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

12.0 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 6A M2
Effective hand hygiene
procedures
100 100
Safe handling and disposal
of sharps
100 100
Effective use of PPE 95 100
Correct use of isolation 89 100
Effective cleaning of ward 100 100
Staff uniform and work
wear
93 89
Average Score 96 98
Meadowlands 2 are commended for achieving full compliance in the
majority of sections within hygiene practices.
In both wards the results of the audit indicate that effective hygiene
practices were in place. Hand hygiene practices observed complied
with WHO (World Health Organisation) guidance on the correct
technique to use for hand washing and appliance of hand rub.
Observations indicated that staff performed hand hygiene at the
appropriate moments for hand hygiene.
In the both wards single use aprons and gloves were worn when in
contact or anticipated contact with blood, body fluids or in potential
contact with contaminated items. Inspectors observed that aprons and
gloves were changed between patients and between different episodes
of care. In Withers 6A a member of staff disposed of PPE incorrectly
into a household waste bin due to the position and distance of the
clinical waste bin.
On the day of the inspection patients in both wards required isolation
and practices observed in relation to the application of isolation
precautions were good and in line with current practice guidance.
A review of documentation in Meadowlands 2 evidenced that a patient
centred care pathway for the identified alert organism was in place and
completed by staff. However in Withers 6A the care plan of the patient
in protective isolation did not indicate that the patient was in isolation or
that any other infection prevention and control measures were in place.
At the feedback session trust representatives advised that new care
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