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

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

Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

requirements. This process supplements

the existing audit tools used by PCSS, IPC

and also existing external audits conducted

by Daniels (sharps box suppliers).

Daniels’ audit completed Oct 2011 and

results disseminated.

13. The trust need to review staff practice in relation to

the administration of medications and provide training

if required.

Nursing

The administration of medications is a

statutory and mandatory training

requirement for nursing staff.

Ongoing

The administration of medications is in the

annual mandatory training study days and

staff are required to complete pre-course

information prior to attendance. Staff must

adhere to the Trust’s Medicines

Management Code.

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.

Nursing

PCSS

IPC

Work / negotiations in relation to the

cleaning manual are still ongoing. In

particular, there is discussion with

nursing/control of infection with reference

bed cleaning. Once agreement is reached

the manual will be finalised.

Ongoing

The manual includes roles and

responsibilities of trust staff in relation to

patient equipment. A template will be used

to record all cleaning of equipment.

Staff have been reminded of protocols in

relation to sterile items.

39

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