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

Ref No Recommendations Designated
department
Action required
Date for
completion/
timescale
17.
18.
The Trust should ensure that hand-hygiene
consumables are available for staff and visitors to
use.
The Trust and individual staff have a collective
responsibility to ensure that staff knowledge is kept
up to date regarding the use of disinfectants.
Nursing
PCSS
Nursing
All staff reminded of responsibility and this will
be monitored.
All staff have been reminded and made
aware of poster advice.
Ongoing
Completed
and ongoing
19.
The Trust should ensure that all cleaning products
are stored in a locked cupboard, in line with
COSHH regulations.
PCSS Locked cupboards are provided. Complete
20.
Further attention to detail is required to ensure that
equipment used for the general cleaning purposes
of a ward are clean, used and stored appropriately,
and fit for purpose.
PCSS
IPECC
A sub-group of IPEC (Infection Prevention &
Environment and Cleanliness Committee) will
be set up to review and standardise cleaning
schedules, and will establish any outstanding
issues of audit standardisation process (see
refs 2 and 3).
Agree a standardised audit which will be used in
all areas. This will include standardised
responsibilities. To be kept under review.
Feb 2012
Dec 2011
Systematic roll out of the agreed standardised
audit using the Maximiser system.
Commencin
g Feb 2012
21.
The Trust and individual staff have a collective
responsibility to ensure that hand hygiene is
carried out in line with WHO guidance and that all
PPE is used appropriately.
IPCT
Balance scorecards, which include WHO
Hand Hygiene audits. All of these aspects will
be monitored through the programme of
Environmental Cleanliness Audits based on
the Cleanliness Matters Strategy.
Complete
and
Ongoing
The IPCT carried out an independent audit
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