Antrim Area Hospital, Antrim - 09 October 2012 - Regulation and ...

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Recommendations 14. 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. 15. 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. 16. The trust and individual staff should ensure that all care plan and care pathway documentation is fully completed and regularly reviewed. 17. The trust and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date regarding the use of disinfectants. 18. The trust and individual staff have a collective responsibility to ensure COSHH data sheets are readily available for all staff to reference. 19. The trust should ensure that all members of staff are familiar with and adhere to the regional dress code policy. 20. The trust and individual staff have a collectible responsibility to ensure medicines are administered in accordance with the trust policy and the medicines management standard (2009). 26
12.0 Key Personnel and Information Members of the RQIA inspection team Mrs E Colgan Mrs L Gawley Mrs S O’Connor Mrs M Keating - Senior Officer Infection Prevention/Hygiene Team - Inspector Infection Prevention/Hygiene Team - Inspector Infection Prevention/Hygiene Team - Inspector Infection Prevention/Hygiene Team Peer Reviewers Melanie Johnston Christine Goan Gillian Smyth Yvonne Black Domestic Manager SHSCT Senior Reviewer RQIA Patient Experience Manager Assistant Support Services Manager WHSCT Observors Damien O’Neill Gemma Mulholland Assistant Services Manager BHSCT Administration Supervisor CSCG, RQIA Trust representatives attending the feedback session The key findings of the inspection were outlined to the following trust representatives: Valerie Jackson Director Acute Services Suzanne Pullins Head of Governance and Patient Safety T. Martin Assistant Director Surgery/ATICS Linda Linford Assistant Director NHSCT Maire Bermingham Assistant Director Corporate Support Services Linda Patton General Manager Medical Specialities Avril Redmond Professional Lead for Nursing Peter Bartley Service Lead Mary Neeson Lead Nurse Surgery Naomi Baldwin Lead Nurse Infection Prevention and Control Rosaleen Burns Ward Manager C1 Anne-Marie Costello Ward Manager A3 Bernie Irvine Ward Manager C5 Ann Hamilton General Manager Domestic Services Trustwide Theresa O’Neill Ward Sister C4 Nuala Mc Cormick Planning Supervisor, Estates Department A. Anderson Band 6 Ward A3 Alan Steward Domestic Services Manager Antrim Area Hospital 27
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 Areas inspected C1 A3 C4 C5
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: leading to the ward. The patient lo
Page 17 and 18: 6.6 Additional Issues Ward A3 Ward
Page 19 and 20: 7.0 Patient Linen STANDARD 3.0 PATI
Page 21 and 22: of the sharps box and its contents
Page 23 and 24: Picture 4: Exposed syringe with 10m
Page 25 and 26: Recommendations 11. The trust shoul
Page 27: Similar issues were identified in W
Page 31 and 32: 13.0 Summary of Recommendations 1.
Page 33 and 34: Reporting & Re-Audit Episode of Ins
Page 35 and 36: 16.0 Action Plan Antrim Area Hospit
Page 37 and 38: Ref number Recommendations 6. The t
Page 39 and 40: Ref number Recommendations 13. Furt
Page 41: Ref number Recommendations 20. The

Antrim Area Hospital, Antrim - 09 October 2012 - Regulation and ...

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