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

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Ref No Recommendations Designated<br />

department<br />

22. The trust should ensure that all members of staff<br />

are familiar with <strong>and</strong> adhere to the regional<br />

dress code policy.<br />

Action required<br />

Where an issue has been highlighted,<br />

action will be taken in conjunction with the<br />

appropriate department to ensure<br />

rectification.<br />

Trust policy available to all staff on Intranet.<br />

Policy is enforced at local level by senior<br />

staff, e.g., Ward Sisters <strong>and</strong> Senior<br />

Managers.<br />

Assurance is gained through<br />

environmental cleanliness audit<br />

programmes, which include daily ward<br />

checks, department <strong>and</strong> managerial<br />

audits, <strong>and</strong> IPC audits monitor<br />

compliance.<br />

Where an issue has been highlighted,<br />

action will be taken in conjunction with the<br />

appropriate department to ensure<br />

rectification.<br />

Date for<br />

completion/<br />

timescale<br />

Complete<br />

46

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