South West Acute Hospital - 13 November 2012 - Regulation and ...

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Areas for improvement were noted in both wards for example in Ward 1 the equipment store was disorganised and overstocked with boxes of supplies on the floor. Staff advised that this was being addressed. In Ward 5 the clean utility room and clinical work surface was untidy and cluttered with equipment, supplies and stationery; storage space appeared insufficient. Inspectors were advised that a review of the empty, underutilised near patient testing room was being carried out with the potential to decant some of the supplies e.g. IV fluid storage. In the equipment store, incontinence pads on shelves, were out of their packaging and equipment was stored in the floor corner. 6.3 Maintenance and Repair The main reception, corridors and stairs were in a good state of repair. Some issues were identified in reception with scuff marks and damage to the wall edging, notably in beside the wheelchair storage area (Picture 2), and cracks and damage to the flooring leading to Ward 1. Picture 2 - Wall damage in reception In Ward 1 flooring at the ward reception, the nurses‟ station and in the toilet were in the process of being repaired. The hinge on a wall cupboard in the clean utility room was loose and the door was ill fitting. There was wall damage in the domestic store and in Room 11 there was sealant dripping from the sides of the ceiling access panel in the en-suite. In Ward 5 sitting room, there was minor wall paintwork damage behind chairs; a ceiling tile in the bathroom was displaced. In Room 10, the base of the shower, where the wall and floor join, was bulging. 6.4 Fixtures and Fittings Fixtures and fittings were in a good state or repair. However in the main reception, outside the Outpatient Department, the end of the water cooler pipework was dirty and a pipe coming out of the ground had been stuffed with paper rather than sealed off. In both wards, felt 12
notice boards which cannot be effectively cleaned, were also observed. Staff advised at the feedback session that this issue was being addressed. In Ward 5 the privacy curtain in the bathroom had no date to identify when it had to be changed. There was no toilet roll holder available on the wall or on the disabled handrail and the bottom inside seal on the fridge door was split. 6.5 Information In both wards there were no posters for nursing staff to reference on the National Patient Safety Agency (NPSA) cleaning colour coded system, linen and waste segregation. Nursing cleaning schedules while available need to be developed further and in Ward 5 staff were ticking rather than signing their name when completing cleaning schedule records. Infection control information was not displayed in both wards for patients and visitors to view, staff advised at the feedback session that this was being addressed. Inspectors also noted that there was no signage in place to indicate restricted access to the kitchen and in Ward 5, there was no signage on the door of the equipment store to denote the storage of oxygen cylinders. In Ward 1 some posters were attached to waste bins with adhesive tape and temperatures for the drugs‟ fridge had been inconsistently recorded. In Ward 5 there were no DHSSPS general infection prevention and control leaflets available for visitors. 6.6. Additional Issues Ward 1 Adhesive tape was used to fix notices (“Please pull”) to doors in the corridor leading to the ward. The wash hand basin in the dirty utility room on the right side of ward was very slow to empty. Audits are not displayed for visitors, staff to view. Ward 5 Discussion with physiotherapy staff indicated that there were no cleaning schedules for the cleaning of patient equipment. Environmental cleaning scores while available in the domestic store were not on display for the general public to view. Inspectors were advised at the feedback that the IPCT are addressing this issue and 13
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 Ward 1 Ward 5 Environm
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: Picture 1: Patient waiting area 6.1
Page 17 and 18: 7.0 Patient Linen STANDARD 3.0 PATI
Page 19 and 20: the sharps‟ box on the resuscitat
Page 21 and 22: Recommendations 7. The trust and in
Page 23 and 24: listed on the checklist, was not av
Page 25 and 26: The use of isolation facilities in
Page 27 and 28: 13.0 Summary of Recommendations 1.
Page 29 and 30: Reporting & Re-Audit Episode of Ins
Page 31 and 32: 16.0 Action Plan Reference Number R
Page 33 and 34: Reference Number Recommendations 6
Page 35: Reference Number Recommendations 12

South West Acute Hospital - 13 November 2012 - Regulation and ...

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