Royal Victoria Hospital, Belfast - 17 July 2012 - Regulation and ...

Royal Victoria Hospital, Belfast - 17 July 2012 - Regulation and ...

11.0 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 4C 5A 6A 7B

Effective hand hygiene


71 85 94 80

Safe handling and

disposal of sharps

100 100 100 100

Effective use of PPE 86 100 94 100

Correct use of isolation 82 N/A 88 86

Effective cleaning of


76 74 76 80

Staff uniform and work


72 86 90 93

Total 81 89 90 90

With the exception of Ward 4C overall compliance was achieved in this

standard. Poor hand hygiene practices were observed in Ward 4C.

Many staff did not carry out all seven steps of the hand wash

technique, staff did not comply with hand hygiene in line with the World

Health Organisation (WHO) five moments of care and patients were

not offered hand hygiene prior to meals. In Ward 7B the majority of

staff observed evidenced effective hand hygiene practice however on

two occasions staff did not undertake the seven step technique

properly and all but one member of staff used antibacterial hand wash

in preference to soap.

Staff in all wards are commended for achieving full compliance for the

section relating to safe handling and disposal of sharps. Wards 5A and

7B were fully compliant with effective use of PPE. In Ward 4C

domestic staff confirmed they did not wear aprons for wet work and a

member of staff was observed not removing gloves after completing an

activity. In Ward 6A a nursing auxiliary was observed leaving an

isolation room having removed PPE and not decontaminating their

hands outside the room.

There were no patients requiring isolation precautions in Ward 5A

therefore this section of the tool kit was not scored. In Wards 4C and

7B inspectors reviewed the notes of a patient with a known infection;

the care pathway was in place however the infection prevention and

control assessment had not been completed. Additionally, in Ward 7B


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