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

6.3 Criterion 1.3
The trust has established clear roles and responsibilities for key
hygiene and cleanliness issues with clear lines of accountability
throughout the organisation, including at Trust Board level
6.3.1 Roles and Responsibilities
The roles and responsibilities in relation to environmental cleanliness
and infection prevention and control are clearly identified within the EC
and IPC annual reports. Responsibility for governance arrangements
rests with the trust Board through to the offices of the Chairperson and
Chief Executive. Inspectors were advised that the Chief Executive is
currently reviewing the structure within service groups to ensure each
trust site has a responsible director on site. Documentation provided
evidenced that environmental cleanliness and infection prevention and
control was a standing item on the trust Board and the governance
assurance committee agenda. The assurance committee provides
reports on EC and IPC to the trust Board. The Chief Executive has
overall responsibility on behalf of the Board of Directors of the trust.
There are mechanisms in place to help assure 'Board to Ward'
governance.
The Medical Director until April 2010 was the designated lead director
responsible for Infection Prevention and Control. The Director of
Nursing and Patient Experience is now the designated lead director for
Infection Prevention and Control and environmental cleanliness. The
Director of Nursing and Patient Experience is accountable to the
assurance committee, executive team and trust board in relation to the
effective strategic leadership and management of this area. The
Director of Nursing and Patient Experience is also responsible for
providing analysis and assurance on operational performance. The
directors of all service groups support the implementation of the
environmental cleanliness strategy and the Infection Prevention and
Control and patient safety delivery plan.
The Head of Patient and Client Support Services is responsible and
accountable for the environmental cleanliness controls assurance
standard and the management of patient and client support services.
The co-directors of Patient and Client Services will ensure the
development, implementation, monitoring and review of cleaning
strategies, practices and plans.
Following the change in lead director a joint Infection Prevention and
Environmental Cleanliness committee has been established.
Documentation evidenced that terms of reference for this have been
agreed.
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