Graceland Nursing Home - Care Home Infection Prevention and Control Assurance Tool

Care Home Infection Prevention and Control Assurance Tool

• Name of Auditor

• Name of Auditor

• Date and Time of audit

  Date

• Nurse in charge at time of audit

• Number of beds in care home

• Number of residents

• Number of residents CoVID 19 positive

• Date of first positive case

  Date

• Date of last positive case

  Date

Standard 1: Leadership in the prevention and control of infection

• Standard Statement: the organisation demonstrates leadership and commitment to infection prevention and control to ensure a culture of continuous quality improvement throughout the organisation.

• Rationale: Robust leadership in infection prevention and control is essential for effective decision-making, effciient use of resources and ensuring the provision of high quality, safe, effective, person-centred care.

• Manager completes regular infection control audits for care home

  Yes

  No

  N/A

• Manager shares any issues identified from audit with teams during safety brief and this is recorded

  Yes

  No

  N/A

• All staff know how to contact Health Protection Team for advice

  Yes

  No

  N/A

• Home has an identified Infection Control lead / champion

  Yes

  No

  N/A

COVID-19 Specific

• Manager will co-ordinate and manage the care staff, to ensure quality care for residents

  Yes

  No

  N/A

• Manager will ensure that all activities are carried out safely

  Yes

  No

  N/A

Standard 2: Education to support the prevention and control of infection

• Standard statement: Education on infection prevention and control is provided and accessible to all healthcare teams to enable them to minimise infection risks that exist in care settings.

• Rationale: To minimise the infection risks associated with healthcare, all staff are provided with the necessary knowledge and skills in infection prevention & control to confidently and competently demonstrate behaviours integral to safe, effective & person-centred care

• All staff have access to & have completed mandatory Infection Prevention & Control (IPC) training

  Yes

  No

  N/A

• Manager ensures that the IPC education needs of their staff and themselves are identified, supported and evaluated through personal development reviews and personal development plans

  Yes

  No

  N/A

• Staff have had training around how to contact GP, Health Protection, Partnership, Care Commission and relatives – check evidence

  Yes

  No

  N/A

• Do staff have access to up to date educational resources (e.g. web based system)

  Yes

  No

  N/A

• Unit has a named Responsible Person for Hand Hygiene and Skin Surveillance as per https//www.hse.gov.uk/skin/professional/health-surveillance.htm

  Yes

  No

  N/A

COVID-19 Specific

• Is there evidence to show that staff have received training about COVID-19, infection prevention and care?

  Yes

  No

  N/A

Standard 3: Communication between organisations and with the patient or their representative

• Standard statement: The organisation has effective communication systems and processes in place to enable continuity of care and infection prevention and control throughout the patient’s journey

• Rationale: Residents are vulnerable to infections and some present an infection risk to other residents, visitors and staff. As a single resident journey can involve staff in multiple care settings, effective care provider communications are vital in infection prevention and control, and safe, effective and person-centred care. Wherever possible, residents and their representatives must be assured of, and involved in, communications regarding their care

• All residents, where appropriate, have been informed of how they and their family can reduce the risk of infection

  Yes

  No

  N/A

• All residents in isolation have the reason for isolation documented in notes

  Yes

  No

  N/A

• When infection risks to or from the resident are identified, all communication with the resident or their representatives is recorded in the notes

  Yes

  No

  N/A

• Staff aware how to identify residents with Infection Risks

  Yes

  No

  N/A

• Infection Prevention & Control posters are displayed (suggest the following):

• Hand hygiene

  Yes

  No

  N/A

• Standard Infection Control Precautions (SICPs)

  Yes

  No

  N/A

• Management of Occupational Exposure Sharps assembly/closure

  Yes

  No

  N/A

• Management of Blood Body Fluid Spills

  Select Yes No N/A

  • Yes
  • No
  • N/A

• 4 moments for Hand Hygiene

  Yes

  No

  N/A

• Linen Segregation

  Yes

  No

  N/A

• Domestic Colour Coding Guidelines

  Yes

  No

  N/A

COVID-19 Specific

• All entrances are clearly sign posted stating the service is closed to visitors due to Covid-19 restrictions?

  Yes

  No

  N/A

• Signage is visible on doors of residents who have tested positive for Covid-19

  Yes

  No

  N/A

• Residents with capacity understand why the precautions are in place – ask one resident

  Yes

  No

  N/A

• Are there any floor markings/signage to indicate the 2 metre social distancing guidance?

  Yes

  No

  N/A

• Is their signage/guidance to remind staff about reporting illness, Covid-19 testing and return to work?

  Yes

  No

  N/A

Standard 4: Infection surveillance

• Standard statement: The organisation has a surveillance system to ensure a rapid response to HAI

• Rationale: Infection surveillance is the ongoing and systematic collection, analysis and interpretation of data, relating to infection , which is used to reduce the risk of infection and improve resident outcomes

• All staff are aware of the process of reporting suspected infection

  Yes

  No

  N/A

• All staff are aware that the findings from the visits by assurance teams and the improvement plans

  Yes

  No

  N/A

COVID-19 Specific

• Staff have accurate records of residents affected

  Yes

  No

  N/A

• When in outbreak, staff complete HPS COVID – 19 Outbreak tool daily

  Yes

  No

  N/A

Standard 5: Antimicrobial stewardship

• Standard statement: The organisation demonstrates effective antimicrobial stewardship

• Rationale: Antimicrobial stewardship, in the form of a co-ordinated programme, has been shown to reduce inappropriate antimicrobial use, improve patient outcomes and reduce adverse consequences of antimicrobial use including, antimicrobial resistance, toxicity and unnecessary costs

• At present there are no question sets available to measure / monitor antimicrobial stewardship

• All nursing staff involved in the prescribing and administration of medicines must comply with 2007

Standard 6: Infection prevention and control policies, procedures and guidance

• Standard statement: The organisation demonstrates implementation of evidence-based infection prevention and control measures

• Rationale: The minimum standard of infection prevention and control to be practiced by all staff, in all care settings, for all care procedures is the application of standard infection control precautions, as detailed in chapter one, of the National Infection Prevention and Control Manual. Standard infection control precautions are the most effective means to prevent cross transmission and cross-infection with micro-organisms in care settings

• All staff can access the local Infection Prevention & Control of Infection Policy

  Yes

  No

  N/A

• All policies are within date and align to HPS National Infection Prevention and Control Manual

  Yes

  No

  N/A

Patient Placement / Assessment for Infection Risk

• Are the residents assessed regularly for infection risks (to themselves and from themselves) and placed appropriately to negate cross-transmission risks?

  Yes

  No

  N/A

• The care home has facilities to isolate those residents presenting an infection risk

  Yes

  No

  N/A

• Doors to isolation/cohort rooms/areas are closed and signage is clear (undertake a resident safety risk assessment for door closure). If the door cannot be kept closed the bed/chair are at the furthest safest point of the room to keep 2m distance from the open door

  Yes

  No

  N/A

COVID-19 Specific

• Visiting is restricted and Visitors log utilised appropriately

  Yes

  No

  N/A

• Staff are checking and recording resident’s temperature at least twice a day, and reporting if raised and checking for other symptoms

  Yes

  No

  N/A

• Staff are logging their own temperature on arrival to the service and if raised, being asked to go home (documented evidence)

  Yes

  No

  N/A

• Residents dining rooms, sitting rooms and other shared space are clean and tidy, and there is evidence of social distancing measures

  Yes

  No

  N/A

• Electric fans should not be in use

  Yes

  No

  N/A

• Facilities are available for virtual visiting for residents

  Yes

  No

  N/A

• Is there a contingency plan for ‘cohorting’ or zoning to keep suspected or confirmed infected residents apart from non-infected residents

  Yes

  No

  N/A

• Records are kept if staff are supervising residents with outdoor exercise to note social distancing

  Yes

  No

  N/A

Hand Hygiene

• Alcohol based hand rub (ABHR) is available at ward entrance / exit and close to point of care

  Yes

  No

  N/A

• All staff in clinical areas are wearing Alcohol Gel

  Yes

  No

  N/A

• Hand washing facilities are designated for staff in their changing area and each floor or unit of the service

  Yes

  No

  N/A

• Staff are bare below the elbows and not wearing wrist watches, bracelets or stoned rings

  Yes

  No

  N/A

• All staff comply with for hand hygiene WHO 4 moments for hand hygiene

  Yes

  No

  N/A

• Hand wash sinks used only for hand washing - not for discarding wash water from basins or other fluids

  Yes

  No

  N/A

• Do all wash hand basins have liquid soap, paper towels and a pedal bin or open bin for waste towels (no flip bins)?

  Yes

  No

  N/A

• Wall mounted or pump dispenser hand cream available in at least one location

  Yes

  No

  N/A

• Staff are observed carrying out effective hand washing technique at the correct times

  Yes

  No

  N/A

• Are there documented checks by the manager on hand hygiene compliance?

  Yes

  No

  N/A

COVID-19 Specific

• Staff should support residents with frequent hand hygiene

  Yes

  No

  N/A

• Staff should include forearms when undertaking hand hygiene when there are incident of COVID-19 in the unit

  Yes

  No

  N/A

Respiratory & Cough Hygiene

• Residents are provided with a supply of tissues if they have respiratory symptoms and supported with

  Yes

  No

  N/A

• Staff can describe respiratory / cough etiquette in care areas

  Yes

  No

  N/A

• Used tissues are promptly disposed of in a bin or disposal bag

  Yes

  No

  N/A

• Staff are aware of what Personal Protective Equipment (PPE) to use for patients with respiratory infections and where to access them

  Yes

  No

  N/A

Personal Protective Equipment (PPE)

• PPE is available close to the point of use and stored appropriately to avoid contamination

  Yes

  No

  N/A

• Staff can don and remove PPE appropriately as per Appendix 6 of the National Infection Prevention & Control Manual

  Yes

  No

  N/A

• Aprons are worn to protect uniform when in close contact with the resident or their environment

  Yes

  No

  N/A

• Appropriate colour coded aprons are worn by domestic staff

  Yes

  No

  N/A

• Correct gloves type is used for task refer to Appendix 5 – Best Practice - Glove Use and Selection

  Yes

  No

  N/A

• Gloves are worn when exposure to blood/body fluids may occur

  Yes

  No

  N/A

• Facial protection is worn where there is a risk of blood/body fluid contamination

  Yes

  No

  N/A

• PPE is changed between resident (or end of task) and appropriately disposed

  Yes

  No

  N/A

COVID-19 Specific

• Ensure staff using the PPE safely and appropriately? (e.g. staff do not wear PPE in break rooms while eating/drinking)

  Yes

  No

  N/A

• Staff aware of need to risk assess for eye protection

  Yes

  No

  N/A

• Staff are aware of and can describe the difference between the following:

Staff Management of Care Equipment

• Staff are aware of and can describe the difference between the following

• Single-use

  Yes

  No

  N/A

• Single person use

  Yes

  No

  N/A

• Re-usable invasive equipment

  Yes

  No

  N/A

• Re-usable non-invasive equipment

  Yes

  No

  N/A

• Sterile stock is in date

  Yes

  No

  N/A

• No communal prodcuts are used i.e. soap, shower gel, shaving foam

  Yes

  No

  N/A

• Commodes are visibly clean

  Yes

  No

  N/A

• Raise toilet seats are visibly clean

  Yes

  No

  N/A

• System in place for mattress checks and audit

  Yes

  No

  N/A

• Mattresses are clean (inside and outside mattress cover)

  Yes

  No

  N/A

• Bed rails/frames clean

  Yes

  No

  N/A

• Equipment is cleaned following resident use (Check a selection of equipment)

  Yes

  No

  N/A

• Appropriate claining materials available and staff aware of correct process for cleaning and decontamination, Appendix 7 NIPCM

  Yes

  No

  N/A

• Yes

  No

  N/A

COVID-19 Specific

• Equipemnt used for residents is either personal or cleaned correctly to prevent cross infection.

  Yes

  No

  N/A

• Personal items must be stored in residents room

  Yes

  No

  N/A

• Staff are aware of products to use during a sustained transmission of COVID

  Yes

  No

  N/A

• Domestic Staff are aware of products to use during a sustained transmission of COVID

  Yes

  No

  N/A

Safe Management of Care Environment

• The care environment is visibly clean, kept free from non-essential items and equipment to facilitate effective cleaning

  Yes

  No

  N/A

• No inappropriate storage i.e. staff cups or food items in clinical areas

  Yes

  No

  N/A

• The care environment well maintained and in a good state of repair

  Yes

  No

  N/A

• The care environment is routinely cleaned in accordance with the Health Facilities Scotland (HFS) National Cleaning Specification:

  Yes

  No

  N/A

COVID-19 Specific

• Staff changing rooms, break rooms and other shared space are clean and tidy, and there is evidence of social distancing measures

  Yes

  No

  N/A

• Enhanced cleaning is undertaken at least at twice daily as per HPS COVID-19: Information and Guidance for Care Homes, Appendix 4 and 5

  Yes

  No

  N/A

Safe Management of Linen

• Clean and used linen is stored separately

  Yes

  No

  N/A

• Used linen is not shaken when removed from beds / trolleys

  Yes

  No

  N/A

• Used linen is not placed on the floor

  Yes

  No

  N/A

• Staff do not carry clean or used linen against their uniforms

  Yes

  No

  N/A

• A laundry receptacle is available at point of use

  Yes

  No

  N/A

• Linen bags are not overfilled

  Yes

  No

  N/A

• Used non infected linen is disposed of in a white linen hamper

  Yes

  No

  N/A

• Soiled / infected linen placed in red water soluble bags / then a clear plastic bag then red linen hamper

  Yes

  No

  N/A

• Is there a safe and appropriate system for laundry? (e.g. correct machine temperature, dissolvable bags for soiled linen)

  Yes

  No

  N/A

COVID-19 Specific

• Confirm that uniform/work wear are not worn to work

  Yes

  No

  N/A

• If staff are taking their uniform/work wear home to wash, do they use disposable/washable bags to transport home?

  Yes

  No

  N/A

Safe Management of Blood & Body Fluid Spillages

• Staff can describe the correct procedure and correct dilution of product or wet/dry blood spillages or where they would find this information, Appendix 7 NIPCM

  Yes

  No

  N/A

• Staff can describe the correct procedure for dealing with urine/vomit/faeces spillage or where they would find this information, Appendix 7 NIPCM

  Yes

  No

  N/A

Safe Disposal of Waste (including Sharps)

• Waste is segregated correctly

  Yes

  No

  N/A

• Waste disposed of at point of use

  Yes

  No

  N/A

• Gelling agent used for suction waste

  Yes

  No

  N/A

• Waste bags are not more than 2/3 full

  Yes

  No

  N/A

• Clinical waste is swan necked, ratchet tied and source identified

  Yes

  No

  N/A

• Waste is stored securely prior to uplift

  Yes

  No

  N/A

• Sharps containers are correctly assembled & labelled with date and name of staff member who assembled container

  Yes

  No

  N/A

• Sharps containers are Free from protruding sharps/not overfilled

  Yes

  No

  N/A

• Sharps containers have temporary closure mechanisms in use

  Yes

  No

  N/A

COVID-19 Specific

• If the care home has a clinical waste contract, there is no need to hold (quarantine) waste for 72 hours

  Yes

  No

  N/A

• If no clinical waste stream all waste items that have been in contact with the individual are disposed of securely within disposable bags. When full, the plastic bag should then be placed in a second bin bag and tied. These bags should be stored in a secure location for 72 hours before being put out for collection

  Yes

  No

  N/A

Occupational Safety: Prevention & Exposure Management, including Sharps

• All staff can describe what to do in the event of blood body fluid exposure

  Yes

  No

  N/A

• Where sharps are in use safety devices should be in place and all staff trained in their use and records kept of training

Standard 7: Insertion and maintenance of invasive devices

• Standard statement: Systems and processes are in place to ensure the safe and effective use of invasive devices, for example, peripheral venous catheters, central venous catheters and urinary catheters

• Rationale: Invasive devices present a significant infection risk to patients. These risks can be minimised by: avoidance of device use where possible
  following evidence-based procedures for insertion and maintenance, and
  removing the device as soon as there is a clinical indication to do so

• Maintenance/insertion bundles are used to ensure best practice for invasive devices i.e. Urinary catheters

  Yes

  No

  N/A

• Bundles are reviewed daily and all elements of bundle for invasive devices completed

  Yes

  No

  N/A

• Staff can describe the care and maintenance of invasive devices

  Yes

  No

  N/A

• Staff aware and competent with asepsis when managing invasive devices

  Yes

  No

  N/A

• Patients given verbal or written information on their invasive devices and this is recorded in patient records

  Yes

  No

  N/A

• Closed system in place for urinary catheters

  Yes

  No

  N/A

• Staff can describe how to obtain CSU using needle free port

  Yes

  No

  N/A

• Urinary catheter bags are above floor level & below waist

  Yes

  No

  N/A

Standard 8: Decontamination

• Standard statement: The environment and equipment (including reusable medical devices used) are clean, maintained and safe for use. Infection risks associated with the built environment are minimised

• Rationale: Effective decontamination is critical in the provision of a safe, clean environment and equipment. The built environment must be designed, planned, constructed, refurbished and maintained to minimise the risk of infection.
  This standard covers the decontamination, management and maintenance of:
  • reusable communal patient care equipment
  • reusable medical devices, and
  • the built environment

• The unit is clean, dust and grit free

  Yes

  No

  N/A

• The unit is free from clutter (floors & work surfaces)

  Yes

  No

  N/A

• Stores are kept off the floor

  Yes

  No

  N/A

• Fixtures and fittings are intact and in good repair

  Yes

  No

  N/A

• A method for recording maintenance issues is available

  Yes

  No

  N/A

• Maintenance team inform all other teams when issues resolved

  Yes

  No

  N/A

• A system is in place to inform the manager of any planned works and that appropriate environmental controls have been taken

  Yes

  No

  N/A

WATER SAFETY

• Evidence/records of water flushing for low useage outlets are available

  Yes

  No

  N/A

COVID-19 Specific

• COVID-19 affected areas should be cleaned at least twice daily paying particular attention to common touch surfaces such as door handles, tablets, mobile phones, light switches, remote controls and bed rails

  Yes

  No

  N/A

Standard 9: Acquisition of equipment

• Standard statement: All equipment acquired for the care environment is safe for use

• Rationale: The infection risk to patients is minimised by having an acquisition process in place that ensures all equipment (including reusable medical devices) is safe for its intended use. Safety refers to minimising the risk of transmission of infection

• Before any purchase / donation of equipment the cleaning & decontamination guidance from manufactures is reviewed

  Yes

  No

  N/A

COVID-19 Specific

• All equipment must be able to tolerate chlorine based products for decontamination

  Yes

  No

  N/A