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

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13. Further attention to detail is required to ensure that equipment used for the general cleaning purposes of a ward is clean, used and stored appropriately and is fit for purpose. 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). 30
Reporting & Re-Audit Episode of Inspection Plan Programme 14.0 Unannounced Inspection Flowchart Environmental Scan: Stakeholders & External Information Plan Programme Consider: Areas of Non-Compliance Infection Rates Trust Information Prioritise Themes & Areas for Core Inspections Prior to Inspection Year Balance Programme January/February Schedule Inspections Prior to Inspection Identify & Prepare Inspection Team Day of Inspection Inform Trust Day of Inspection Carry out Inspection A Is there immediate risk requiring formal escalation? NO YES Invoke RQIA IPHTeam Escalation Process Day of Inspection Feedback Session with Trust 14 days after Inspection 28 days after Inspection Preliminary Findings disseminated to Trust Draft Report disseminated to Trust NO Does assessment of the findings require escalation? YES Invoke RQIA IPHTeam Escalation Process A 14 days later Signed Action Plan received from Trust Within 0-3 months Is a Follow-Up required? Based on Risk Assessment/key indicators or Unsatisfactory Quality Improvement Plan (QIP)? YES Invoke Follow-Up Protocol Process enables only 1 Follow-Up NO Open Report published to Website YES Is Follow-Up satisfactory? NO DHSSPS/HSC Board/PHA PHA 31
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 and 28: Similar issues were identified in W
Page 29 and 30: 12.0 Key Personnel and Information
Page 31: 13.0 Summary of Recommendations 1.
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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