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

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

1.0 Inspection Summary

An unannounced inspection was undertaken to the Royal Victoria

Hospital, on the 17 July 2012. The hospital was assessed against the

Regional Healthcare Hygiene and Cleanliness Standards and the

following areas were inspected:

• Ward 4C - Orthopaedic

• Ward 5A - Vascular

• Ward 6A - Gastro-intestinal Surgery

• Ward 7B - Medical Respiratory

Inspection Outcomes

Overall the inspection teams found evidence that the Royal Victoria

Hospital was working to comply with the Regional Healthcare Hygiene

and Cleanliness standards. Improvements in the overall levels of

compliance have been noted since the previous inspection, three of the

wards achieved an overall partially compliant score and Ward 6A

achieved an overall compliant score.

Inspectors found that further improvement was required in the following

areas. The environment in all wards required attention to detail where

cleaning; clutter, and at times poor maintenance and repair, notably in

Ward 5A, have impacted negatively on the scoring.

Although all wards scored overall compliance for the standard

regarding hygiene factors, the section on materials and equipment for

cleaning, indicates that more work is required to improve practice. In

the hygiene practices standard, Ward 4C scored a minimal compliance

in the section hand hygiene procedures and none of the wards were

compliant for the section concerning effective cleaning of the ward. In

all wards, all staff groups must implement hygiene and infection

prevention and control practices consistently to minimise the potential

risk of transmission of infection to patients, visitors and staff. As a

result of the findings for Wards 4C and 5A a follow up inspection will be

carried out within three months.

The inspectors noted that good practice by staff resulted in compliance

in the following sections of the audit tool; the management of waste

and used linen and within the Hygiene Factors and Hygiene Practices


The inspection resulted in 22 recommendations for the BHSCT and the

Royal Victoria Hospital, a full list of recommendations is listed in

Section 13.

A detailed list of preliminary findings is forwarded to Belfast Health and

Social Care Trust within 14 days of the inspection to enable early

action on identified areas which have achieved non complaint scores.


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