Spreadsheet: 85719d1285767985-conditional-formatting-testing-
Sheet: Form

 | Previous audit score: |  | 89 | %
QUALITY MONITORING PROGRAMME Audit Tool for: INFECTION CONTROL - THEATRES AND DSU 2009/10 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 2010-09-29 00:00:00
 | Theatre |  |  |  |  |  |  |  | Business Unit: |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date of audit:
 | Printed name of Auditor(s): |  |  |  |  |  |  |  |  |  |  |  |  |  | Job Title(s):
 | Signature(s):
 | Where the word 'and' is used in a statement, both elements are required for a YES result to be achieved |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 2 |  |  | 3 |  |  | Compliance |  |  |  |  |  | row1 | row2 | row3
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Yes | No | N/A | Yes | No | N/A | Total YES | No YES available
SECTION 1:  Auditor(s) to ask three members of staff (Standard Awareness)
1 |  | Member of staff can access the following policies and can articulate their relevance to environmental cleanliness |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
 |  | —           CP 154 Hand Hygiene Policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1
 |  | —           CP 178 Standard Precautions Policy
 |  | —           CP 215 Safe handling of Soiled / Fouled linen
 |  | —           CP 177 Prevention and Management Of Body Fluid Exposure from Needle-Stick
 |  | and Sharps Injuries and Splashes
 |  | —           The Health and Social Care Act 2008 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | row1 | row2 | row3
2 |  | Staff member contributes to completing daily cleaning lists |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
3 |  | Staff member aware of infection control audits |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
4 |  | Staff member aware of High Impact Intervention observational audits (saving lives) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
5 |  | Staff member knows how to action deep cleaning of rooms ([NAME]) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
6 |  | All spillages are managed immediately as per decontamination guidance |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 0 | 0
 | 111
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | #N/A
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance
SECTION 2 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (Anaesthetic Rooms) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | Compliance
 |  | Anaesthetic room is in a satisfactory state |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Total YES | No YES available
7 |  | Work surfaces are clean and tidy and free from clutter |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
8 |  | All surfaces of anaesthetic machine have been cleaned daily |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
9 |  | Anaesthetic machine work surfaces are tidy and free from clutter |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
10 |  | Sharps containers are correctly assembled |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
11 |  | Containers are less than 2/3 full Container is free from protruding objects |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
12 |  | Container is labelled and signed according to Trust policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
13 |  | Staff are aware of action to be taken following needle stick injury |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
14 |  | Sharps containers are off the floor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
15 |  | All fridges are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
16 |  | Fridges are used appropriately |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
17 |  | Trolley's are clean and tidy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
18 |  | IV drip poles (with or without a mayo stand) is clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
19 |  | Storage bins / containers are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
20 |  | Intubation trolley is clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
21 |  | All single use items e.g. endotracheal tubes, are clearly labelled |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
22 |  | All sterile items have packaging integrity and expiry dates |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
23 |  | Anaesthetic facemask racks are clean |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
24 |  | There is a cleaning record for any re-usable anaesthetic masks |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
25 |  | Wash hand basins are clean with an appropriate supply of paper hand towels and hand wash solution |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
26 |  | [NAME] is foot operated and visibly clean |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
27 |  | Waste sack is no more than 2/3 full |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
28 |  | Computer terminal is clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
29 |  | All posters / notices are laminated and secured via blue tack or its equivalent |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
30 |  | Hand wash dispenser is fit for purpose |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
31 |  | Ventilation vents are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
32 |  | Disposable aprons are available |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
33 |  | Gloves are available |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
34 |  | SEPPS is available and used for cannulation |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
35 |  | VIP score is recorded for IV / cannulae and is documented |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
36 |  | Examination light clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
37 |  | Trolleys containing monitoring equipment are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
38 |  | Machinery is free from strips of tape |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
39 |  | Are reusable patient monitoring devises cleaned between patients? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
40 |  | Non-reusable patient monitoring equipment is labelled as single use / single patient use |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 22 | 29 | 0 | 0
 | 111 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0.7586206896551724 |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
SECTION 3 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (operating rooms & scrub bays) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | Compliance |  | 1 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Total YES | No YES available | 0 | 0
41 |  | A range of hand wash brushes are available and disposed of appropriately |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
42 |  | The soap dispenser nozzles are cleaned daily to prevent blockages |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
43 |  | The soap dispenser nozzles are replaced when blocked |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
44 |  | Liquid soap / hand wash solution dispensers are clean and fully functioning |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
45 |  | [NAME] is available and correctly constructed |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
46 |  | Sharps container is less than 2/3 full |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
47 |  | Sharps container is labelled and signed according to trust policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
48 |  | Sharps containers are off the floor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
49 |  | Staff are aware of action to be taken in case of needle stick injury |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
50 |  | Glove dispensers are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
51 |  | Gown & Glove prep trolley is clean and uncluttered |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
52 |  | Waste bin for used hand towels and glove and gown packaging is suitable for purpose |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
53 |  | There is a sufficient supply and range of surgical gloves for interventional surgery |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
54 |  | Shelves and storage containers are clean and free from dust |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
55 |  | There is a sufficient supply of sterile scrub gowns for the operative session |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1 | 0
56 |  | Sterile items have package integrity and are within their use by date |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
57 |  | Ventilation vents are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
58 |  | All computer terminals, keyboards and PACS carts are clean and free from dust |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
59 |  | Anaesthetic circuits are changed as per local and national guidance |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
60 |  | Free standing insuflator unit(s) for endoscopic procedures are clean, dust and debris free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
61 |  | Diathermy unit is clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
62 |  | Suction unit(s) are clean and free of debris |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
63 |  | Suction units liners are changed when 3/4 full or at the end of the list |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
64 |  | There is a cleaning schedule for cleaning any high surfaces (above head height) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
65 |  | Pendants / air and piped gas supply booms are clean and free of dust |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
66 |  | All surfaces of the Anaesthetic machine are clean and tidy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
67 |  | Floor runners are clean and fully functional, including wheel castors |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
68 |  | Bowl stands are clean and fully functional, including wheel castors |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
69 |  | Operating table and table accessories are clean and functional |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
70 |  | Integrity is maintained on operating table mattress and surgeons stool (and any other similar equipment) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
71 |  | Swab rack holder is free from contamination |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
72 |  | Swab rack holder is free from rust |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
73 |  | All work surfaces are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
74 |  | All storage units are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
75 |  | Waste bins / containers are fit for purpose |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
76 |  | Operating lights and booms are clean and free from dust |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
77 |  | Operating theatre doors are closed providing patient privacy and dignity / maximising positive ventilation |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
78 |  | Microscopes / laser units are clean and free from debris (*equipment not normally stored in theatre) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
79 |  | Floors are clean and free from spillages / debris |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
80 |  | All posters / notices are laminated and secured via blue tack or its equivalent |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
81 |  | Eye protection is available |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
82 |  | DVT prophylactic equipment is single patient use |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
83 |  | Resuscitation trolley and defibrillator is clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
84 |  | The theatre is free from personal clothing and belongings |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
85 |  | No food or beverages in the theatre |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 14 | 16 | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0.875 |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
SECTION 4 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (setting up rooms) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | Compliance |  | 1 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Total YES | No YES available | 0 | 0
86 |  | Ventilation vents are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
87 |  | Stock cupboards are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
88 |  | Suture rack is clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
89 |  | Surgical blade dispensers are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
90 |  | Instrument storage is well maintained |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
91 |  | Sterile items have package integrity and ARE within their use by date |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
92 |  | Stock is not stored on the floor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
93 |  | Lotions used for interventional surgery are single use (where applicable) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
94 |  | All storage boxes / units are clean and free from dust |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
95 |  | Free standing trolleys and stands (including wheel castors) are clean |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
96 |  | Fluid warming cabinet is clean |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
97 |  | Sterile fluid once opened is not re-used |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
98 |  | Long lumen instruments are decontaminated in the correct manner |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
99 |  | There are appropriate records to allow instrument traceability |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
100 |  | Staff can articulate how single use items are identified |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
101 |  | Single use items are only used once |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 0 | 0 | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | #N/A |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
SECTION 5 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (sluice-waste disposal room) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | Compliance |  | 1 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Total YES | No YES available | 0 | 0
102 |  | Sharps container is correctly assembled |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
103 |  | Sharps container is labelled and signed according to Trust policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
104 |  | A sharps bin is available for disposal endoscopic instruments (where appropriate) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
105 |  | Sharps container is less than 2/3 full |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
106 |  | Sharps containers are off the floor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
107 |  | Staff can articulate action to be taken in the case of needle stick injury |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
108 |  | A dilution chart is available for the Trust recommended disinfectant |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
109 |  | A COSHH sheet is available for the Trust recommended disinfectant |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
110 |  | Mops and mop buckets are clean and fit for purpose |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
111 |  | Mops are not stored wet |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
112 |  | Personal protective clothing is available |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
113 |  | Sluice is clean and free from spillages |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
114 |  | Any spillages are dealt with in line with Trust policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
115 |  | All waste is segregated according to Trust policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
116 |  | A poster is available to demonstrate the different waste streams |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
117 |  | Foot operated waste bins are used |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
118 |  | Bins are clean and rust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
119 |  | Staff know which linen bags are used for different categories of linen |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
120 |  | The appropriate linen bags are available within the sluice-waste disposable area |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
121 |  | A poster is available to show which linen goes in which bag |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 0 | 0 | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | #N/A |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0
SECTION 6: Ask three members of the perioperative team how the surgical outcomes are enhanced by the promotion of a safe and clean environment |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 2 |  |  | 3 |  |  | Compliance
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Yes | No | N/A | Yes | No | N/A | Total YES | No YES available
122 |  | Practitioner can articulate the steps undertaken for the first scrub of the day |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
123 |  | Practitioner can articulate on effective gowning and gloving technique |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
124 |  | Practitioner can articulate what constitutes a sterile field |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
125 |  | Practitioner can articulate how sharps are handled during surgical interventions |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
126 |  | All staff are aware of PEAT Inspections |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
127 |  | Staff member is aware of cleaning standards relating to the environment |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
128 |  | Staff member can articulate the roles and responsibilities of the team relating to tidiness and cleanliness of the environment |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | 1 |  |  | 1 | 0 | 0 | 0 | 0 | 0 |  | 0 | 0 | 0
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | #N/A
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance
SECTION 7: LINK PRACTITIONER Standard: Clinical practices will reflect compliance with infection prevention & control guidelines |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | Compliance
Ask a member of the theatre team |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Total YES | No YES available
129 |  | Staff are aware of the infection control website |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
130 |  | Staff know how to find up to date infection control information other than the website |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
131 |  | Staff can name the theatre link practitioner |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
132 |  | The link practitioner has attended at least 50% of the link meetings per year |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
133 |  | Staff member is aware of which Saving Lives audits are being undertaken in the theatre suite |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
134 |  | Staff member has had a Hand Hygiene assessment |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | #N/A
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance
SECTION 8 Standard: The perioperative environment will be maintained appropriately to negate the risk of cross infection (Recovery area) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | Compliance
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Total YES | No YES available
135 |  | Work surfaces are clean and free from clutter |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
136 |  | All surfaces of the Anaesthetic machine are clean and free from clutter |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
137 |  | Daily cleaning of anaesthetic machine is recorded on cleaning list |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
138 |  | Sharps containers are correctly assembled |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
139 |  | Sharps containers are off the floor |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
140 |  | Sharps container is less that 2/3 full |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
141 |  | Sharps container is labelled and signed according to trust policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
142 |  | Staff are aware of action to be taken in case of needle stick injury |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
143 |  | Glove and apron dispensers are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
144 |  | Wash hand basins are clean with an appropriate supply of paper hand towels and hand wash solutions |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
145 |  | Intubation trolley is clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
146 |  | All single use items e.g. endotracheal tubes are clearly labelled |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
147 |  | All re-usable items have packaging integrity |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
148 |  | Face masks are clearly labelled as single use items |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
149 |  | All fridges are clear and used appropriately |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
150 |  | Drip stands are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
151 |  | Storage bins / containers are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
152 |  | Trolleys are cleaned daily and between patients |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
153 |  | Mattress integrity is maintained |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
154 |  | Patient wall monitors are cleaned daily |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
155 |  | Patient monitoring devises e.g. BP cuffs are cleaned between patients |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
156 |  | All computer terminals, keyboards and PACS carts are clean and free from dust |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
157 |  | All posters / notices are laminated and secured with blue tack |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
158 |  | Ventilation vents are clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
159 |  | SEPPS is available and used for cannulation |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
160 |  | VIP score is recorded for IV / cannulae and documented |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
161 |  | Blanket warmer is clean and free from dust |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
162 |  | Glucotrend machine is cleaned daily |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
163 |  | Suction containers are visibly clean |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
164 |  | Suction containers are less than 3/4 full |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
165 |  | Personal protective equipment is available |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
166 |  | Recovery sluice is clean and free from spillages |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
167 |  | A dilution chart is available for the Trust recommended disinfectant |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
168 |  | A COSHH sheet is available for the Trust recommended disinfectant |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
169 |  | All waste is segregated according to Trust policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
170 |  | The foot operated waste bin is clean and fit for purpose |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
171 |  | A poster is available to demonstrate the different waste streams |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1 | 0
172 |  | Staff are aware of the different bags for different categories of linen |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1
173 |  | Staff can locate the poster giving the above information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1
174 |  | Mops are not stored wet |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1
175 |  | Linen is segregated according to Trust policy |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1
176 |  | A poster is available to show which linen goes into which bag |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 0 | 1
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 0 | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | #N/A |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
SECTION 9: Standard: The environment will be maintained appropriately to negate the risk of cross infection (communal areas) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  |  | Compliance
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Yes | No | N/A | Total YES | No YES available
177 |  | All equipment stored in communal areas is clean and dust free |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0
178 |  | Shared storage areas are cleaned as part of the cleaning schedule |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0
179 |  | Domestic cleaning audits are available |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 | 0 | 0 | 1 | 1 | 1
180 |  | Visitors to the theatre areas are wearing the appropriate theatre attire |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0
181 |  | Theatre staff when leaving the area are wearing the appropriate attire |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0
182 |  | Staff coffee lounges are cleaned as part of the cleaning schedule |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0
183 |  | Waste bins are clean and fit for purpose |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
184 |  | Correct waste stream is in use |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 1 |  | 0 | 1 | 1 | 1 | 0 | 0
 | Auditors Comments: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Number |  |  | 7 | 8 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0.875 |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | %  Compliance |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
Audit Compliance %
Section 1: |  |  | #N/A
Section 2: |  |  | 0.7586206896551724 |  |  | [NAME] to calculate completion in each section
Section 3: |  |  | 0.875 |  |  | Number of yes answers |  |  |  |  |  |  |  |  |  | X 100 = % compliance in each section
Section 4: |  |  | #N/A |  |  | Number of available yes answers
Section 5: |  |  | #N/A
Section 6: |  |  | #N/A |  |  | [NAME] to calculate OVERALL compliance
Section 7: |  |  | #N/A |  |  | Number of yes answers in audit |  |  |  |  |  |  |  |  |  |  | X 100 = % Overall Compliance
Section 8: |  |  | #N/A |  |  | Number of available yes answers in audit
Section 9: |  |  | 0.875
Overall: |  |  | #N/A