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

12.0 Hygiene Practices
STANDARD 7.0
HYGIENE PRACTICES
Hand hygiene procedures; handling and disposal of sharps; use
of PPE; use of isolation facilities and implementation of infection
control procedures; cleaning of ward/department; staff uniform
and work wear
Hygiene practices Ward 1 Ward 2
Effective hand hygiene
procedures
57 100
Safe handling and
disposal of sharps
100 100
Effective use of PPE 78 100
Correct use of isolation 82 100
Effective cleaning of ward 94 90
Staff uniform and work
wear
96 100
Average score 84 98
In Ward 2 the results of the audit indicate that effective hygiene
practices were in place. Hand hygiene practices observed complied
with WHO (World Health Organisation) guidance on the correct
technique to use for hand washing and appliance of hand rub.
Observations indicated that staff performed hand hygiene at the
appropriate moments of hand hygiene. The only issue which was
identified for improvement related to lack of Control Of Substances
Hazardous to Health (COSHH) data sheets for Actichlor Plus, the same
issue was also raised in Ward 1.
In Ward 1 the effective hand hygiene procedures section was minimally
compliant, staff observed, did not comply with hand hygiene practice in
relation to the five moments of care as directed by WHO (World Health
Organisation). The observation of staff practice regarding the use of
PPE and the correct use of isolation resulted in a partially compliant
score.
Some of the examples of poor practice observed were, a member of
staff cleaning a commode did not wear an apron and did not wash their
hands prior to leaving the dirty utility room, they did then use the
alcohol rub on the other side of the corridor. A member of medical staff
entered the clinical preparation room after taking blood, they did not
remove their gloves or wash their hands. Another member of medical
staff was observed wearing a long sleeved jumper and after being
challenged by staff rolled up the sleeves. Approximately 30 minutes
later inspectors observed that the medic had rolled the sleeves back
down when attending to another patient. A student nurse did not
decontaminate their hands immediately on leaving a patient. A
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