Belfast City Hospital, Belfast - 20 October 2011 - Regulation and ...

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12.0 Key Personnel and Information Members of the RQIA inspection team Mrs E Colgan - Senior Officer Infection Prevention/Hygiene Team Mrs L Gawley - Inspector Infection Prevention/Hygiene Team Mrs S O'Connor - Inspector Infection Prevention/Hygiene Team Mrs M Keating - Inspector Infection Prevention/Hygiene Team Mrs L Watt - Ulster Independent Clinic Ms S Baird - Northwest Independent Clinic Mrs Y Black - Western Health and Social Services Trust Mrs N Donnelly - Western Health and Social Services Trust Trust representatives attending the feedback session The key findings of the inspection were outlined to the following trust representatives: Colm Donaghy - Chief Executive Tony Stevens - Medical Director Brenda Creaney - Executive Director of Nursing Jennifer Welsh - Director, Cancer and Specialist Services Colin Cairns - Co-Director PCSS Caroline Leonard - Co-Director, Cancer and Specialist Services David Robinson - Clinical Coordinator and Acting Associate Director of Nursing Damien O’Neill - ASM, Medicine Paul McGarrity - ASM (Gynaecology) Seamus Trainor - Senior Manager, PCSS Anne McAuley - Governance Manager, SMWCH Gerard McCallan - Divisional Estates Manager Gillian Traub - Service Manager, Oncology and Haematology Jackie Campbell - Service Manager Judy Buchanan - Infection Prevention and Control Nurse Clare Shannon - Ward Manager, 7 South Alison Millar - Ward Sister, 5 South Deborah McKelvey - Ward Sister, 10 North Rosie Gray - Ward Sister, 6 North Kim Aughey - PCSS Operations Manager Ian Wilson - Estates Officer Stephen Lawson - Estates Officer Aisling Cartin - Estates Officer Ruth Finn - Infection Prevention and Control Nurse Joanne Stewart - Deputy Ward Sister, 10 North Jason Keys - Estates Officer, Student 32
Supporting documentation A number of documents have been developed to support the inspection process, these are: • Infection Prevention/Hygiene Inspection Process (methodology, follow up and reporting) • Infection Prevention/Hygiene Team Inspection Protocol (this document contains details on how inspections are carried out and the composition of the teams) • Infection Prevention/Hygiene Team Escalation Policy • RQIA Policy and Procedure for Use and Storage of Digital Images This information is currently available on request and will be available in due course on the RQIA website. 33
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
Page 5 and 6: Table 1 Ward 5S 6N 7S 10N General E
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: The inspection teams noted, that al
Page 15 and 16: Picture 2: Clean and tidy treatment
Page 17 and 18: 6.3 Maintenance and Repair In all a
Page 19 and 20: Recommendations 1. The trust should
Page 21 and 22: Recommendations 7. The trust should
Page 23 and 24: the ward did not have a clinical wa
Page 25 and 26: 9.0 Patient Equipment STANDARD 5.0
Page 27 and 28: 10.0 Hygiene Factors STANDARD 6.0 H
Page 29 and 30: In all wards there were issues iden
Page 31 and 32: improvement is also required in sta
Page 33: 3. Staff also provided feedback on
Page 37 and 38: 14. The trust should ensure that ha
Page 39 and 40: 15.0 Escalation Process RQIA Hygien
Page 41 and 42: Ref No Recommendations Designated d

Belfast City Hospital, Belfast - 20 October 2011 - Regulation and ...

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