Antrim Area Hospital, Antrim - 12 October 2011 - Regulation and ...

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10.0 Hygiene Factors STANDARD 6.0 HYGIENE FACTORS Hand wash facilities; alcohol hand rub; availability of PPE; availability of cleaning equipment and materials. Hygiene factors Availability and cleanliness of WHB and 96 consumables Availability of alcohol rub 100 Availability of PPE 100 Materials and equipment for cleaning 98 Average Score 98 Picture 5 Example of hand washing facilities and PPE station The unit is to be commended in achieving full compliance in the sections regarding availability of alcohol rub and personal protective equipment (PPE) and an overall high compliance score in this standard. There was good provision of hand washing facilities and PPE stations in the unit (Picture 5). Inspectors observed in the preparation room, the underside of the hand washing sink was dirty, and in the kitchen, the underside of the soap and paper towel dispensers was dirty. The practice of storing the dishwasher detergent on the floor beside the dishwasher was not in accordance with Control of Substances Hazardous to Health (COSHH) regulations and a green catering dustpan and brush were noted on the domestic trolley used for cleaning general and sanitary areas. With minimum staff effort full compliance could be achieved in all sections. Recommendations 8. The trust should ensure that hand washing sinks and consumables are clean. 9. The trust should ensure that all cleaning products are stored in a locked cupboard, in line with COSHH regulations. 18
11.0 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 Effective hand hygiene procedures 93 Safe handling and disposal of sharps 77 Effective use of PPE 100 Correct use of isolation N/A Effective cleaning of ward 95 Staff uniform and work wear 86 Average Score 90 Staff are to be commended for achieving compliance in this standard and full compliance in the effective use of PPE. The section concerning the correct use of isolation was not assessed as there were no patients in the unit being nursed under isolation precautions. The following issues relating to staff practice, need to be addressed. A domestic was unsure of the 7 step hand hygiene procedure and there were a few instances of re-sheathed needles. In one instance a needle and syringe were not discarded as a single unit. This practice increases the potential risk of staff receiving a sharps injury when disconnecting the needle and syringe and should stop immediately. COSHH data sheets for domestic staff were also not available on the ward. The NHSCT has a uniform policy which applies to all staff. Inspectors were disappointed to note that a doctor was wearing a loose tie, two members of nursing staff wearing stoned earrings and a domestic wearing “crocs”. Staff changing facilities were available for staff to change into and out of their uniform at work. Recommendations 10. The trust should ensure that staff receive instructions and training on the correct hand washing technique. 19
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
Page 5 and 6: Table 2 General environment Recepti
Page 7 and 8: 2.0 Background Information to the I
Page 9 and 10: 4.0 Unannounced Inspection Process
Page 11 and 12: Level of Compliance Percentage scor
Page 13 and 14: electric kettle in the kitchen, the
Page 15 and 16: Recommendations 1. The trust should
Page 17 and 18: 8.0 Waste and Sharps STANDARD 4.0 W
Page 19: 9.0 Patient Equipment STANDARD 5.0
Page 23 and 24: 12.0 Key Personnel and Information
Page 25 and 26: Reporting & Re-Audit Episode of Ins
Page 27 and 28: 16.0 Action Plan Reference number R

Antrim Area Hospital, Antrim - 12 October 2011 - Regulation and ...

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