Infection Control Action Plan. Date audited: 16/01/2015. The Surgery (DE6 1RR) The Surgery Clifton Road Ashbourne DE6 1RR

Transcription

1 Infection Control Action Plan Date audited: 16/01/2015 Location: Client name: The Surgery (DE6 1RR) The Surgery Clifton Road Ashbourne DE6 1RR Broom Ward Shelley Maxwell-Jones Notes: Corrective actions: Other Corrective Actions Governance and Documentary Evidence There should be a local risk assessment to establish which policies, procedures and protocols are required for the regulated activities provided. Code of Practice for the prevention and control of infections 2010 Criterion 9 Infection Control policy in place and updated There should be a programme in place that defines the infection prevention and control assurance framework/infrastructure. Code of Practice for the prevention and control of infections 2010 Criterion 1 Infection Control policy in place and updated Toy cleaning schedules should be available to provide information on the ; National specifications for cleanliness Toys are on cleaning schedule where in place (daily) Template: Primary Care with Minor Surgery (AT017) Date Approved: Page 1 of 6

2 type and frequency of cleaning. in the NHS: primary care medical and dental premises NPSA 2010 Decontamination certificate should be available and accompany all equipment for service or repair. MHRA DB 2003 (05) Management of Medical Devices prior to repair, service or investigation Not required all equipment uses disposable parts (exception the only place there is a risk of contamination is the ear syringe protocol for cleaning after use in place) A comprehensive risk assessment should be available for the management of healthcare waste which includes: staff training; provision of waste disposal facilities; separation of waste streams and provision of a waste contractor. Expertise HTM Safe management of healthcare waste DH ; NICE clinical guideline 139 Infection - Prevention and control of Healthcare associated infections in primary and community care NICE 2012 Waste disposal covered in Infection Control policies, all reviewed and updated in, including: Clinical Waste Protocol Safe use and disposal of Sharps Protocol Decontamination of reusable instruments Policy Disposal single use instrument Policy Registered with Environmental Health and have a registered clinical waste disposal contractor A deputy to the person responsible for vaccine management should be identified and aware of their accountability/responsibility. Clinical Environment Vaccine Management Protocol update in progress Carpet is not appropriate in clinical areas and should be replaced with a washable, impermeable floor surface e.g. vinyl material, which is continuous, non-slip and where possible joint-less. environment DH ; HBN Performance requirements for building elements used in healthcare facilities DH 2011 (element 1); HBN Part A: Flooring DH All treatment rooms have clinical flooring and all procedures take place in these rooms. Regarding consultation rooms, and as per CQC Mythbusters: Carpets can be used in areas where the risk of spillage is lower, such as consulting rooms, waiting area, dispensing RT/EO Template: Primary Care with Minor Surgery (AT017) Date Approved: Page 2 of 6

3 Environmental cleaning schedules should include low surfaces. ; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 areas and administrative, storage and meeting rooms..skirting boards are on the cleaning schedules already. All other surfaces are included as well. The reception/public areas should be kept clean at all times. environment DH ; Code of Practice for the prevention and control of infections 2010 Criterion 2; National specifications for cleaning in the NHS: primary care medical and dental premises AHCP Constantly monitored by reception. Cleaned in the morning and tidied at lunchtime, and as required (e.g. in event of spillage etc) Chairs/furniture coverings should be wipeable and able to withstand regular cleaning. environment DH ; Code of Practice for the prevention and control of infections 2010 Criterion 2 Currently not wipeable. Cost prohibitive to replace all chairs. Will be done as part of ongoing replacement programme. Non washable keyboards should be provided with a wipeable cover which remains insitu during service user treatment. National specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010 Keyboards are regularly wiped with antiseptic solution Toys should be cleaned according to cleaning schedule and whenever soiled/contaminated. National specifications for cleaning in the NHS: primary care medical and dental premises AHCP Toys are on cleaning schedule where in place (daily) Toys should be stored in a robust container or on wipeable surface. Light pulls should be cleaned regularly or replaced. Waiting room toys and books in plastic container. Otherwise in clinical rooms on wipeable surfaces On cleaning schedules (daily). Replaced as needed Clinical Practice Template: Primary Care with Minor Surgery (AT017) Date Approved: Page 3 of 6

4 Re-usable facial protection should be decontaminated after each use with detergent and water. Hand Hygiene ; National specifications for cleaning in the NHS; primary care medical and dental premises NPSA To EO to check EO Taps on the clinical hand wash basins should not have swan neck fittings and should be considered for replacement. environment DH ; HBN 00-03: Clinical and clinical support spaces DH 2010; HBN Part C: Sanitary assemblies DH ; HBN Perf req for building elements used in healthcare facilities DH 2011 Cost prohibitive to code at time of install. Will consider when replacing The practice considers this presents negligible risk Clinical hand wash basins should not have an overflow. environment DH ; HBN 00-03: Clinical and clinical support spaces DH 2010; HBN Part C: Sanitary assemblies DH ; HBN Perf req for building elements used in healthcare facilities DH 2011 Cost prohibitive to code at time of install. Will consider when replacing The practice considers this presents negligible risk Clinical wash-hand basins should be wallmounted using concealed brackets and fixings. The dispenser should not be free standing on the work top or the drainer, even if plunger operated and should be wall mounted. environment DH environment DH Cost prohibitive to code at time of install. Will consider when replacing The practice considers this presents negligible risk All soap dispensers are wall-mounted. Pump operated gel is available whilst we source new reliable wall mounted dispensers. In progress RT will test new wall mounted dispenser and then purchase for whole practice Hand cream should be available in wall World Health Organisation Guidelines on Available in dispensary. RT request June15 Template: Primary Care with Minor Surgery (AT017) Date Approved: Page 4 of 6

5 mounted or pump-operated dispensers in at least one area. Waste Management hand hygiene in healthcare 2009; NICE clinical guideline 139 Infection - Prevention and control of healthcare associated infections in primary and community care NICE 2012 to AMc to purchase hand cream to place in sluice room (accessible to all clinicians) All waste bins should be fully enclosed and fire retardant. HTM Safe management of healthcare waste DH ; HBN 00-09: Infection control in the built environment DH ; Firecode HTM 05-03: Operational Provisions Part F: The prevention and control of arson in NHS healthcare premises DH Office waste bins are not enclosed but this presents negligible risk. Protocols cover disposal of any items that have risk e.g. glass/sharps etc. The waste storage area should be cleaned regularly. HTM Safe management of healthcare waste DH ; HBN 00-09: Infection control in the built environment DH Now put on cleaning schedule to sweep out. Decontamination of Environment Blood and body fluid spillage kit should be available. Purchased and in place All staff should be aware of the correct procedure to use in event of blood/body fluid spillages. ; National specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010 Spillage protocol displayed in kitchen area and sluice room. Also distributed with Infection Control Policy update April 15. To be covered in Infection Control training session April 15 EO 23/4/15 Cleaning/domestic staff should be given training on the importance of storing the cleaning equipment dry. Revised Healthcare Cleaning Manual ACHP Cleaning equipment stored separately according to protocol. Template: Primary Care with Minor Surgery (AT017) Date Approved: Page 5 of 6

6 Disposable mop heads should be discarded at least daily. Disposable mop heads purchased. Vaccine Management including Transport and Storage Records should be kept of when the vaccine fridge is cleaned. Review of vaccine management policy in progress EO Vaccine fridge should not be overstocked as air cannot circulate freely and temperatures will be adversely affected. Review of vaccine management policy in progress EO The power supply for the vaccine fridge should be switchless so that it cannot be accidently switched off. Quote requested RT May15 Template: Primary Care with Minor Surgery (AT017) Date Approved: Page 6 of 6