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

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Location Ref No Recommendations Designated Lead Department Action required Date for Completion Timescale 3 The Trust should ensure controls assurance documentation clearly outlines agreed timeframes for actions required. Nursing PCSS Controls Assurance documentation is completed 6-monthly and is currently up to date. For each of the DHSSPS Controls Assurance Standards the Trust has an identified operational lead. Each CAS lead is responsible for ensuring substantive compliance with the relevant standards. Each lead produces an action and implementation plan and target dates should be appropriately set. All Controls Assurance Standards are reported on at Controls Assurance Committee. Complete 4 The Trust should finalise the draft statutory and mandatory training policy and review the training programme to ensure it is easy to read and includes infection prevention and control training for all relevant staff groups. Human Resources This policy is currently out for consultation with a view to being presented to Policy Committee for approval on 29 June 2011. Thereafter it will be formally launched across the Trust: Infection Prevention and Control is referenced in this policy document. IPC Training for all staff (including Medical staff) is available by applying through the Training Administration System (TAS). Infection Prevention Control staff provide infection prevention training at all Medical Staff inductions. End of June 2011 52
Location Ref No Recommendations Designated Lead Department Action required Date for Completion Timescale 5 The Trust should develop BICS (British Institute Cleaning Science) training for all domestic staff. PCSS New training facility being refurbished to become an accredited BICS training centre on RGH site. Facility to be handed over August 2011 BICS accreditation of centre. Training for further staff to become BICS trainers and assessors to be carried out October 2011 March 2012 Location for second accredited centre to be identified June 2012 Accreditation of new centre by BICS October 2012 6 The Trust needs to review and improve the recording and monitoring systems that are currently in place to ensure compliance with mandatory training. Line Managers and Trainers The responsibility for record keeping around training programmes is referenced within the training policy. Trainers who provide the portfolio of Trust programmes carry responsibility for maintaining the records. Managers are also expected to ensure that staff comply with statutory / mandatory training requirements. Complete The time management system only applies to Patient and Client Support Services staff and will not indicate the ratio of staff trained in IPC across the Trust per discipline and service group. 53
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 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: 17.0 Action Plan Recommendations Lo
Page 57 and 58: Location Ref No Recommendations Des
Page 59 and 60: Location Ref No Recommendations Des
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Musgrave Park Hospital, Belfast - 10 March 2011 - Regulation and ...

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