KEY: EQR = Essential Quality Requirements are the minimum requirements for compliance as detailed in the Health and Social Care Act 2008 (Code of Practice on the prevention and control of infections and related guidance, 2015). BP = Best Practice are standards that exceed the Essential Quality Requirements and if not already compliant at the time of audit, the practice should develop detailed plans showing how the practice intends to work towards achieving Best Practice requirement. INFECTION PREVENTION & CONTROL AUDIT Section 1: The Management of Infection Prevention and Control (General Management) Standard: Infection prevention and control is managed effectively and complies with the Health and Social Care Act 2008: Code of practice on the prevention and control of infection and related guidance. Questions EQR / BP Yes () No () N/A () Remedial action to resolve problem Rationale / Resources 1 Is there a named clinical lead person in the practice for infection prevention and control? EQR Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance (2015): Criterion 1 2 Does the practice have infection prevention and control policies? EQR Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance (2015): Appendix D Criterion 9 Part 4 Guidance Tables: Table 3 3 Is infection prevention and control included in all staff induction programmes? EQR Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance (2015): Criterion 6 and 10
appropriate immunisations have been given.) 4 Has the issue of immunity to Measles, Rubella and Varicella in clinical staff been considered in the practice and a risk assessment undertaken? EQR Department of Health (2003) "Chickenpox (varicella) immunisation for healthcare workers" Section 3: Environment Standard: The environment is designed and managed to minimise reservoirs for microorganisms and reduce the risk of cross-infection to patients, staff and visitors. Questions EQR / BP Yes () No () N/A () Remedial action to resolve problem Rationale / Resources 1 Are all areas including clinical areas and equipment visibly clean and free from extraneous items? EQR National Patient Safety Agency - The national specifications for cleanliness in the NHS: Guidance on setting and measuring cleanliness outcomes in primary care medical and dental premises. Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance (2015):Criterion 2 National Patient Safety Agency- National specifications for cleanliness: primary medical and dental premises (2010) National Patient Safety Agency - Primary Care Cleaning Audit Score Sheet (2010) 2 Are there comprehensive written specifications for cleaning the environment and equipment in the practice? EQR Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance (2015): Criterion 2 3 Are there up to date cleaning schedules which includes regular cleaning of clinical, admin and sanitary areas (e.g. toilets, fans, air conditioners, EQR Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance (2015): Criterion 2
training in infection prevention and control and cleaning in a healthcare environment appropriate to role? associated infections and related guidance (2015): Criterion 1 Section 4: Hand Hygiene Standard: The practice has a clear mechanism to ensure effective implementation of hand hygiene procedures are in place and hand hygiene is practiced at all times to reduce the potential for cross infection between staff, patients, the environment and equipment. Questions EQR / BP Yes () No () N/A () Remedial action to resolve problem Rationale / Resources 1 Does the practice have a Hand Hygiene Policy? EQR Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance (2015): Criterion 9 World Health Organisation 2009 - Section 16 National Patient Safety Agency – Clean Your Hands Campaign 2 Are posters displayed adjacent to hand washbasins featuring the hand hygiene process? BP National Patient Safety Agency – Clean Your Hands Campaign 3 Does your practice policy demonstrate an awareness of the DH uniform policy? (e.g. bare below the elbows) EQR Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance (2015): Criterion 9 DH Uniforms and Work wear 2010 4 Are there wash basins dedicated to hand hygiene in each clinical and consulting room which can be easily accessed? EQR Health Technical Memorandum - 64 Sanitary assemblies. Health Building Note 00-10 part C Sanitary Assemblies 5 Do all hand wash basins for use in connection with clinical EQR Department of Health - Health and Social Care Act 2008 Code of Practice for the prevention and control of healthcare associated infections and related guidance
accumulation of dust and dirt? HBN 11-01 Health Building Notes for Primary and community care Facilities for Primary and Community Care Services. Available from Space for Health 8 Is the treatment couch protected with disposable paper towel that is changed after each patient? EQR 9 Are skin antiseptics (e.g. chlorhexidine) and paper towels available for aseptic hand washing? EQR 10 Is an antiseptic (e.g. alcohol based chlorhexidine) used for skin prep prior to all cutting procedures? EQR 10 Are single use sterile gloves available in latex and non-latex (e.g. nitrile) material? EQR 11 Is there a designated stainless steel trolley available for use in this room only? EQR 12 Is there a clean infectious waste bin with a foot pedal that is in operation and is hands free? EQR Section 13: Vaccine Storage and Cold Chain Standard: Vaccines are stored and transported safely. Questions EQR / BP Yes () No () N/A () Remedial action to resolve problem Rationale / Resources 1 Does the GP Practice follow the standards set out in the Green Book (DH, 2010)? EQR Department of Health Green Book Chapter 3 Storage, Distribution and Disposal of Vaccines
INFECTION PREVENTION & CONTROL ACTION PLAN Name of Practice: Date: Name of staff member completing form: Designation of staff member completing form: Question Number EQR or BP Problem identified Remedial action to resolve problem Person responsible for outcome and planned achievement date. (Problems should normally be remedied within a maximum of 3 months of the problem having been identified, unless building work is required) Date when action completed