(Re-audit) - 14 July 2011 - Regulation and Quality Improvement ...

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12.0 Key Personnel and Information Members of the RQIA inspection team Mrs E Colgan Mrs L Gawley Mrs S O’Connor Mrs M Keating - Senior Officer Infection Prevention/ Hygiene Team - Inspector Infection Prevention/ Hygiene Team - Inspector Infection Prevention/ Hygiene Team - Inspector Infection Prevention/ Hygiene Team Peer Reviewers Ann Hamilton - Manager, Domestic Services, NHSCT Lyn Buckley - Inspector, Nursing Homes, RQIA Melanie Johnston - Domestic Services Manager, SHSCT Noelle Donnelly - Assistant Support Services Manager, WHSCT Trust representatives attending the feedback session The key findings of the inspection were outlined to the following trust representatives Colm Donaghy - Chief Executive Brenda Creaney - Director of Nursing Aidan Dawson - Co Director, Acute Services Linda Linford - Senior Manager, Associate Director of Nursing Jeff Thompson - Senior Manager, PCSS Nancy Scott - Senior Manager, PCSS, RVH Caroline Lecky - Assistant Services Manager, Medicine Jillian Martin - Assistant Services Manager, Ward 7C Irene Thompson - Lead Nurse, Infection Prevention and Control Mary Hanrahan - Senior Infection Prevention & Control Nurse Cecilia Kearns - WBH, Operational Manager, RVH Una McGivern - Sister, Ward 5F Rosemary McDonald - Sister, Ward 7C Sharon Moffett - Ward Sister, Ward 6D Kitty Thompson - Infection Prevention and Control Nurse Sharon McConkey - Deputy Ward Sister, 4E Supporting documentation A number of documents have been developed to support the inspection process, these are: Infection Prevention/Hygiene Inspection Process (methodology, follow up and reporting) Infection Prevention/Hygiene Team Inspection Protocol (this document contains details on how inspections are carried out and the composition of the teams) Infection Prevention/Hygiene Team Escalation Policy 34
RQIA Policy and Procedure for Use and Storage of Digital Images This information is currently available on request and will be available in due course on the RQIA website. 35
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary As a result
Page 5 and 6: Table 2 Environment 8 June 2011 4E
Page 7 and 8: Table 5 Patient Equipment 8June 201
Page 9 and 10: 2.0 Background Information to the I
Page 11 and 12: 4.0 Unannounced Inspection Process
Page 13 and 14: Level of Compliance Percentage scor
Page 15 and 16: Environment 14 July 2011 4E 5F 6D 7
Page 17 and 18: In Ward 5F, initial observation wou
Page 19 and 20: Recurring issues identified in Ward
Page 21 and 22: 3. The trust should review its envi
Page 23 and 24: store and in Ward 5F damaged wooden
Page 25 and 26: Ward 5F and 6D, frayed waste bin la
Page 27 and 28: 9.0 Patient Equipment STANDARD 5.0
Page 29 and 30: 9.2 Additional Issues Ward 4E A doc
Page 31 and 32: liquid soap or hand towel dispenser
Page 33 and 34: 11.0 Hygiene Practices STANDARD 7.0
Page 35: In Ward 7C, a detailed cleaning sch
Page 39 and 40: 13. The trust and individual staff
Page 41 and 42: 15.0 Escalation Process RQIA Hygien
Page 43 and 44: Ref No Recommendations Designated d
Page 45 and 46: Ref No Recommendations Designated d
Page 47: Ref No Recommendations Designated d

(Re-audit) - 14 July 2011 - Regulation and Quality Improvement ...

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