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

1.0 Inspection Summary
An unannounced inspection was undertaken to Causeway Hospital,
on the 14 June 2012. The hospital was assessed against the Regional
Healthcare Hygiene and Cleanliness standards and the following areas
were inspected:
Elective Surgery
Medical 2
Causeway Hospital is an acute hospital which offers a range of
services including a 24 hour Accident and Emergency Department.
Elective Surgery is a 15 bedded ward, comprising of two patient bed
bays and single room ensuite facilities. Medical 2 incorporates 12
medical beds and a further 15 beds in the Medical Assessment Unit.
Inspection Outcomes
The results of the inspection showed both wards achieved an overall
compliance level and staff are commended for their commitment to
providing a safe and clean environment for patients. However
inspectors observed that whilst the environment was generally clean,
further work is required to ensure cleaning and monitoring is carried out
especially in areas difficult to access. The trust should continue their
work in providing clutter free ward environments, and ensure that there
is an on-going programme of maintenance and repair.
Staff knowledge of products used for the cleaning and decontamination
of equipment and the environment need to improve. Observation of
staff indicated compliance with hygiene and infection prevention and
control practices. However inspectors observed that not all medical
staff adhered to the trust’s dress code policy and trust representatives
indicated that this would be brought to the attention of the Medical
Director.
The inspection resulted in 19 recommendations for Causeway Hospital,
a full list of recommendations is listed in Section 13.
A detailed list of preliminary findings is forwarded to Northern 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
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