Introduction

The Health and Social Care Act (2008) provides an assurance framework that ensures appropriate systems are in place for patient/service users and staff to be cared for where the risk of Healthcare Associated Infection (HCAI) is kept to a minimum. To ensure continual improvement it is important to have effective policies and procedures relating to infection prevention and control in place and that they are rigorously and consistently applied.

The following Quality Improvement Tool has been designed for the purpose of auditing treatment rooms and was completed by Ken Topliss, IP&C Nurse Specialist , Southern Health, who provided a baseline audit on 31/08/16.

Using this tool, the practice has re-audited the treatment rooms to measure it’s performance on Infection Control for 2016-17. An additional Infection Control audit was completed in February 2017 by Debbie Stimpson, Practice Manager and outcomes shared with Kim Badcock, Infection Control Lead and the Nursing Team.

Question / Yes / No / N/A / Comments
Is the environment visibly clean / Y
Is the environment free from any visible damage / Y
Is the furniture made of impermeable and washable materials / Y
Are all furnishings and fittings visibly clean / Y
Are all furnishings and fittings in a good state of repair / Y / Nurse Chair, see action plan
Are all surfaces smooth, impervious (for easy cleaning) and with covered edges / Y
Is the floor visibly clean / Y
Is the floor covering washable and impervious to moisture / Y
Is the flooring in a good state of repair / Y
Is there a designated hand wash basin / Y
Is the hand wash basin plug free / Y
Is the hand wash basin overflow free / Y
Is the waste offset so the water does not flow directly into it / Y
Are elbow/sensor taps available / Y
If no elbow or sensor taps, are staff aware how to turn off the taps with a paper towel / N/A
Are mixer taps or thermostatically controlled water available / Y
Is the hand wash basin accessible / Y
Is the hand wash basin in a good state of repair / Y
Is the hand wash basin visibly clean / Y
Are hand wash basins free from extraneous items / Y
Is the soap dispensed from a single use cartridge / Y
Is the liquid soap wall mounted / Y
Is the soap dispenser visibly clean / Y
Are paper towels available from an enclosed dispenser / Y
Is the paper towel dispenser visibly clean / Y
Is there a promotional hand hygiene poster displayed / Y / Printed on soap dispenser, separate poster not required
Is there a hands free domestic waste bin available for the disposal of paper towels / Y
Is the foot pedal of the domestic bin in good working order / Y
Is the domestic waste bin visible clean, including lid and pedal / Y
Is the domestic waste bin in good condition / Y
Are alcohol based hand rub bottles wall mounted in treatment rooms / Y
Is there a designated work surface/trolley for clinical procedures i.e. dressings / Y
Are dressing trolleys/trays structurally sound and in a good state of repair / Y
Are dressing trolleys/trays visibly clean / Y
Are all products stored above floor level / Y
Is there sufficient storage space / Y
Are all work surfaces free from clutter / Y
Are shelves used to store sterile products visibly clean / Y
Are all cupboards visibly clean / Y
Is the drug refrigerator used for the storage of drugs only / Y
Is the examination couch cover impervious and washable / Y
Is the examination couch/chair visibly clean / Y
Is the couch/chair in a good state of repair / Y
Are the disposable couch roll/sheets changed between patients / Y
Are couch rolls stored off the floor on a couch roll holder / Y
Are all curtains/blinds visibly clean and on a cleaning/ replacement schedule / Y
Are individual fabric items laundered after single use / N/A
Is there a hands free waste bin available for the disposal of offensive waste / N/A
Is the offensive waste bin visibly clean including the lid and the pedal / N/A
Is the offensive waste bin in good condition / Y
Is there a hands free waste bin available for the disposal of infectious waste / Y
Is the foot pedal of the infectious waste bin in good working order / Y
Is the infectious waste bin visibly clean including the lid and the pedal / Y
Is the infectious waste bin in good condition / Y

The overall compliance score is 100%

Comments/Recommendations

The following points were made last year for our consideration:

  • Window blinds need to be cleaned on a six monthly basis within treatment rooms – plastic blinds have now been installed so that this can be done
  • The nurses chair is fabric, again when replacing a washable vinyl would be appropriate – both chairs in the Nurse treatment rooms have been replaced with washable vinyl
  • Any damage to the flooring needs to be repaired, again for effective cleaning – flooring has all been repaired, edges re-sealed in treatment and clinical rooms
  • Although using Alcohol Gel, the containers do not state this clearly – labels have now been applied to make this obvious
  • Sharps bins are fine wo be placed on a hard surface, but SH will arrange for brackets to be sent so that they can be hung on trolleys or on the wall.
  • Fans should not be kept in the treatment room unless in use – to be put in storage when not being used
  • OCS do not have High Cleaning on their rota – this was not felt to be entirely satisfactory – some areas for improvement ‘best practice’ noted and will be fed back to NHS Property Services at the next BUG meeting.