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Inspection report

Date of Inspection: 3, 14 January 2013
Date of Publication: 7 February 2013
Inspection Report published 7 February 2013 PDF

People should be cared for in a clean environment and protected from the risk of infection (outcome 8)

Not met this standard

We checked that people who use this service

  • Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 3 January 2013 and 14 January 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

People were not cared for in a well cleaned environment and the provider had not taken reasonable steps to ensure that their healthcare workers were protected from infection.

Reasons for our judgement

Effective systems were not in place to adequately reduce the risk and spread of infection.

We found that the provider had a number of written policies and procedures relating to hygiene and infection control. Policies that we reviewed included those for managing spillages, managing waste and also a needle stick injury policy which had been developed by the local general hospital. The doctor leading the service was the nominated infection control lead.

We carried out a visual inspection of the premises and noted that this appeared clean and tidy. We saw some evidence that the clinic made efforts to minimise risk of contamination and infections arising. For example, the clinic used single use equipment items, which were disposed of after use. Antimicrobial hand gels to kill or inhibit the growth of bacteria were also available at reception and throughout the premises.

People we spoke to told us that the provider's premises had appeared clean on each of their visits. One person who had undergone a surgical procedure told us "The room had been prepared immaculately. I was very impressed."

We saw that clinical waste bins and sharps containers were available throughout the premises. Waste was segregated and stored appropriately pending collection from the rear of the building. This meant that staff were following best practice guidelines in regard to waste management.

However the cleaning standards required were not documented and there was no schedule in place at the time of our first visit showing the dates and times that cleaning had taken place. This is a procedure which a provider would normally have in place to demonstrate compliance with criterion 2 of the Health and Social Care Act 2008 code of practice on the prevention and control of infection. The provider did not have a copy of this guidance. At the time of our second visit we were shown a copy of a schedule that recorded the cleaning tasks performed in one room but this did not cover all areas of the building and therefore we did not judge that this was sufficient.

We looked at the cleaner's equipment and supplies and saw that there was only one mop and one mop head available. The staff confirmed that the mop was used for all rooms within the building and had also been used over the recent period by a builder who was undertaking alterations on the premises. As the provider did not have separate, colour-coded mops for the different areas this meant that there was a risk of cross contamination between the areas cleaned.

The manager confirmed to us that no environmental or infection control monitoring was undertaken.

We spoke to the staff on our first visit and the manager on our second visit about the needle stick injury policy. We found that the staff and manager were not clear about what the policy was. The registered manager felt sure that the staff working with needles within the service had received appropriate vaccinations to protect them from Hepatitis B which is a blood borne virus. However the manager could not provide evidence of vaccination or immunity as this was not recorded on staff records. This meant there was a risk that staff were not properly trained and protected against the risk of blood borne infections.