Causeway Hospital - 14 June 2012 - Regulation and Quality ...

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Recommendations

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Recommendations 14. The trust should ensure that hand washing sinks and consumables are clean, adequately stocked and fit for purpose. 15. The trust should ensure that all cleaning products are stored in line with COSHH regulations. 16. The trust and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date in the use of general cleaning products. 20
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 Elective Surgery Medical 2 Effective hand hygiene 95 procedures 88 Safe handling and disposal 100 of sharps 100 Effective use of PPE 84 100 Correct use of isolation 94 95 Effective cleaning of ward 79 87 Staff uniform and work 84 wear 88 Total 89 93 In this standard both wards achieved compliance, with full compliance and no issues identified in the safe handling and disposal of sharps. Medical 2 further achieved full compliance in the effective use of PPE. In both wards staff were aware of the 7 step hand hygiene technique for use with soap or alcohol rub. However in Medical 2 inspectors observed that medical staff did not always carry out hand hygiene appropriately; prior to donning gloves or after leaving the patient’s environment, part of the World Health Organisation (WHO) 5 moments of care. In Medical 2 a registered nurse was not aware that alcohol rub should not be used for hand hygiene when caring for a patient with Clostridium difficile. In Elective Surgery there was variation in practice for nursing staff taking blood pressure; some staff wore gloves and aprons while some staff did not wear any PPE. Inspectors noted that in Medical 2 a member of medical staff did not wear an apron or put on gloves prior to a procedure and after donning gloves inappropriately touched the environment, contaminating the gloves. In both wards the use of isolation facilities was satisfactory however in the Elective Surgery ward nursing care plans, were not available in the nursing notes for patients with a potential infection. In Medical 2 there were inconsistencies in staff documentation for the care bundle for peripheral intravenous lines. 21
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
Page 5 and 6: Table 2 Environment Elective Surger
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: uild-up of bacteria and subsequentl
Page 15 and 16: 6.5 Information In both wards there
Page 17 and 18: 7.0 Patient Linen STANDARD 3.0 PATI
Page 19 and 20: protruding from the open aperture (
Page 21: 10.0 Hygiene Factors STANDARD 6.0 H
Page 25 and 26: Recommendations 17. The trust and i
Page 27 and 28: 13.0 Summary of Recommendations 1.
Page 29 and 30: Reporting & Re-Audit Episode of Ins
Page 31 and 32: 16.0 Action Plan Recommendations Re
Page 33 and 34: Reference Number Recommendations 9
Page 35: Reference Number Recommendations 17

Causeway Hospital - 14 June 2012 - Regulation and Quality ...

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