Kingsbridge Private Hospital, Belfast - 20 January 2012

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Recommendations

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Recommendations 12. The hospital should ensure hand washing facilities are clean and accessible. 13. The hospital should ensure alcohol rub dispensers and filled and clean. 14. The hospital should ensure PPE is available, fit for purpose and worn by staff. 15. The hospital should ensure equipment for general cleaning is clean and fit for purpose. 18
11.0 Hygiene Practices STANDARD 7.0 HYGIENE PRACTICES Hand hygiene procedures; handling and disposal of sharps; use of PPE; use of isolation facilities and implementation of infection control procedures; cleaning of ward/department; staff uniform and work wear. Hygiene Practices Effective hand hygiene procedures 67 Safe handling and disposal of sharps 100 Effective use of PPE 83 Correct use of isolation N/A Effective cleaning of the facility 82 Staff uniform and work wear 97 Average Score 86 In this standard overall compliance was achieved, the safe handling and disposal of sharps was fully compliant, however a minimally compliant score was achieved in effective hand hygiene procedures. Staff were observed entering the dirty utility room on several occasions but failed to use alcohol hand rub to decontaminate their hands. Staff were also observed not washing their hands before donning disposable gloves. Personal protective equipment, disposable gloves and aprons were worn where appropriate. Staff did not wear the appropriate head protection when in the endoscope unit, staff in the adjoining theatre were observed wearing their head protection continuously instead of as a single use item. Nursing staff when questioned, were not aware of NPSA guidelines for colour coding of cleaning equipment in relation to theatres. The information on dilution rates for cleaning and disinfection chemicals was displayed in the domestic store but was difficult to read, and when domestic staff were questioned they were they were unable to give the correct dilution rates for the cleaning agent or disinfectant in use in the hospital. A dress code policy is in place within the hospital and generally staff were compliant, however inspectors observed that a member of theatre staff was wearing hoop earrings. 19
Page 1 and 2: 33333333333333333333333333333333 RQ
Page 3 and 4: 1.0 Inspection Summary A joint insp
Page 5 and 6: Table 1 Areas Inspected Environment
Page 7 and 8: 2.0 Background Information to the I
Page 9 and 10: 4.0 Announced Inspection Process Th
Page 11 and 12: Level of Compliance Percentage scor
Page 13 and 14: The main hospital reception on the
Page 15 and 16: 7.0 Patient Linen STANDARD 3.0 PATI
Page 17 and 18: waste and sharps to ensure safe and
Page 19: 10.0 Hygiene Factors STANDARD 6.0 H
Page 23 and 24: 12.0 Endoscopy Suite STANDARD 8.0 E
Page 25 and 26: 12.1 Specialist Patient Equipment I
Page 27 and 28: 14.0 Summary of Recommendations 1.
Page 29 and 30: 15.0 Escalation Process RQIA Hygien
Page 31 and 32: Reference number Recommendations 8.

Kingsbridge Private Hospital, Belfast - 20 January 2012

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