Downe Hospital, Downpatrick - 15 February 2011 - Regulation and ...

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6.0 Standard 1.0: Organisational Systems and Governance The following sections summarise how the systems and governance arrangements in the trust/organisation comply with the criterion of Standard 1.0 of the Regional Healthcare Hygiene and Cleanliness Standards. 6.1 Criterion 1.1 The trust has established and communicated policies and procedures in relation to key hygiene and cleanliness issues (including environmental cleanliness, infection prevention and control, cleaning, waste management, sharps handling, linen management, equipment management, decontamination, disinfection, staff uniform and work wear, inoculation injury, planned programmes for mattress and curtain replacement) 6.1.1 Policies and Procedures A review of the documentation evidenced that a range of policies and procedures have been developed and implemented to support the requirements of the standard statement and a policy development and communication process has been established within the trust. The Safe and Effective Care department co-ordinates the process for the consultation, issue and dissemination of all trust-wide policies. All policies and procedures are issued for trust wide consultation to a representative group, and the final policy is issued on the trust policy intranet site at the start of each month for all staff to read. New policies are also discussed at ward or department monthly meetings. This was verified by the review of ward minutes. In addition all new or reviewed policies are tabled at the trust policy committee and nursing governance committee meetings. Hygiene and cleanliness policies are also highlighted in a quarterly ‘Hygiene/Cleanliness Improvement’ newsletter. Most of the Patient Experience (PE) staff do not have direct access to the trust's intranet site. Information is disseminated through a cascade of meetings from the management and co-ordinator team meetings, to ward/department team meetings in line with the policy for effective communications within the PE department. The policies viewed were up to date, and within review timescales. A new policy, jointly drafted by the Infection Prevention and Control (IPC) team and PE titled ‘The Cleaning and Decontamination of the Care Environment and Equipment Guidance and Principles’, is currently awaiting signature by relevant directors. The IPC team are to be commended on their work on the policy ‘Guidance for Safe Handling of Laundry’. This has been forwarded to the editorial board of the 12
Regional Infection Prevention and Control manual as the draft document for comment and possible inclusion within the manual. 6.1.2 Compliance with DHSSPS Standards The review of compliance with the DHSSPS Controls Assurance standards in relation to IPC and Environmental Cleanliness (EC) indicated that both the internal and external assessments achieved an overall compliance score. Analysis of the information provided in relation to environmental cleanliness, indicates that four medium priority actions require further work and one high priority action in relation to funding for the Downe hospital is still under discussion. The Infection Prevention Controls Assurance action plan documents five medium actions requiring further work, all of which are scheduled for completion by January 2011. The trust should continue to develop the Controls Assurance standards action plans and ensure that full details are provided on progress. 6.1.3 Annual Reports The annual report for IPC was available for the year April 2009 - March 2010. This outlines a summary of the key IPC initiatives and activities of the trust and provides an assessment of performance against agreed targets for the year. Initiatives reported on include multidisciplinary antimicrobial weekly ward rounds in the Downe and Lagan Valley hospitals and a trust-wide review of all antimicrobial prescriptions in wards where C difficile cases were being managed. In relation to education and training, the report acknowledges that only 71 per cent of staff were trained in infection prevention and control against a target of 80 per cent for the two years from April 2008 to March 2010. As a positive point, the trust has promoted the work of IPC link staff and held a conference to provide an opportunity for staff to discuss and share ideas. The report also documented the trust has not met its target in relation to Healthcare Associated Infections (HCAI) reductions in the following areas. Healthcare associated infections DHSSPSNI target 2009-10 Trust figures 2009-10 Over target C difficile 89 99 10 MRSA 20 28 8 The trust’s stated action to reduce these figures was to review and implement the principles of Aseptic Non Touch Technique (ANTT). The inspectors found little evidence at ward level to support the implementation of this recommendation. While the inspection identified that that the trust does have systems in place to prevent HCAIs, these 13
Page 1 and 2: RQIA Infection Prevention/Hygiene A
Page 3 and 4: 1.0 Inspection Summary This is the
Page 5 and 6: staff. Currently 110 staff are regi
Page 7 and 8: Table 6 Hygiene factors Ward 1 Ward
Page 9 and 10: 3.0 Inspections The DHSSPS has devi
Page 11 and 12: The findings, report and follow up
Page 13: Compliant 85% or above Partial comp
Page 17 and 18: 6.2 Criterion 1.2 The trust has eff
Page 19 and 20: 6.3 Criterion 1.3 The trust has est
Page 21 and 22: The audit outcomes are available on
Page 23 and 24: 6.5 Criterion 1.5 The trust has rob
Page 25 and 26: 6.6 Criterion 1.4 The trust has app
Page 27 and 28: 7.0 Environment STANDARD 2.0 GENERA
Page 29 and 30: 7.3 Maintenance and Repair This is
Page 31 and 32: 8.0 Patient Linen STANDARD 3.0 PATI
Page 33 and 34: 9.0 Waste and Sharps 9.1 Waste STAN
Page 35 and 36: 10.0 Patient Equipment STANDARD 5.0
Page 37 and 38: 12.0 Hygiene Practices STANDARD 7.0
Page 39 and 40: 13.0 Additional Issues 13.1 Issue 1
Page 41 and 42: 15.0 Summary of Recommendations 1.
Page 43 and 44: Notification of Inspection Plan Pro
Page 45 and 46: 17.0 RQIA Hygiene Team Escalation P
Page 47 and 48: Recommendations 4. The trust need t
Page 49 and 50: Recommendations 19. All waste bins

Downe Hospital, Downpatrick - 15 February 2011 - Regulation and ...

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