Muckamore Abbey Hospital, Antrim - 25 April 2012 - Regulation and ...

16.0 Action Plan
Reference
number
Recommendations
1. The trust should ensure that systems and processes in
place for environmental cleaning, providing the
necessary assurance that cleaning is carried out
effectively. (Repeated)
Designated
department
Nursing
PCSS
IPC
Action required
‘Roles and responsibilities of Staff in
relation to Environmental Cleanliness and
Cleanliness of Equipment’ policy under
review.
Date for
completion/
timescale
Work / negotiations in relation to the
cleaning manual are still ongoing. In
particular, there is discussion with
nursing/control of infection with reference to
bed cleaning. Once agreement is reached
the manual will be finalised.
Jun 2012
2. The trust should ensure suitable supplies are held to
ensure timely replacements of fixtures associated with
hand hygiene.
Nursing
PCSS
All of these aspects will be monitored
through the programme of Environmental
Cleanliness Audits based on the
Cleanliness Matters Strategy and results
fed back through Balanced Scorecards.
Hand towel and soap dispensers are stock
items and once ordered should be received
within 1 week.
Ongoing
Complete
3. The health care environment should be repaired and
maintained, and damaged fixtures and fitting replaced to
maintain public confidence and to help reduce the risk of
the spread of infection. (Repeated)
4. Staff should continue to develop nursing cleaning
schedules in line with the trusts guidelines. (Repeated)
Estates
IPC
Other
appropriate
staff
Nursing
IPECC
This is ongoing as part of Estate daily
maintenance and refurbishment
programmes.
A sub-group of IPECC (Infection Prevention
& Environment and Cleanliness Committee)
has been set up to review and standardise
cleaning schedules, and will establish any
outstanding issues of audit standardisation
process.
Ongoing
Complete
* indicates stated for a second time 26