.2 Training

There are several trainers working on IPC issues, including professional training courses for paramedics and technicians and staff working on the YAS Statutory and Mandatory Training Programme. The amount of time devoted to this will vary from course to course and all training is provided and validated by external accreditation bodies. For the period 01 April 2009 – 31 March 2010, 1475 staff members received IP&C training within a classroom environment and 616 staff members received training via e-learning.

4.3 Equipment and Consumables

£1.8 million was utilised in the acquisition of re-usable medical equipment and consumable items.

4.4 Vehicle Make-ready Activity

This service has been expanded and has staffing levels of approximately 90 WTE with five supervisors. This is an overall investment in staff of £1.66 million during 2009-2010.

4.5 Estates

£1.29 million was utilised in the refurbishment of 56 ambulance stations to incorporate improved IP&C facilities.

5 Root-cause Analysis (RCA) Requests and Findings from Acute

Trusts 5.1 Trends in Healthcare Associated Infection (HCAI) Statistics

Periods of direct patient contact in A&E Operations and the Patient Transport Service (PTS) are usually short (normally less than one hour); therefore, it is difficult to produce information on HCAI outcomes specific to ambulance services.

There were no HCAI’s reported to YAS as a direct intervention from YAS staff.

5.2 Untoward Incidents and incident reporting

There have been no serious untoward incidents which have been related to IPC issues.

Internal reports to the IPC meetings have shown incidents or issues relating to the following:


Incident reporting has been promoted throughout YAS which has shown an increase of 57.94% in the number of incidents that were reported from the previous year. IP&C incidents reported has increased by 152.94% (35.29% increase excluding swine flu incidents) Actions taken to mitigate incident risks in relation to IP&C

• A dedicated swine flu telephone line and email contact was commenced within YAS during the pandemic to answer queries from staff. Fit testing of FFP3 masks is continuing throughout the trust and to date 1560 staff have successfully been tested.

• A 28 day deep clean schedule of vehicles was commenced in all areas of YAS.

• Sharps management was promoted throughout the trust including updating of the Waste Management e-learning course.

5.3 Locally Identified Goals

YAS has identified three local goals associated with incidents arising as part of our activities. These are as follows:

1. The introduction of sterile cannulation packs for operational A&E

activities in order to have an aseptic field for cannulation in non-life threatening situations was commenced in November 2009. Familiarisation of the product was delivered by the IPCN to Clinical Team Educators (CTE) throughout November and December 2009. The familiarisation will then be cascaded to staff via the CTE programme. The IPCN is also familiarising student paramedic and paramedic conversion students through training schools and external educational bodies.

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2. The introduction of IP&C e-learning was commenced in November 2009. Hand hygiene and Standard Precautions modules have been made available. Other modules currently in progress are

• Aseptic Technique • MRSA • Clostridium difficile • Vehicle decontamination • Cleaning and decontamination of medical devices and

equipment • Infection Prevention and Control for Community Responders

. 3. The third initiative relates to an improvement in decontamination and

cleaning provision at acute hospital locations across YAS, of which there are currently 19 sites. The introduction of purpose-built IPC units sited outside emergency departments will allow YAS to clean and re-stock vehicles. This continuing initiative remains in its early stages and requires support from acute trusts and also supportive planning authority decisions with funding of around £1 million to be considered by commissioners. Inevitably, this is a long term project but YAS is currently working with York, Hull and Barnsley Hospitals as three potential trial sites.

6 Hand Hygiene and Aseptic Protocols 6.1 Implementation of ‘cleanyourhands’

YAS signed up early to the national campaign and issued the second tranche of campaign information to its 110 ‘champions’ in September 2009.

Posters were distributed throughout YAS via the champions to promote the campaign. The 5 moments for hand hygiene booklets were distributed to A&E and PTS operational staff via the CTE’s and PTS Managers. In addition to this, 5 moments training literature and guidance was made available to the YAS intranet site.

All operational A&E and PTS staff now have access to personal-issue alcohol hand gel and there are moist wipes available on all vehicles to aid hand cleaning in areas where there is no access to soap and running water.

6.2 Application of aseptic no-touch clinical protocols

Additional material was provided to CTE’s during the introduction of the sterile cannulation packs relating to the use of the cannulation packs and the application of sterile gloves. This information was additionally made available on the trust intranet.


6.3 IV Catheters

The cannulation process is taught and assessed through training schools and external educational facilities. This process is also updated through the Candidate Workbook for CTE Programme.

6.4 Future Plans

YAS is committed to implementation future phases of the cleanyourhands campaign. An education programme will be devised to fully implement and adopt the 5 moments for hand hygiene. The aseptic technique e-learning module will be promoted to clinical staff throughout the first quarter of 2010/2011

7 Decontamination 7.1 Arrangements

7.1.1 Internal Arrangements

YAS has reduced many of its requirements for decontamination and cleaning of patient-contact devices by the introduction of single-use items wherever possible.

New biocidal cleaning products for the cleaning of vehicles were introduced to YAS in order to assist in the fight against HCAI’s. In June 2009 the product was introduced during the deep cleaning of vehicles and in September 2009 the product was introduced in the form of surface wipes to be used by operational staff during their work day. This product is available at all ambulance stations to allow operational staff to clean their vehicles. 27 steam cleaners have been provided by YAS to assist with the cleaning of vehicles, training has been completed by all domestic cleaning staff that will operate this machinery. In September 2009 a blood spillage pack was introduced to all vehicles to assist with small blood spillages. For large spillages, there is access to disinfectant tablets at all ambulance stations and acute trust emergency departments.


Alcohol wipes remain on vehicles and these are used to clean areas that the biocidal wipe cannot safely clean, currently oxygen cylinder attachments and oxygen saturation probe sensor.

7.1.2 Third Party Premises

YAS continues to receive support from acute trusts which provide access to decontamination facilities and maintain stocks of appropriate cleaning materials for YAS to use at their emergency departments. Where YAS have a designated decontamination area within an acute trust, cleaning products and supplies are monitored by YAS staff and replenished accordingly.

7.1.3 Contracted-out Services

There are no contracted-out services for decontamination provision. YAS does employ contract cleaners as part of the ‘vehicle make-ready service’ but it is planned that an in-house team will be fully responsible for this during 2010-2011.

7.2 Audit

The IPCC approved an audit plan for 2009-10 at its January 2009 meeting, part of which covers the auditing of vehicles and premises. Cleaning schedules are present in the saloon area of vehicles (Appendix A) and are audited (Appendix B)

Cleaning schedules are present in stations and are audited (Appendix C & D – some fields removed from the form to fit the reports format)

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% of vehiclesachieving onedeep cleanevery 28 days


8 Cleaning Services 8.1 Management Arrangements (in-house or contracted-out)

YAS only uses in-house cleaning provision for items which are not single use.

We use contract cleaners in some locations covered by YAS as part of the vehicle make-ready service. All the cleaners employed to work within this service have been trained in IPC issues and procedures as part of their induction to YAS.

8.2 Monitoring Arrangements

Monitoring is managed by audit on a weekly or monthly basis depending on the area being monitored.

8.3 Clinical Responsibility

Everyone involved in patient care has a responsibility to work to the highest IPC standards to protect and care for patients and prevent HCAI's. This is reflected in an addendum to their job description.

All staff involved in patient contact have a responsibility to undertake cleaning and other IPC measures during and after each patient episode. This protects patients and reduces the overall burden on cleaning staff supporting the development of a safe and clean environment and removing the potential for avoidable needlestick injuries.

Clinicians are responsible for the routine cleaning of vehicles between patient journeys. The vehicle and its equipment can be returned to base for a deep clean if appropriate.

Clinical staff are also responsible for cleaning equipment between patient journeys as part of the YAS emergency preparedness measures for pandemic flu reducing the potential for cross-infection, including infections such as Influenza.

8.4 Managerial Responsibility and Budgets Allocated

As part of its service rationalisation, all YAS cleaning activity will be contained within the Fleet and Equipment Services division of the Finance Directorate.

The YAS ‘vehicle make-ready service’ resolves problems relating to vehicles requiring deep clean or routine cleaning outside of normal operating requirements.

Further investment would be needed to achieve the recommended NPSA weekly deep-clean of vehicles and equipment which will require a


further 125 cleaning staff at a cost of £2.5 million if this scheme moves from its current advisory position to that of becoming mandatory. The NPSA confirmed in February 2009 that this scheme was recommending best practice and not mandatory at this time.

8.5 Access to Clinical Vehicles

The Trust carries extra capacity on its front line vehicles to allow for downtime associated with vehicle or equipment cleaning and make-ready activities.

The current downtime for vehicle deep-cleaning is reported to the Board. The current YAS performance indicator is that for each business unit there is a target of vehicles cleaned against operational vehicles on fleet of 96%. For the year 2009/2010 the target was exceeded at 103.47% of vehicles (some vehicles were deep cleaned more than once in 28 days)

The Trust currently has over 1000 operational vehicles in its fleet and the cleaning provision was unified across YAS at the end of 2008. This unification is monitored and reported to the Board on a regular basis.

8.6 User Satisfaction Measures

There have been no formal complaints received relating to the condition of YAS vehicles or equipment used on them.

In addition to formal complaints’ procedures, YAS also uses a number of user-satisfaction measures to assess performance and learn lessons.

Traditionally YAS has used PTS patient satisfaction surveys via its Patient Advice and Liaison Service (PALS) to record issues relating to vehicle cleanliness. These questionnaires are returned via a pre-paid leaflet available on the vehicle or via Patient Reception Centres/Liaisons in Hospitals.

There are also checks carried out by cleaning supervisors for vehicle and premises’ cleanliness.

9 Audit 9.1 Audit Programme

The extent of the current YAS IPC audit for 2009-10 as approved by the IPCC in January 2009 is shown below.


In addition to the proposed plan there have been a number of significant activities undertaken by or on behalf of YAS during the year which is shown below.

9.1.1 Provision of reports to Strategic IP&C Committee five times per annum 9.1.2 Devise a range of auditing tools and provide training for relevant

Managers and staff to use them. 9.1.3 Evaluate current IP&C training course content 9.1.4 Statistically sample a range of IP&C indicators in accordance with

British Standard 6001:2006 9.1.5 Audit of compliance against premises cleaning KPI’s produced by Fleet 9.1.6 Audit of compliance against vehicle and equipment KPI’s produced by

Fleet 9.1.7 Compliance against the requirements of the code in line with the

amended Health Act requirements 9.1.8 Monitoring the numbers of staff formally trained in IP&C compliance in a

classroom setting or at induction 9.1.9 Monitoring the numbers of staff trained in IP&C via the YAS e learning

protocol 9.1.10 Biennial inspections of YAS workplaces by Health, Safety & Risk staff

relating to IP&C issues and compliance 9.1.11 Hand hygiene audit twice per annum 9.1.12 Compliance with and actions taken relating to any MHRA or NHS

Estates or NPSA alerts issued each year 9.1.13 The creation and removal of data flags within control re community

outbreaks identified by YAS stakeholders 9.1.14 Training course modification to reflect changes in IP&C advice/practice 9.1.15 Training course modification to reflect any lessons learned from SUI’s or

MRSA Root Cause investigations.

Findings from the audits have led to a number of improvements that have proved beneficial to the safety of patients, staff and others. Training programmes have been reviewed and from June 2010, the IP&C element of all courses will be delivered by the IPC Nurse to ensure a robust and consistent approach throughout across the Trust. Training attendance has been reviewed and there has been an increase in the numbers of staff that have attended training within a classroom environment. In order to improve the IP&C education further, a Clinical Team Educator workbook was commissioned with specific assessments in relation to IP&C. A comprehensive programme of premise upgrades was commissioned and completed. This work improved the cleaning facilities and staff welfare facilities within all YAS premises. Through partnership working, YAS now receives outbreak alerts from all areas of Yorkshire. This information is disseminated to Access and Response and Patient Transport Services to effectively inform staff attending a premise where an outbreak of infections has occurred. This has reduced the risk of cross contamination and provides further safeguards for the welfare of staff.


9.2 Care Quality Commission

The Care Quality Commission (CQC) visited YAS in July 2009 and published its results in August 2009. Its findings were reported to the IPCC, Integrated Governance Committee and Trust Board actions on these were captured in the remainder of the 2009-2010 work plan.

9.3 Antibiotic Prescribing (Report from Antimicrobial Pharmacist)

No YAS clinical staff currently prescribe antibiotics. Only Emergency Care Practitioners dispense courses of antibiotics under patient group directions produced in line with national recommendations. Changes to the Health & Social Care Act (2008) now require ambulance trusts to have an antimicrobial prescribing policy. Preparations for this policy have commenced and are due to be finalised in the first quarter of 2010-2011.

10 Targets and Outcomes 10.1 Care Quality Commission Registration 2009-2010

YAS was registered in April 2009 in relation to Infection Prevention and Control with one condition; the actions required to fulfil this condition were completed by 30 June 2009. The removal of the condition was confirmed by the CQC in its report in August 2009 following a successful inspection. YAS was identified as the only ambulance trust in England without recommendations relating specifically to IPC following the inspections by the CQC.

10.2 CQC HCAI Registration Submission

YAS is projecting continued compliance with the Care Quality Commission Standards for IPC in 2010-2011.

10.2 Risk Management Scheme for Trusts (RMST)

YAS have successfully met Level 1 with the NHS Litigation Authority (NHSLA) auditors.

We are now working to embed IPC policies and guidance during 2010-2011 in preparation to retain level one, and to equip the Trust to proceed to Level 2 in 2011-2012.


11 Training Activities 11.1 Induction for all New Staff

Induction is undertaken at both a corporate and local level, all new employees to the trust are captured through an induction. Corporate induction captures issues relating to IPC.

11.2 Statutory and Mandatory Training

YAS statutory and mandatory training programme includes training relating to IPC. From February 2008 to January 2010 there have been 2013 staff trained on this module within a classroom environment. From November 2009 when the hand hygiene e-learning was made available to January 2010, 604 members of staff have successfully completed this. 196 staff have also completed the standard precautions e-learning package during the same timeframe.

For A&E staff there is a Candidate Workbook for the CTE Programme that can be completed with their CTE, which incorporates IP&C. Current figures are being compiled on the number completed.

11.3 For IPC Specialists

The IPCN is currently undertaking an MSc Certificate in Infection Control.

The IPCN is a regular member of the National Ambulance Service Infection Prevention & Control Network in addition to attending local meetings throughout the whole of Yorkshire.

Relevant conferences have been attended, including the widely recognised national Infection Prevention Society conference. Additional conferences have been attended where subjects have included, 5 moments for hand hygiene, IV therapy, reducing HCAI’s.

11.4 For DIPC

The DIPC has attended in-house training sessions related to IPC issues and is updated through the IPCC. The DIPC was represented by the IPCN at a national ambulance network DIPC study day.

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Appendix A – Deep Clean Monitoring

Scheduled Vehicle Deep Clean Monitor

This Operational Vehicle was last Deep Cleaned on:

Day Date Cleaned By Cleaners Signature

Yorkshire Ambulance Service operates a 28 day frequency for scheduled Operational Vehicle Deep Cleaning


Appendix B – Deep Clean AuditSt

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Nam

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Func

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Act

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Station 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 14 Station 2 1 0 0 1 1 1 0 1 0 0 0 1 0 1 7 Station 3 x x x x x x x x x x x x x x 0 Station 4 x x x x x x x x x x x x x x 0 Station 5 x x x x x x x x x x x x x x 0 Station 6 x x x x x x x x x x x x x x 0 Station 7 x x x x x x x x x x x x x x 0 Station 8 x x x x x x x x x x x x x x 0

Achievable Score 2 2 2 2 2 2 2 2 2 2 2 2 2 2 28

Total Score 2 1 1 2 2 2 1 2 1 1 1 2 1 2 21


Appendix C – Station Cleaning Audit

Stat

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3: N

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4: G

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5: W

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7: W

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9: W

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13: K

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orks

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d tid

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Act

ual S

core

Station 1 1 1 1 1 1 1 1 1 1 1 1 1 1 22 Station 2 1 0 0 1 1 1 0 1 1 1 1 1 0 17 Station 3 x x x x x x x x x x x x x 0 Station 4 x x x x x x x x x x x x x 0 Station 5 x x x x x x x x x x x x x 0 Station 6 x x x x x x x x x x x x x 0 Station 7 x x x x x x x x x x x x x 0 Station 8 x x x x x x x x x x x x x 0 Station 9 x x x x x x x x x x x x x 0

Achievable Score 2 2 2 2 2 2 2 2 2 2 2 2 2 0

Total Score 2 1 1 2 2 2 1 2 2 2 2 2 1 0


Appendix D – Estates General Cleaning Audit

Audit Area PASS FAIL Not Applicable

1 Waste bins managed

2 Carpeted areas clean and tidy

3 Non carpeted areas clean and tidy

4 General areas / Reception clean and tidy

5 Walls, doors and skirtings clean

6 Furniture and appliances dusted, polished and tidy

7 Windows and window frames clean

8 Toilets clean

9 Washrooms clean

10 Shower area clean and C1 recording form current

11 Handwashing IP&C gels, soaps, hand creams available

12 Paper drying products available (toilet rolls, hand towels, kitchen roll)

13 Kitchen worksurfaces clean and tidy

14 Kitchen sink and draining area clean and tidy

15 Cooker clean inside and out

16 Microwave clean inside and out

17 Fridge/Freezer Clean inside and out, C2 recording form current

18 All other appliances clean

19 Cleaners cupboard and tools clean and tidy

20 Sluice/Sluice room clean and tidy

21 All chemicals and supply's stored correctly

infection prevention and control - yorkshire ambulance · pdf filethe principal role in the...

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