Royal Victoria Hospital, Belfast - 27 September 2012

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Level of Compliance Percentage scores can be allocated a level of compliance using the compliance categories below. The categories are allocated as follows: Compliant: 85% or above Partial Compliance: 76% to 84% Minimal Compliance: 75% or below Colour Each section within the audit tool will receive an individual and an overall score, to identify areas of partial or minimal compliance to ensure that the appropriate action is taken. 10
6.0 Environment STANDARD 2.0 GENERAL ENVIRONMENT Cleanliness and state of repair of public areas; cleanliness and state of repair of ward/department infrastructure; cleanliness and state of repair of patient bed area; cleanliness and state of repair of toilets, bathrooms and washrooms; cleanliness and state of repair of ward/department facilities; availability and cleanliness of isolation facilities; provision of information for staff, patients and visitors. Environment 4C 4C 5A 5A 17 July <strong>27</strong> Sept 17 July <strong>27</strong> Sept Reception N/A N/A N/A 69 Corridors, stairs lift 88 92 83 83 Public toilets 86 85 N/A N/A Ward/department – general (communal) 90 97 72 93 Patient bed area 83 91 72 88 Bathroom/washroom 87 91 65 85 Toilet N/A N/A N/A N/A Clinical room/treatment room 66 79 50 N/A Clean utility room 85 94 59 93 Dirty utility room 86 96 71 92 Domestic store 73 90 64 95 Kitchen N/A N/A 57 79 Equipment store 67 81 80 97 Isolation 76 N/A 86 90 General information 60 95 85 90 Total 80 90 70 88 The above table outlines the findings in relation to the general environment of the facilities inspected. The findings indicate that there was improvement in both wards. The findings in respect of the general environment are detailed in the following sections. 6.1 Cleaning Ward staff have worked hard to action issues highlighted in the previous inspection. The scores in this section indicate good improvement resulting in both wards achieving overall compliance in this standard. However continued effort is required in relation to maintaining a dust free environment in both wards. In Ward 4C dust observed on the under carriage of patients beds, fans at the bedside, and air vents were still dusty. In the clinical room dust 11
Page 1 and 2: The RQIA Infection Prevention/Hygie
Page 3 and 4: 1.0 Inspection Summary The unannoun
Page 5 and 6: The following tables give an overvi
Page 7 and 8: Table 7 Hygiene Practices 4C 17 Jul
Page 9 and 10: 3.0 Inspections The DHSSPS has devi
Page 11: 5.0 Audit Tool The audit tool used
Page 15 and 16: commenced in Ward 5A, on the day of
Page 17 and 18: 8.0 Waste and Sharps STANDARD 4.0 W
Page 19 and 20: 9.0 Patient Equipment STANDARD 5.0
Page 21 and 22: 10.0 Hygiene Factors STANDARD 6.0 H
Page 23 and 24: Picture 4: Open padlock on chemical
Page 25 and 26: Supporting documentation A number o
Page 27 and 28: Plan Programme 14.0 Unannounced Ins
Page 29 and 30: 16.0 Action Plan Reference number R
Page 31: * indicates stated for a second tim

Royal Victoria Hospital, Belfast - 27 September 2012

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