Healthcare Associated Infection (HAI) Inspection Audit Tool Hospital: Date: Inspector: Department: GUIDANCE The tool is based on a variety of national policies and procedures, the NHS Quality Improvement (NHS QIS) Healthcare Associated Infection (HAI) standards (March 2008) and a variety of nationally recognised audit tools. Inspectors will be aware of and follow the Healthcare Environment Inspectorate (HEI) Inspection methodology. During inspection, inspectors should inspect clean areas before dirty (ie. inspect kitchen areas prior to the inspection of sluices or isolation rooms.) Inspectors may use digital cameras provided to capture images of particular concern or to highlight examples of good practice. These images should only be taken of the ward/area environment and should at no time include images of patients, their relatives or staff. Where appropriate these images will be embedded into the inspection report. If the inspector identifies any serious concerns during the inspection, they should bring this to the attention of the lead inspector for the team in the first instance. Any area of serious concern which requires immediate action will be brought to the attention of the person in charge and senior management of the hospital before the inspection team leave the premises. These concerns will also be reported to the Chief Inspector, HEI. All criteria should be marked either yes/no or non-applicable. It is not acceptable to enter a non-applicable response where an improvement in a standard may be achieved. For example, where a national standard is not being met, a non-applicable must not be used: Hand Hygiene 4 Soft absorbent paper towels are available at all hand washing sinks In the example above it is not appropriate to mark non-applicable where soft absorbent towels are not in use as the national standard is to use them. Therefore, if they are not in use, a no score must be allocated. The action plan will then reflect the change in practice required. Produced by: Tracy Walker Page: 1 of 20 Review Date:
If a standard is not achievable because a facility is absent or a practice not undertaken, the use of nonapplicable is acceptable. For example in a clinical area, which does not have isolation facilities the following would be not applicable: (a) Hand Hygiene 34 All staff use the correct procedure for decontaminating hands Comments should be written on the form for each of the criteria at the time of the audit clearly identifying any issues of concern and areas of good practice. These comments can then be incorporated into the final report. Feedback of information and report findings The inspection team should verbally report any areas of concern and of good practice to the person in charge of the area being inspected prior to leaving. A written report will be developed by HEI and will be given to the NHS board for action. The report will clearly identify areas requiring action. The NHS board is responsible for developing an improvement action plan to address the issues identified within a given timescale. Produced by: Tracy Walker Page: 2 of 20 Review Date:
GENERAL ENVIRONMENT The environment will be maintained appropriately to reduce the risk of cross infection. General Environment (first impressions) 1 On entering the patient environment does it smell pleasant? 2 The facility is in good decorative order 3 The corridors are clutter free The environment is clean and free of dust and debris and/or in good decorative order. 4 Floors (including edges and corners) 5 High surfaces Low surfaces 6 Windows 7 Curtains and blinds 8 Air vents are these on a cleaning programme? 9 Radiators 10 Work station equipment is visibly clean (eg. phones, computer keyboards) 11 Walls 12 Doors 13 Lights (incl. fittings, switches and pull cords) Produced by: Tracy Walker Page: 3 of 20 Review Date:
WARD/DEPARTMENT KITCHENS - Kitchens will be maintained to reduce the risk of cross infection in accordance with legislation. 1 The floor is clean (including edges and corners) 2 The kitchen is uncluttered, clean, fresh smelling and free of inappropriate items (eg. noncatering items) 3 There is no evidence of infestation or animals in the kitchen. If bait boxes are in place, look for date or dust to determine if still active. (Action taken if infestation noted.) 4 Fly screens are in place over opening windows. 5 Insectacutor is clean and serviced every year. 6 Fans and extraction units are clean and free from dust and grease. 7 Disposable paper roll is available for drying equipment and surfaces 8 Cleaning materials used in the kitchen are colour coded and are stored separately to other ward cleaning equipment and away from food. 9 A non-clinical hand wash sink (SHTM 64) is available with liquid soap and disposable paper towels are available 10 Kitchen units and worktops are in good state of repair. 11 12 Cupboards, drawers and shelves are: a) clean and clutter free and in a good state of repair b) with no inappropriate items stored Dried food items: a) have a use by/best before date b) are in date c) stored in covered containers 13 Catering patient drinks trolleys are clean and in good state of repair. Produced by: Tracy Walker Page: 4 of 20 Review Date:
14 Bread bins and toasters (if used) are clean 15 Water coolers and ice machines (if used) are: a) clean b) on a planned maintenance and cleaning programme (check documented evidence) c) mains supplied (if they are for patient use) 16 Ice machines requiring a scoop (if used) have the scoop stored in a lidded container outside the machine. 17 Cutlery & crockery is clean and the central dishwashing system is satisfactory. 18 Waste bins are: a) clean b) foot operated c) in good working order d) labeled general waste 19 Waste bags are colour coded as per policy. 20 Microwaves (if used) are clean inside and out 21 If local policy allows a microwave to be used to heat patient food a temperature probe is used to ensure the correct temperature has been checked (check for probe and records) 22 Fridges and freezers are: a) clean and free from a build up of ice b) contain a working thermometer. 23 There is evidence that daily temperatures are: a) recorded b) appropriate action is taken if standards are not met (refrigerator temperature must be less than 8 C or as local policy. Freezer temperature - 18 C) 24 Patient and staff food in the fridge is: Produced by: Tracy Walker Page: 5 of 20 Review Date:
a) labeled b) expiry dated c) and stored appropriately (eg. covered) (check random items). 25 Hot and cold food is held in appropriate storage prior to service 26 The kitchen fridge is free from inappropriate items (ie. drugs or specimens) 27 Milk is: a) not expired b) stored under refrigerator conditions 28 Correct use of green PPE for catering areas is used 29 Cleaning schedules for the kitchen are available and appropriately completed Produced by: Tracy Walker Page: 6 of 20 Review Date:
CLINICAL PREPARATION ROOM/TREATMENT ROOM - This area may be multifunction but will be for clean practice, may be used for storage of clinical equipment and supplies, drug preparation area, +/- patient procedures. 1 The clinical preparation room is clean, free from dust and spillage and clutter free 2 The area is in good decorative order, shelves, cupboards, worktops, floors are clean and intact. 3 The room is free from inappropriate items of equipment 4 Any clinical or patient equipment is clean and free from dust, spills etc, drip stands, fans, dressing trolleys. 5 Clinical hand washing facilities (SHTM 64) are available including liquid soap and paper towels 6 Waste bins are available which are: a) foot operated b) in good working order c) labeled appropriately for clinical waste (check bag) d) labeled appropriately for general waste (check bag) e) Not more than 2/3rds full 7 There is an identified storage for clean and sterile equipment 8 All stock/equipment are stored above floor level 9 There is an effective stock rotation system randomly select items and check date, esp. sterile single use items. 10 Check for temperature records of medicine fridge (ie. when storing vaccines, insulin, etc). Fridge must be locked. Drugs must not be left out of fridge & unattended. 11 Check appropriate versions of posters are available for guidance on: a) hand washing b) waste disposal c) sharps injury d) antimicrobial prescribing Produced by: Tracy Walker Page: 7 of 20 Review Date:
SAFE HANDLING AND DISPOSAL OF SHARPS Sharps will be handled safely to prevent the risk of needle stick injury Check all sharps bins to ensure they comply with Waste Management Policy 1 The bins in use comply with national standards (UN 3291.BS 7320) 2 Have not been over filled above the manufacturer s guideline and are free of protruding sharps. 3 Have been assembled correctly, dated and signed according to hospital policy 4 Sharp bins are used in accordance with ergonomic manual handling principles (ie. off the floor and using brackets) 5 The temporary closure mechanism is used when bins are not in use 6 Sharps trays with integral sharps bins are available for use at the point of care. These trays are visibly clean and compatible with the sharps bins in use 7 Sharps should be disposed of directly into a sharps bin at the point of use/care (if observed) 8 Once full the sharps bin is sealed and locked bins are stored in a locked room, cupboard or container, away from public access. 9 An empty sharps bin is available on the cardiac arrest trolley Produced by: Tracy Walker Page: 8 of 20 Review Date:
HANDLING AND DISPOSAL OF LINEN - Linen is managed and handled appropriately to prevent cross infection. CLEAN linen is: 1 Stored in a designated area (not in sluice or bathroom or on the floor) (designated linen trolley is acceptable) 2 Free from stains and in a good state of repair (randomly check linen) The clean linen storage facility is: 3 Clean and free from dust 4 Free from inappropriate items 5 In a good state of repair USED linen is: 6 a) Segregated in appropriate colour coded bags according to policy. b) Are alginate bags used for the use of contaminated linen and clothing? 7 Put in linen bags that are less that 2/3 full and capable of being secured 8 Stored in a secure placec prior to disposal Observational 9 Linen skips and the appropriate linen or waste bags are taken to the point of care or area required (staff are not carrying soiled linen or leaving it on the floor) 10 Correct colour coded PPE is worn when handling used or contaminated linen 11 Fabric slings for patient hoist systems are clean and a system is in place for single patient use 12 Curtain changes are on a planned programme and curtains are clean Produced by: Tracy Walker Page: 9 of 20 Review Date:
PATIENT EQUIPMENT & BEDSPACE/PATIENT USE FACILITIES - There is a system in place that ensures as far as reasonably practicable that all re-useable equipment is properly decontaminated prior to use and that the risks associated with decontaminating facilities and processes are adequately managed. All decontamination must be undertaken in accordance with local policy and manufacturer's instructions. 1 The responsibility for the cleaning of dedicated patient equipment/furniture is clearly defined 2 Are triggering systems to indicate equipment is clean and ready for use in place? 3 Check for staff sign off of cleaning schedules. Is it a consistent system? The following is visibly clean, in a good state of repair and free from dust and body fluids: 4 Commodes How many commodes were checked? How many found to be clean? 5 a) Bedpans (rigid plastic/stainless steel) b) Toilet riser aids 6 IV Stands 7 Vital signs monitoring trolley including saturation probes and blood pressure cuffs 8 IV pumps/syringe drivers 9 Cardiac monitors 10 Crash Trolleys (emergency trolleys) 11 Suction units (both wall mounted and portable, which may be near emergency trolleys) 12 Near patient testing equipment (eg. Blood glucose machines) 13 Patient trolleys 14 Dressing trolleys - Check waste bags are not clipped or tied to trolleys. 15 Bed rails, and under frame of bed check for dust. 16 Mattress & Pillows are clean and on a cleaning schedule.(mhra guidance) How many mattresses were inspected? How many were found to be clean? 17 Wheelchairs and seat cushions, (these may be patients own or departmental, please state) 18 Manual handling equipment (including hoists/pat slides etc) Produced by: Tracy Walker Page: 10 of 20 Review Date:
19 Patient wash bowls are decontaminated appropriately between patients and are stored clean, dry and inverted. 20 Disposable paper towels on couches/trolleys is changed between patient use 21 Chairs and footstools (should be covered with impermeable washable material) 22 Patient bed/side tables & locker tops How many bowls were checked? How many were found to be clean? 23 Patient equipment eg. call bells, audiovisual and wall mounted lamps are visibly clean, earphones are clean and single use. Is Patientline installed? If yes, who cleans the fixtures? Bathrooms/Washrooms/Toilets 24 Bathrooms/washrooms/toilets are clean and in good decorative order 25 a) High surfaces are clean b) Low surfaces are clean 26 Floors including edges and corners are free of dust and grit 27 Bathrooms are free from communal items (eg. creams, talcum powder and shampoos etc) 28 Bathrooms are uncluttered and not used for storing inappropriate equipment or items. 29 Non-clinical handwashing facilities are available (SHTM 64) 30 A foot operated labeled waste disposal bin is available to dispose of used paper towels. 31 The bin is clean, free from spillages inside and out and in a good state of repair. 32 There is a facility for sanitary waste disposal where appropriate. Is an external contractor responsible for cleaning these units? 33 Toilet seats are clean and ready for use (check underneath) Check any toilet riser aids are clean. Produced by: Tracy Walker Page: 11 of 20 Review Date:
34 Appropriate cleaning materials are readily available for staff to clean the bath/shower between use. 35 Cleaning materials used by staff are stored securely. 36 Baths, showers and sinks out of use have a planned provision for running water weekly (review documented evidence). Produced by: Tracy Walker Page: 12 of 20 Review Date:
DEPARTMENTAL WASTE HANDLING AND DISPOSAL - Waste is disposed of safely without the risk of contamination or injury Waste Handling 1 Clinical waste posters and/or a waste policy identifying waste segregation are visible in all areas 2 Various bins are available (eg. clinical, prescription drugs in a pharmaceutical waste bin, cytotoxics) and labeled and used correctly (visibly check bin contents) 3 All bags are tied, labeled and secured before leaving the place of generation (eg. ward) 4 Bags are stored in an appropriate hold area (which is inaccessible to the public or locked) and not observed in public areas (locked bins in corridors are acceptable) 5 All waste bins are foot operated, lidded, clean (inside and out) & in good working order 6 Waste bags/bins are not more than 2/3 full 7 Suction waste must be disposed of in a manner which prevents spillage (eg. Canisters/liners are disposed of into rigid leak-proof containers or suction waste has been solidified with a gelling agent). Produced by: Tracy Walker Page: 13 of 20 Review Date:
DOMESTIC SERVICES - Observation of cleaning equipment and practice and inspection of Domestic Services Room. Domestic s Room 1 A domestic s room (DSR) is available, clean and in a good state of repair. 2 Information on the HFS colour coding system in use is available in the domestics room 3 Cleaning equipment is colour coded in line with National Colour Coding Guidelines (Observe the use of cleaning equipment in practice). 4 A supply of equipment and materials is available to domestic staff 5 Mops and buckets are stored according to the local policy 6 Mop heads are laundered daily or are disposable (single use) 7 Equipment used by the domestic staff is clean, well maintained and stored in a locked area 8 Machines used for floor cleaning are clean and dry 9 Chemicals used by domestic staff are stored in accordance with local risk assessment and COSHH regulations (in a locked area or cupboard) 10 Products used for cleaning and disinfection comply with policy and are used at the correct dilution 11 Diluted products are discarded after 24 hours (ask staff) 12 Waste is stored appropriately for collection (locked system) 13 No inappropriate materials or equipment are stored in domestics room (observe for non-domestic equipment) 14 Domestic staff have access to an Infection Control Manual and relevant policies. 15 Personal protective clothing is available and appropriately used. Observe the use of PPE. 16 Hand hygiene facilities are available for domestic use 17 A sluice is available for disposal of used cleaning fluids. Produced by: Tracy Walker Page: 14 of 20 Review Date:
HAND HYGIENE & DRESS CODE - Hands will be decontaminated correctly and in a timely manner using a cleansing agent, at the facilities available to reduce the risk of cross infection. Staff should be dressed appropriately for their duties. 1 Liquid soap is: -available at all hand washing sinks -provided as single use cartridge dispensers 2 Dispensers and nozzles are visibly clean 3 Soft absorbent paper towels are available at all hand washing sinks 4 Paper towel dispensers are visibly clean, dust free and in a good state of repair 5 A foot operated waste disposal bin is available to dispose of used paper towels 6 Wall mounted or pump dispenser hand cream is available for use in at least one location Hand wash sinks: 7 Are free from used equipment and inappropriate items (including nail brushes in clinical areas) 8 Are clean and dedicated for that purpose 9 Conform to national guidance (HTM 64 & SHTM 64). Check that they do not have plugs, overflows or that the water jet does not flow directly into the plughole. Produced by: Tracy Walker Page: 15 of 20 Review Date:
10 Are there sufficient numbers of sinks in accordance with national and local guidance (eg. one sink per four beds in acute care settings) 11 Sinks are accessible (not blocked by equipment or furniture etc) 12 Have appropriate temperature control to provide suitable hand wash water 13 Have elbow operated or automated taps in clinical areas Check alcohol hand rub is available for use throughout clinical area. 14 Entrance/exits to wards and departments 15 Directly accessible at the point of care. If a clinical assessment has taken place and the use of alcohol gel is deemed not suitable, view the risk assessment. (Personal dispensers for staff are acceptable) Observational Check staff comply with NHSScotland dress code 16 Clinical staffs' nails are short and free from nail varnish. No false nails. 17 Staff working in clinical areas have long hair tied back and off the collar 18 Staff uniforms are clean 19 Clinical staff who do not wear a uniform, do not wear unsecured ties or draped scarves 20 All staff wear short sleeves or roll sleeves to elbow length 21 No wrist watches/stone rings or other wrist jewellery are worn by staff carrying out patient care (plain band ring acceptable) Observational - General 22 Individual alcohol hand rub is available for clinical procedures if required 23 Posters promoting hand decontamination are available and displayed in areas visible to staff before File Name: and after 20110217 patient HAI contact Inspection Audit Tool Produced by: Tracy Walker Page: 16 of 20 Review Date:
24 Antibacterial solutions/scrubs (eg. Hibiscrub) are not used for social hand washing 25 Antibacterial solutions are used for invasive procedures and surgical scrubs (Ask staff) 26 Do staff wash or decontaminate hands (before, during, after contact with the patient and their environment)? 27 All staff use the correct procedure for decontaminating hands Produced by: Tracy Walker Page: 17 of 20 Review Date:
CLINICAL PRACTICE - Clinical practices will be based on best practice and reflect infection control guidance. The following criteria are areas which can be reviewed. They do not cover all aspects of care but can give some indication that appropriate infection control measures are in place. Personal Protective Equipment 1 Sterile and non-sterile gloves are available and conform to national guidelines 2 Eye protection is available (shatterproof may be required in some areas) 3 Facemasks are available to staff when required (eg. influenza) 4 Disposable plastic aprons are available in wall mounted containers 5 There is a colour coded system and policy in place for the use of plastic aprons in clinical practice. Catheter care 7 Protocols are in place for catheter hygiene 8 All catheters must be a sterile closed drainage system. 9 Non-sterile gloves are worn for emptying urinary catheter bags 10 A disposable receptacle or heat disinfected jug is used for emptying urinary catheter bags 11 Catheter stands are in use, there are no catheters bags touching the floor (bags are below bladder level) Peripheral Vascular Catheter (PVC) and Central Vascular Catheters (CVC) 12 PVC/CVC bundle or Evidence-based Care Plan is in use (or equivalent) 13 Is the department adopting SPSP methodology with the PVC/CVC bundle? (or equivalent) 14 Transparent sterile dressings are used to cover intravenous cannula sites (check if date of insertion is recorded at site and care plan/bundle) 15 Is the PVC/CVC dressing clean and secure? 16 Evidence of regular site inspection (ask nurse to Produced by: Tracy Walker Page: 18 of 20 Review Date:
produce documented evidence) 17 For CVCs only - Ask Nurse or Dr, if policy states 2% Chlorhexidine gluconate in 70% Isopropol alcohol is to be used for cleaning insertion site or for cannulation. Isolation 18 Isolation facilities are available (ie. identify number of single rooms) 19 Any symptomatic patient presently on the ward is being nursed with the appropriate isolation precautions and according to hospital policy (either in isolation or cohort) 20 Does the patient have dedicated toilet facility with cleaning schedule and record? 21 Does the patient have dedicated equipment? 22 Is correct hand hygiene practiced (liquid soap & water for cdiff)? 23 Clear instructions for staff and visitors are in place when a patient is in isolation. 24 Separate colour coded cleaning equipment is in use for isolation facilities Produced by: Tracy Walker Page: 19 of 20 Review Date:
DISPLAY INFORMATION & DOCUMENTATION The following should be checked on inspection. If any paper copies of policies or guidelines are noted, check version control dates & responsibilities for update. 1 Audit: (good examples of) mattress hand hygiene environmental clinical ie. PVC 2 Surveillance Statistical Process Control (SPC) run charts: MRSA/MSSA Clostridium Difficile Surgical Site Infection (SSI) 3 Do staff understand SPC data? Ask nursing & medical 4 Cleaning schedules Domestic Clinical Staff 5 Estates maintenance log books/systems 6 Staff training evidence specific to HAI 7 Patient HAI information in a variety of formats (including how to launder clothes at home) 8 Policy information for clinical staff on antimicrobial practice 9 Infection Control Manual (check for version control on any paper copies) Produced by: Tracy Walker Page: 20 of 20 Review Date: