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

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Plan Programme 14.0 Unannounced Inspection Flowchart Environmental Scan: Stakeholders & External Information Prior to Inspection Year Plan Programme Prioritise Themes & Areas for Core Inspections Balance Programme Consider: Areas of Non-Compliance Infection Rates Trust Information RQIA Hygiene Team January/February Schedule Inspections Prior to Inspection Identify & Prepare Inspection Team Episode of Inspection Day of Inspection Day of Inspection Inform Trust Carry out Inspection Is there immediate risk requiring formal escalation? NO YES Invoke RQIA IPHTeam Escalation Process A Day of Inspection Feedback Session with Trust 14 days after Inspection 28 days after Inspection Preliminary Findings disseminated to Trust Draft Report disseminated to Trust NO Does assessment of the findings require escalation? YES Invoke RQIA IPHTeam Escalation Process A Reporting & Re-Audit 14 days later Within 0-3 months Signed Action Plan received from Trust Is a Follow-Up required? Based on Risk Assessment/key indicators or Unsatisfactory Quality Improvement Plan (QIP)? YES Invoke Follow-Up Protocol Process enables only 1 Follow-Up NO Open Report published to Website YES Is Follow-Up satisfactory? NO DHSSPS/HSC Board/PHA 36
15.0 Escalation Process RQIA Hygiene Team: Escalation Process B RQIA IPH Team Escalation Process Concern / Allegation / Disclosure Inform Team Leader / Head of Programme MINOR/MODERATE Has the risk been assessed as Minor, Moderate or Major? MAJOR Inform key contact and keep a record Inform appropriate RQIA Director and Chief Executive Record in final report Inform Trust / Establishment / Agency and request action plan Notify Chairperson and Board Members Inform other establishments as appropriate: E.g.: DHSSPS, RRT, HSC Board, PHA, Seek assurance on implementation of actions Take necessary action: E.g.: Follow-Up Inspection 37
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 and 34: 3. Staff also provided feedback on
Page 35 and 36: Supporting documentation A number o
Page 37: 14. The trust should ensure that ha
Page 41 and 42: Ref No Recommendations Designated d

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

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