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

6.3 Criterion 1.3
The trust has established clear roles and responsibilities for key
hygiene and cleanliness issues with clear lines of accountability
throughout the organisation, including at Trust Board level
6.3.1 Roles and Responsibilities
The roles and responsibilities in relation to environmental cleanliness
and infection prevention and control are clearly identified.
Responsibility for governance arrangements rests with the trust board
through to the offices of the Chairperson and Chief Executive. The
Chief Executive has overall responsibility on behalf of the Board of
Directors of the trust. There are mechanisms in place to help assure
'Board to Ward' governance. The environmental sub committee report
through the risk management committee and the infection control sub
committee report through the safe and effective care committee. Both
sub committees provide a progress up date three times a year and an
annual report. The risk management and safe and effective care
committees in turn report to the governance committee bi-monthly.
The Director of Nursing for Primary Care and Elderly Care and
Governance is the designated clinical lead for all strategic and
operational aspects of infection prevention and control. The Infection
Control Doctor is part of the Medical Directorate is an member of the
IPC team. The Director of Human Resources and Corporate Affairs is
responsible and accountable for the environmental hygiene aspects of
HCAI in line with the management of PE department.
A HCAI steering group has been established to support the Infection
Prevention and Control committee, and reports to the Chief Executive
and the Executive Management Team (EMT). The group, formed to
monitor the trust HCAI rates, reduction initiatives and care bundles
meets fortnightly to monthly and is led by the Medical Director.
A trust Environment and Waste committee considers all aspects of
waste management and reports within governance structures and the
escalation process to the Corporate Control committee and onwards to
the Governance Assurance committee.
Roles and responsibilities for hygiene and cleanliness issues are
outlined in a standard clause in every staff member's job description.
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