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

The draft report which includes the high level recommendations in a
Quality Improvement Plan is forwarded within 28 days of the inspection
for agreement and factual accuracy. The draft report is agreed and a
completed action plan is returned to RQIA within 14 days from the date
of issue. The detailed list of preliminary findings is available from RQIA
on request.
The final report and Quality Improvement Plan will be available on the
RQIA website. Reports and action plans will be subject to performance
management by the Health and Social Care Board and the Public
Health Agency.
Notable Practice
The inspection identified the following areas of notable practice:
• Care bundles are performed for insertion and maintenance of
peripheral IV lines, maintenance of central lines and urinary
catheterization
• Audits are carried out on; hand hygiene, peripheral vascular
catheters, central venous catheters, urinary catheter care
• Ward 5A has implemented a care bundle for the acutely ill
patient
• Vapourised hydrogen peroxide cleans are carried following
discharge of patients with VRE (Vancomycin Resistant
Enterococcus) infection
• Ward 6A has initiated a “Body Chart” for use with each
patient. This is a good visual trigger for staff to quickly
identify catheters, cannulae, wounds, pressure areas
• In Ward 6A and 7B, the use of the electronic handover tool
has shortened handover time to approximately 10 minutes
and can highlight IPC issues for staff
The RQIA inspection team would like to thank the BHSCT and in
particular all staff at the Royal Victoria Hospital for their assistance
during the inspection.
The following tables give an overview of compliance scores noted in
areas inspected by RQIA:
Table 1 summarises the overall compliance levels achieved.
Tables 2-7 summarise the individual tables for sections two to seven of
the audit tool as this assists the organisation to target areas that
require more specific attention.
2