Daisy Hill Hospital, Newry - Regulation and Quality Improvement ...

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are specifically trained in the area. This allows the team to work in close conjunction with the ward managers and to facilitate efficient bed turn around. The team is regularly audited to ensure that this process is effective. The IPC team are currently involved in producing monitoring results for the following care bundles: Central Venous Catheter Ventilator associated pneumonia Surgical site infection (caesarean sections and orthopaedics). This data is reported on a monthly basis to the trust board, DHSSPS and the HSC Safety Forum. The data is also available on the Institute for Healthcare Improvement (IHI) Extranet and the SHSCT has shown consistent improvement in reducing HCAIs. On the ward the results of audits and dashboard results are displayed on various notice boards which should be commended. However, at times there was so much information displayed that this could be confusing, especially to patients and the general public. The trust should provide a more user friendly approach to this display and to emphasis and celebrate the results obtained. Recommendations 11. Processes should be reviewed to ensure that monthly information provided at ward level is consistent and user friendly. 26
6.6 Criterion 1.6 The trust has appropriate mechanisms for communicating the results of internal monitoring and audit to the relevant staff at all levels throughout the trust 6.6.1 HCAI and environmental cleanliness performance data is disseminated through the line management structures to all staff, and the review of the available documentation evidenced that this is a standing agenda item at staff meetings. The trust confirmed, in their submitted documentation that the outcomes of all HCAI audits are available on the trust intranet. There are displays on ward dashboards of all the relevant Key Performance Indicators for the ward. Environmental Cleanliness Commode audits Hand hygiene audits Bare below the elbow Care Bundles Environmental cleanliness departmental audit scores, for hospitals are sent to directors and to the environmental cleanliness committee members, on a monthly basis, to share with their staff groups. Environmental cleanliness audit scores and failures are shared with estates and ward managers by domestic managers. Environmental departmental audits are displayed in domestic stores. The minutes of domestic services staff meetings, show that environmental audit scores are discussed, infection control issues are highlighted and staff are informed of new policies being issued. These policies are held in the supervisor's office for staff to access. Each IPC nurse has responsibility for specific facilities, to support and guide staff, in the delivery of safe, effective and evidence informed practice, this involves ensuring action plans are implemented following IPC audits. Hand hygiene, environmental cleanliness and IPC issues are standing agenda items on all directorate and team meetings. There is evidence of a culture from "Board to Ward" to reduce HCAI by the implementation and monitoring of HCAI/IPC action plans and ongoing training and development to enable staff to deliver on the trust's HCAI/IPC agenda. The trust's Infection Prevention and Control Communications Strategy has been recognised at two prestigious awards events. The strategy, which includes the vibrant 'Clean Hands, Safe Hands' signage, was the winner in the Best Marketing Initiative category at the Greater Newry 27
Page 1 and 2: RQIA Infection Prevention/Hygiene A
Page 3 and 4: 1.0 Inspection Summary This is the
Page 5 and 6: audits and of performance against c
Page 7 and 8: Table 5 Patient Equipment Female Ma
Page 9 and 10: 3.0 Inspections The DHSSPS has devi
Page 11 and 12: The findings, report and follow up
Page 13 and 14: Compliant 85% or above Partial comp
Page 15 and 16: 6.1.2 Compliance with DHSSPS Standa
Page 17 and 18: identified in relation to IPC and E
Page 19 and 20: The infection prevention control te
Page 21 and 22: 6.3 Criterion 1.3 The trust has est
Page 23 and 24: 6.4 Criterion 1.4 The trust has est
Page 25 and 26: 6.4.3 Root Cause Analysis The trust
Page 27: 6.5 Criterion 1.5 The trust has rob
Page 31 and 32: 7.0 Environment STANDARD 2.0 GENERA
Page 33 and 34: cluttered appearance of the domesti
Page 35 and 36: 8.0 Patient Linen STANDARD 3.0 PATI
Page 37 and 38: mechanisms, to prevent spillage and
Page 39 and 40: Picture 5: laryngoscope handles and
Page 41 and 42: chemicals were not stored under loc
Page 43 and 44: consideration should be given to re
Page 45 and 46: 14.0 Summary of Recommendations 1.
Page 47 and 48: Notification of Inspection Plan Pro
Page 49 and 50: 16.0 RQIA Hygiene Team Escalation P
Page 51 and 52: Number Recommendation Action Owner

Daisy Hill Hospital, Newry - Regulation and Quality Improvement ...

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