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

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14. The trust and individual staff have a collective responsibility to ensure that equipment is clean, stored correctly and in a good state of repair. 15. The trust and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date regarding equipment cleaning. 16. The trust should ensure that hand washing sinks and consumables are available, clean, working and in a good state of repair. 17. The trust should ensure that all cleaning products are stored in a locked cupboard, in line with COSHH regulations. 18. Further attention to detail is required to ensure that equipment used for the general cleaning purposes of a ward are clean, used and stored appropriately and are fit for purpose. 19. The trust and individual staff have a collective responsibility to ensure that hand hygiene is carried out in line with WHO guidance and that all PPE is used appropriately. 20. The trust and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date with regard to isolation, cleaning and decontamination of equipment. 21. The trust and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date regarding the use of disinfectants. 22. The trust should ensure that all members of staff are familiar with and adhere to the regional dress code policy. 32
14.0 Unannounced Inspection Flowchart Plan Programme Environmental Scan: Stakeholders & External Information Prior to Inspection Year Plan Programme Prioritise Themes & Areas for Core Inspections Balance Programme Consider: Areas of Non-Compliance Infection Rates Trust Information January/February Schedule Inspections Prior to Inspection Identify & Prepare Inspection Team Episode of Inspection Day of Inspection Day of Inspection Inform Trust Carry out Inspection Is there immediate risk requiring formal escalation? NO YES Invoke RQIA IPHTeam Escalation Process A Day of Inspection Feedback Session with Trust 14 days after Inspection 28 days after Inspection Preliminary Findings disseminated to Trust Draft Report disseminated to Trust NO Does assessment of the findings require escalation? YES Invoke RQIA IPHTeam Escalation Process A Reporting & Re-Audit 14 days later Within 0-3 months Signed Action Plan received from Trust Is a Follow-Up required? Based on Risk Assessment/key indicators or Unsatisfactory Quality Improvement Plan (QIP)? YES Invoke Follow-Up Protocol Process enables only 1 Follow-Up NO Open Report published to Website YES Is Follow-Up satisfactory? NO DHSSPS/HSC Board/PHA 33
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
Page 5 and 6: Table 1 Ward 4C 5A 6A 7B Environmen
Page 7 and 8: 2.0 Background Information to the I
Page 9 and 10: 4.0 Unannounced Inspection Process
Page 11 and 12: Level of Compliance Percentage scor
Page 13 and 14: educe the potential risk for the tr
Page 15 and 16: Picture 1: Tidy mail box storage Pi
Page 17 and 18: In Wards 4C and 5A National Patient
Page 19 and 20: 7.0 Patient Linen STANDARD 3.0 PATI
Page 21 and 22: 8.0 Waste and Sharps STANDARD 4.0 W
Page 23 and 24: 13. The trust need to review staff
Page 25 and 26: Picture 5: Glucose monitor casing a
Page 27 and 28: tablets were decanted into an unlab
Page 29 and 30: dust in the isolation room would su
Page 31 and 32: 12.0 Key Personnel and Information
Page 33: 13.0 Summary of Recommendations 1.
Page 37 and 38: 16.0 Action Plan Reference number R
Page 39 and 40: Reference number Recommendations De
Page 45: Reference number Recommendations De

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

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