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

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action on identified areas which have achieved non complaint scores. The draft report which includes the high level recommendations in a Quality Improvement Plan is forwarded within 28 days of the inspection for agreement and factual accuracy. The draft report is agreed and a completed action plan is returned to RQIA within 14 days from the date of issue. The detailed list of preliminary findings is available from RQIA on request. The final report and Quality Improvement Plan will be available on the RQIA website. Reports and action plans will be subject to performance management by the Health and Social Care Board and the Public Health Agency. Notable Practice The inspection identified the following areas of notable practice: There was good documentation and information available for support services staff on cleaning practices The ward manager was in the process of reviewing and indexing policies and guidelines for easier staff reference The RQIA inspection team would like to thank the staff at Muckamore Abbey Hospital for their assistance during the inspection. The following tables give an overview of compliance scores noted in areas inspected by RQIA: Table 1 summarises the overall compliance levels achieved. Tables 2-7 summarise the individual tables for sections two to seven of the audit tool as this assists organisation to target areas that require more specific attention. Table 1 Areas Inspected General Environment 79 Patient Linen 89 Waste 71 Sharps 79 Equipment 77 Hygiene Factors 86 Hygiene Practices 92 Average Score 82 Compliant: 85% or above Partial Compliance: 76% to 84% Minimal Compliance: 75% or below 2
Table 2 General Environment Reception 84 Corridors, stairs lift 82 Public toilets N/A Ward/department - general (communal) 68 Patient bed area 79 Bathroom/washroom 57 Toilet 75 Clinical room/treatment room 80 Clean utility room 90 Dirty utility room N/A Domestic store 76 Kitchen 94 Equipment store N/A Isolation N/A General information 81 Average Score 79 Table 3 Patient Linen Storage of clean linen 85 Storage of used linen 92 Laundry facilities N/A Average Score 89 Table 4 Waste and Sharps Handling, segregation, storage, waste Availability, use, storage of sharps 71 79 Compliant: 85% or above Partial Compliance: 76% to 84% Minimal Compliance: 75% or below 3
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3: 1.0 Inspection Summary An unannounc
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 and 32: Ref No. Recommendations Designated
Page 33: Ref No. Recommendations Designated

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

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