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EVIDENCE
There is an infection prevention and control policy in place which includes:-
1. Procedures
2. Staff training for:-
• Hand washing
• Sharps management
• Waste management
• Decontamination
Contents
Page
Hand Hygiene 2
Environment 4
Disposal of Waste 6
Decontamination 12
1
Hand Hygiene
2
17 There is no bar soap at hand washing
basins in treatment/clinical areas
18 Alcohol hand rub is available at the point
of care as per local and national
standards
19 Clinical staff are encouraged to use hand
moisturisers that are pump operated or
personal use
20 Soft absorbent paper towels are available
at all hand wash sinks
21 There are no re-usable cotton towels
used to dry hands
22 There are no re-usable nailbrushes used
or present at clinical hand wash sinks
23 There is a foot operated bin for waste
towels in close proximity to hand wash
sinks which are fully operational
Additional Comments:
3
Environment
1
http://www.sheffield.nhs.uk/infectioncontrol/resources/commphamracyroomspecles.pdf
2
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4097532
3
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61830
4
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59818
4
All dispensers, holders and all
parts of the surfaces of dispensers
of soap and alcohol gels, paper
towel/couch roll/toilet paper
holders are visibly clean with no
body substances, dust, dirt or
debris or adhesive tape
There is a procedure in place for
regular decontamination of
curtains and blinds where windows
are present
Furniture in patient areas e.g.
chairs and couches are made of
impermeable and washable
materials
Chairs are free from rips and tears
Furniture that cannot be cleaned is
condemned in clinical practice
areas
Tables are tidy and uncluttered to
enable effective cleaning
Medical equipment is cleaned,
maintained and stored
appropriately
Additional Comments:
5
Disposal of Waste
Additional Comments:
6
Spillage and/or Contamination with Blood/Body Fluids
Standard Statement: Body Fluid spillage or contamination is dealt with in a way that
reduces the risk of cross infection.
Yes No N/A Comments
1 The pharmacy has comprehensive
procedures for dealing with body fluid
spillages
2 Systems are in place to ensure body fluid
spillage procedures are available to all
staff
3 Staff are aware of procedures for dealing
with body fluid spillages.
4 Staff who have previously come in
contact5 with spillages (blood and body
fluids) have been successfully
immunised against Hepatitis B
5 All equipment and the environment is
visibly clean with no body substances,
dust dirt or debris
6 Dedicated blood and body fluid spillage
kits6 are available for decontaminating
and cleaning body fluids and are in date.
7 Personal protective equipment is
available (as per spillage kit)
8 Equipment used to clear up body fluid
spillages is disposable or able to be
decontaminated (as per spillage kit)
9 Appropriate disinfectants are available for
cleaning all body fluid spillages, for
example Milton 2% at 1000ppm or
chlorclean
Additional Comments:
5
Green Book advises post exposure vaccination following contamination in eyes, mouth, fresh cuts &
abrasions (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079917)
6
E.g.Wallace Cameron Body Fluid Kit Piccolo Dispenser 1012045 available from NPA
7
Personal Protective Equipment
Additional Comments:
8
Prevention of Blood/Body Fluid Sharps Injuries, Bites and Splashes
9
15 Sharps bins are used for the disposal of
sharps only
16 Needles and syringes are discarded as a
single unit
17 Syringes with a residue of Prescription
Only Medication are disposed of
according to current legislation
18 The temporary closure mechanism is
used when the bin is not in use*
19 Full sharps containers are sealed only
with the integral lock – tape or stickers
are not used
20 Sealed and locked bins are stored in a
locked facility away from public access
21 Sharps containers are available for use
and located within easy reach
22 Sharps containers are visibly clean with
no body substances, dust, dirt or debris
23 Inappropriate re-sheathing of needles
does not occur.
* When not being used immediately the sliding lid on the sharps bin should be kept
closed but not ‘clicked’ locked.
Additional Comments:
10
Safe Storage of Vaccines
11
14 Alternative and appropriate storage is
available in the event of a breakdown or
repair of the vaccine refrigerator
Additional comments:
Decontamination
Standard Statement: Decontamination of re-usable medical instruments will ensure
all such instruments are adequately decontaminated prior to re-use and any
associated risks are managed.
(Obviously syringes and needles used in the administration of flu vaccines will not be re-
used. Furthermore, other medical devices such as CO Monitors, Peak Flow Meters, In-
check dials, etc, must be used with disposable mouthpieces. However, steps should be
taken to ensure that the equipment itself is cleaned effectively and disinfected as
appropriate.)
Additional Comments:
12