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

Reference
number
Recommendations
Designated
department
Action required
Agree a standardised audit which will be
used in all areas. This will include
standardised responsibilities. To be kept
under review.
Date for
completion/
timescale
Commenced
Feb 2012
Systematic roll out of the agreed
standardised audit using the Maximiser
system.
5. The trust should ensure the correct handling and storage
of clean and used linen in a designated area, including
equipment which is clean and fit for purpose.
Nursing
Guidance regarding storage of linen is in
the Regional Infection Prevention Manual.
Linen storage and segregation guidance
has been circulated to all Directorates.
Complete
This states that all linen must be stored off
the floor in a clean dedicated area that
allows for ease of access and rotation of
stock and that Linen rooms must have
shelving that are easy to clean, and
cleaning frequencies must be at least
quarterly.
6. The trust should monitor the implementation of its
policies and procedures in respect of the management of
waste and sharps to ensure that safe and appropriate
practice is in place. (Repeated)
PCSS
Nursing
The trust will pilot and roll out across all
facilities the use of an electronic tool to
audit waste management compliance
against policy, procedure and RQIA
requirements. This process will supplement
the existing audit tools used by PCSS, IPC
and also existing external audits conducted
by Daniels (sharps box suppliers).
Pilot completed
Roll-out
programme
across Trust
completed Apr
2012
Daniels’ audit completed Oct 2011 and
results disseminated.
Complete
7. The trust should ensure waste bins are provided at all
hand washing sinks.
PCSS
Nursing
This is monitored as part of the
Environmental Cleanliness Audit
Ongoing
* indicates stated for a second time 27