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

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support the delivery and maintenance of high quality environmental cleanliness within the BHSCT. The report summarises the governance arrangements, the monitoring and audit arrangements and recommendations for the forthcoming year. The annual report for infection prevention and control was available for the year 2009/10 and outlines a summary of the key IPC initiatives and activities of the trust and provides an assessment of performance against agreed targets for the year. The following information outlines that the trust has met its target reductions in the following areas: The number of MRSA blood stream (bacteraemia) infections in the trust in the year 2009/10 was 62 compared to 86 the previous year, a reduction of 28 per cent. The number of cases of Clostridium difficile infections in the trust in the year 2009/10 was 163 compared to 327 the previous year, a reduction of 50 per cent. To support and promote best practice it would have been beneficial if the specific actions introduced by the trust to achieve these reductions had been included in the annual report. The annual report and information gained on the inspection highlights that there has been progress made with implementing the 'Saving Lives Programme' of, reducing infection and delivering clean safe care to ensure compliance with high impact interventions. The concept of care bundle or high impact interventions can be used to describe a collection of evidence based processes needed to care effectively for patients undergoing particular treatments with associated risks such as: Care bundle to prevent surgical site infection Urinary catheter care bundle Peripheral intravenous cannula care bundle Central venous catheter care bundle Care bundle to reduce the risk from Clostridium difficile Hand hygiene compliance remains a priority and audits report high compliance rates across the trust. 6.1.4 Risk Management A comprehensive risk management strategy is in place and includes the production of risk registers at various levels within the trust. The strategy is based on the Australian/New Zealand standard 4360:2004 on risk management. A review of the strategy indicated that risks, priority levels and an explanation of actions required with timescales are identified. 14
A sample of the different services group risk registers were reviewed. Risks have been identified in relation to IPC, estates and environmental cleanliness. The summaries provided evidenced that all risks have been reviewed with a proposed action and rescored accordingly. The risk register table has not been colour coded in the residual risk score column making it difficult at first glance to identify that the risk has been reviewed in line with the risk management strategy. It is suggested that the risk register is appropriately colour coded for easy of understanding. Recommendations 1. The trust should ensure that all policies and procedures are reviewed and updated as necessary. 2. The trust should develop an Infection Prevention and Control policy review/development timetable and an Infection Prevention and Control strategy. 3. The trust should ensure controls assurance documentation clearly outlines agreed timeframes for actions required. 15
Page 1 and 2: RQIA Infection Prevention/Hygiene A
Page 3 and 4: 1.0 Inspection Summary This is the
Page 5 and 6: An assurance strategy is in place t
Page 7 and 8: Table 6 Hygiene Factors 6A M2 Avail
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: eview of documentation evidenced th
Page 19 and 20: areas. PCSS are currently running a
Page 21 and 22: There are a range of supporting sub
Page 23 and 24: of every element is identified as t
Page 25 and 26: The terms of reference for the Medi
Page 27 and 28: 6.5 Criterion 1.5 The trust has rob
Page 29 and 30: 6.6 Criterion 1.6 The trust has app
Page 31 and 32: 7.0 Environment STANDARD 2.0 GENERA
Page 33 and 34: 7.3 Maintenance and Repair Withers
Page 35 and 36: nursing cleaning schedules are requ
Page 37 and 38: 9.0 Waste and Sharps 9.1 Waste STAN
Page 39 and 40: 10.0 Patient Equipment STANDARD 5.0
Page 41 and 42: 11.0 Hygiene Factors STANDARD 6.0 S
Page 43 and 44: 12.0 Hygiene Practices STANDARD 7.0
Page 45 and 46: 13.0 Key Personnel and Information
Page 47 and 48: 14.0 Summary of Recommendations 1.
Page 49 and 50: 28. The trust should ensure the con
Page 51 and 52: Reporting & Re-Audit Episode of Ins
Page 53 and 54: 17.0 Action Plan Recommendations Lo
Page 55 and 56: Location Ref No Recommendations Des

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