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

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planning documentation has recently been devised which will allow nurses to capture this information. A review of COSHH data sheets indicated that nursing staff have access to a data sheet for Actichlor Plus disinfectant. Inspectors also noted that mechanisms are in place to ensure urgent cleaning is carried out as needed. In both wards staff were unable to change into their uniform on arriving and prior to leaving work as appropriate facilities have not been provided. Recommendations 27. The trust and individual staff have a collective responsibility to ensure that all PPE is available and disposed of appropriately. 28. The trust should ensure the continued development and implementation of care plans that reflect the infection prevention and control needs of the patient. 29. The trust should ensure that the requirement for staff changing facilities as set out by the Department of Health building standard are incorporated into future new build plans. 42
13.0 Key Personnel and Information Members of the RQIA Inspection Team Mrs E Colgan - Senior Officer Infection Prevention/Hygiene Team Mrs L Gawley - Inspector Infection Prevention/Hygiene Team Mrs S O'Connor - Inspector Infection Prevention/Hygiene Team Mrs M Keating - Inspector Infection Prevention/Hygiene Team Trust representatives attending the feedback session The key findings of the inspection were outlined to the following trust representatives Ms Brenda Creaney - Director of Nursing Mrs Olive MacLeod - Co-Director Nursing Governance Mrs Lorna Bingham - Deputy Assistant Director of Nursing Acute Services Mr Aidan Dawson - Co-Director Acute Services Mr Colin Cairns - Co-Director PCSS Mrs Nicky Vincent - Governance Manager, Acute Mrs Jacqui Austin - Governance Manager Ms Irene Thompson - Lead Nurse, Infection Prevention and Control Mr Earl Moffitt - Senior Manager PCSS Mrs Susan Corscadden - Senior Nurse, Infection Prevention and Control Mr Kevin Taylor - Divisional Operations Manager, Estates Mr Aidan Shaw - Operations Manager, MPH Ms Noreen Hoy - Nurse Development Lead, Trauma and Orthopaedics Ms Lucia Smyth - Support Services Manager, Greenpark Ms Lila Hill - Ward Manager, Meadowlands 2 Ms Tanya Eccles - Ward Manager, 6B overseeing 6A Ms Nora Stevenson - Deputy Ward Manager, Meadowlands 2 Ms Marcella Jenkinson - Deputy Ward Manager 6A Mr Philip Ramsey - Acting ASM Ms Moira Kearney - Assistant Services Manager, N’Rehab Ms Carolyn Herron - Assistant Support Services Manager, MPH Ms Geraldine Coyle - ASM Intermediate Care Mr Thomas Hughes - Infection Prevention and Control Nurse Ms Janeen McKeown - Infection Prevention and Control Nurse Apologies: Mr Colm Donaghy - Chief Executive 43
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 and 16: eview of documentation evidenced th
Page 17 and 18: A sample of the different services
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: 12.0 Hygiene Practices STANDARD 7.0
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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