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

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14. The trust should monitor the implementation of its policies and procedures in line with its ‘Cleaning and Decontamination of the Care Environment and Equipment; - Guidance and Principles’. 15. The trust should consider publishing the environmental cleanliness audit scores. 16. Linen should be packaged to minimise the risk contamination during transit. 17. There should be appropriate safe storage of linen at ward level. 18. All waste bins should be cleaned and dried to prevent damage, and rusted bins should be identified and replaced. 19. The trust should monitor the implementation of its policies and procedures in respect of the management of waste and sharps to ensure that safe and appropriate practice is in place. 20. The trust and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date; equipment is clean and in good repair. 21. Staff should ensure that cleaning equipment is cleaned appropriately after use and that it is in good working order and fit for purpose. 22. Staff should ensure that best practice in respect of hand washing, use of alcohol rub and the wearing of PPE is followed at all times. 23. The trust should ensure that all staff comply with the regional dress code guidelines. 24. Correct notation is made in patients care plans regarding isolation status. 25. All staff are aware and comply with the universal precautions in place when a patient is in isolation. 40
Notification of Inspection Plan Programme 16.0 Announced Inspection Flowchart Environmental Scan: Stakeholders & External Information Plan Programme Consider: Areas of Non-Compliance Infection Rates Trust Information Prioritise Themes & Areas for Core Inspections Prior to Inspection Year Balance Programme January/February Schedule Inspections Identify Inspection Team 6 weeks prior to inspection Notify organisation of inspection date and send draft programme and self assessment Make request for supplementary information from organisation e.g.: Policies & Procedures Management Audits Training Records Organisation advises of affiliate for inspection required 3 weeks prior to inspection Organisation returns self assessment and supplementary information NO Is all information returned? YES IPHTeam analyse returned information IPHTeam identify areas to be inspected Prepare Inspection Team 1 week prior to inspection Notification of final on-site programme 41
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 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: 15.0 Summary of Recommendations 1.
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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