In and OUTPATIENT Full Ward Audit Template May 2015

Infection Prevention and Control Quality Improvement Tools
(Adapted from Infection Prevention and Society Tools)

Inpatient and Outpatient Areas
Ward/Department: Performed by:
Date:
Question Guidance Yes No N/A Comment
1 Infection Prevention and Control Management
Standard: Infection prevention and control is managed effectively, given high priority and seen as an integral part of the overall business
within the ward/department
1.1 Infection Prevention and Control Management - General Management
a Is there a named lead person Ask who the lead person is. This may
responsible for infection prevention and be a link nurse.
control?
b Is Infection Prevention and Control Review job descriptions
outlined in the job description of all
clinical staff?
c Are infection prevention and control Ask for minutes.
related topics agenda items at
staff/business meetings?
d Are there up to date local contact Ask for the list of contact numbers.
telephone numbers available to obtain Check that they are the most up to
advice pertaining to infection prevention date.
and control?
e Is there evidence of a process for Ask to see incident records.
reporting untoward incidents in relation
to infection prevention and control?
f Is there evidence that audits have been Ask to see most recent audit and
undertaken and practice changed to action plan. This must include hand
improve infection prevention and hygiene audits, high impact
control? interventions and patient focused
audits
g Is mandatory surveillance data fed back Check minutes of meetings to ensure
to staff (this relates to MRSA, MSSA surveillance is discussed and action
IPC Annual Audit Tool May 2015

bacteraemias, C.difficile and Surgical site resulting from root cause analysis
surveillance)? document
1.2 Infection Prevention and Control Management - Staff Health
a Do Occupational Health policies require Randomly select 2 members of staff
staff to be offered immunisation in line and ask whether their immunisation
with current national guidance? status has been assessed
b Is there a policy on staff exclusion from Check policy – check staff are aware
work with regards to infection of the need to remain off work for 48
prevention? hours after resolution of illness such
as D&V, Group A Strep
c Are staff aware of the procedure for Ask a member of staff to explain
managing an inoculation contamination procedure
injury?
d Is there a policy/poster available for an Ask to see
inoculation contamination injury?
e Is eye/face protection worn by staff Ask staff to show you where these are
when anticipating contact with blood or kept
bodily fluids with a high risk of splashing
into the face or eyes?
1.3 Infection Prevention and Control Management - Staff Training
a Is infection control included in all staff Check training includes; HH, PPE ,
induction programmes? handling & disposal of sharps,
decontamination of equipment,
management of blood and bodily fluid
spillages, waste specimen handling
b Have staff received mandatory training Check training records detail infection
in infection prevention and control in prevention and control training.
line with local policy and training needs
analysis?
c Is there a process in place to ensure all Ask to see process for follow up of
non-attendees at mandatory training are non-attendees to mandatory training
followed up? program
1.4 Infection Prevention and Control Management - Policies, Procedures and Guidelines
a Are up to date infection prevention and Check staff can access policies and
control policies and staff guidelines that all documents are dated within
available and accessible for staff? the last 2 years. Also check that the
following are included; hand hygiene

ppe, sharps handling and disposal ,
decontamination of equipment,
management of blood and bodily
fluids, waste management
b Are care pathways/care plans Identify a patient with MRSA and
maintained for patients with alert C.diff. Check that a care pathway has
organisms/conditions? been commenced and is accurately up
to date
c Are systems in place to ensure infection Check policy/local procedure for
prevention input is sought prior to purchasing new equipment. Check for
purchase of equipment? evidence that infection prevention
team has been consulted prior to
purchase
d Are there comprehensive written Check cleaning schedules; ensure
cleaning standards and procedures? responsibility for cleaning all areas is
clearly identified
e Are there clearly outlined staff Identify who is responsible for
responsibilities for cleaning dedicated cleaning specific pieces of equipment.
areas/equipment? Check cleaning schedule for details
f Are cleaning processes and outcomes Check audit records and action plans if
audited regularly? non-compliant
g Are up to date cleaning schedules clearly Ask to see the department cleaning
displayed? programme and specifications
2 Environment
Standard: The environment is designed and managed effectively to minimise reservoirs for micro-organisms and reduce the risk of cross
infection to patients, staff and visitors.
2.1 Environment - General environment and fittings
a Is there a designated hand wash basin? Visually check.
b Is the hand wash basin plug free? Check the hand wash basin does not
have a plug.
c Is the hand wash basin overflow free? Check the hand wash basin does NOT
have an overflow.
d Is the waste offset so the water does not Check the water from the tap does
flow directly into it? NOT flow directly into the plug hole.
e Are elbow/sensor taps available? Visually check.
f Are mixer taps or thermostatically Test water temperature.
controlled water available?
g Is the hand wash basin accessible? Check for obstructions e.g.
equipment.
h Is the hand wash basin in a good state of Check there are no cracks or chips.
repair?
i Is the hand wash basin visibly clean? Check plugholes and overflows for
cleanliness &
build-up of lime scale.
j Is hand wash basin free from extraneous e.g. mugs, medicine pots etc.
items?
k Is the soap dispensed from a single use Check cartridge, there should be
cartridge? enough soap for the next two uses.
l Is the liquid soap dispenser wall Check that the soap dispenser is wall
mounted? mounted.
m Is the soap dispenser visibly clean? Check the nozzle for build-up of soap
and debris.
n Are paper towels available from an Paper towels should be soft tissue
enclosed dispenser? with enough in the dispenser for the
next two washes.
o Is the paper towel dispenser visibly Check underside of dispenser.
clean?
p Is there a promotional hand hygiene Check for poster. It should be
poster displayed? laminated, clean and relevant to the
room.
q Is there a hands-free domestic waste bin Visually check.
available for the disposal of paper
towels?
r Is the foot pedal of the domestic waste Check the foot pedal opens the lid.
bin in good working order?
s Is the domestic waste bin visibly clean, Check bins are clean externally and
including lid and pedal? internally.
t Is the domestic waste bin in good Check for rust i.e. underneath lid.
condition?
v Are alcohol based hand rub dispensers Check there is no build up on the
visibly clean? nozzle. The dispenser should be
functioning with enough solution in
the dispenser for the next two uses.
x Is the environment visibly clean? Check walls, windows, ceilings, fans

and light fittings are free from
dust/debris/insects etc.
y Is the environment free from any visible Check for flaking paint, damaged
damage? walls/ceilings/window frames and
surfaces. Check for evidence of action
taken to repair.
z Is furniture made of impermeable and Check furniture.
washable materials?
aa Are all furnishings and fittings visibly Check all areas are clean, behind and
clean? under surfaces.
bb Are all furnishings and fittings in a good Where there is damage, check for
state of repair? evidence of action taken to ensure
repair or replacement.
cc Are all surfaces smooth, impervious (for Check all surfaces.
easy cleaning) and with coved edges?
dd Is the floor visibly clean? Check the edges and corners are
clean and free of dust and grit.
ee Is the floor covering washable and Is the floor covering appropriate for
impervious to moisture? the room.
ff Is the flooring in a good state of repair? Check for rips and tears.
gg Are ward or clinic televisions / display Check up to three.
screens visibly clean?
hh Are computer systems visibly clean? Check up to three.
ii Are all telephones visibly clean? Check receiver.
jj Are free standing/desk fans visibly Check up to three.
clean?
kk Are air vents visibly clean? Check vents are free from dust.
ll Is there a mechanism to ensure that Check records are completed
infrequently used outlets are flushed for
a minimum of three minutes, twice
weekly?
2.2 Environment - Patient Care Areas e.g. Bays and Side Rooms
a Is the environment visibly clean? Check walls, windows, ceilings, fans
b Is the environment free from any visible Check for flaking paint, damaged

taken to repair.
c Is furniture made of impermeable and Check furniture.
washable materials?
d Are all furnishings and fittings visibly Check all areas are clean, behind and
e Are all furnishings and fittings in a good Where there is damage, check for
f Are all surfaces smooth, impervious (for Check all surfaces.
g Is the floor visibly clean? Check the edges and corners are
h Is the floor covering washable and Is the floor covering appropriate for
i Is the flooring in a good state of repair? Check for rips and tears.
j Are there designated hand wash basins? Visually check.
k Are the hand wash basins plug free? Check the hand wash basin does not
have a plug.
l Are the hand wash basins overflow free? Check the hand wash basin does NOT
have an overflow.
m Is the waste offset so the water does not Check the water from the tap does
n Are elbow/sensor taps available? Visually check.
o Are mixer taps or thermostatically Test water temperature.
p Are all hand wash basins accessible? Check for obstructions e.g.
equipment.
q Is the soap dispensed from a single use Check cartridge, there should be
r Is the liquid soap dispenser wall Check that the soap dispenser is wall
mounted? mounted.
s Is the soap dispenser visibly clean? Check the nozzle for build-up of soap
and debris.
t Are paper towels available from an Paper towels should be soft tissue
next two washes.
u Is the paper towel dispenser visibly Check underside of dispenser.
clean?
v Is there a promotional hand hygiene Check for poster. It should be
room.
w Is there a hands-free domestic waste bin Visually check.
towels?
x Is the foot pedal of the domestic waste Check the foot pedal opens the lid.
y Is the domestic waste bin visibly clean, Check bins are clean externally and
z Is the domestic waste bin in good Check for rust i.e. underneath lid.
condition?
aa Alcohol hand rub is available at the point Check this is in reach at each
of care? bed/trolley space or all staff have a
personal supply
bb Are alcohol based hand rub dispensers Check there is no build up on the
cc Are bed and trolley bases, including cot Check three bed spaces/trolleys.
sides, visibly clean and free from dust?
dd Is there evidence of an audit programme Check records
to check the condition of bed
mattresses, couch mattresses and
covers?
ee Is the examination couch cover Check for rips and tears
impervious and washable?
ff Are covers to mattresses/examination Check for rips and tears
couches/tilt tables in a good state of
repair?
gg Do pillows have an impervious cover or Check Records.
are laundered on patient discharge?
hh Are pillows visibly clean and in a good Check couch for rips/tears.
state of repair?
ii Are patient lockers and bed side tables Check three lockers/bed side tables
visibly clean and free from marks?
jj Are bedside entertainment systems Check for rips/tears
visibly clean?
kk Are bedside entertainment systems Check if pillow is visibly soiled.
cleaned every week and between
patients?
ll Are the ear phones for the bedside Check visually for staining and
entertainment systems replaced damage.
between patients?
mm Are patient call bells visibly clean? Check a minimum of three sets.
nn Are curtains/blinds visibly clean? Check documentation.
oo Is there a cleaning SOP in the patient’s Check case notes to locate cleaning
notes? SOP to suggest that the bed space was
adequately cleaned prior to admission
2.3 Environment - Bathroom/Shower Rooms
taken to repair.
c Are all bathroom fixtures and fittings Check all areas are clean, behind and
visibly clean? under surfaces.
d Are all fixtures and fittings in a good Where there is damage, check for
e Are all surfaces smooth, impervious (for Check all surfaces.
f Is the floor visibly clean? Check the edges and corners are
g Is the floor covering washable and Is the floor covering appropriate for
h Is the flooring in a good state of repair? Check for rips and tears.
i Is there a designated hand wash basins? Visually check.
j Is the hand wash basins plug free? Check the hand wash basin does not
have a plug.

k Is the hand wash basin overflow free? Check the hand wash basin does NOT
have an overflow.
l Is the waste offset so the water does not Check the water from the tap does
m Are elbow/sensor taps available? Visually check.
n Are mixer taps or thermostatically Test water temperature.
o Is the hand wash basin accessible? Check for obstructions e.g.
equipment.
p Is the soap dispensed from a single use Check cartridge, there should be
q Is the liquid soap dispenser wall Check that the soap dispenser is wall
mounted? mounted.
r Is the soap dispenser visibly clean? Check the nozzle for build-up of soap
and debris.
s Are paper towels available from an Paper towels should be soft tissue
next two washes.
t Is the paper towel dispenser visibly Check underside of dispenser.
clean?
u Is there a promotional hand hygiene Check for poster. It should be
room.
v Is there a hands-free domestic waste bin Visually check.
towels?
w Is the foot pedal of the domestic waste Check the foot pedal opens the lid.
x Is the domestic waste bin visibly clean, Check bins are clean externally and
y Is the domestic waste bin in good Check for rust i.e. underneath lid.
condition?
z Are all toiletries single use? Check for evidence of communal
toiletries in bathroom.
aa Are bathrooms free from inappropriate Check bathroom not being used for
items? storing e.g. mattresses
bb Are baths/showers visibly clean? Visually check

cc Are shower curtains visibly clean? Check for mould
dd Are anti-slip bath/shower mats visibly Check underneath mat for mould.
clean, dry and free from mould?
ee Are hoists visibly clean and in a good Visually check.
state of repair?
2.4 Environment - Toilets
taken to repair.
c Are all fixtures and fittings visibly clean? Check all areas are clean, behind and
under surfaces.
i Is there a designated hand wash basin? Visually check.
j Is the hand wash basin plug free? Check the hand wash basin does not
have a plug.
have an overflow.

equipment.
mounted? mounted.
and debris.
next two washes.
clean?
room.
towels?
condition?
z Are toilet(s) visibly clean? Check underneath the toilet seat.
aa Are the toilet(s) in a good state of Check for damage.
repair?
bb Is there a mechanism to ensure that Check for supply of detergent wipes
toilet cleaning can be carried out as or other cleaner.
needed?
cc Are toilet brushes and holders visibly Are toilet brushes and holders visibly
clean? clean?
dd Are toilets free from inappropriate Check for items that are not used in a
items? toilet.
ee Are raised toilet seats visibly clean and Check underneath the raised seat.
stored off the floor?
2.5 Environment - Sluice/Dirty Utility
taken to repair.
c Are all furnishings and fittings visibly Check all areas are clean, behind and
d Are all furnishings and fittings in a good Where there is damage, check for
hi Is the flooring in a good state of repair? Check for rips and tears.
i Are there designated hand wash basins? Visually check.
have a plug.
have an overflow.
o Are all hand wash basins accessible? Check for obstructions e.g.
equipment.
p Is there a designated deep sink for Visually check
washing used equipment?
q Are cleaning/disinfectant products Are cleaning/disinfectant products
available? available
r Can staff describe which products should Can staff describe which products
be used for cleaning and disinfection? should
s Is there a disposal unit available to Visually check
dispose bodily fluids?
t Are re-usable bedpans and urinals Check for a washer disinfector to
processed through a washer disinfector? process bedpans/urinals
u Are bedpans and urinals visibly clean? Visually check
v Is the bedpan washer or macerator Visually check
visibly clean?
w Is the macerator or bedpan washer in Check macerator is working correctly
good working order? by closing the lid, applying water
(enough to cover seal. Start machine
and check for air bubbles rising from
the seal or small splashes. – CHECK
MANUFACTURER’S INSTRUCTIONS /
USE EYE PROTECTION
x Is the washer disinfector tested and Check documentation available
maintained in line with HTM 2030 or
equivalent?
y Are bedpans and urinals stored Visual check
inverted?
z Is the rack visibly clean and in good Visually check
condition?
aa Are commodes in good state of repair? Check for rust, damage and dirt
bb Are commodes visibly clean and ready Check underneath the seat,
for use? underside, frame, footrest and check
that green tape is applied over the
arms
cc Is the room free from communal items? Check for creams flannels,
dd Are re-usable catheter stands of an easy Check stands
cleanable design?
ee Are catheter stands visibly clean? Check stands
ff Are measuring jugs either disposable or Check for disposable jugs /washer
processed through a washer disinfector? disinfectors
gg Is there a hands free waste bin available Visually check
for the disposal of infectious/healthcare
risk waste?
hh Is the foot pedal of the Check the foot pedal opens the lid
infectious/healthcare
risk waste bin in good working order?
ii Is the infectious/healthcare risk waste Check the bins are clean internally and
bin visibly clean, including lid and pedal? externally
jj Is the infectious/healthcare risk waste Check for rust i.e. underneath lid
bin in good condition?
kk Are staff aware of the procedure for Are staff aware of the procedures to
dealing with spillages of blood and other be
bodily fluids?
ll Is personal protective equipment Check for gloves, aprons and eye
available? protection
mm Are alcohol based hand rub dispensers Check there is no build up on the
2.6 Environment - Clean Utility
taken to repair.
i Is there a designated hand wash basin? Visually check.
have a plug.
have an overflow.
equipment.
mounted? mounted.
and debris.
next two washes.
clean?
room.
towels?
condition?
z Are alcohol based hand rub dispensers Check there is no build up on the
aa Is there sufficient storage space? Check visually

bb Are all shelves and cupboards visibly Check visually
clean?
cc Are all items stored above floor level? Check visually
dd Is the drug refrigerator used to store Check visually
drugs only?
2.7 Environment - Store Room
taken to repair.
c Are all fixtures and fittings visibly clean? Check all areas are clean, behind and
under surfaces.
i Is there sufficient storage space? Check visually
j Are all shelves and cupboards visibly Check visually
clean?
k Are all items stored above floor level? Check visually
2.8 Environment - Domestics Cupboard
taken to repair.
i Are there designated hand wash basins? Visually check.
have a plug.
have an overflow.
o Are all hand wash basins accessible? Check for obstructions e.g.
equipment.
p Is there a disposal unit for the disposal Visual check
of contaminated water?
q Are mops and buckets stored clean and Check storage and cleanliness of mops
dry? and buckets
r Are detachable mop wringers removed Remove and check underneath
and cleaned daily?
s Are mop heads laundered or disposable? Check policy for frequency of changes
t Is there a colour coding system in place Check cleaning products are colour
for cleaning equipment? coded and posters are displayed
u Are cleaning cloths laundered or Observe practice
disposable?

v The area is free from inappropriate Check for nurses equipment, food,
items? clothing
w Is cleaning equipment and machinery Visually check
left clean and dry after use?
x The domestic trolley is clean and in a Visual check
good state of repair?
y The domestic trolley is free of Visual check
inappropriate items?
2.9 Environment - Linen Management
taken to repair.
c Are all surfaces smooth, impervious (for Check all surfaces.
d Is the floor visibly clean? Check the edges and corners are
e Is the floor covering washable and Is the floor covering appropriate for
f Is the flooring in a good state of repair? Check for rips and tears.
g Is there a designated clean store for Check for linen in sluice or bathroom
linen? and also no inappropriate items
h Is linen all stored off the floor? Visual check
i Is the area /room used to store clean Check linen room for inappropriate
linen free from inappropriate items? equipment – Christmas tree, hair
dressing equipment etc.
j If trolleys are used for the transportation Check trolleys
of linen for bed making, are they stored
clean and empty after use?
k Is linen used placed directly into Observe practice or ask a member of
appropriate colour coded bags at the staff
point of use?
l Are water soluble bags used for soiled Observe practice ask staff to describe
and/or infected linen?
m Are used linen bags /containers less than Check linen bags
2/3rds full?
n Are linen skips visibly clean? Visual check
o Is linen stored in a designated area until Ask member of staff which room is
collection e.g. sluice/dirty room? used to store dirty linen
p Do staff wear disposable gloves and Observe practice or ask a member of
aprons when handling soiled linen? staff to describe
3. Patient Equipment Standard:
All patient equipment is cleaned and maintained appropriately to prevent cross infection.
3.1 Patient Equipment
a Is all equipment detailed on a cleaning Ask to see cleaning schedule and
schedule? check it is comprehensive. Is all
equipment documented?
b Are schedules completed, signed and up Check schedules are completed,
to date with frequencies and signed and up to date.
responsibilities identified?
c Are items sent for service, inspection or Ask to see the form used to mark
repair, appropriately cleaned and/or items being sent for service,
disinfected, and a label of contamination inspection or repair.
status attached?
d Is loaned equipment decontaminated Ask staff to describe the process.
prior to use unless received from an
accredited sterile services
department/unit?
e Are sterile products stored above floor? Check store/clean utility/treatment

etc.
f Are sterile packs sealed and Check a selection of packs.
undamaged?
g Are all sterile items in date? Check a selection of items.
h Can staff describe the symbol used to Ask a member of staff to describe the
indicate single use? symbol.
i Single use items are not reprocessed but Observe for single use items such as
disposed of following each use? catheter bags, syringes, thermometer
probes, scissors, opened dressings
j Are all re-usable instruments returned Check laryngoscope blades, handles,

to a sterile services provider for supra glottis airways.
decontamination?
k Are cleaning products available for Check against local policy/guidelines.
routine cleaning of equipment? Check availability, for example look in
dirty utility rooms.
3.2 Equipment – Mobile Equipment
a Is mobile equipment such as drug Inspect during audit.
trolleys, notes trolleys, mobile X-Rays,
ultrasound equipment visibly clean?
b Is there a system to routinely clean Check record system.
mobile equipment and is this
monitored?
3.3 Equipment - Monitoring and Physiological Equipment
a Is all equipment in a good state of Check for evidence of the
repair? repair/replacement of damaged or
broken equipment.
b Is blood pressure monitoring equipment Check there is no sticky tape or other
visibly clean? attachments which prevents effective
cleaning.
c Are all stethoscopes visibly clean? Check for body substances, dust, dirt,
debris or adhesive tape.
d Is blood glucose monitoring equipment Check for body substances, dust, dirt,
visibly clean? debris or adhesive tape.
e Is all equipment routinely cleaned Observe practice or ask a member of
between every patient with general staff to describe procedure.
purpose detergent or as per local e.g. Tristel fuse for infection
policy/manufacturer’s instructions
where this differs?
f Are IV stands/pumps visibly clean? Inspect up to three.
g Are monitoring leads/straps Check three.
decontaminated between patients?
h Are tourniquets single use or Visually check/ask staff
decontaminated between use?
3.4 Equipment – Resuscitation Equipment
a Are items on the resuscitation trolley Check three items on the trolley.
visibly clean?
b Is resuscitation equipment either single Check laryngoscope blades,
use or reprocessed through a sterile ambubags, face masks.
services provider?
3.5 Equipment – Respiratory Equipment
a Are non-invasive positive pressure Observe practice or ask a member of
ventilation (NIPV) masks single patient staff to describe procedure.
use or reprocessed through a sterile
services provider between patients?
b Are head straps for NIPV visibly clean? Visually check.
c Is the suction machine visibly clean and Check.
dry?
d Are nebulisers stored clean and dry Check they are cleaned as per
between use? manufacturer’s instructions or local
guidelines.
e Are nebuliser kits changed every 24 Ask a member of staff to confirm what
hours? the local policy is
f Are disposable suction liners used and Observe practice or ask a member of
changed between patients? staff to describe procedure
3.6 Equipment – Moving and Handling Equipment
a Is manual handling equipment stored Check there are none stored in an
appropriately? inappropriate areas such as sluice or
bathroom
b Are manual handling slings/sheets single Inspect in use slings/question staff
use or laundered after use?
c Are hoists visibly clean and in a good Visually check
state of repair?
d Are PAT (Patient Assisted Transfer) Visually check.
slides stored off the floor?
3.7 Equipment – Specialist Equipment
a Are slings/splints e.g. Bradford single Check 2
use or centrally laundered between each
patient use?
b Are cryo cuffs single patient use or Observe practice or ask a member of
decontaminated between patients? staff to describe procedure.
c Is gym equipment e.g. wobble boards, Visually check
balls, exercise bikes visibly clean and of
an easily cleanable design?

d Are continence aids such as electro Observe practice or ask a member of
muscle graph and vaginal pressure staff to describe procedure.
electrodes single use or reusable and
centrally decontaminated?
e Are bladder scanners visibly clean? Check there is a procedure in place
to ensure bladder scanners are
cleaned between patients.
3.8 Equipment – Stored Equipment
a Is stored patient equipment e.g. IV Inspect stored equipment, check
stands, pumps, mattresses, bariatric identification system to flag clean for
equipment visibly clean ready for use use
and identified as such?
3.9 Equipment - Miscellaneous Equipment

a Are aids such as walking sticks, Zimmer Check two.
frames, helping hands visibly clean and
stored in a suitable area?
b Are wheelchairs visibly clean and in a Visually check cleanliness and
good state of repair? damage.
c In paediatric areas are toys visibly clean? Check a selection of toys.
d Are toys made of a material that is easily Check toys

cleaned?
4 Waste
Standard: Waste is managed safely and in accordance with legislation so as to minimise the risk of infection or injury to residents, staff and
the public.
a Are separate waste streams available in Check that different coloured bags are
accordance with local guidelines? available e.g. for offensive and
infectious/healthcare waste
b Staff are appropriately segregating Visually check the contents of the
waste? different waste streams
c Are waste bags capable of being Check bags are no more than two
securely tied? thirds full
d Are infectious/healthcare risk waste Observe practice
bags labelled before storage and
disposal?
e Is infectious/ healthcare risk waste Check waste is stored separately –
stored separately to domestic waste in a describe process
secure designated facility/area?
f Is offensive waste stored separately to Check waste is stored separately and
domestic waste in a secure designated it is locked
storage facility/area?
5 Isolation Precautions
Standard: Evidence based best practice is being consistently applied to prevent transmission of infection
a Are patients in contact isolation in a Identify all patients on contact
single room or appropriate cohort? precautions. A cohort must consist of
patients with the same diagnosed
infection.
b If a single room is not available and a Check documentation
cohort is not feasible is there a
documented risk assessment of the
patient?
c Does the room/bay have doors that can Visual check
be closed to separate it from other
patients?
d Are staff/visitors made aware of any Check for notice on door indicating
additional precautionary measures? that contact precautions are in place.
e Is personal protective equipment Check for aprons/gowns and gloves
available to staff before they enter the outside room
room?
f Are hand hygiene facilities available and Check all patients on contact
accessible within and outside the room? precautions For cohorts: 1 hand wash
basin per room (4 beds in acute
settings) and alcohol hand rub at the
point of care i.e. on the bed or
personal dispenser.
g Is a dedicated/en-suite toilet facility or Check all patients on contact
an allocated commode available for use precautions.
by the patient?
h Is reusable equipment dedicated for the Check equipment e.g. hoist sling,
patient’s use? monitoring equipment etc.
i Is personal protective equipment worn Check that staff are wearing gloves
when in contact with the patient or their and aprons/gowns.
immediate environment?
j Is personal protective equipment Observe staff members leaving a
removed and disposed of in the room? contact precautions area.
k Is hand hygiene performed after removal Observe staff members leaving a
of personal protective equipment and contact precautions area. Moment 5
prior to leaving the room? - after contact with patient
surroundings
l Is the patient aware of the rationale for Check all patients/residents on
their placement on contact precautions? contact precautions.
m Is the patient and or relative provided Check for leaflets e.g. MRSA,
with a relevant information leaflet Clostridium difficile, Norovirus.
where available?
n Is the patient environment cleaned daily Check local policy for appropriate
with a suitable detergent and/or cleaning agent.
disinfectant?
Twice daily if CPE positive
o Is separate colour coded cleaning Check local policy for colour coding.
equipment in use for contact
precautions areas/rooms?
p Is an assessment of the ongoing need for Review patient/resident records.
contact precautions made daily and this
documented?
6 Personal Protective Equipment
Standard: Protective clothing is available and worn for all aspects of care which may involve contact with blood or body fluids or where
asepsis is required
a Are single use plastic aprons available? Check they are readily available
b Are plastic aprons stored appropriately E.g. – not stored in dirty utility
away from risk of contamination?
c Are single use aprons worn when in Observe practice or ask a staff
contact or anticipated contact with member
bodily fluids or contaminated items or
significant physical contact?
d Are single use aprons changed between Observe practice
patients?
e Are aprons changed between each Check apron is changed when moving
episode of care on the same patient? from dirty procedure to clean
f Range of sterile and none sterile gloves Check gloves are readily available and
available? have to CE mark
g Gloves worn for any invasive procedure? Observe practice e.g. insertion of
catheter. Check HIIs
h Are gloves worn when in contact or Observe practice
anticipated contact with bodily fluids or
contaminated items?
i Hand hygiene performed following glove Check gloves are not worn when
removal? handling records, answering phones,
using computers.
7 Sharps Safety
Standard: Sharps are managed safely to reduce the risk of inoculation injury.
a Are sharps containers assembled Check bins
correctly?
b Are sharps containers labelled with date Visual check
and signature?
c Are all sharps bins free from protruding Visual check
sharps?
d Are the contents off all sharps Visual check
containers below the “fill line”?
e All sharps containers have the Visual check
temporary closure mechanism in place?
f Are used sharps disposed of without re Observe practice / ask member of
sheathing? staff
g Are sharps disposed of at the point of Observe practice or ask a member of
use? staff to describe procedure – are bins
compatible with trays
h Has training been provided where Ask member of staff to explain how
needle safe devices are in use? needle safe works
i Are locked containers stored in a secure Check sharps awaiting collection
facility away from public access until
collected for disposal?
j Are sharps containers safely positioned Check bins are not stored in an open
out of reach of vulnerable people? access area and are positioned at a
safe height.

8 Food Hygiene
a Are water coolers/ice machines on a Visual check
portable supply e.g. mains or treated
water supply?
b Is the water cooler/ice making machine Ask a member of staff about practice,
cleaned at least once a week according check local
to the manufacturer`s instructions? instructions.
c Is the water cooler/ice machine on a Ask for evidence (written).
planned maintenance programme?
d If used for consumption, does the ice Check that it`s not dispensed into a
making machine dispense ice from a storage container.
nozzle directly into a receptacle on
demand?
e The refrigerator checklist is up to date Observe that this is being completed
and accurate? daily and that the fridge temperature
reflects the temperature recorded
f All items of equipment stored in the Visual check
kitchen are appropriate?
h Kitchen cupboards are clean and well Visual check
maintained?
i All opened food (e.g. cereals) are stored Visual check
in pest proof containers?
j The microwave oven is clean and well Visual check
maintained?
k Cleaning materials are colour coded and Visual check
the correct colour is in use? Ask staff
l Hands are washed immediately prior to Observe practice
serving meals? Ask staff
m Clean pink plastic apron is worn for Observe practice
giving out meals and assisting with Ask staff
feeding?
Total
Number YES

Number of elements – Number of N/As x 100

In and OUTPATIENT Full Ward Audit Template May 2015

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In and OUTPATIENT Full Ward Audit Template May 2015

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Infection Prevention and Control Quality Improvement Tools

(Adapted from Infection Prevention and Society Tools)

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

e Are sterile products stored above floor? Check store/clean utility/treatment

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

3.9 Equipment - Miscellaneous Equipment

d Are toys made of a material that is easily Check toys

IPC Annual Audit Tool May 2015

IPC Annual Audit Tool May 2015

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