Kingsbridge Private Hospital, Belfast - 20 January 2012

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Table 5 Patient Equipment Patient equipment 87 Table 6 Hygiene Factors Availability and cleanliness of wash hand 96 basin and consumables Availability of alcohol rub 92 Availability of PPE 82 Materials and equipment for cleaning 81 Average Score 88 Table 7 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 ward 82 Staff uniform and work wear 97 Average Score 86 Table 8 Endoscopy Suite Scrub Room N/A Endoscopy Theatre 97 Endoscopy 60 decontamination room Specialist 90 Equipment/practices Policies and Procedures 93 Average Score 85 Compliant: 85% or above Partial Compliance: 76% to 84% Minimal Compliance: 75% or below 4
2.0 Background Information to the Inspection Process RQIA’s infection prevention and hygiene team was established to undertake a rolling programme of unannounced inspections of acute hospitals. The Department of Health Social Service and Public Safety (DHSSPS) commitment to a programme of hygiene inspections was reaffirmed through the launch in <strong>20</strong>10 of the revised and updated version of 'Changing the Culture' the strategic regional action plan for the prevention and control of healthcare-associated infections (HCAIs) in Northern Ireland. The aims of the inspection process are: • to provide public assurance and to promote public trust and confidence • to contribute to the prevention and control of HCAI • to contribute to improvement in hygiene, cleanliness and infection prevention and control across health and social care in Northern Ireland In keeping with the aims of the RQIA, the team will adopt an open and transparent method for inspection, using standardised processes and documentation. 5
Page 1 and 2: 33333333333333333333333333333333 RQ
Page 3 and 4: 1.0 Inspection Summary A joint insp
Page 5: Table 1 Areas Inspected Environment
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 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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