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Governance and IPC management

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0 of 16 answered

General Management

1.01
Is there a named individual in the practice responsible for oversight of infection prevention and control?
What good looks like Lead person is responsible for ensuring audits are up to date, policy up to date, disseminated info. May be a link nurse/champion
1.02
Is there a named Sepsis link within the practice?
What good looks like There is a national expectation for all practices to have a lead for sepsis awareness. See link to Sepsis Trust in Appendix
1.03
Are infection prevention and control related topics agenda items at staff/business meetings?
What good looks like IPC should be an agenda item for practice meetings and include feedback from HCAI RCA/new and updated guidance/local learning from IPC incidents as appropriate.
1.04
Are there up to date local contact telephone numbers available to obtain advice pertaining to infection prevention and control?
What good looks like Should include UKHSA/CCG numbers/emails.
1.05
Is there evidence that regular IPC audits are undertaken to highlight IPC issues?
What good looks like All practices are encouraged to undertake annual auditing and regular focussed audits inbetween (e.g. hand hygiene, cleaning), see monthly IPC audit in appendix
1.06
Are there local risk assessments which document challenges to provide effective infection prevention?
What good looks like This may be evidenced in local risk register, incident book, Datix, Root Cause Analysis and Action plans developed to address identified risks.

Staff Health

2.01
Staff are offered immunisation in line with current National Guidance/Green book?
What good looks like This may be evidenced in local induction processes for employment
2.02
Is there a policy on staff exclusion from work with regards to infection prevention?
What good looks like Check policies highlight the need to remain off work for 48 hours after resolution of illnesses such as diarrhoea/vomiting/Group A Streptococcal infection.

Staff Training

3.01
Is infection prevention and control included in all staff induction programmes?
What good looks like Check training includes: Hand Hygiene, PPE, Handling & disposal of Sharps, Decontamination of equipment. Management of blood/body fluid spillage, Waste, Specimen Handling
3.02
Is there a process in place to ensure all staff received mandatory training in infection prevention and control in line with local policy and training needs analysis and identify any staff overdue?
What good looks like Training records are available that details Infection prevention and control training and upto date compliance.
3.03
Is Sepsis awareness and management included in mandatory training as applicable to individual staff role?
What good looks like Check training content for details of Sepsis training.

Policies, Procedures and Guidelines

4.01
Are up to date infection prevention and control policies and guidelines available and accessible by staff?
What good looks like Check staff can easily access current versions. Policies should include: Hand hygiene, personal protective equipment, sharps handling and disposal, decontamination of equipment, management of blood/body fluid spillage, waste management.
4.02
Are systems in place to ensure infection prevention is considered prior to purchase of equipment?
What good looks like Purchasing of new equipment should include consideration of effective cleaning (e.g. can be easily disessembled, can withstand cleaning with chlorine)
4.03
Is it clearly defined which staff are responsible for cleaning specific areas and equipment and are these detailed on cleaning schedules?
What good looks like Details of responsibility, method and frequency are available. A sample audit is availble in national cleaning standards, see link in appendix
4.04
Are cleaning processes and outcomes audited regularly and action taken as appropriate?
What good looks like Confirm process including evidence of audit and actions completed.
4.05
If applicable, where there are carpets there is a documented process to ensure they are regularly cleaned?
What good looks like Carpets should be shampooed at a frequency to ensure all edges and corners should be visibly clean with no blood and bodily substances, dust, dirt, debris, or spillages

The other 13 modules

294 further questions, plus room-by-room auditing, the action plan and exports.

SICP 1: Hand hygiene 16
SICP 2: Patient placement and assessment for infection risk 5
SICP 3: PPE (personal protective equipment) 19
SICP 4: Respiratory and cough hygiene 7
SICP 5: Safe disposal of waste, including sharps 24
SICP 6: Safe management of blood and body fluid spillages 8
SICP 7: Safe management of care equipment 24
SICP 8: Safe management of linen, including uniforms and workwear 7
SICP 9: Safe management of sharps and inoculation injuries 8
SICP 10: Safe management of the care environment 10
Environment by room 103
Minor operations suite 47
Specimens, water and ice 16

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