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

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Ref No. Recommendations Designated department Action required appropriate department to ensure rectification. Date for completion/ timescale 10. Equipment used for the general cleaning of a ward should be clean, and fit for purpose. Nursing PCSS Regular training is provided to all appropriate staff. 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. Feb 2012 Environmental cleanliness audit programmes, which include daily ward checks, department and managerial audits, and IPC audits monitor compliance. Where an issue has been highlighted, action will be taken in conjunction with the appropriate department to ensure rectification. 11. The trust should ensure that staff knowledge and practice is kept up to date in relation to the dilution rates for disinfectants in use. 12. Detailed nursing schedules should be developed to ensure all equipment and staff responsibilities are defined. Nursing Nursing IPECC Regular training is provided to all appropriate staff. All staff have been reminded and made aware of poster advice. Mandatory IPC training is provided, poster advice issued to wards, staff questioned at audit. 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. Completed and ongoing Feb 2012 30
Ref No. Recommendations Designated department Action required Agree a standardised audit which will be used in all areas. This will include standardised responsibilities. To be kept under review. Date for completion/ timescale Commencing Feb 2012 13. Hand hygiene audits should be commenced and the information displayed. Nursing IPECC Systematic roll out of the agreed standardised audit using the Maximiser system. Once the audit tool for non-acute wards and departments has been developed and agreed, audits will be commenced and information displayed as appropriate. Jun 2012 31
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
Page 5 and 6: Table 2 General Environment Recepti
Page 7 and 8: 2.0 Background Information to the I
Page 9 and 10: 4.0 Unannounced Inspection Process
Page 11 and 12: Level of Compliance Percentage scor
Page 13 and 14: particularly around windows frames.
Page 15 and 16: drawers and free standing units, bo
Page 17 and 18: 7.0 Patient Linen STANDARD 3.0 PATI
Page 19 and 20: 7 The trust should monitor the impl
Page 21 and 22: 10.0 Hygiene Factors STANDARD 6.0 H
Page 23 and 24: 11.0 Hygiene Practices STANDARD 7.0
Page 25 and 26: 12.0 Key Personnel and Information
Page 27 and 28: Reporting & Re-Audit Episode of Ins
Page 29 and 30: 16.0 Action Plan Ref No. Recommenda
Page 31: Ref No. Recommendations Designated

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

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