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

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On the ward the results of audit are displayed on various notice boards which should be commended. However, at times there was so much information displayed which could be confusing especially to patients and the general public. There was no information on the EC displayed. The trust should provide a more user friendly approach to this display and to emphasis and celebrate the results obtained. Recommendations 9. The trust should ensure that audits of practice are undertaken to help improve compliance in peripheral IV cannula and hand hygiene. 22
6.6 Criterion 1.4 The trust has appropriate mechanisms for communicating the results of internal monitoring and audit to the relevant staff at all levels throughout the trust 6.6.1 Health Care Associated Infection (HCAI) performance data is disseminated through the line management structures to all staff and the review of the available documentation evidenced that this is a standing agenda item at staff meetings. The trust confirmed in their submitted documentation that the outcomes of all HCAI audits are available on the trust intranet. IPC information was displayed on ward dashboards however from a patient and visitor perspective these could be difficult to understand. These were: environmental cleanliness hand hygiene audits care bundles Within the PE department, monthly reports outlining key findings from the audit programme are forwarded to senior PE managers. Quarterly reports outlining scores for cleaning, nursing and estates are forwarded to the EMT and reported via the relevant governance committees. PE and estates present a report to the EMT six monthly and at the end of the year. The annual report is completed and submitted to the trust Board via the Corporate Control committee and placed on the Patient Experience and Cleanliness Matters intranet sites. Compliance results are shared with PE staff on a daily basis by coordinators following audits and via the PE team briefing system as part of the communication strategy. The IPC annual report is presented to the IPC committee and presented to the trust Board. IPC performance is regularly reported through the IPC committee and the HCAI steering group and from assistant directors to their senior managers and to all staff. IPC link nurse meetings regularly highlight findings from audits and identify areas for action. Department managers have an informal process to ensure feedback on the level of compliance and the required on-going corrective action in response to all audits. Dashboard information and performance are discussed at staff team meetings, ward manager meetings, relevant governance meetings, and included as part of performance management scorecards. The governance and patient involvement department is to be commended for the newsletter they produce which highlights learning from the RQIA hygiene reviews. It provides information on recurring 23
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 and 14: Compliant 85% or above Partial comp
Page 15 and 16: Regional Infection Prevention and C
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: 6.5 Criterion 1.5 The trust has rob
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

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