Infection Control Action Plan - …

1 ResponsibilityIC NurseIC NurseNightingalen/aLaurie BentonAll disinfectant and cleaning products must have a COSHH data of Substances Hazardous to Health Regulations 2002 Complaint as at July 2013. COSHH sheets avaiable on intranet, under practice policies, Infection controlEnvironmental cleaning check lists should be kept to provide documentary evidence of monitoring that all environmental surfaces have been routinely and thoroughly of Practice for the prevention and Control of infections 2010 Criterion 2; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 Compliant as at June 2013. Audits completed by NightingaleToy cleaning check lists should be kept to provide documentary evidence of monitoring that all toys have been routinely and thoroughly specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 N/a.

2 No toys policyThere 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 The manual should contain policies, procedures and protocols required by the local risk of Practice for the prevention and Control of infections 2010 Criterion 9 and table 3 Corrective ActionsGovernance and Documentary EvidenceCorrective ActionReferenceEvidence of Compliance Client name:West Essex (NCB Essex LAT) Infection Control Action PlanDate audited:20/06/2013 Location:Thaxted SurgeryCopyright IPC Management (Holdings) Ltd 2005 2013 Template: Primary Care with Minor Surgery (AT017) Date Approved: 10/07/2013 Report Version Page 1 of 16 IC NurseIC NurseIC NurseN/ALaurie BentonResponsibilityNHS England/CCG to make training availableAll staff should have regular 12 monthly updates on Infection Control of Practice for the prevention and Control of infections 2010 Criteria 1, 5, 6 and 10 Written schedules for flushing of taps / showers should be available to provide information on location of taps and frequency of 04-01 The Control of Legionella, hygiene, "safe" hot water, cold water and drinking water systems Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems N/A.

3 Based on our risk assessment this is not RecordsCorrective ActionReferenceEvidence of Compliance Ensure that the practice has a written protocol indentifying a designated waiting area for service users with communicable of Practice for the prevention and Control of infections 2010 Criteria 7 and 9 Complaint. Custom and practice - staff put patients with rashes in a separate owners/occupiers must conduct a risk assessment of hot & cold water supplies for legionella 04-01 The Control of Legionella, hygiene, "safe" hot water, cold water and drinking water systems Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems COMPLAINT. RISK ASSESSMENT REVISED JULY certificate should be available and accompany all equipment sent for service or DB 2003 (05) Management of Medical Devices prior to repair, service or investigationStaff should be aware of the need to complete a certificate of decontamination for all re-usable clinical equipment, prior to sending for repair or DB 2003 (05) Management of Medical Devices prior to repair, service or investigationRe-usable clinical equipment decontamination check lists should be kept to provide documentary evidence of monitoring that all re-usable clinical equipment has been routinely and appropriately of Practice for the prevention and Control of infections 2010 Criterion 2; Revised Healthcare Cleaning Manual NPSA 2009.

4 National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 Copyright IPC Management (Holdings) Ltd 2005 2013 Template: Primary Care with Minor Surgery (AT017) Date Approved: 10/07/2013 Report Version Page 2 of 16 ResponsibilityNHS England/CCG to make support availableNHS England/CCG to make support availableCOMPLETER esponsibilityn/aCorrect as and when refurbishments carried out in premises maintenance walls have no defects which reduce effectiveness of cleaning. Repair/refurbish damaged areas so that surfaces are impervious and 30 Infection Control in the Built Environment DH 2003; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011 (element 2)Clinical EnvironmentCorrective ActionReferenceEvidence of Compliance Consultation / examination rooms should ONLY be used for low risk clinical procedures and clean tasks 00-03: Clinical and clinical support spaces DH 2010; Facilities for primary and community care services: Planning and design manual 1183 :England DH 2011 Current building makes full compliance impossible.

5 However, we are not taking any undue or inappropriate risk and have no evidence of significant events of incidentsLocal arrangements should be in place for staff to have access to Occupational Health services and of practice for the prevention and Control of infections 2010 Criteria 10 The practice should have access to the appropriate Competent Persons for vaccine fridges and Legionella Against Infectious Disease Ch. 3 Management of Vaccines DH 2011; HTM 04-01 Ch Part B (2006) Operational management; The Control of Legionella Bacteria in Water Systems Approved Code of COMPLIANT. We use medicines management CCG provided support for cold chain policy. See above re ActionReferenceEvidence of Compliance Staff should be aware of how to contact local Infection prevention and Control support for of Practice for the prevention and Control of infections 2010 Criteria 1, 5, 8 and table 2 All staff should have regular 12 monthly updates on hand hygiene training as part of their Infection prevention and Control of Practice for the prevention and Control of infections 2010 Criteria 1, 5, 6 and 10 COMPLIANT.

6 Signs in all relevant locations throughout the buildingCopyright IPC Management (Holdings) Ltd 2005 2013 Template: Primary Care with Minor Surgery (AT017) Date Approved: 10/07/2013 Report Version Page 3 of 16 Correct as and when refurbishments carried out in premises maintenance as and when refurbishments carried out in premises maintenance as and when refurbishments carried out in premises maintenance as and when refurbishments carried out in premises maintenance staff. Inspection by Laurie BentonEnvironmental cleaning schedules should include high Healthcare Cleaning Manual NPSA 2009; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 COMPLIANT. Ref Cleaning schedulesAll inappropriate items and clutter should be cleared away and stored in appropriate storage spaces, to leave surfaces clear for effective This is clearly stated in staff room work surfaces joints and seams must be sealed to avoid build up of debris and facilitate 30 Infection Control in the Built Environment DH 2003 Environmental cleaning schedules should include low Healthcare Cleaning Manual NPSA 2009; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 COMPLIANT.

7 Ref Cleaning schedulesIn clinical areas and associated corridors, there should be a continuous return between the floor and the wall a coved skirting with a minimum height of 30 Infection Control in the Built Environment DH 2003; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011 (element 1)Carpet is not appropriate in clinical areas and should be replaced with a washable, impermeable floor surface vinyl material, which is continuous, non-slip and where possible 30 Infection Control in the Built Environment DH 2003; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011 (element 1)Treatment rooms compliant. Consulting rooms to be corrected as and when. Flooring in clinical areas should be heat sealed at seams/edges to prevent the accumulation of dust and dirt and facilitate 30 Infection Control in the Built Environment DH 2003; HBN 00-10 Performance requirements for building elements used in healthcare facilities DH 2011 (element 1)Copyright IPC Management (Holdings) Ltd 2005 2013 Template: Primary Care with Minor Surgery (AT017) Date Approved: 10/07/2013 Report Version Page 4 of 16 IC NurseIC Nurse to NurseIC NurseCorrect as and when refurbishments carried out in premises maintenance as and when refurbishments carried out in premises maintenance as and when refurbishments carried out in premises maintenance to purchase someIC Nurse to Nurse to plastic aprons should be worn for National Evidence Based Guidelines for Preventing Healthcare Associated infections in NHS Hospitals in England 2007.

8 NICE (2012) Prevention and Control of healthcare COMPLIANT. Aprons are supplied. HCAs and nurses resp for their use. Eye protection must be available full-face visor, goggles or mask with integral (2012) Prevention and Control of healthcare associated infections in primary and community care; Personal Protective Equipment at Work Regulations 2005 Disposable gloves should be worn for National Evidence Based Guidelines for Preventing Healthcare Associated infections in NHS Hospitals in England 2007; NICE (2012) Prevention and Control of healthcare COMPLIANT. Gloves are supplied. HCAs and nurses resp for their use. Non washable keyboards should be provided with a wipeable cover which remains insitu during service user specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010 Clinical PracticeCorrective ActionReferenceEvidence of Compliance All chairs/furniture used service users should be covered in an impermeable material and be 30 Infection Control in the Built Environment DH 2003 Chairs/furniture coverings should be wipeable and able to withstand regular cleaning.

9 HFN 30 Infection Control in the Built Environment DH 2003 Privacy curtains should be changed 6 specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 Disposable curtains should be changed by their due specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 Consumables and small items should be stored in covered boxes or storage 30 Infection Control in the Built Environment DH 2003 Examination/treatment couch should be kept clean and dust free at all times and be included in the daily cleaning specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010 COMPLIANT. See cleaning schedules. Nightingale daily. Nurses/HCAs during the dayCopyright IPC Management (Holdings) Ltd 2005 2013 Template: Primary Care with Minor Surgery (AT017) Date Approved: 10/07/2013 Report Version Page 5 of 16 IC Nurse to Nurse to Nurse to NurseIC NurseResponsibilityCorrect as and when refurbishments carried out in premises maintenance on the clinical hand wash basins should not have swan neck fittings and should be considered for 00-10 Performance requirements for building elements used in healthcare facilities DH 2011 Warm water and liquid detergent should be used for cleaning dressing trolleys/procedure trays.

10 Detergent wipes can also be used. National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010 Hand HygieneCorrective ActionReferenceEvidence of Compliance Single use medical devices/items opened for a procedure and not used must be of Practice for the prevention and Control of infections 2010 Criterion 9; MHRA Single use medical devices: Implications and consequences for re-use MDA DB 2006(04) DH 2011; The Medical Devices Regulations 2002 COMPLIANT. Stated in IC policyWarm water and a liquid detergent should be used for cleaning medical devices/clinical equipment. Detergent wipes can also be specifications for cleaning in the NHS: primary care medical and dental premises NPSA 2010 Clinical EquipmentCorrective ActionReferenceEvidence of Compliance Staff must adhere to 'single use' legislation and not re-process any 'single use' medical of Practice for the prevention and Control of infections 2010 Criterion 9; MHRA Single use medical devices: Implications and consequences for re-use MDA DB 2006(04) DH 2011; The Medical Devices Regulations 2002 COMPLIANT.