Kingsbridge Private Hospital, Belfast - 20 January 2012

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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. 16. The hospital and individual staff have a responsibility to ensure that hand hygiene is carried out in line with the seven step technique and that all PPE is used appropriately. 17. The hospital and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date with regard to the correct dilution rates for chemicals and colour coded equipment used for cleaning and decontamination of equipment and specialist patient equipment. 18. Staff should comply with the hospitals dress code policy. 19. The environment of the endoscopy suite should be clean and free of clutter. <strong>20</strong>. The decontamination room should be fit for purpose and comply with relevant standards. 21. Improvements required in the decontamination process should be addressed and work commenced to comply with CFPP. 22. All recommendations as outlined by the HEIG inspectors in their key findings report should be addressed. 26
15.0 Escalation Process RQIA Hygiene Team: Escalation Process B RQIA IPH Team Escalation Process Concern / Allegation / Disclosure Inform Team Leader / Head of Programme MINOR/MODERATE Has the risk been assessed as Minor, Moderate or Major? MAJOR Inform key contact and keep a record Inform appropriate RQIA Director and Chief Executive Record in final report Inform Trust / Establishment / Agency and request action plan Notify Chairperson and Board Members Inform other establishments as appropriate: E.g.: DHSSPS, RRT, HSC Board, PHA, Seek assurance on implementation of actions Take necessary action: E.g.: Follow-Up Inspection 27
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 and 20: 10.0 Hygiene Factors STANDARD 6.0 H
Page 21 and 22: 11.0 Hygiene Practices STANDARD 7.0
Page 23 and 24: 12.0 Endoscopy Suite STANDARD 8.0 E
Page 25 and 26: 12.1 Specialist Patient Equipment I
Page 27: 14.0 Summary of Recommendations 1.
Page 31 and 32: Reference number Recommendations 8.

Kingsbridge Private Hospital, Belfast - 20 January 2012

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