Hand hygiene Audit Tool for General Practice

NOTES:
 This audit tool should be used as a monthly rolling programme of audit of compliance with your ‘Hand hygiene * Staff should be ‘Bare Below the Elbows’
Policy’. All staff should be assessed for hand hygiene technique on at least an annual basis. (BBE) when delivering direct care to
residents. BBE is being free from long-
 All columns should be completed.
Action

sleeved clothing, wrist and hand jewellery

 During clinical situations, where possible, staff should be observed undertaking ‘Key Moments’ – see overleaf. (other than one plain band ring). Long
 During non-clinical situations, e.g. assessing hand hygiene technique after a team meeting, tick N/A in the sleeves, if worn, should be rolled or pushed
up to the elbows. Finger nails should be
‘Key Moments’ column. short and clean, no nail varnish, false or
 In the event of non-compliance, action plans should be produced and reviewed regularly. acrylic nails, nail extensions or nail jewellery.
 Completed audit tools should be kept locally for good practice assurance and as evidence for CQC **Refer to the ‘Hand hygiene technique for
inspections. staff’ poster overleaf.

Auditor Practice Name Date

‘Key Moments’ The correct hand Paper towels are

Staff are ‘Bare Cuts and grazes
Was the opportunity hygiene technique disposed of without
Observation Staff member being observed taken to clean their
Below the are covered with a
is used when touching the waste
Elbows’* waterproof plaster
hands at each moment cleaning hands** bin lid
No. 1 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

No. 2 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

No. 3 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

No. 4 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

No. 5 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

No. 6 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

No. 7 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

No. 8 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

No. 9 Yes  No  N/A  Yes  No  Yes  No  Yes  No  Yes  No 

Yes  No  N/A 
No. 10 Yes  No  Yes  No  Yes  No  Yes  No 

Community Infection Prevention and Control, Harrogate and District NHS Foundation Trust Version 2.00 November 2021 © Harrogate and District NHS Foundation Trust
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 KEY MOMENTS FOR HAND HYGIENE

Your 5 moments for hand hygiene at the point of care

WHEN? Clean your hands before touching a patient when

BEFORE
approaching him/her.
1 PATIENT
WHY? To protect the patient against harmful germs carried
CONTACT
on your hands.
WHEN? Clean your hands immediately before any
BEFORE A
clean/aseptic procedure.
2 CLEAN/ASEPTIC
WHY? To protect the patient against harmful germs,
PROCEDURE
including the patient’s own, from entering his/her body.
WHEN? Clean your hands immediately after an exposure
AFTER BODY
risk to body fluids (and after glove removal).
3 FLUID
WHY? To protect yourself and the healthcare environment
EXPOSURE RISK
from harmful patient germs.
WHEN? Clean your hands after touching a patient and
her/his immediate surroundings, when leaving the patient’s
AFTER PATIENT
4 CONTACT
side.
WHY? To protect yourself and the healthcare environment
from harmful patient germs.
WHEN? Clean your hands after touching any object or
AFTER
furniture in the patient’s immediate surroundings when
CONTACT WITH
5 PATIENT
leaving—even if the patient has not been touched.
WHY? To protect yourself and the healthcare environment
SURROUNDINGS
from harmful patient germs.

Community Infection Prevention and Control, Harrogate and District NHS Foundation Trust Version 2.00 November 2021 © Harrogate and District NHS Foundation Trust
Page 2 of 2