Infection Prevention & Control Audit Tool 2013
Adapted from Infection Prevention Society (IPS) Quality Improvement Tool (2011)
General Practice
= 95-100% / Full Compliance= 80-94% / Action Required
= 70-79% / Urgent Action Required
= < 69% / Practice Priority
Audit Area: / GP Surgery:
Address:
Auditor:
Accompanied By:
Date:
Standards Audited / Tick / %Score
Management of Infection Prevention & Control
Environment: General
Environment: Treatment Rooms
Environment: GP Consulting Rooms
Environment: Dirty Utility / Sluice
Patient equipment
Sharps handling & disposal
Personal Protective Equipment
Vaccine storage & transportation
Overall Score
Wirral CT Audit Tool – GP Practice - 14 -
Management of Infection Prevention and Control
Standard: Infection prevention and control is managed effectively, given high priority and seen as an integral part of the business within the surgery/health centre/clinic.
/ Question / Yes / No / N/A / Comment /1 / Is there a named lead person responsible for infection prevention and control?
2 / Are infection prevention and control related topics agenda items at staff/business meetings?
3 / Are there up to date local contact telephone numbers available to obtain advice pertaining to infection prevention and control?
4 / Is there evidence of a process for reporting untoward incidents in relation to infection prevention and control?
5 / Is there evidence of a previous practice audit and completed action plan?
6 / Are up to date infection prevention and control policies and guidelines available and accessible by staff?
7 / Are there comprehensive written cleaning standards and procedures?
8 / Are there clearly outlined staff responsibilities for cleaning dedicated
areas/equipment?
9 / Are cleaning processes and outcomes audited regularly?
10 / Are up to date cleaning schedules clearly displayed?
11 / Is infection prevention and control included in all staff induction programmes?
12 / Have staff received mandatory training in infection prevention and control in line with practice policy and training needs analysis?
13 / Are staff offered immunisation in line with current national guidance and practice policies?
14 / Is there guidance on staff exclusion from work with regards to infection prevention?
Environment: General
Standard: The environment is designed and managed to minimise reservoirs for micro-organisms and reduce the risk of cross infection to patients, staff and visitors.
Question / Yes / No / N/A / Comment1 / Is furniture made of impermeable and washable materials?
2 / Are all furnishings and fittings visibly clean?
3 / Are all furnishings and fittings in a good state of repair?
4 / Are all surfaces smooth, impervious (for easy cleaning)?
5 / Are all posters wipeable?
6 / Is the floor visibly clean?
7 / Is the flooring in a good state of repair?
8 / Does the establishment have a process for cleaning carpets?
9 / Is the environment tidy and uncluttered?
10 / Is there a procedure for the management of toys?
11 / Is there a record of cleaning toys which includes frequencies of cleaning?
12 / Is there a designated storage area for toys?
13 / Is the storage area/toy box visibly clean?
14 / Are toys visibly clean?
15 / Are toys made of a cleanable material?
16 / Are children`s books clean and undamaged?
17 / Is there a disposal unit for the disposal of contaminated waste water in domestic room?
18 / Is the unit for the disposal of contaminated waste water visibly clean?
19 / Are mops and buckets stored clean, dry and mops stored inverted?
20 / Are detachable mop bucket wringers removed and cleaned daily?
21 / Are mop heads laundered or disposable?
22 / Is there a colour coding system in place for cleaning equipment?
23 / Is cleaning equipment and machinery left clean and dry after use?
24 / Are cleaning cloths laundered or disposable?
25 / Is there a low level facility for staff to fill buckets with water for cleaning?
26 / Is the waste storage area clean and tidy?
27 / Are waste bags labelled/tagged before storage and disposal?
28 / There are no overfilled waste bags/bins?
Environment: Treatment Room.
Standard: The environment is designed and managed to minimise reservoirs for micro-organisms and reduce the risk of cross infection to patients, staff and visitors.
Question / Yes / No / N/A / Comment1 / Is furniture made of impermeable and washable materials?
2 / Are pillows enclosed in a washable impervious cover?
3 / Are all furnishings and fittings visibly clean?
4 / Are all furnishings and fittings in a good state of repair?
5 / Are all surfaces smooth, impervious (for easy cleaning)?
6 / Is the floor visibly clean?
7 / Is the floor covering washable and impervious to moisture?
8 / Is the flooring in a good state of repair?
9 / Is there a designated hand wash basin?
10 / Is the hand wash basin plug free?
11 / Is the hand wash basin overflow free?
12 / Are elbow/sensor taps available?
13 / Are mixer taps available?
14 / Is the hand wash basin accessible?
15 / Is the hand wash basin in a good state of repair?
16 / Is the hand wash basin visibly clean?
17 / Are hand wash basins free from extraneous items?
18 / There are no re-usable nail brushes evident at hand wash sinks.
19 / Is the soap dispensed from a single use cartridge?
20 / Is the liquid soap dispenser wall mounted?
21 / Is the soap dispenser visibly clean?
22 / Are paper towels available from an enclosed dispenser?
23 / Is the paper towel dispenser visibly clean?
24 / There are no re-usable cotton towels used to dry hands
25 / Is there a promotional hand hygiene poster displayed?
26 / Are staff adhering to bare below the elbows?
27 / Is there a foot operated, lidded waste bin available for the disposal of paper towels?
Question / Yes / No / N/A / Comment
28 / Is the foot pedal of the domestic waste bin in good working order?
29 / Is the domestic waste bin visibly clean, including lid and pedal?
30 / Is the domestic waste bin in good condition?
31 / Is alcohol-based handrub available at the point of care?
32 / Is there a foot operated, lidded waste bin available for the disposal of clinical waste?
33 / Is the foot pedal of the clinical waste bin in good working order?
34 / Is the clinical waste bin visibly clean, including lid and pedal?
35 / Is the clinical waste bin in good condition?
36 / Is waste segregated correctly?
37 / Is there a designated trolley for clinical procedures?
38 / Are dressing trolleys/trays structurally sound and in a good state of repair?
39 / Are dressing trolley/trays visibly clean?
40 / Are all products stored above floor level?
41 / Are all work surfaces free from clutter?
42 / Are shelves used to store sterile products visibly clean?
43 / Are all cupboards visibly clean?
44 / Is the examination couch/chair cover impervious and washable?
45 / Is the couch/chair visibly clean?
46 / Is the couch/chair in a good state of repair?
47 / Are the disposable couch roll/sheets changed in between patients?
48 / Are couch rolls stored off the floor on a couch roll holder?
49 / Are all curtains visibly clean and on a cleaning/replacement schedule?
Environment: GP Consulting Room.
Standard: The environment is designed and managed to minimise reservoirs for micro-organisms and reduce the risk of cross infection to patients, staff and visitors.
Question / Yes / No / N/A / Comment1 / Is furniture made of impermeable and washable materials?
2 / Are pillows enclosed in a washable impervious cover?
3 / Is the furniture visibly clean?
4 / Is the furniture in a good state of repair?
5 / Are all surfaces smooth, impervious (for easy cleaning)?
6 / Is the floor visibly clean?
7 / Is the flooring in a good state of repair?
8 / Is there a designated hand wash basin?
9 / Is the hand wash basin plug free?
10 / Is the hand wash basin overflow free?
11 / Are elbow/sensor taps available?
12 / Are mixer taps available?
13 / Is the hand wash basin accessible?
14 / Is the hand wash basin in a good state of repair?
15 / Is the hand wash basin visibly clean?
16 / Are hand wash basins free from extraneous items?
17 / There are no re-usable nail brushes evident at hand wash sinks
18 / Is the soap dispensed from a single use cartridge?
19 / Is the liquid soap dispenser wall mounted?
20 / Is the soap dispenser visibly clean?
21 / Are paper towels available from an enclosed dispenser?
22 / Is the paper towel dispenser visibly clean?
23 / There are no re-usable cotton towels used to dry hands?
24 / Is there a promotional hand hygiene poster displayed?
25 / Is there a foot operated, lidded domestic waste bin available for the disposal of paper towels?
26 / Is the foot pedal of the domestic waste bin in good working order?
Question / Yes / No / N/A / Comment
27 / Is the domestic waste bin visibly clean, including lid and pedal?
28 / Is the domestic waste bin in good condition?
29 / Are alcohol based hand rub bottles available at the point of care?
30 / Is there a foot operated, lidded waste bin available for the disposal of clinical waste?
31 / Is the foot pedal of the clinical waste bin in good working order?
32 / Is the clinical waste bin visibly clean, including lid and pedal?
33 / Is the clinical waste bin in good condition?
34 / Is waste segregated correctly?
35 / Is there sufficient storage space?
36 / Are all areas free from clutter and inappropriate items?
37 / Is the examination couch/chair cover impervious and washable?
38 / Are the disposable couch roll/sheets changed in between patients?
39 / Is the couch/chair visibly clean?
40 / Is the couch/chair in a good state of repair?
41 / Are couch rolls stored off the floor on a couch roll holder?
42 / Are all curtains visibly clean and on a cleaning/replacement schedule?
Environment: Dirty Utility /Sluice
Standard: The environment is designed and managed to minimise reservoirs for micro-organisms and reduce the risk of cross infection to patients, staff and visitors.
Question / Yes / No / N/A / Comment1 / Are all furnishings and fittings visibly clean?
2 / Are all furnishings and fittings in a good state of repair?
3 / Are all surfaces smooth, impervious (for easy cleaning) and with coved edges?
4 / Is the floor visibly clean?
5 / Is the floor covering washable and impervious to moisture?
6 / Is the flooring in a good state of repair?
7 / Are all work surfaces smooth, impervious, with coved edges to facilitate easy cleaning?
8 / Are all work surfaces visibly clean?
9 / Is the dirty utility room free from clutter and inappropriate items?
10 / Is there a designated hand wash basin?
11 / Is the hand wash basin plug free?
12 / Is the hand wash basin overflow free?
13 / Are elbow/sensor taps available?
14 / Are mixer taps available?
15 / Is the hand wash basin accessible?
16 / Is the hand wash basin in a good state of repair?
17 / Is the hand wash basin visibly clean?
18 / Are hand wash basins free from extraneous items?
19 / There are no re-usable nail brushes evident at hand wash sinks.
20 / Is the soap dispensed from a single use cartridge?
21 / Is the liquid soap dispenser wall mounted?
22 / Is the soap dispenser visibly clean?
23 / Are paper towels available from an enclosed dispenser?
24 / Is the paper towel dispenser visibly clean?
25 / There are no re-usable cotton towels used to dry hands
26 / Is there a promotional hand hygiene poster displayed?
27 / Is there a foot operated, lidded waste bin available for the disposal of paper towels?
Question / Yes / No / N/A / Comment
28 / Is the foot pedal of the domestic waste bin in good working order?
29 / Is the domestic waste bin visibly clean, including lid and pedal?
30 / Is the domestic waste bin in good condition?
31 / Are alcohol based hand rub dispensers visibly clean?
32 / Is there a foot operated, lidded waste bin available for the disposal of clinical waste?
33 / Is the foot pedal of the clinical waste bin in good working order?
34 / Is the clinical waste bin visibly clean, including lid and pedal?
35 / Is the clinical waste bin in good condition?
36 / Is waste segregated correctly?
37 / Is there a dedicated deep sink for washing used equipment?
38 / Is there a disposal unit available for disposal of body fluids?
39 / Are cleaning/disinfectant products available for decontamination of equipment and the environment?
40 / Can staff describe which products should be used for routine cleaning?
41 / Are spillage kits or alternative available for use on body fluid spillages?
42 / Are staff aware of the procedures to be used when removing body fluid spillages?
43 / Is personal protective equipment available?
Patient Equipment.
Standard: All patient equipment is cleaned and maintained appropriately to prevent cross infection.
Question / Yes / No / N/A / Comment1 / Is all equipment detailed on a cleaning schedule?
2 / Are schedules completed, signed and up to date with frequencies and responsibilities identified?
3 / Are cleaning products available for routine cleaning of equipment?
4 / Are items sent for service, inspection or repair, appropriately cleaned and/or disinfected, and a label of contamination status attached?
5 / If single use items are used are they disposed of following use?
6 / Can staff describe the symbol used to indicate single use items?
7 / Is all equipment in a good state of repair and clean?
8 / Is all reusable equipment routinely cleaned between every patient with general purpose detergent or as per local policy/manufacturer`s instructions where this differs?
Sharps Handling and Disposal.