Environmental audit tool - NHSGGC

1 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Primary Care Division Infection Control audit tool Site : Location : Speciality : Head of Department (or nominee): audit Date : Completed By : Accompanied By (if applicable) : 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Index Introduction How to use this audit tool Section 1 General Section 2 Toilet Area Section 3 Shower Area Section 4 Sluice Room (Disposal) Section 5 Domestic Services Room Section 6 Consulting Room / Treatment Room Section 7 Local decontamination (contact Infection Control Team for information) Section 8a Kitchens General Section 8b Kitchens - Refrigerator Section 8c Kitchens - Cookers / Microwaves Section 8d Kitchens - Dishwashing Section 8e Kitchens - Training Section 9 Handwashing Facilities Section 10 Waste Disposal Section 11 Sharps Handling & Disposal Section 12 Linen Storage, Bagging & Laundering Section 13 Clinical Practice Section 14 Cleaning & Disinfection Section 15 Care of Equipment Section 16 Staff Facilities Section 17 Vaccine Storage Section 18 Minor Surgery Section 19 Baby Changing Facilities Scoring Summary Action Plan Example audit Calendars Recommended Reading 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Introduction In recent years there has been an increase in concern about the risks to health from receiving treatment and care.

2 The Clinical Standards Board for Scotland published standards for Healthcare Associated Infection (HAI) Infection Control, December 2001 (Ref: ISBN 1-903766-12-5), a copy of which can be obtained from Trust Clinical Standards Facilitator (0141 211 3916). These standards are used by the NHS Quality Improvement Scotland, to assess the quality of Infection Control provided in both the Primary Care and hospital settings throughout Scotland. As part of the process of ensuring that these standards are met, as well as ensuring that the quality of the infection control practice within the Trust is of a high standard, the Prevention and Control of Infection Team has developed an Infection Control Environmental audit tool . This audit tool defines the acceptable standards for a managed environment which minimises the risk of infection to patients, staff and relatives. These standards reflect current legislation, national guidelines and good practice of infection control within a healthcare environment.

3 To ensure that staff at a local level has ownership of the standards, the Head of Department or nominee should demonstrate compliance through self assessment using the audit tool provided. The Environmental audit tool is divided into sections containing the relevant standard and criteria, not all sections may be applicable to your area. It is anticipated that the relevant sections of the audit tool are completed at least once a year by staff at local level, As hand washing is the single most important means of preventing the spread of infection, section 9 hand washing facilities should be completed on a monthly basis. It is advised that the section on how to use this audit tool is read, prior to undertaking the audit . Further information in relation to the self assessment process or audit tool can be obtained by contacting a member of the Prevention and Control of Infection Team by: Email Lesley Telephone 0141 211 3568 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 How to use this audit tool 1.

4 Inpatient areas; Heads of Department or nominated member of staff should identify and complete all sections relevant to their area. Outpatient areas ( Health Centres, Resource Centres) For ease of collation and reporting an identified person within the locality should be responsible for distribution of relevant sections of audit tool to areas and in collating the return of completed action plans and scores to the Infection Control Team (ICT) within the required time frame. 2. Section 9 Handwashing Facilities should be completed on a monthly basis locally, however score and action plan need only be returned to ICT as indicated by timeframe identified by score. 3. Other relevant sections should be completed at least yearly, or as indicated by scoring achieved (see scoring sheet for more details) or by the Infection Control Team in the returned summary report 4. It is suggested that an audit calendar (enclosed) should be completed to chart the relevant sections indicating when re- audit is required 5.

5 To each criterion within the relevant sections, place a cross in the appropriate box (Yes, No or Not Applicable) 6. All criteria which are not fully met require action. However, there are some criteria that require immediate action. These criteria are clearly marked. 7. An action plan, available at the back of the document, should be completed for all actions, indicating realistic timeframes (Immediate actions should be included). To assist in completing your action plan a copy of the Infection Control Team action plan for all sections and criteria is available within the intranet and Public Folder- infection control. For any further advice, contact a member of the Infection Control Team. A Copy of the action plan, score and copies of Infection Control audit reports should be retained at ward/department level as evidence of compliance with these standards, which will be reviewed by the Infection Control Team as part of their planned audit programme.

6 8. A copy of each completed section score and action plan should be returned via identified person (if applicable) HAI lead, to the Infection Control Team within given timeframe by email to or by post to Sarah Caulfield, Secretary to Risk Management Department, Ward 4, Risk Management department, 1055 Great Western Road, Glasgow, G12 OXH. 9. Your Department will be given a summary report and advice on when to re- audit by the Infection Control Team 10. The ICT will collate a response for overall Primary Care Division Performance to NHS Quality Improvement Scotland (Clinical Standards Board Scotland) Healthcare Associated Infection (HAI) Infection Control, reporting any common themes, challenges, good practice through the Infection Control Committee and Risk Management Advisory Group 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Section 1 General Standard: The general environment will be maintained appropriately to negate the risk of cross infection Criteria Yes No N/A Action and lockers are clean and in a good state of repair.

7 Immediate floor coverings are clean and in good state of repair. Immediate is not present on high horizontal surfaces. level surfaces are clean and free from dust extractor fans are in operation, they must be clean and free from dust. and blinds are clean and in good repair toys are available, they are clean, in a good state of repair and capable of being cleaned and withstanding chemical disinfectants. Immediate There is a cleaning schedule available within the ward/department Total Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Section 2 Toilet Area Standard: The toilet area will be maintained appropriately to negate the risk of cross infection. Criteria Yes No N/A Action toilet area and fixtures are clean and dry Immediate toilet area is free of extraneous items fixtures and fittings are in good repair sinks are fitted with mixer taps sink is clean Immediate soap is available at all Handwashing sinks Immediate soap dispensers are clean Immediate paper towels are available in a wall mounted dispenser.

8 Disposal facilities are appropriate See Section 10 Waste Disposal seats and toilet aids are clean and dry Immediate disposal is available in female toilets is a cleaning schedule available Total Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Section 3 Shower Area Standard: The shower area will be maintained appropriately to negate the risk of cross infection. Criteria Yes No N/A Action areas are clean and dry and in good state of repair Immediate area is free of extraneous items creams, bedpans shower area furnishings/fittings are in good repair tiles, flooring curtains are clean Immediate chairs are clean and dry Immediate disposal facilities are appropriate foot operated sack holders with domestic waste sack are run daily prior to use bath/shower mats are clean and hung dry over the bath rail between use is a cleaning/replacement schedule for shower curtains Total Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Section 4 Sluice Room (Disposal) Standard: The sluice room will be maintained appropriately to negate the risk of cross infection.

9 Criteria Yes No N/A Action and fittings are clean, dry and free from spillages Immediate surfaces and fittings are in good repair and free from extraneous items Immediate is a sink for washing equipment bedpan shells, suction jars. is a dedicated handwashing sink sinks are fitted with mixer, elbow/wrist operated taps is a wall mounted antiseptic scrub/liquid soap dispenser Immediate paper towels are available in wall mounted dispenser Immediate disposal facilities are appropriate See Section 10 waste disposal macerator is clean and functioning racks are clean Sub-total Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Section 4 (cont d) Sluice Room (Disposal) Criteria Yes No N/A Action Sub-total (from previous page) are clean, ready for use and in a good state of repair Immediate holders and jugs are stored clean, inverted or on racks bowls are stored clean and dry and inverted, or patients own are stored in locker Immediate packs/equipment are not stored in the sluice Immediate reagents are kept in a locked cupboard Immediate nurses green sluice mops and buckets are available mop and bucket is correctly colour coded (green).

10 Buckets are stored clean, dry and inverted mop heads laundered after each individual use. Total Comments 02/04/2008 Version 2 Revised may2004 Review Date: April 2006 Section 5 Domestic Services Room Standard: The domestic services room will be maintained appropriately to negate the risk of cross infection. Criteria Yes No N/A Action and fittings are clean and in good repair Immediate floor is clean, dust free and free from spillages Immediate is a Belfast sink or deep sink available for cleaning equipment is a dedicated handwashing sink sinks are fitted with mixer, elbow/wrist operated taps soap is available and dispenser is clean Immediate paper hand towels are available in wall mounted dispensers Immediate items used for the purpose of cleaning are stored in the room clothing is available plastic aprons, gloves agents are suitably stored in a locked cupboard Immediate equipment used by the Domestic staff is clean, well maintained and stored securely.