Muckamore Abbey Hospital, Antrim - 16 February 2012

RQIA 

Infection Prevention/Hygiene 

Unannounced inspection 

Belfast Health and Social Care Trust 

Muckamore Abbey Hospital 

16 February 2012

Contents 

1.0 Inspection Summary 1 

2.0 Background Information to the Inspection Process 5 

3.0 Inspections 6 

4.0 Unannounced Inspection Process 7 

4.1 Onsite Inspection 7 

4.2 Feedback and Report of the Findings 7 

5.0 Audit Tool 8 

6.0 Environment 10 

6.1 Cleaning 11 

6.2 Clutter 12 

6.3 Maintenance and Repair 13 

6.4 Fixture and Fittings 13 

6.5 Information 14 

6.6 Additional Issues 15 

7.0 Patient Linen 17 

7.1 Management of Linen 17 

8.0 Waste and Sharps 19 

8.1 Waste 19 

8.2 Sharps 19 

9.0 Patient Equipment 21 

10.0 Hygiene Factors 23 

11.0 Hygiene Practice 26 

11.1 Additional Issues 28 

12.0 Key Personnel and Information 29 

13.0 Summary of Recommendations 30 

14.0 Unannounced Inspection Flowchart 32 

15.0 RQIA Hygiene Team Escalation Policy Flowchart 33 

16.0 Action Plan 34

1.0 Inspection Summary 

An unannounced inspection was undertaken to Muckamore Abbey 

Hospital, on the 16 February 2012. The hospital was assessed 

against the Regional Healthcare Hygiene and Cleanliness standards 

and the following areas were inspected: 

Donegore Ward 

Erne Ward 

Muckamore Abbey Hospital, which is part of the Belfast Health and 

Social Care Trust, provides inpatient, assessment and treatment 

facilities for people with severe learning disabilities. 

Donegore Ward is a newly built, single storey, 9 bedded ward, with 

single room en-suite facilities. Female patients with various challenging 

behaviours and dependency levels are cared for in this ward. 

Erne Ward, is one of the remaining older 1950s style buildings on the 

Muckamore site, it is a single storey, 14 bedded ward, caring for fully 

dependant male patients with complex physical and learning disability 

needs. 

The inspectors were informed by senior staff that Erne ward is due to 

close in approximately 12 - 18 months. 

Inspection Outcomes 

Donegore Ward - achieved an overall compliance score for the 

inspection. Inspectors observed that the environment in general was 

clean and staff demonstrated compliance with hygiene and infection 

prevention and control practices. 

Erne Ward - an overall minimal compliance score was achieved. 

Overall the inspection findings in this ward are of concern and indicate 

that improvement is required in the majority of areas, of particular 

concern were the findings in relation to hygiene practices and patient 

equipment. Inspectors also identified issues in relation to the cleaning 

and maintenance of the ward. 

To provide an acceptable and safe environment for patients prior to 

closure it is recommended that the issues highlighted in the report are 

reviewed and addressed. 

As a result of the findings for Erne there was immediate escalation of 

these to the trust chief executive and a follow up inspection will be 

carried out within three months. 

The inspection resulted in 26 recommendations for Muckamore Abbey 

Hospital, a full list of recommendations is listed in Section 13. 

1

A detailed list of preliminary findings is forwarded to Belfast Health and 

Social Care Trust within 14 days of the inspection to enable early 

action on identified areas which have achieved non complaint scores. 

The draft report which includes the high level recommendations in a 

Quality Improvement Plan is forwarded within 28 days of the inspection 

for agreement and factual accuracy. The draft report is agreed and a 

completed action plan is returned to RQIA within 14 days from the date 

of issue. The detailed list of preliminary findings is available from RQIA 

on request. 

The final report and Quality Improvement Plan will be available on the 

RQIA website. Reports and action plans will be subject to performance 

management by the Health and Social Care Board and the Public 

Health Agency. 

Notable Practice 

The inspection identified the following areas of notable practice: 

Good use of white boards which were wipeable and at times 

magnetic 

Domestic services had received recent update training, 

based on the DHSSPS new guidance on how to clean sinks 

Good domestic schedules and information in the domestic 

store detailed and included up to date information on how, 

when and the specific equipment and materials needed for 

cleaning 

The RQIA inspection team would like to thank the staff at Muckamore 

Abbey Hospital for their assistance during the inspection. 

The following tables give an overview of compliance scores noted in 

areas inspected by RQIA: 

Table 1 summarises the overall compliance levels achieved. 

Tables 2-7 summarise the individual tables for sections two to seven of 

the audit tool as this assists organisation to target areas that require 

more specific attention. 

2

Table 1 

Donegore Erne 

Environment 92 71 

Patient Linen 94 77 

Waste 88 79 

Sharps 91 86 

Equipment 87 44 

Hygiene Factors 89 78 

Hygiene Practices 87 58 

Total 90 70 

Table 2 

Environment Donegore Erne 

Reception 92 84 

Corridors, stairs lift N/A 65 

Public toilets 98 81 

Ward/department - 

general(communal) 

89 68 

Patient bed area N/A 91 

Bathroom/washroom 84 60 

Toilet 97 67 

Clinical room/treatment 

room 

95 81 

Clean utility room N/A N/A 

Dirty utility room(Disposal 

store) 

97 N/A 

Domestic store 97 63 

Kitchen(Servery) 96 87 

Equipment store N/A 67 

Isolation 96 76 

General information 68 39 

Total 92 71 

Table 3 

Linen Donegore Erne 

Storage of clean linen 96 61 

Storage of used linen 100 93 

Laundry facilities 87 N/A 

Total 94 77 

Compliant: 

85% or above 

Partial Compliance: 76% to 84% 

Minimal Compliance: 75% or below 

3

Table 4 

Waste and sharps Donegore Erne 

Handling, segregation, 

storage, waste 

Availability, use, storage of 

sharps 

88 79 

91 86 

Table 5 

Patient Equipment Donegore Erne 

Patient equipment 87 44 

Table 6 

Hygiene Factors Donegore Erne 

Availability and cleanliness 

of WHB and consumables 

96 79 

Availability of alcohol rub 77 80 

Availability of PPE 83 67 

Materials and equipment 

for cleaning 

98 85 

Total 89 78 

Table 7 

Hygiene practices Donegore Erne 

Effective hand hygiene 

procedures 

80 43 

Safe handling and disposal 

of sharps 

100 50 

Effective use of PPE 100 73 

Correct use of isolation N/A N/A 

Effective cleaning of ward 63 56 

Staff uniform and work 

wear 

93 70 

Total 87 58 

Compliant: 

85% or above 

Partial Compliance: 76% to 84% 

Minimal Compliance: 75% or below 

4

2.0 Background Information to the Inspection Process 

RQIA’s infection prevention and hygiene team was established to 

undertake a rolling programme of unannounced inspections of acute 

hospitals. The Department of Health Social Service and Public Safety 

(DHSSPS) commitment to a programme of hygiene inspections was 

reaffirmed through the launch in 2010 of the revised and updated 

version of 'Changing the Culture' the strategic regional action plan for 

the prevention and control of healthcare-associated infections (HCAIs) 

in Northern Ireland. 

The aims of the inspection process are: 

to provide public assurance and to promote public trust and 

confidence 

to contribute to the prevention and control of HCAI 

to contribute to improvement in hygiene, cleanliness and infection 

prevention and control across health and social care in Northern 

Ireland 

In keeping with the aims of the RQIA, the team will adopt an open and 

transparent method for inspection, using standardised processes and 

documentation. 

5

3.0 Inspections 

The DHSSPS has devised Regional Healthcare Hygiene and 

Cleanliness standards. RQIA has revised its inspection processes to 

support the publication of the standards which were compiled by a 

regional steering group in consultation with service providers. 

RQIA's infection prevention/hygiene team have planned a three year 

programme which includes announced and unannounced inspections 

in acute and non-acute hospitals in Northern Ireland. This will assess 

compliance with the DHSSPS Regional Healthcare Hygiene and 

Cleanliness standards. 

The inspections will be undertaken in accordance with the four core 

activities outlined in the RQIA Corporate Strategy, these include: 

Improving care: we encourage and promote improvements in the 

safety and quality of services through the regulation and review of 

health and social care 

Informing the population: we publicly report on the safety, 

quality and availability of health and social care 

Safeguarding rights: we act to protect the rights of all people 

using health and social care services 

Influencing policy: we influence policy and standards in health 

and social care 

6

4.0 Unannounced Inspection Process 

Trusts receive no advanced notice of the onsite inspection. An email 

and telephone call will be made by the Chief Executive of RQIA or 

nominated person 30 minutes prior to the team arriving on site. The 

inspection flow chart is attached in Section 14. 

4.1 Onsite Inspection 

The inspection team was made up of four inspectors, three from 

RQIA’s infection prevention/hygiene team and one from RQIA’s review 

directorate. One inspector led the team and was responsible for 

guiding the team and ensuring they were in agreement about the 

findings reached. Membership of the inspection team is outlined in 

Section 12. 

The inspection of ward environments is carried out using the Regional 

Healthcare Hygiene and Cleanliness audit tool. The inspection 

process involves observation, discussion with staff, and review of some 

ward documentation. 

4.2 Feedback and Report of the Findings 

The process concludes with a feedback of key findings to trust 

representatives including examples of notable practice identified during 

the inspection. The details of trust representatives attending the 

feedback session is outlined in Section 12. 

The findings, report and follow up action will be in accordance with the 

Infection Prevention/Hygiene Inspection Process (methodology, follow 

up and reporting). 

The infection prevention/hygiene team escalation process will be 

followed if inspectors/reviewers identify any serious concerns during 

the inspection (Section 15). 

A number of documents have been developed to support and explain 

the inspection process. This information is currently available on 

request and will be available in due course on the RQIA website. 

7

5.0 Audit Tool 

The audit tool used for the inspection is based on the Regional 

Healthcare Hygiene and Cleanliness standards. The standards 

incorporate the critical areas which were identified through a review of 

existing standards, guidance and audit tools (Appendix 2 of Regional 

Healthcare Hygiene and Cleanliness standards). The audit tool follows 

the format of the Regional Healthcare Hygiene and Cleanliness 

Standards and comprises of the following sections. 

1. Organisational Systems and Governance: policies and 

procedures in relation to key hygiene and cleanliness issues; 

communication of policies and procedures; roles and 

responsibilities for hygiene and cleanliness issues; internal 

monitoring arrangements; arrangements to address issues 

identified during internal monitoring; communication of internal 

monitoring results to staff. 

This standard is not audited when carrying out unannounced 

inspections however the findings of the organisational 

system and governance at annual announced inspection will 

be, where applicable, confirmed at ward level. 

2. General Environment: cleanliness and state of repair of public 

areas; cleanliness and state of repair of ward/department 

infrastructure; cleanliness and state of repair of patient bed area; 

cleanliness and state of repair of toilets, bathrooms and 

washrooms; cleanliness and state of repair of ward/department 

facilities; availability and cleanliness of isolation facilities; 

provision of information for staff, patients and visitors 

3. Patient Linen: storage of clean linen; handling and storage of 

used linen; ward/department laundry facilities 

4. Waste and Sharps: waste handling; availability and storage of 

sharps containers 

5. Patient Equipment: cleanliness and state of repair of general 

patient equipment 

6. Hygiene Factors: hand wash facilities; alcohol hand rub; 

availability of personal protective equipment (PPE); availability of 

cleaning equipment and materials. 

7. Hygiene Practices: hand hygiene procedures; handling and 

disposal of sharps; use of PPE; use of isolation facilities and 

implementation of infection control procedures; cleaning of 

ward/department; staff uniform and work wear 

8

Level of Compliance 

Percentage scores can be allocated a level of compliance using the 

compliance categories below. The categories are allocated as follows: 

Compliant 

85% or above 

Partial compliance 76 to 84% 

Minimal compliance 75% or below 

Each section within the audit tool will receive an individual and an 

overall score, to identify areas of partial or minimal compliance to 

ensure that the appropriate action is taken. 

9

6.0 Environment 

STANDARD 2.0 

GENERAL ENVIRONMENT 

Cleanliness and state of repair of public areas; cleanliness and 

state of repair of ward/department infrastructure; cleanliness and 

state of repair of patient bed area; cleanliness and state of repair 

of toilets, bathrooms and washrooms; cleanliness and state of 

repair of ward/department facilities; availability and cleanliness of 

isolation facilities; provision of information for staff, patients and 

visitors. 

Environment Donegore Erne 

Reception 92 84 

Corridors, stairs lift N/A 65 

Public toilets 98 81 

Ward/department - 

general(communal) 

89 68 

Patient bed area N/A 91 

Bathroom/washroom 84 60 

Toilet 97 67 

Clinical room/treatment 

room 

95 81 

Clean utility room N/A N/A 

Dirty utility room(Disposal 

store) 

97 N/A 

Domestic store 97 63 

Kitchen(Servery) 96 87 

Equipment store N/A 67 

Isolation 96 76 

General information 68 39 

Total 92 71 

The above table outlines the findings in relation to the general 

environment of the facilities inspected. The findings indicate that there 

are concerns regarding Erne ward and in particular the minimally 

compliant areas highlighted in red which require immediate attention. 

The findings in respect of the general environment are detailed in the 

following sections. 

Inspectors note that there is a large variation in the age of the two 

wards inspected and the facilities available at ward level. Donegore, a 

new modern spacious build, has up to date fixtures, fittings and décor 

throughout the ward including sanitary and communal areas, with 

single en-suite bedrooms. Erne, an old 1950s style building, requires 

redecoration, maintenance and repair throughout. Personal care is 

10

delivered in communal sanitary areas and bedrooms are single or multi 

bedded rooms. 

6.1 Cleaning 

At the time of the inspection there was some evidence to indicate 

compliance with regional specifications for cleaning. The inspectors 

observed that regular cleaning mechanisms were in place however 

these were not always implemented or monitored. Cleaning 

mechanisms prevent the build-up of dust and debris, which in turn 

prevents the build-up of bacteria and subsequently reduces the 

potential risk for the transmission of infection. 

In Donegore, cleaning was of a satisfactory standard however greater 

attention to detail was required to ensure stains and smudges were 

removed from flooring and walls, windows and glass panelling and the 

kickboard in the kitchen servery. 

Inspectors observed that in Erne work was required to improve the 

standard of cleaning. Throughout the ward high and low level surfaces 

were dusty. Windows, windowsills, blinds, glass panelling, flooring, 

walls, skirting, ceiling lights and radiators required cleaning as dust soil 

or stains were observed. 

In both wards, limescale was noted on the taps of sinks in the general 

ward, the sinks in sanitary areas and on shower or bath fittings. In 

Erne greater attention was required to cleaning sinks throughout the 

ward. Particular care was required to ensure that limescale is removed 

from taps and fittings as recent evidence has shown that limescale may 

harbour biofilms and the build-up of limescale can interfere with good 

cleaning and disinfection by masking and protecting pathogens. 

Improvement was required in both wards when cleaning shower chairs. 

In Donegore the underneath of the shower chair was splashed and 

dirty. In Erne the top and underside of the specialist shower chair was 

extremely dirty. Faeces was noted on the seat, castors and the top 

and underside frame of the chair. Inspectors were concerned to note 

that this chair was used to shower patients. This was immediately 

brought to the attention of nursing staff who were not aware of their 

responsibility to clean the chair after use. Staff were unable to inform 

inspectors of when the chair had been last cleaned however on request 

from the inspectors they did clean the chair. 

In Erne, the underside of the dining room tables and chair crevices 

were dirty, and the padded sensory furniture was stained. Inspectors 

were concerned that staff were not fully checking patients beds as in 

one patient bed debris was noted under the cover, on the bed sheet. 

11

In Donegore the bath was dirty; the charge nurse confirmed he would 

contact the bath manufacturer for advice on a safe cleaning product for 

staff to use when cleaning the bath. 

In Erne bathroom and toilet, the toilet brush was faecally stained and 

the toilet brush holder was dusty and in the bathroom the underside of 

the toilet seat was stained. In the shower room there were faecal 

stains on the shower wall and there were a number of faecal deposits 

covering the shower base. In the clinical room the equipment sink 

drain required cleaning and the seal of the drugs fridge was dirty. 

The cleaning of the single bedrooms inspected in Donegore was 

generally good, however, attention to detail could be improved to 

ensure marks and stains are removed from walls and debris from 

between the glass window panes. 

In a side room in Erne, it was noted that the bedframe and underneath 

the mattress, were dirty, there was faecal staining on the head board 

and the inside of the mattress cover was stained; there was a strong 

smell of urine from the mattress. This is not acceptable practice as it 

compromises patient dignity and the delivery of care in a safe and 

clean environment. Although staff advised that mattress checks were 

carried out there were no records to substantiate this. One staff 

member advised that the moving and handling of a mattress to carry 

out a check was a health and safety/manual handling issue; staff had 

not been trained on how to carry out mattress checks. This issue 

should be reviewed by the trust manual handling and health and safety 

officer. 

In this side room, further work was required to ensure dirt is removed 

from the inside of the radiator and stains from the window. Inspectors 

noted that the hand washing sink, plughole and overflow required 

cleaning and there were faecal stains on the sink splash back. 

6.2 Clutter 

In both wards there was 

evidence of an emphasis in 

providing clutter free 

environments (Picture 1). 

However inspectors observed 

that some rooms and surfaces 

were cluttered in appearance. 

Picture 1: Donegore, Storage cupboards 

In Donegore the disposal 

room was small and untidy 

and in the clinical room the 

top surface of the 

venepuncture trolley was 

cluttered with equipment. 

12

Inspectors observed that in Erne a large stock of communal toiletries 

were in use and incontinence pads were stored out of packaging on the 

shelf behind the toilet; increasing the potential for aerosol 

contamination when flushing the toilet. The clinical room was cluttered 

in appearance, equipment was stored on top of cupboards, hanging 

basket attachments were kept in a cupboard and laundry bags were 

placed on top of a chair. Christmas decorations were stored in a 

bedroom, impeding effective cleaning. 

6.3 Maintenance and Repair 

Inspectors noted that when comparing both wards there was a marked 

difference in the areas where maintenance and repair was required. 

Donegore was generally in a good state of repair however minor wall 

plaster and paintwork damage was observed in the general ward and 

some areas of flooring, notably in the communal areas had minor rips 

and tears. 

In contrast in Erne, wall plaster and paintwork, skirting, door and door 

frame and floor damage was observed throughout the ward, including 

the single room inspected. Inspectors observed chipped dado rails, 

worn floor joins, exposed damaged wooden doors and door frames and 

missing or chipped skirting. A hole in the shower room door had been 

plugged with paper and the flooring around the soil pipe in the 

bathroom had not been sealed. A strong smell of urine was also 

present in the toilet. 

6.4 Fixtures and Fittings 

Inspectors observed worn, scored, damaged or torn furniture; tables, 

settees and chairs in both wards. It was also noted that toilet roll 

dispensers were not available at all toilets. 

In Donegore the fixtures, fittings and equipment were modern and up to 

date however in Erne they were old, worn and in need of replacement 

or repair. 

In Erne the public telephone was cracked and repaired with adhesive 

tape, a wall unit was on the floor of the visitors’ toilet and toilet seat 

fittings in sanitary areas were old, worn and rusted. Inspectors noted 

that there was a lack of toilet roll holders throughout the ward. Wooden 

shelving in the domestic store was unsealed, the domestic sluice sink 

enamel was chipped and the wooden panel worn and the tap in the 

patients toilet was dripping. 

Inspectors also observed in Erne that there were no patient privacy 

curtains or portable screens available in the multi bedded rooms and 

throughout the ward the lighting was dim, possibly hindering effective 

cleaning. 

13

In Erne the emergency pull cord in the bathroom was taped to the 

ceiling and therefore inaccessible in the event of an emergency. 

Staff advised that the bath was not used on a regular basis however 

were unable to advise if the water was run to prevent the development 

of legionella. 

A similar issue was noted in the single room where sink taps were old 

and worn. The tap twist mechanisms had been removed and the 

plughole sealed to prevent the flow of water. Staff were unsure if the 

water supply to the sink had been turned off or if there was the 

possibility of water pooling in the sink pipework system; therefore 

creating the potential for the development/spread of legionella if the tap 

mechanisms were reactivated. 

6.5 Information 

In both wards there were no up to date information leaflets available on 

hand hygiene, general infection prevention and control, MRSA and 

Clostridium difficile. It was also noted that there was no poster for staff 

on the management of an inoculation injury. In Donegore information 

on the segregation of waste was not available and in Erne there was no 

National Patient Safety Agency (NPSA) cleaning colour coded poster 

present for nursing staff to reference. In both wards there was good 

domestic schedules and information in the domestic store detailed and 

included up to date information on how, when and the specific 

equipment and materials needed for cleaning (Picture 2). 

Picture 2: Erne, Domestic schedules and information 

In Erne some posters were attached to surfaces with adhesive tape 

rather than blu tac and the information folder in the kitchen was 

damaged; the waterproof cover was split and therefore unable to be 

effectively cleaned. 

Inspectors noted that in Donegore nurse cleaning schedules while 

available did not detail all equipment to be cleaned. In Erne there were 

no nursing equipment cleaning schedules available. Schedules which 

detail all equipment specific to the ward and staff roles and 

responsibilities should be developed and displayed. 

14

Fridge temperature readings were recorded in both wards however in 

Donegore the record sheet did not evidence action taken for variations 

in temperature and in Erne there was no temperature range for staff to 

reference. 

6.6 Additional Issues 

Donegore 

Erne 

There were no toilet roll dispensers in the en-suite toilets 

Issues identified that compromise patient dignity and the delivery 

of care in a safe and clean environment have been forwarded to 

the RQIA Mental Health and Learning Disability Team for 

performance management 

The lighting throughout the ward was dim, possibly hindering 

effective cleaning 

Christmas decorations were stored in a bedroom, impeding 

effective cleaning 

The emergency pull cord in the bathroom was taped to the ceiling 

and therefore inaccessible in the event of an emergency 

Inspectors observed that there were no patient privacy curtains or 

portable screens available in the three bedded room 

Recommendations 

1. The trust should ensure that the systems and processes in 

place for environmental cleaning, provide the necessary 

assurance that cleaning is carried out effectively and that all 

staff are aware of their responsibilities. 

2. The healthcare environment should be repaired and 

maintained, damaged fixtures and fittings replaced to help 

reduce the risk of the spread of infection. 

3. The trust should ensure that water systems are maintained 

appropriately to prevent the development of legionella. 

4. The trust and staff should work to maintain clutter free ward 

environments. 

5. The trust should ensure all relevant information leaflets and 

posters are available for patients, visitors and staff to 

reference and use. 

15

6. Detailed nursing cleaning schedules should be developed. 

7. The trust should ensure a standard drugs fridge temperature 

recording sheet is developed for staff to use. 

8. The trust and individual staff have a collective responsibility 

to ensure that patients dignity is maintained at all times and 

care is delivered in a safe and clean environment. 

16

7.0 Patient Linen 

STANDARD 3.0 

PATIENT LINEN 

Storage of clean linen; handling and storage of used linen; ward/ 

department laundry facilities. 

7.1 Management of Linen 

Linen Donegore Erne 

Storage of clean linen 96 61 

Storage of used linen 100 93 

Laundry facilities 87 N/A 

Total 94 77 

Donegore staff are commended for achieving an overall high 

compliance score in this standard, with full compliance achieved in the 

storage of used linen. In contrast Erne achieved overall partial 

compliance, with a minimally compliant score in the storage of clean 

linen. 

In Donegore clean linen store, the only issue identified was chipped 

flaky paint on the walls. In Erne the clean linen store was cluttered, the 

shelving was not sealed and unable to be effectively cleaned, the walls 

and door were stained and damaged and skirting was inaccessible to 

clean. 

Inspectors noted in Erne that although the trust has implemented sleep 

knit fitted sheets and bedding, flat linen and woolen blankets were 

stored in the clean linen store. It was also observed in the shower 

room that towels were stored uncovered in a wicker storage basket, 

behind the toilet; increasing the potential for aerosol contamination 

when flushing the toilet. This was also noted in Donegore, towels and 

a facecloth were stored uncovered on top of a storage unit beside the 

toilet in the bathroom. In a bedroom in Erne, washed and ironed 

multiple patients’ clothing, from the main laundry, was observed stored 

on top of a patient’s bed (Picture 2). 

17

Picture 2: Erne, Multiple patients clothing on a bed 

In both wards there were no issues identified with the handling and 

storage of used linen. Used linen skips were clean, however in Erne 

torn reusable linen bags were observed. 

Erne’s linen and patient clothing was processed in the main hospital 

laundry, Donegore had a ward based laundry. Inspectors noted in the 

ward laundry chipped flaky paintwork on the walls, the floor in front of 

the washing machine was rusted and there was limescale on the taps. 

It was also noted that some of the colour coded plastic containers for 

storing patient clothing were cracked and there was no PPE dispenser 

for the disposable aprons and gloves, boxes of gloves were stored on 

work surfaces. 


9. The trust should ensure the correct handling and storage of 

clean linen in a designated area or in equipment which is 

clean and fit for purpose. 

18

8.0 Waste and Sharps 

STANDARD 4.0 

WASTE AND SHARPS 

Waste: Effectiveness of arrangements for handling, segregation, 

storage and disposal of waste on ward/department 

Sharps: Availability, use and storage of sharps containers on 

ward/department 

Waste and sharps Donegore Erne 

Handling, segregation, 

storage, waste 

Availability, use, storage of 

sharps 

88 79 

91 86 

8.1 Waste 

The inspection evidenced that there were arrangements in place for the 

handling, segregation, storage and disposal of waste which generally 

comply with local and regional guidance. Donegore achieved 

compliance in this standard, Erne achieved partial compliance. 

In both wards inspectors observed that waste was segregated and 

disposed of incorrectly. In Donegore household waste was disposed of 

into a pharmaceutical black lidded burn bin and in Erne general use 

sharps were observed inappropriately disposed of into a cytotoxic 

sharps box. 

In both wards it was noted that not all toilets had a household waste 

bin. In Donegore there was no household waste bin in a toilet and the 

domestic store and the household waste bin in the bathroom was 

starting to rust at the base. In Erne the outside of the household waste 

bin, in the domestic store, was stained and the base was rusty. In the 

bathroom the base of the household waste bin was dirty and in the 

shower room the lid of the household waste bin was faecally stained. 

Inspectors also noted a waste bag tied to the domestic trolley and 

nursing staff were not aware of how to dispose of suction waste. 

8.2 Sharps 

Wards are commended for achieving compliance in this standard. 

Sharps boxes in use conformed to BS7320 (1990)/UN9291 standards. 

In both wards either sharps boxes or a black lidded burn bin were not 

assembled correctly; labelled with the date, locality and staff signature. 

19

This is unsafe practice as correct labelling ensures that if there is a 

spillage of sharps waste from the sharps box or an injury to a staff 

member as a result of incorrect assembly/disposal, the area the sharps 

box originated from can be immediately identified. Identifying the origin 

of the sharps box and its contents is imperative to assist in the 

immediate risk assessment process carried out following a sharps 

injury and also to ensure that staff who incorrectly assembled/disposed 

of the sharps box can receive education on the correct procedures to 

follow. This practice was immediately addressed by the charge nurse 

in Donegore. 

Inspectors observed that sharps boxes were stored securely, tagged 

and signed prior to collection however in Erne the sharps boxes were 

dusty and staff advised that they had been waiting some time for the 

boxes to be collected. In both wards integral sharps trays, used to 

store a sharps box and equipment when carrying out a procedure, 

were not available; stainless steel receivers or an enamel lidded dish 

were in use. 

It was observed in all wards that the temporary closure mechanisms, to 

prevent spillage and impede access, were in place when the sharps 

boxes were not in use. 


10. The trust should monitor the implementation of its policies 

and procedures in respect of the management of waste and 

sharps to ensure that safe and appropriate practice is in 

place. 

11. The trust should ensure that waste bins and equipment used 

in the management of waste and sharps are clean and that 

waste bins are available and fit for purpose. 


to ensure that staff knowledge is kept up to date regarding 

the safe and the correct handling and disposal of waste and 

sharps. 

20

9.0 Patient Equipment 

STANDARD 5.0 

PATIENT EQUIPMENT 

Cleanliness and state of repair of general patient equipment. 

Patient Equipment Donegore Erne 

Patient equipment 87 44 

Donegore is commended for achieving compliance in this standard 

however in contrast Erne achieved minimal compliance; cleaning 

carried out was of an unsatisfactory standard. A concentrated effort is 

required by all staff in Erne to improve and maintain the standard of 

equipment cleaning at ward level. 

Issues identified in both wards for action were respiratory equipment 

stored out of packaging, staff not aware of the symbol for single use, 

replacing reusable old, worn and grubby tourniquets and cleaning the 

tray of the water cooler/ice machine. In Donegore one further issue to 

be addressed related to repairing chipped and peeling laminate on the 

drugs trolley. 

In Erne, inspectors were concerned to note that a significant amount of 

patient equipment inspected required cleaning and some stock 

equipment was out of date. In the clinical room a box of sterile single 

use blood venepuncture sets was out of date and a large stock of 

laryngeal masks were due to expire in February 2012; this would 

indicate stock rotation was not carried out. Reusable equipment was 

not decontaminated between patient use or discarded if single use; 

scissors. Reusable stainless steel kidney dishes and trays were dirty, 

staff advised that these were not routinely used. The commode was 

stained with faeces, the seat lid was split, the underside was 

stained/rusty and there was no trigger tape insitu to identify that the 

commode had been cleaned. Dirty commode pots (Picture 4) were 

stacked in the corner of the shower room; a staff member advised staff 

that these were used as receptacles to wash patients. 

21

Picture 4: Erne, Dirty commode pot 

Stored patient equipment was dirty, worn and there was no trigger tape 

insitu, the patient wash bowl had label residue present and was not 

stored inverted when not in use. The inside of the portable nebuliser 

machine had debris present, reusable suction canisters were 

dusty/dirty and the portable suction machine was dusty. The reusable 

single patient use nebuliser mask and chamber on the portable 

nebuliser machine was dirty and stored uncovered; staff had not 

changed or cleaned the mask after use. 

The underside of the drugs trolley was stained, the linen trolley was 

cluttered and the frame was worn. The hoist frame was dusty, stained, 

the frame was worn to the metal and not all staff were able to advise 

inspectors how to clean reusable hoist slings. Debris was noted in the 

wheelchair crevices, the standing aid in the bathroom was stained and 

dusty and the seat of the weighing scales was stained. It was also 

observed that due to the position of the portable resuscitation bag 

bedside the hand washing sink the bag was splashed with water. 



to ensure that patient equipment is clean, stored correctly, in 

a good state of repair and changed in line with manufactures 

guidelines. 



equipment cleaning. 

22

10.0 Hygiene Factors 

STANDARD 6.0 

HYGIENE FACTORS 

Hand wash facilities; alcohol hand rub; availability of PPE; 

availability of cleaning equipment and materials. 

Hygiene Factors Donegore Erne 

Availability and cleanliness 

of WHB and consumables 

96 79 

Availability of alcohol rub 77 80 

Availability of PPE 83 67 

Materials and equipment 

for cleaning 

98 85 

Total 89 78 

Donegore achieved an overall compliance score in this standard. Erne 

achieved overall partial compliance, with a minimal compliance score in 

the availability of PPE. 

In Erne greater attention to detail was required to ensure hand washing 

sinks and fixtures and fittings were clean, accessible, working and in a 

good state of repair. Access to the hand washing sink in the clinical 

room was blocked with equipment, in the bathroom the sink overflow 

was dirty, in the toilet the sink was worn and stained. The hand 

washing sink in the visitors’ toilet was not draining; there was pooled 

water present and the cold water tap was dripping. In Donegore the 

clinical hand washing sink in the toilet had an overflow present. 

In general the underside of soap and hand towels dispensers was 

clean however care should be taken to ensure the underside of all 

dispensers are cleaned regularly. In Erne inspectors noted that there 

was no consistent approach to the placement of wall mounted soap 

and hand towel dispensers. In toilet areas there was either a soap 

dispenser and no hand towels or hand towels and no soap dispenser, 

therefore neither patients or staff were able to carry out effective hand 

hygiene. 

During the inspection, inspectors requested that liquid soap should be 

made available immediately at the sink in the shower room. A staff 

member advised that soap had been present at the sink however the 

container had become empty and had been thrown out, the staff 

member placed a portable pump soap dispenser at the sink. It was 

concerning to note that during the inspection, although numerous staff 

used this room for the delivery of patient care they did not appear to 

observe the lack of soap for hand washing purposes. 

23

In both wards, wall mounted alcohol rub dispensers were not available 

at the entrance or throughout the ward, however in Donegore a 

dispenser was available in the front lobby and in Erne’s clinical room. 

In Erne individual staff use portable alcohol rub dispensers and 

individual staff bottles of alcohol rub were not in use; staff advised that 

there were available if requested. 

Inspectors observed a range of PPE available however in both wards 

there was no consistent approach to the storage of PPE. Disposable 

single use aprons and gloves were either stored in cupboards or on 

wall mounted holders beside toilets; increasing the potential risk of 

aerosol contamination. In Erne sterile gloves were stored on a shelf 

above the toilet in the shower room, there was no face protection 

available for general use and overshoes were available for use when 

showering patients. The use of overshoes should be reviewed as 

these can split easily and have the potential to cause airborne 

dispersal when removed due to the elastic trim expanding and 

contracting sharply. 

In Donegore not all nursing staff were aware of the dilution rate for the 

cleaning agent in use. In Erne cleaning solutions were not stored in 

accordance with Control of Substances Hazardous to Health (COSHH) 

regulations in a locked area; the back kitchen door was open. Open 

tubs of detergent cleaning wipes had dried out; this would indicate they 

were not used regularly. 

In Erne attention to detail was required in the cleaning and storage of 

equipment used for general cleaning. Inspectors noted that some mop 

buckets and dust pans required cleaning and not all mop buckets and 

basins were stored inverted. Some inverted buckets had not been 

dried out effectively resulting in pools of water on the shelving. Two 

old, cluttered, stained and worn domestic trolleys were observed. 

Inspectors noted and were advised that a new domestic trolley had 

been delivered to the ward on the day before the inspection (Picture 5). 

Picture 5: Erne, New domestic trolley 

24


15. The trust should ensure that hand washing sinks are clean, 

working and in a good state of repair. 

16. The trust should review and take a consistent approach to 

the placement of soap, hand towels and alcohol rub 

dispensers. 


to ensure that wall mounted dispensers are clean and that 

consumables are available for use. 


to ensure that PPE is stored appropriately. 

19. The trust should ensure that all cleaning products are stored 

in a locked cupboard, in line with COSHH regulations. 


to ensure that staff knowledge is kept up to date in the use of 

general cleaning products. 

21. Further attention to detail is required to ensure that 

equipment used for the general cleaning purposes of a ward 

is clean, fit for purpose and stored appropriately. 

25

11.0 Hygiene Practices 

STANDARD 7.0 

HYGIENE PRACTICES 

Hand hygiene procedures; handling and disposal of sharps; use 

of PPE; use of isolation facilities and implementation of infection 

control procedures; cleaning of ward/department; staff uniform 

and work wear. 

Hygiene practices Donegore Erne 

Effective hand hygiene 

procedures 

80 43 

Safe handling and disposal 

of sharps 

100 50 

Effective use of PPE 100 73 

Correct use of isolation N/A N/A 

Effective cleaning of ward 63 56 

Staff uniform and work 

wear 

93 70 

Total 87 58 

Donegore is commended for achieving overall compliance in this 

standard and full compliance in the safe handling and disposal of 

sharps and effective use of PPE. In contrast inspectors were 

concerned to note that Erne achieved minimal compliance in all 

sections of this standard. A concentrated effort, supported by senior 

management, is required in Erne to improve and maintain practices 

within this standard. 

In both wards not all nursing and care staff were aware of the 7 step 

hand hygiene technique for use with soap or alcohol rub. In Erne 

inspectors observed that hand hygiene was not carried out 

appropriately during personal care or when socially working with 

patients. Not all nursing and care staff were aware of when to 

appropriately use antibacterial hand washing solution; one staff 

member routinely used hibiscrub hand disinfectant after hand washing 

with soap and water. On observation inspectors noted that due to the 

lack of consumables there was limited opportunity for staff to carry out 

hand hygiene on patients. Hand hygiene audits were not carried out at 

ward level. 

There were no issues identified in Donegore with the safe handling and 

disposal of sharps and effective use of PPE. 

26

Picture 6: Erne, Venepuncture set 

with blood insitu 

In Erne a sharp was not 

disposed of safely into a 

sharps box at the point of use; 

a butterfly venepuncture set, 

with blood in the tubing, was 

observed in an old enamel 

tray stored in a cupboard 

(Picture 6). It was also noted 

on questioning of staff that not 

all staff were aware of the 

correct steps and 

management of an inoculation 

injury. 

Inspectors in Erne observed that sterile gloves were inappropriately 

used for toileting patients and delivering personal care. Face 

protection was not used by nursing and care staff when there was a 

risk of aerosol contamination from cleaning a shower chair, which was 

heavily soiled with faeces, and domestic staff were inappropriately 

using vinyl gloves when cleaning. As already mentioned in the 

environment section there was a lack of toilet roll holders throughout 

the ward. Staff advised that toilet roll is not routinely used on patient; 

communal tena wash cream is used to cleanse patients after toileting. 

It is advised that the practice is reviewed in regards to tena wash 

cream being a non rinse cleanser and toilet roll should be considered 

when removing heavy soiling. 

In both wards inspectors did not see routine cleaning of equipment 

between use, nursing staff on Erne were unfamiliar with their 

responsibility for cleaning. Discussion with staff identified that not all 

nursing and care staff were aware of the correct disinfectant solution to 

use or its dilution rate for general disinfectant cleaning or for cleaning 

blood and body fluid spillages. It was also noted that not all nursing 

and care staff were aware of the procedure to follow when cleaning 

blood and body fluid spillages. The majority of nursing and care staff 

were not aware of the NPSA domestic cleaning colour coded system. 

In both wards work is required to ensure adherence to the trust and 

regional dress code policy and the concept of ‘bare below the elbow’. 

In Donegore a member of nursing staff did not have long hair tied up 

off the collar and a domestic wore stoned earrings. In Erne one care 

staff was wearing a hoodie and another was wearing a long sleeved 

shirt. A nurse’s uniform was stained around the pocket, one member 

of staff was wearing a watch and two members of care staff were 

wearing nail polish. There were no changing facilities for nursing or 

domestic staff to change out of their uniform and care staff were 

unfamiliar with the trust’s uniform laundry policy. 

27

11.1 Additional Issues 

Donegore 

Erne 

Hand hygiene audits were not carried out 

Staff advised that toilet roll is not routinely used on patient; 

communal tena wash cream is used to cleanse patients after 

toileting. It is advised that the practice is reviewed in regards to 

tena wash cream being a non rinse cleanser and toilet roll should 

be considered when removing heavy soiling 


22. 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. 


ensure safe practice is carried out when handling sharps. 


ensure that staff knowledge is kept up to date with regard to 

cleaning and decontamination of equipment and the environment. 

25. The trust should ensure that all members of staff are familiar with 

and adhere to the regional dress code policy. 


ensure that personal care is delivered appropriately, using the 

correct equipment and solutions. 

28

12.0 Key Personnel and Information 

Members of the RQIA inspection team 

Mrs S O'Connor - Inspector Infection Prevention/Hygiene Team 

Mrs M Keating - Inspector Infection Prevention/Hygiene Team 

Mrs L Gawley - Inspector Infection Prevention/Hygiene Team 

Mrs Helen Hamilton - Project Manager, Review Directorate 

Trust representatives attending the feedback session 

Mr Barry Mills 

Mr Ramond Davey 

Mr Darren Hamill 

Mrs Mary Hanrahan 

Ms Helen Burke 

Mr Michael McBride 

- Operations Manager, Nursing 

- Support services Manager 

- Estates Service Manager 

- Senior Infection Prevention and Control Nurse 

- Ward Manager, Erne 

- Ward Manager, Donegore 

Supporting documentation 

A number of documents have been developed to support the inspection 

process, these are: 

Infection Prevention/Hygiene Inspection Process (methodology, 

follow up and reporting) 

Infection Prevention/Hygiene Team Inspection Protocol (this 

document contains details on how inspections are carried out and 

the composition of the teams) 

Infection Prevention/Hygiene Team Escalation Policy 

RQIA Policy and Procedure for Use and Storage of Digital Images 

This information is currently available on request and will be available 

in due course on the RQIA website. 

29

13.0 Summary of Recommendations 

1. The trust should ensure that the systems and processes in 

place for environmental cleaning, provide the necessary 

assurance that cleaning is carried out effectively and that all 

staff are aware of their responsibilities. 


maintained, damaged fixtures and fittings replaced to help 

reduce the risk of the spread of infection. 

3. The trust should ensure that water systems are maintained 

appropriately to prevent the development of legionella. 

4. The trust and staff should work to maintain clutter free ward 

environments. 

5. The trust should ensure all relevant information leaflets and 

posters are available for patients, visitors and staff to 


6. Detailed nursing cleaning schedules should be developed. 

7. The trust should ensure a standard drugs fridge temperature 

recording sheet is developed for staff to use. 


to ensure that patients dignity is maintained at all times and 

care is delivered in a safe and clean environment. 

9. The trust should ensure the correct handling and storage of 

clean linen in a designated area or in equipment which is 

clean and fit for purpose. 


and procedures in respect of the management of waste and 

sharps to ensure that safe and appropriate practice is in 

place. 

11. The trust should ensure that waste bins and equipment used 

in the management of waste and sharps are clean and that 

waste bins are available and fit for purpose. 



the safe and the correct handling and disposal of waste and 

sharps. 


to ensure that patient equipment is clean, stored correctly, in 

30

a good state of repair and changed in line with manufactures 

guidelines. 



equipment cleaning. 

15. The trust should ensure that hand washing sinks are clean, 

working and in a good state of repair. 

16. The trust should review and take a consistent approach to 

the placement of soap, hand towels and alcohol rub 

dispensers. 


to ensure that wall mounted dispensers are clean and that 

consumables are available for use. 


to ensure that PPE is stored appropriately. 

19. The trust should ensure that all cleaning products are stored 

in a locked cupboard, in line with COSHH regulations. 


to ensure that staff knowledge is kept up to date in the use of 

general cleaning products. 


equipment used for the general cleaning purposes of a ward 

is clean, fit for purpose and stored appropriately. 


to ensure that hand hygiene is carried out in line with WHO 

guidance and that all PPE is used appropriately. 


to ensure safe practice is carried out when handling sharps. 


to ensure that staff knowledge is kept up to date with regard 

to cleaning and decontamination of equipment and the 

environment. 

25. The trust should ensure that all members of staff are familiar 

with and adhere to the regional dress code policy. 


to ensure that personal care is delivered appropriately, using 

the correct equipment and solutions. 

31

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 

RQIA Hygiene Team 

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 


Carry out Inspection 

A 

Is there immediate risk 

requiring formal escalation? 

NO 

YES 

Invoke 

RQIA 

IPHTeam 

Escalation 

Process 


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 

32

15.0 Escalation Process 

RQIA Hygiene Team: Escalation Process 

B 

RQIA IPH 

Team 

Escalation 

Process 

Concern / Allegation / Disclosure 

Inform Team Leader / Head of Programme 

MINOR/MODERATE 

Has the risk been 

assessed as Minor, 

Moderate or Major? 

MAJOR 

Inform key contact and keep a record 

Inform appropriate RQIA Director and Chief Executive 

Record in final report 

Inform Trust / Establishment / Agency 

and request action plan 

Notify Chairperson and 

Board Members 

Inform other establishments as appropriate: 

E.g.: DHSSPS, RRT, HSC Board, PHA, 

HSENI 

Seek assurance on implementation of actions 

Take necessary action: 

E.g.: Follow-Up Inspection 

33

16.0 Action Plan 

Ref No. 


1. The trust should ensure that the systems and processes 

in place for environmental cleaning; provide the 

necessary assurance that cleaning is carried out 

effectively and that all staff are aware of their 

responsibilities. 

Designated 

department 

Nursing 

PCSS 

IPC 

Action required 

‘Roles and responsibilities of Staff in 

relation to Environmental Cleanliness and 

Cleanliness of Equipment’ policy under 

review. 

Work / negotiations in relation to the 

cleaning manual are still ongoing. In 

particular, there is discussion with 

nursing/control of infection with reference 

to bed cleaning. Once agreement is 

reached the manual will be finalised. 

Date for 

completion/ 

timescale 

Mar 2012 

Jun 2012 


maintained, damaged fixtures and fittings replaced to 

help reduce the risk of the spread of infection. 

3. The trust should ensure that water systems are 

maintained appropriately to prevent the development of 

legionella. 

4. The trust and staff should work to maintain clutter free 

ward environments. 

5. The trust should ensure all relevant information leaflets 

and posters are available for patients, visitors and staff to 


Estates 

IPC 

Other 

appropriate 

staff 

Estates 

All 

Directorates 

IPC 

All of these aspects will be monitored 

through the programme of Environmental 

Cleanliness Audits based on the 

Cleanliness Matters Strategy and results 

fed back through Balanced Scorecards. 

This is ongoing as part of Estate daily 

maintenance and refurbishment 

programmes. 

Water systems are managed under the 

auspices of the Water Safety & Usage 

Group and the Trust’s Water Management 

Plan. 

Planned programme of de-clutter and 

deep cleaning in place. Ongoing space 

utilisation and de-cluttering is being driven 

by Service Managers. 

The Trust has secured funding from the 

PHA to take forward the issue of HCAI 

communication. 

Ongoing 

Ongoing 

Ongoing 

Ongoing 


6. Detailed nursing cleaning schedules should be Nursing A sub-group of IPECC (Infection Complete 

34

Ref No. 


Designated 

department 


developed. IPECC Prevention & Environment and 

Cleanliness Committee) has been set up 

to review and standardise cleaning 

schedules, and will establish any 

outstanding issues of audit 

standardisation process. 

Agree a standardised audit which will be 

used in all areas. This will include 

standardised responsibilities. To be kept 

under review. 

Systematic roll out of the agreed 

standardised audit using the Maximiser 

system. 

Date for 

completion/ 

timescale 

Commencing 

Feb 2012 

7. The trust should ensure a standard drugs fridge 

temperature recording sheet is developed for staff to use. 

Nursing 

The Medicines Code outlines procedures 

for use of medicine fridges. A 

pharmaceutical refrigerator temperature 

log sheet is maintained for each individual 

fridge, with records being maintained and 

monitored by Ward Managers. 

Ongoing 

8. The trust and individual staff have a collective 

responsibility to ensure that patients’ dignity is maintained 

at all times and care is delivered in a safe and clean 

environment. 

Nursing 

The Trust has a Patient Privacy and 

Dignity Policy. The contents of this policy 

and the importance of adhering to it will 

be re-iterated to all relevant staff. 

Complete 

9. The trust should ensure the correct handling and storage 

of clean linen in a designated area or in equipment which 

is clean and fit for purpose. 

Nursing 

Guidance regarding storage of linen is in 

the Regional Infection Prevention Manual. 

Linen storage and segregation guidance 

has been circulated to all Directorates. 

Complete 

This states that all linen must be stored off 

the floor in a clean dedicated area that 

allows for ease of access and rotation of 

stock and that Linen rooms must have 

shelving that are easy to clean, and 

35

Ref No. 


Designated 

department 


cleaning frequencies must be at least 

quarterly. 

Date for 

completion/ 

timescale 


and procedures in respect of the management of waste 

and sharps to ensure that safe and appropriate practice is 

in place. 

PCSS 

Nursing 

The Trust will pilot and roll out across all 

facilities the use of an electronic tool to 

audit waste management compliance 

against policy, procedure and RQIA 

requirements. This process will 

supplement the existing audit tools used 

by PCSS, IPC and also existing external 

audits conducted by Daniels (sharps box 

suppliers). 

Daniels’ audit completed Oct 2011 and 

results disseminated. 

Pilot 

completed 

Roll-out 

programme 

across Trust to 

be completed 

by Apr 2012 

Complete 

11. The trust should ensure that waste bins and equipment 

used in the management of waste and sharps are clean 

and that waste bins are available and fit for purpose. 

PCSS 

Nursing 

This is monitored as part of the 

Environmental Cleanliness Audit 

Programme. 

Ongoing 

Regional contract for bins at adjudication 

stage. 

Environmental cleanliness audit 

programmes, which include daily ward 

checks, department and managerial 

audits, and IPC audits monitor 

compliance. 

Where an issue has been highlighted, 

action will be taken in conjunction with the 

appropriate department to ensure 

rectification. 


responsibility to ensure that staff knowledge is kept up to 

date regarding the safe and the correct handling and 

disposal of waste and sharps. 

IPC 

There is a training programme available to 

all staff. 

Update and refresher training will continue 

Complete 

36

Ref No. 


Designated 

department 

to be provided. 


Date for 

completion/ 

timescale 









suppliers). 

Pilot 

completed 

Roll-out 

programme 


be completed 


‘Daniels’ audit completed in October 2011 

and results have been disseminated 

Safer Needle Device Group met again in 

Dec 2011. 


responsibility to ensure that patient equipment is clean, 

stored correctly, in a good state of repair and changed in 

line with manufactures guidelines. 

Nursing 

PCSS 





bed cleaning. Once agreement is reached 

the manual will be finalised. 


The manual includes roles and 

responsibilities of trust staff in relation to 

patient equipment. A template will be 

used to record all cleaning of equipment. 



date regarding equipment cleaning. 

Nursing 

Role and responsibilities policy in place. 

Cleaning statements document for all 

wards and departments to be finalised 

and disseminated. This forms part of the 

cleaning manual. 

Complete 


37

Ref No. 


15. The trust should ensure that hand washing sinks are 

clean, working and in a good state of repair. 

Designated 

department 

PCSS 




Programme. Staff are reminded of the 

importance of replenishing dispensers. 

Date for 

completion/ 

timescale 

Ongoing 





compliance. 





Regular training is provided to all 

appropriate staff. 

16. The trust should review and take a consistent approach 

to the placement of soap, hand towels and alcohol rub 

dispensers. 

PCSS 

Nursing 

As part of the departmental audit process, 

all sinks will be checked for soap, hand 

towel and alcohol rub dispensers. 

Complete 


responsibility to ensure that wall mounted dispensers are 

clean and that consumables are available for use. 

PCSS 



Programme. Staff are reminded of the 

importance of replenishing dispensers. 

Ongoing 





compliance. 





38

Ref No. 


Designated 

department 


Date for 

completion/ 

timescale 


responsibility to ensure that PPE is stored appropriately. 

Nursing 

IPC 



This is monitored during IPC visits and 

audits. 

Ongoing 

Ward staff will monitor on an ongoing 

basis 

19. The trust should ensure that all cleaning products are 

stored in a locked cupboard, in line with COSHH 

regulations. 

PCSS 

Locked cupboards are provided. 

Ward managers and PCSS supervisors 

carry out regular checks to ensure all staff 

comply with COSHH procedures. Audited 

as part of Belfast Risk Assessment and 

Audit Tool (BRAAT). 

Complete and 

ongoing 



date in the use of general cleaning products. 


equipment used for the general cleaning purposes of a 

ward is clean, fit for purpose and stored appropriately. 

PCSS 

Nursing 

PCSS 

The Trust is BICS accredited and is in the 

process of training supervisors and 

assessors in BICS. Training is ongoing 

and includes staff knowledge in the use of 

cleaning materials. 





compliance. 

Ongoing 

Ongoing 









39

Ref No. 



responsibility to ensure that hand hygiene is carried out in 

line with WHO guidance and that all PPE is used 

appropriately. 

Designated 

department 

IPCT 





bed cleaning. Once agreement is reached 

the manual will be finalised. 

Balance scorecards, which 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. 

Date for 

completion/ 

timescale 

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). 


responsibility to ensure safe practice is carried out when 

handling sharps. 

PCSS 

The IPCT is currently devising an 

educational tool to remind staff of the 

appropriate use of PPE. 

There is a training programme available to 

all staff. 

Update and refresher training will continue 

to be provided. 

Complete 









suppliers). 

Pilot 

completed 

Roll-out 

programme 


be completed 


‘Daniels’ audit completed in October 2011 

40

Ref No. 


Designated 

department 


and results have been disseminated 

Date for 

completion/ 

timescale 

Safer Needle Device Group met again in 

Dec 2011. 



date with regard to cleaning and decontamination of 

equipment and the environment. 

IPCT 

Mandatory Infection Prevention & Control 

training is delivered by IPCN Team. 

Staff to be reminded of the link to the 

regional Infection Control Manual and the 

‘Medical and Nursing Equipment Cleaning 

Guide’ has been re-circulated. 

Ongoing 

All service managers received email 

copies of the cleaning guide poster for 

dissemination to all wards and 

departments. Assurance is gained 

through environmental cleanliness audit 




compliance. 





25. 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 

Ongoing 

41

Ref No. 


Designated 

department 

basis. 


Date for 

completion/ 

timescale 


responsibility to ensure that personal care is delivered 

appropriately, using the correct equipment and solutions. 

Nursing 

All ward staff are now using the 

appropriate equipment and materials. 

Complete 

42

Muckamore Abbey Hospital, Antrim - 16 February 2012

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