Infection Prevention and Control Care Home Audit Guidance Notes

Background The National Infection Control audit tools were originally developed in 2004 primarily for acute trusts. The tools were revised in 2005 to provide a tool relevant to community settings. Criteria/standards within the tool have been developed using a consistent methodology including extensive literature search and expert opinion. They were reviewed again in 2010 and published in 2011 as ‘Quality Improvement Tools’ by the Infection Prevention Society. Link below; improvement-tools/quality-improvement-tools/

Why Audit? Annual audit can assist your home assess compliance with National Infection Prevention and Control standards. Inform future planning for the home. Provides opportunity to recognise good practice and identify poor practice. Good preparation and evidence for CQC inspections. Provides documented evidence that your home has carried out an audit and that you have an action plan in place for any areas of non compliance (required to achieve Level 1 & 2 accreditation).

Audit Tool The audit tool covers a range of areas that include; Hand Hygiene. Environmental cleaning. Decontamination of equipment. Disposal of waste. Dealing with body fluid spillages. Personal Protective Equipment (PPE). Sharps handling. Laundry. Please note this is not an exhaustive list.

Competency The audit tool can be used by: Infection Control Specialists. Trained Audit Personnel. Care Home Managers/Staff. The audits can be undertaken all at once or section by section over time. The time it takes to carry out the audit will depend on the size of your care home.

Auditing Criteria should be marked either ‘yes’ ‘No’ or ‘N/A’. The aim is to achieve a ‘yes’ for each individual standard or question. It is not acceptable to enter an ‘N/A’ response where a national standard must be achieved. These areas are identified on the audit tool by a black square.

Auditing Tips Make sure you fill in each standard as Yes, No or NA. Do not leave any blank. If a standard is not achievable because a facility is absent or a practice is not undertaken then the use of ‘N/A’ is acceptable and say why in the comments section.

Tips Continued…. One tool can be used for the whole home. Allocate enough time to undertake the audit. The comments section should be used to note areas of concern or the rational for scoring it as a Yes/No or N/A. Above all its important to be honest !

Audit Scoring For ease each section can be scored individually. Manual scoring : Add the total number of "Yes" answers. Then divide this figure by the total number of questions answered (include all ‘Yes’ and ‘No’ answers but exclude the ‘N/A’s). Then multiply by 100 to get the percentage score. Formula: Add the total number of yes answers Total number of yes and no responses x 100 = %

Action Planning Your action plan should include all areas of non compliance (all questions marked ‘No’). Set timely but realistic dates for completion. Some may take longer to implement due to environmental limitations and funding required but its important to agree realistic timescales. Discuss action plans as part of team meetings. Prioritise individual sections of the action plan dependant on the associated risk.

Risk Rating Option It is important to prioritise the action plan. A suggestion is to use a risk rated system: Red (urgent requires immediate action). Amber (requires action to be completed within 3 months). Green (requires completed action plan within 12 months).

Contact/Support If you have any questions or would like some support with your audit please contact your local Infection Prevention and Control Nurse.