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

Ref
number
Recommendations
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.
Designated
department
Domestic/
Nursing
Domestic/
Nursing/
Other
disciplines
Nursing/
Other
disciplines
Director
Nursing
Action required
Training is given to all relevant staff in the
usage and storage of cleaning equipment
and products as part of their induction.
Additional training is provided if
equipment or products change
Hand hygiene monitored at ward level.
Performance contained within Trust
Board reports. Staff found to be non
compliant are retrained and frequency of
auditing is increased
Relevant Directors to issue a reminder to
staff regarding this important issue
Relevant Directors to issue a reminder to
staff regarding this important issue.
Major project currently underway to
introduce new Nursing Assessment and
Plan of Care documentation to all wards
in acute hospitals.
Date for
completion/
timescale
Actioned
Actioned and
Ongoing
Actioned
Actioned
A Quality Improvement workstream,
including monthly audits, monitors
individual ward compliance with record
keeping indicators. Electronic audit
results are available at ward level for
immediate improvement activity.
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