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Inspection report

Date of Inspection: 29 January 2013
Date of Publication: 26 April 2013
Inspection Report published 26 April 2013 PDF | 82.03 KB

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

Meeting 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 29 January 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

Our judgement

People were cared for in a clean, hygienic environment.

People were protected from the risk of infection because appropriate guidance had been followed.

Reasons for our judgement

There were effective systems in place to reduce the risk and spread of infection. The practice had two decontamination areas which we observed were staffed by a dedicated decontamination nurse. The nurses told us that they had all had cross infection training annually last done in March 2012, of which we saw the documented evidence. All the staff were wearing protective clothing which we noted was changed when they were in non clinical areas. We saw PPE readily available.

We saw evidence of the updated cross infection policy with a named lead and the practice manager showed us evidence of the quarterly cross infection audits the last January 2013. The improvements that have taken place have increased the compliance from 86.5% to 96%.

The practice manager told us that they had a Legionella risk assessment which showed the practice was fully compliant. The nurses told us that they flushed the water lines between each patient and at the start of every session. A chemical was used in the water that supplies the headpieces.

We noted that the waste was segregated appropriately and that instruments were transported in lockable containers.

We saw evidence of the maintenance of the autoclaves, July 2012 and the daily logs kept of each cycle of sterilisation undertaken. We saw that instruments are kept in dated pouches which are checked weekly there is a documented procedure for the rotation of instruments.

We saw the sharps injury policy and noted that two incidents by trainee nurses were dealt with in the appropriate way. We saw evidence of staff immunisation for Hepatitis B.

There are daily documented check lists for each surgery which are signed and dated.

The cleaning of the practice follows national guidelines and we saw evidence of this in place. Cleaning materials are kept in a dedicated cupboard.The patients told us they thought the practice was 'very clean'.