Care/Nursing Home

Infection Prevention and Control

Self-Audit Tool

Prepared on behalf of BNSSG CCG by:

Karen Oliveira l RN/RM/NMP l PGCert, BSc, ILM, TD l BNSSG CCG - Nurse Advisor Health Protection & IPC Cell
Name of Care/Nursing Home Manager Date of Audit

Provider/Proprietor Name of Auditor/Position Review Date of Audit

Reason for Audit CCG Private/Local Authority

Contents

Section Standard Page Number

2
 1 The environment must be maintained appropriately to reduce and 6
minimise the risk of cross infection.

2 Hands will be decontaminated correctly and in a timely manner, to

reduce the risk of cross infection. 21
As a minimum a handwash basin, wall mounted liquid soap dispenser
and wall mounted disposable paper towels dispenser must be provided
in each resident’s room for use by health and social care professionals,
carers and relatives.
This provision must also extend to toilets, sluices, treatment rooms,
laundry and kitchen areas.
Alcohol rub must also be available to care staff and visitors and
positioned in appropriate areas.

3 Personal Protective Equipment (PPE) is readily available for staff to use

throughout the home.
All care staff and health care workers don PPR appropriately when 26
undertaking care.

4 The safe management and disposal of sharps.

All staff must be aware of what to do in the event of a sharps and 28
needle stick injury, (inoculation).

5 All waste will be handled and disposed of appropriately in line with 31

3
 current legislation.

6 Decontamination of all equipment. The risks associated with

decontamination facilities and process are adequately managed. 33
Decontamination of equipment must be undertaken in accordance with
manufacturers’ instructions.

7 Clinical practices should be evidence based and performance following

training and in-line local policy standards. Staff should follow current 37
standard infection prevention and control guidance.

8 Quality assurance ensuring there are robust systems and procedures 42

in place for Infection Prevention and Control.

4
 Introduction

Audit is a requirement of the Health and Social Care Act 2008, code of practice for registered providers on the
prevention and control of health care associated infections and related guidance, which states that registered
providers must audit compliance against key infection prevention and control policies and procedures. Ideally, for
quality and assurance purposes registered care/nursing homes providers should complete an IPC audit
annually.

Homes may also be asked to undertake an IPC audit if they have had two residents within the care/nursing
home with the same infection.

This audit is based on the Department of health (2006) IPC audit tool and adapted from the Community
Healthcare Audit published by Leeds Community Health. When completed the care-nursing home will gain an
overall perspective of any IP&C issues that may need to be addressed.

Self-assess against each of the standards by entering Yes, No or N/A in the appropriate box for the whole of the
audit. You can also add any comments you may have in the end column against each standard.

There is an easy to use scoring system which enables you to highlight the percentage risk for each standard.

How to work out the percentage of each standard:

85% or above Compliant Low Risk

76-84% Partial Compliance Medium Risk
75% or below Minimal Compliance High Risk

Once the audit is completed then an action plan can be formed and progress monitored.

5
Standard 1:
The environment must be maintained appropriately to reduce and minimise the risk of cross infection.

General Environment
Reception; Lounge and Dining areas; Communal bathrooms, YES NO N/A NOTES
Toilets, Residents rooms & en-suites, Sluice, Domestic house
keeper; Laundry; Pets.

REF
1.1 Communal and residents’ rooms are free from unpleasant
smells-mal-odours

1.2 The general environment is clean and free from dust

1.3 Curtains and blinds are free from stains, dust and
cobwebs

1.4 Curtains
There is a cleaning programme in place for regular
decontamination for all curtains and blinds (evidence of
signing sheet)

1.5 Carpets
Carpeted areas are clean and in a good state of repair

1.6 There is a robust cleaning programme in place for the

6
 system cleaning of carpets in both communal and
residents’ rooms (evidence of frequency is documented)

1.7 Furniture
The furniture is in a good state of repair and is free from
rips and tears

1.8 Furniture in residents’ areas, e.g. chairs and settees, are

made of impermeable and washable materials

1.9 There is a cleaning programme in place for regular

decontamination of furniture (evidence of frequency is
documented)

7
Clinical Room-Treatment Room
(Medicines Room) YES NO N/A NOTES

Ref
1.10 There is an identified area for the storage of clean and
sterile equipment

1.11 All items of sterile equipment are in date and intact

(Randomly check two items)

1.12 Dressing trolleys are clean and in a good state of repair

1.13 Suction unit is clean and dry

1.14
Staff are able to recognise the single use symbol

1.15 Single-use items are not re-used or re-processed

1.16 The ventilation is suitable and appropriate for the room

1.17 Hand hygiene facilities are available in the clinical room

1.18 Impervious flooring including edges and corners are free

from dust and grit

1.19 All high and low surfaces are free from dust and cobwebs

8
1.20 Shelves, bench tops and cupboards are free from clutter
and clean inside and out, and are free from dust and
spillage

1.21 All products and items are stored above floor level

9
Bathrooms
YES NO N/A NOTES
Ref
1.22 Bathrooms/Washrooms are clean

1.23 There is no evidence off inappropriate storage of

communal items e.g. single -use creams, talcum powder,
flannels

1.24 Anti-slip bath/shower mats are clean and hungover the

bath-rail to dry between use

1.25 Lifting aids are waterproof, easy to clean and

appropriately maintained e.g. check underneath bath
seats-slings

1.26 Slings are single resident use or cleaned between each

patient

1.27 Slings contaminated with bodily fluid are laundered

immediately

1.28 The mechanical hoist is clean and in a good state of repair

1.29 Bathrooms are not used for equipment storage

1.30 Baths, sinks and accessories are clean

10
1.31 Appropriate cleaning materials are available to clean the
bath after use

1.32 Wall tiles and all fixtures (including soap dispensers and
towel holders) are lcean, free from mould and intact

1.33 Shower curtains are subject to a cleaning programme and

are clean and free from mould

1.34 To reduce the risk of legionella growth there is

documented evidence that baths, showers and sinks that
are taken out of use have planned provision for weekly
running of water

1.35 Floors including edges and corners are free from dust and
grit

11
Toilets
YES NO N/A NOTES
Ref
1.36 Hand washing facilities in communal toilets have only, wall
mounted liquid soap and paper towel dispensers (no. bars of
soap or fabric towels or nail brushes)

1.37 A poster demonstrating the correct hand washing technique

is above all communal hand wash facilities

1.38 There is sufficient odour control

1.39 Flooring is impervious and sealed including edges and

corners and re free of dust and grit

1.40 Toilet tissue is dispensed from a sealed tissue dispenser

1.41 Hand washing facilities in residents own toilet (en-suite) have

wall mounted liquid soap and paper towels dispensers for
care workers to decontaminate hands at the point of care

1.42 In each toilet area the bin must be a foot operated pedal bin
for disposal of paper towels lined with a domestic waste bag

1.43 In communal toilets there is a facility for sanitary waste

12
 disposal with an appropriately coloured bag (offensive
waste/clinical waste) and must be foot operated pedal bin

1.44 All toilets are visibly clean with no body fluid contamination,
lime scale stains etc

13
Sluice
YES NO N/A NOTES
Ref
1.45 A dirty utility area is available

1.46 A separate sink is available for decontamination of patient

equipment

1.47 A sluice hopper is available for disposal of body fluids

1.48 The integrity of fixtures and fittings ae intact

1.49 Separate hand washing facilities are available including

liquid soap and paper towels

1.50 The room is clean and free from inappropriate items

1.51 The floor is clean and free from spillages

1.52 Floors including edges and corners are free of dust and grit

1.53 Cleaning equipment is colour coded

Wash bowls are stored clean and dry and inverted on a rack
1.54 or stored clean and dry in the resident’s room (for their own

14
 use only)

1.55 Bed pans, commode buckets, urinals and jugs are stored on
inverted racks

1.56 Commodes are visibly clean and cleaned after each use

1.57 Commodes and commode frames are in a good state of

repair and are subject to a weekly cleaning programme with
between patient use during outbreak situations.

1.58 Appropriate facilities are available and are clean and in

working order to ensure correct disposal or disinfection of
bed pans and urinals (macerator and/or washer disinfector)

1.59 Shelves and cupboards are clean inside and out and free of
dust, litter or stains

15
Domestic House-keeping) Room YES NO N/A NOTES

Ref
1.60 There is a robust cleaning programme schedule in place for
the regular decontamination throughout the establishment
(documented evidence) e.g. policy

1.61 Equipment used by the domestic is clean, well maintained

and stored in a locked area in accordance with COSHH
regulations

1.62 Information on the colour coding system in use is available in

the domestics’ room

1.63 Personal protective equipment is available and appropriately

used by house-keeping staff (gloves and aprons, masks
when indicated

1.64 Products used for cleaning and disinfection comply with

policy and are used at the correct dilution

1.65 Cleaning agents are stored in clearly marked containers

1.66 Disposable cloths are colour coded

1.67 Machines used for floor cleaning are clean and dry

1.68 Colour coded buckets and mops are stored dry and inverted
16
1.69 The room has no inappropriate materials or equipment
stored

17
Laundry YES NO N/A NOTES

Ref
1.70 Laundry facilities are sited so that soiled articles, clothing
and infected linen are not carried through the areas where
food is stored, prepared, cooked or eaten and do not intrude
on other service users

1.71 The laundry floor finishes are impermeable and the wall
finishes are readily cleanable

1.72 Linen is segregated in appropriate categories

1.73 Bags are less than 2/3rds full and capable of being secured

1.74 Water soluble or alginate bags are available for soiled

infected linen

1.75 In the event of an outbreak of infection (e.g. diarrhoea and

vomiting) linen is laundered immediately
Staff know how to handle soiled-infected laundry (randomly
1.76 ask member of staff)

1.77 Single-use gloves and aprons are available for use by

laundry staff

1.78 Staff are aware that manual sluicing is not good practice
18
 (randomly ask a member of staff)

1.79 Washing machines/tumble dryers are serviced regularly

1.80 Clean linen is stored in a clean, dry area (not in the sluice or
bathroom)

1.81 Hand washing facilities are available in the laundry room with
wall mounted liquid soap and paper towel dispenser

1.82 Hand washing facilities are free of clutter and accessible

Waste – a foot operated pedal bin is available for disposal of

1.83 paper towels

19
Pets YES NO N/A NOTES

Ref
1.84 Animals used for pet therapy are appropriately wormed and
vaccinated and have a flea management programme

1.85 Evidence that pets feeding areas, cages and bedding is

changed and cleaned regularly

1.86 Posters encouraging hand hygiene after handling animals

are visible in health care environments – must apply to staff
and visitors

Total number of ‘YES’ answers – x 100

-------------------------------------------------------- =
Total number of ‘YES’ and ‘NO’ responses

Standard 1Total Percentage score

20
Standard 2:
Hands will be decontaminated correctly and in a timely manner, to reduce the risk of cross infection.
As a minimum a hand wash basin, wall mounted liquid soap dispenser and wall mounted disposable
paper towels dispenser must be provided in each resident’s room for use by health and social
professionals, carers and relatives.
This provision must also extend to toilets, sluices, treatment rooms, laundry and kitchen areas.
Alcohol rub must also be available to care staff and positioned in appropriate areas.

REF Standard 2 YES NO N/A NOTES

2.1 Wall mounted liquid soap (sealed single-use cartridge) is

available at all hand wash sinks
(liquid soap must be topped up

2.2 Soap dispensers including nozzles are visibly clean and not
leaking

2.3 Wall mounted paper towels are available at all hand wash
sinks (including in residents’ rooms for care staff to dry their
hands on)

2.4 Wall mounted or pump dispenser hand cream is available for

use (do not refill)

2.5 There are no nail brushes on sinks in communal areas

The hand wash sinks are free from used equipment and
21
2.6 inappropriate items

2.7 Hand Hygiene posters promoting hand decontamination are

displayed above every communal hand basin sink

2.8 Hand washing facilities are clean and intact (check sinks,
taps, splash backs)

2.9 Elbow operated or automated taps are available in hand

wash sinks in clinical/treatment rooms

2.10 Taps in clinical areas are thermostatically controlled leaver or

mixer taps

2.11 All care staff are ‘Bare Below the Elbows’, (No wrist
watches, stoned rings or other wrist jewellery are worn by
staff carrying out care)

2.12 The nails of care workers carrying out care are short, clean
and free from false nails and free from nail varnish

2.13 Staff have received training in infection control that includes

specific Hand Hygiene training
All residents are actively offered and encouraged to use
2.14 Hand Hygiene facilities prior to meals

2.16 Alcohol hand rub is available for use at point of care

22
2.17 All residents are offered Hand Hygiene facilities prior to
meals

2.18 Visitors and guests are actively informed to decontaminate

their hands before and after leaving the establishment. There
are clear notices on all entrances and exits

2.19 Hand Hygiene facilities are available for visitors / guests to

use

23
Observational Hand Hygiene assessment:
For purposes of quality assurance staff and carers must
undertake observational Hand Hygiene assessments Essential YES NO N/A NOTES
Steps to Safe Clean tool bundle or equivalent
Ref
2.20 Care and ancillary staff use the correct procedure for
decontaminating hands (observe practice)
 Before and after each activity
 Prior to clinical procedures
 After a clinical procedure
 After handling contaminated items
 After leaving an isolation area
 Prior to handling food

2.21 Care / nursing /ancillary staff can indicate when it is

appropriate to use alcohol rub and when it is appropriate to
use soap and water (question staff)
Care / nursing / ancillary staff can indicate when it is more
2.22 appropriate to use liquid soap and water rather than alcohol
get (for example, when providing care for residents with
suspected Norovirus diarrhoea and vomiting and or residents
with Clostrdium difficile)

Total number of ‘YES’ answers – x 100

-------------------------------------------------------- =
Total number of ‘YES’ and ‘NO’ responses

Standard 2 Total Percentage score

24
25
Standard 3:
Personal Protective Equipment (PPE) is readily available for staff to use throughout the home.
All care staff and healthcare workers don PPE appropriately when undertaking care
REF Standard 3 YES NO N/A NOTES

3.1 Sterile non-powdered gloves are available for aseptic

procedures (x10 as a minimum at all times)

3.2 Where staff or residents are latex sensitive, latex free

gloves must be available for use

3.3 CE non-powdered, non-sterile gloves are available for all

staff

3.4 Gloves and aprons must be worn as single-use items for

each care intervention/task

3.5 Gloves and aprons are stored appropriately to prevent

cross contamination (for example, do NOT store directly
above toilets)

3.6 Staff and carers, when handling bodily fluids ensure both
disposable plastic aprons and gloves are readily available
and worn
Staff are aware of how to appropriately deal with spillages
3.7 of blood or bodily fluids (spillage kits available – held at a
central point for staff to access)

26
3.8 Appropriately gloves and aprons are available for domestic
housekeeping duties

3.9 Colour coded disposable aprons are available for staff use
and used appropriately

3.10 Masks, visors and eye protection are available for use

Total number of ‘YES’ answers – x 100

-------------------------------------------------------- =
Total number of ‘YES’ and ‘NO’ responses

Standard 3 Total Percentage score

27
Standard 4:
The safe management and disposal of sharps.
All staff must be aware of what to do in the event of a sharps and needle stick injury (inoculation)
REF Standard 4 YES NO N/A NOTES

4.1 Robust inoculation injury policy is available for all staff to

access

4.2 All staff know the procedure to be followed should a

sharps injury occur (ask one member of staff at random)

4.3 Posters are visible regarding information of ‘what to do in

the event of sharps injury’ including the initial first aid
procedures

4.4 The Hepatitis B status of exposure prone staff has been

risk assessed

4.5 Sharps containers are available and conform with BS7320

& UN3291 standards
Sharps containers are assembled correctly and are dated,
4.6 labelled and signed at point of assembly

4.7 Sharps are disposed of directly (at the point of care) into
the sharps container

28
4.8 Ensure a sharps tray with integral sharps bin is available -
especially if there is some walking distance involved to the
point of care delivery

4.9 Sharps containers are only filled to the fill line (less than
2/3rds full)

4.10 Staff do not re-sheath needles

4.11 Needles and syringes are disposed of as a single unit

4.12 Sharps containers are free from protruding sharps

4.13 Sharps containers are stored above floor level and out of
reach of clients and visitors

4.14 The temporary closure is used when the sharp container is

not in use

4.15 Full containers are dated and signed at the point of closure

Total number of ‘YES’ answers – x 100

-------------------------------------------------------- =

29
Total number of ‘YES’ and ‘NO’ responses

Standard 4 Total Percentage score

30
Standard 5:
All waste will be handled and disposed of appropriately in line with current legislation

REF Standard 5 YES NO N/A NOTES

5.1 The waste disposal policy is up to date and available to

staff

5.2 The home has a service with a registered company for the
disposal of waste in accordance with H&S at work act,
Environmental protection Duty of Care Regs (1991),
COSHH & Hazardous Waste Regulations (2005)

5.3 There is correct segregation and labelling of waste bins

including: Clinical, Offensive, Infected, sharps, batteries,
glass, household (Domestic) waste.

5.4 Waste bins are of appropriate size, clean, pedal foot

operated and lidded

5.5 Waste bags are filled less than 2/3rds full and securely
sealed and labelled with the name of the home

5.6 The disposal area is locked and inaccessible to

unauthorised persons and animals (including rodents)

5.7 The waste storage area is cleaned regularly and is tidy

31
Total number of ‘YES’ answers – x 100
-------------------------------------------------------- =
Total number of ‘YES’ and ‘NO’ responses

Standard 5 Total Percentage score

32
Standard 6:
Knowledge of Decontamination
REF Standard 6 YES NO N/A NOTES

6.1 There is a comprehensive and up-to-date decontamination

policy available

6.2 Manufacture instructions are available for the

decontamination of newly purchased equipment

6.3 Staff can state the procedure for the decontamination of

commonly used patients care equipment e.g. commodes,
mattresses (ask three members of staff)

6.4 The roles and responsibilities for cleaning patient

equipment is clearly defined. For example, bed frames,
mattresses, commodes – documented evidence is
available.

33
Check the following general items are visibly clean and in a
good state of repair:
REF YES NO N/A NOTES

6.5 Dressing trolleys (clean and free runs)

6.6 Mattresses and bases:

Ensure there is clear documented evidence

6.7 The mattress covers are clean and intact

6.8 Bed rails and cot sides are clean and include in the
cleaning programme

6.9 Pillows are clean and intact

6.10 Wheelchairs and cushions clean and intact

6.11 Residents wash bowls ae decontaminated appropriately

and are stored clean and dry

Manual handling is managed according to local policy and is

34
visibly clean, check:
REF YES NO N/A NOTES

6.12 Hoist slings / bath seats / shower chairs (check under seat
and frames)

6.13 Handling belts and hoist slings are single resident use

6.14 Document evidence of cleaning / laundry programme for

the handling belts and hoist slings
Respiratory equipment is managed according to local policy
and manufactures’ instructions, check:

6.15 Oxygen masks / nasal cannula

6.16 Nebulisers and giving sets (single use)

Patient / resident equipment

6.17 Catheter stands ae clean and in good state of repair

35
6.18 Bedpans / potties, slipper pans / bedpan holders / urinals
are visibly clean and stored appropriately

6.19 All the surfaces of commodes are clean (including frame

and underneath the pan area) and commodes are in a
good state of repair

Total number of ‘YES’ answers – x 100

-------------------------------------------------------- =
Total number of ‘YES’ and ‘NO’ responses

Standard 6 Total Percentage score

36
Standard 7:
Clinical practices should be evidence based and performance following training and in-line local policz
standards.
Staff should follow basic standard infection
REF Standard 7 YES NO N/A NOTES

7.1 Aseptic guidance / policy is up to-date and available for all

care staff

7.2 Staff performing activities which require aseptic technique

are trained to do so

7.3 Up-to-date documented evidence of staff competencies to

undertake aseptic technique

7.4 When performing aseptic technique staff can demonstrate

appropriate hand hygiene decontamination (audit practice)

7.5 Dressing packs are stored in a clean, dry area above floor
level and are available at all times

7.6 A dressing trolley is available, which is cleaned before and

after each use according to policy

7.7 Staff are trained to collect, handle and store specimens

7.8 There is clearly identified fridge designed for the storage of

37
 specimens

7.9 There is a record to show that the fridge is operating at the

correct temperature

7.10 The fridge is maintained according to manufactures

instructions
Catheter Care YES NO N/A NOTES

7.11 There is an up to-date catheter policy / guidance available

for staff to access
Up to-date records of staff training

7.12 Evidence of up to-date staff training to insert urinary

catheters

7.13 Evidence of up to-date staff training to empty urinary

catheters

7.14 Appropriate care plans are in place that include the

implementation of standard precautions (Hand hygiene
and use of PPE)

7.15 Ensure residents with long term in dwelling urinary

catheters, have been appropriately risk assessed and
pending the result referred to Urology and Continence
Team

38
7.16 Has a trial without catheter (TWOC) been considered,
check resident s’ records

7.17 Catheter bags are positioned below the level of the

bladder (with the exception of the belly bag)

7.18 Catheter bags are positioned above floor level

7.19 Urine bags are emptied using the tap following best
practice ‘wipe with alcohol wipe, allow to dry and wipe with
another wipe after drained’

7.20 Breaks in the closed catheter systems are kept to a

minimum e.g. appropriate emptying of urine bag

7.21 All urinary catheter specimens collected for diagnostic and

screening reasons are documented

7.22 All samples are collected from a needle free sample port

7.23 Isopropyl alcohol impregnated swabs are available to

clean the port which is left to dry after cleaning and prior to
accessing the port

Enteral Feeding

39
7.24 Staff who perform enteral feeding have received
appropriate training

7.25 Decontamination of hands

Ensure minimal handling and non-touch technique is used
during all procedures involving enteral feeding

7.26 Feeds are stored appropriately as per manufactures

instructions and where applicable food hygiene legislation
and stock is rotated

7.27 There is a system of checking expiry dates

7.28 After each feeding episode unused feed is discarded

7.29 Check enteral giving sets are single-use and disposed of

correctly

Total number of ‘YES’ answers – x 100

-------------------------------------------------------- =
Total number of ‘YES’ and ‘NO’ responses
Standard 7 Total Percentage score

40
Standard 8: Organisational controls:
Quality assurance ensuring there are robust systems and procedures in place for Infection Prevention
and Control
REF Standard 8 YES NO N/A NOTES

8.1 Policies and Guidance:

All staff / carers are aware of where to access the up to-
date Infection Prevention and Control Manual containing
policies and guidance for the Care Home (ask minimal of 3
members of staff)

8.2 Legionellas Control – there is a robust programme in place

for the running of un-used taps / showers to reduce the
risk of growth of legionella.
Document evidence of legionella report.

8.3 Education and training records:

All care staff have accessed and received appropriate
Infection Prevention and Control training beyond that
delivered during the induction period (documented
evidence of training records for all staff)

8.4 There is a designated Infection Prevention and Control

lead in the home – as per CQC requirements

41
8.5 There is a named Infection Prevention and Control link
champion (depending on the size of the organisation there
should be more than one)

8.6 All staff are aware of the basic signs of infection (ask
minimal of 3 members of staff)

8.7 All staff know who to inform if clients exhibit signs of

infection (ask minimal 3 members of staff)

8.8 Information on infections such as, MRSA and Clostridium

difficile infection / colonisation identified in patients /
residents is collated

8.9 Outbreak Management:

There is an appropriate and up to-date Outbreak policy/
guidelines available for all staff to follow (includes
information on timely recognition and reporting of outbreak
situations)

8.10 All staff are aware of the role of multi agencies in the event
of an outbreak (e.g. Public health England, CCG team who
provide advice and monitoring)

8.11 Environmental cleaning: A robust programme is in place

including the roles and responsibilities for the general day-
42
 to-day cleaning activities, and terminal cleaning activities
(for example, following an outbreak, and/or when a
resident vacates the room)

8.12 The care environment must be cleaned to the highest

possible standard meeting the residents and the public
expectations. There is a robust process in place to monitor
and audit cleaning activities – documented evidence
available for inspection

8.13 When transferring a resident ensure a ‘transfer form’ is

completed and sent with the resident (including information
of infection status)

8.14 On admission to the Care Home ensure you have received

a transfer form

8.15 Staff know where to obtain advice on infection control,

including when the manager is not on duty

Total number of ‘YES’ answers – x 100

-------------------------------------------------------- =
Total number of ‘YES’ and ‘NO’ responses
Standard 7 Total Percentage score

Audit Result:

43
INFECTION PREVENTION AND CONTROL AUDIT RESULTS

IPC Standard Result Date of planned Date of review

and action plan review
Date of result
1 General Environment
2 Hand Hygiene
3 PPE
4 Sharps
5 Waste Management
6 Decontamination & Equipment
7 Clinical Practice
8 Organisation Controls

85% or above Compliant Low risk

76-84% Partial compliance Medium Risk
75% or below Minimal compliance High Risk

44
ACTION PLAN

REF ACTION REQUIRED PERSON REVIEW

RESPONSIBLE DATE

45
46