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

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Recommendations

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Location Ref No Recommendations Designated Lead Department Action required Date for Completion Timescale The Trust is working as part of a regional project for a HR system that will address this issue. This is ongoing. 7 The Trust should ensure that accountability for infection prevention and control is outlined in all job descriptions. Human Resources A paragraph outlining the Trust’s commitment to IPC has been added to all job descriptions and the Trust job description template that is used by managers. The recruitment and selection team also carry out a check on all job descriptions received into the department to ensure this paragraph has been included. Complete 8 Formalised action plans and reports should be developed for safety leadership walkrounds and the effectiveness of ten-minute observational environmental audits reviewed. Risk & Governance PCSS PCSS is currently restructuring and following this will reconsider its overall approach to observational audit throughout the Trust. The protocol for Safety Leadership Walkrounds is undergoing review and a position paper will be tabled at Executive Team. Sep 2011 9 The Trust should develop a central intranet site for all staff to access HCAI scorecards and IPC audit results. Nursing Awaiting confirmation from IT on request for IPC site. Jun 2011 10 The IPCT to develop an audit programme. Nursing In place as per workplan. Apr 2011 54
Location Ref No Recommendations Designated Lead Department Action required Date for Completion Timescale 11 The Trust should ensure continued microbiological support for the RCA process. Medical Director Nursing The Trust will ensure continue commitment to this process. Ongoing 12 The ‘Getting Relationships Right’ Communication Strategy to include timescale for actions to be achieved. Corporate Communications An update of the Communications Strategy commended in April 2011. Jun 2011 13 The Trust should review and standardise the EC audit documentation and audit tools in use PCSS Environmental Cleanliness Group PCSS Environmental Cleanliness Group will establish any outstanding issues of audit standardisation process. Agree a standardised audit which will be used in all areas. This will include standardised responsibilities. Sep 2011 Dec 2011 Systematic roll out of the agreed standardised audit using the Maximiser system. Commencing Feb 2012 14 Processes should be reviewed to ensure that audit results for patient and public information is displayed at ward level, is user friendly and representative of Trust achievements. Nursing Standardisation of balanced score cards and development of IT solution underway Sep 2011 15 The development of an IPC Communication Strategy. Nursing Included in IPC strategy (see Ref. No. 2) Jun 2011 16 IPC and EC to be a standing item on the agenda for staff meetings. PCSS The need to place IPC and EC on agenda for staff meetings has been raised with other Directors by the Director of Nursing and User Jun 2011 55
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 and 54: 17.0 Action Plan Recommendations Lo
Page 55: 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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