Muckamore Abbey Hospital, Antrim - 16 February 2012

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Ref No. Recommendations 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. Designated department IPCT Action required cleaning manual are still ongoing. In particular, there is discussion with nursing/control of infection with reference 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). 23. The trust and individual staff have a collective 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 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). Pilot completed Roll-out programme across Trust to be completed by Apr <strong>2012</strong> ‘Daniels’ audit completed in October 2011 40
Ref No. Recommendations Designated department Action required and results have been disseminated Date for completion/ timescale Safer Needle Device Group met again in Dec 2011. 24. The trust and individual staff have a collective responsibility to ensure that staff knowledge is kept up to 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 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. 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
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 Donegore Erne Environment 9
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: delivered in communal sanitary area
Page 15 and 16: Inspectors observed that in Erne a
Page 17 and 18: Fridge temperature readings were re
Page 19 and 20: 7.0 Patient Linen STANDARD 3.0 PATI
Page 21 and 22: 8.0 Waste and Sharps STANDARD 4.0 W
Page 23 and 24: 9.0 Patient Equipment STANDARD 5.0
Page 25 and 26: 10.0 Hygiene Factors STANDARD 6.0 H
Page 27 and 28: Recommendations 15. The trust shoul
Page 29 and 30: Picture 6: Erne, Venepuncture set w
Page 31 and 32: 12.0 Key Personnel and Information
Page 33 and 34: a good state of repair and changed
Page 35 and 36: 15.0 Escalation Process RQIA Hygien
Page 37 and 38: Ref No. Recommendations Designated
Page 39 and 40: Ref No. Recommendations Designated
Page 41: Ref No. Recommendations Designated

Muckamore Abbey Hospital, Antrim - 16 February 2012

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