Muckamore Abbey Hospital, Antrim - Regulation and Quality ...

16.0 Action Plan
Ref No. Recommendations Designated
department
1. The trust should ensure that the systems and processes
in place for environmental cleaning provide the necessary
assurance that cleaning is carried out effectively and that
all staff are aware of their responsibilities.
Nursing
PCSS
IPC
Action required
‘Roles and responsibilities of Staff in
relation to Environmental Cleanliness and
Cleanliness of Equipment’ policy under
review.
The consultation process in relation to the
cleaning manual has resulted in requests
for significant changes to the content and
format. Work is ongoing to have a revised
final consultation document by February
2012.
Date for
completion/
timescale
Mar 2012
Feb 2012
2. The healthcare environment should be repaired and
maintained, damaged fixtures and fittings replaced to
maintain public confidence and to help reduce the risk of
the spread of infection.
Estates
IPC
Other
appropriate
staff
All of these aspects will be monitored
through the programme of Environmental
Cleanliness Audits based on the
Cleanliness Matters Strategy and results
fed back through Balanced Scorecards.
This is ongoing as part of Estate daily
maintenance and refurbishment
programmes.
Ongoing
Ongoing
3. Detailed nursing cleaning schedules should be
developed.
Nursing
IPECC
A sub-group of IPECC (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.
Feb 2012
Agree a standardised audit which will be
used in all areas. This will include
standardised responsibilities. To be kept
under review.
Commencing
Feb 2012
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