Musgrave Park Hospital, Belfast - 10 March 2011 - Regulation and ...

eview of documentation evidenced that a quality ward improvement
team (QWIT) has been established to support service groups in
meeting QWIP objectives. Discussion with trust representatives
indicated that they were in the process of developing a three year IPC
strategy.
In the submitted self assessment, the trust confirmed that all staff have
access to the intranet or access through their line manager. Systems
have been put in place to ensure that all staff have the knowledge and
capability to access hard copies of the relevant policies and
procedures. Discussion with nursing staff on the wards evidenced that
they were aware of, and had access to, the regional online infection
prevention and control manual.
6.1.2 Compliance with DHSSPS Standards
The review of compliance with the DHSSPS Controls Assurance
standards in relation to Environmental Cleanliness (EC) and Infection
Prevention and Control (IPC) indicated that both the internal
assessments achieved an overall compliance score.
A review of the information provided by the trust indicated an overall
score of 84 per cent for EC, an improvement of 13 per cent, and 91 per
cent for IPC was achieved in the controls assurance standards. An EC
and IPC action plan progress report addresses issues identified from
the self assessment.
The 2009/10 action plan progress reports contain updates on the
progress of the action plans against each criterion however agreed
timescales of the actions required were not always evident.
The analysis of the trust documentation confirms that environmental
cleanliness and infection prevention and control remain a trust priority
and the programmes of activities have been developed and
implemented to assist in the reduction of health care associated
infections. Work has continued to achieve compliance with the
following:
6.1.3 Annual Reports
The Quality Standards for Health and Social Care DHSSPS
2006
Saving Lives High Impact Interventions (DH 2007)
Environmental Cleanliness Standards DHSSPS 2005
Controls Assurance Standard for Infection Control DHSSPS v
2009
The Environmental Cleanliness annual report for the year 2009/10
outlines the trust’s position in relation to environmental cleanliness and
it also advises the trust Board of the controls and systems in place to
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