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

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.

Nursing

PCSS

Audit Tool (BRAAT).

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial audits,

and IPC audits monitor compliance.

Ongoing

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Regular training is provided to all

appropriate staff.

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.

IPCT

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.

Balance scorecards include WHO Hand

Hygiene audits. All of these aspects will be

monitored through the programme of

Environmental Cleanliness Audits based on

the Cleanliness Matters Strategy.

Complete and

ongoing

The IPCT carried out an independent audit

and results have been fed back.

Independent audits will be carried out 4

times a year (2 of which will be carried out

by Infection Prevention and Control).

The IPCT is currently devising an

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