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

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.

Nursing

All staff have been reminded and made

aware of poster advice.

Mandatory IPC training is provided, poster

advice issued to wards, staff questioned at

audit.

Complete and

ongoing

22. The trust should ensure that all members of staff are

familiar with and adhere to the regional dress code

policy.

All

Directorates

Trust policy available to all staff on Intranet.

Policy is enforced at local level by senior

staff, e.g., Ward Sisters and Senior

Managers.

Complete

The Ward Sister/Charge Nurse Support

Improvement and Accountability

Framework (SIAF) includes an indicator

relating to compliance with the dress code

policy and this is audited on a quarterly

basis.

Ongoing

43

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