Longstone Hospital, Armagh - Regulation and Quality Improvement ...

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Contents 1.0 Inspection Summary 1 2.0 Background Information to the Inspection Process 5 3.0 Inspections 6 4.0 Unannounced Inspection Process 7 4.1 Onsite Inspection 7 4.2 Feedback and Report of the findings 7 5.0 Audit Tool 8 6.0 Environment 10 6.1 Cleaning 10 6.2 Clutter 13 6.3 Maintenance and Repair 14 6.4 Fixture and Fittings 15 6.5 Information 15 7.0 Patient Linen 17 7.1 Management of Linen 17 8.0 Waste and Sharps 18 8.1 Waste 18 8.2 Sharps 18 9.0 Patient Equipment 19 10.0 Hygiene Factors 20 11.0 Hygiene Practice 22 12.0 Key Personnel and Information 24 13.0 Summary of Recommendations 25 14.0 Unannounced Inspection Flowchart 27 15.0 RQIA Hygiene Team Escalation Policy Flowchart 28 16.0 Action Plan 29
1.0 Inspection Summary An unannounced inspection was undertaken to the Longstone Hospital, on the 6 April 2011. The hospital was assessed against the draft Regional Healthcare Hygiene and Cleanliness standards and the following area was inspected: Sperrin Ward Longstone Hospital is located within a large health service site on the outskirts of Armagh. Sperrin Ward is one of three wards which make up the Cedarwood complex. The ward comprises of living space, bedrooms, sanitary areas, day rooms, kitchen, dining room, office and stores. Areas such as the visitors’ seating area, public toilet, treatment room, interview room and domestic store are communal areas shared between the three wards. The ward provides inpatient care and treatment to adult males with learning disability and challenging behaviour. As a result of the findings a follow up inspection will be carried out within three months. The inspection resulted in 25 recommendations for the Southern Health Social Care Trust (SHSCT) and Longstone Hospital, a full list of detailed actions is listed in Section 13. A detailed list of preliminary findings is forwarded to Southern Health and Social Care Trust within 14 days of the inspection to enable early action on identified areas which have achieved non complaint scores. The draft report which includes the high level recommendations in a Quality Improvement Plan is forwarded within 28 days of the inspection for agreement and factual accuracy. The draft report is agreed and a completed action plan is returned to RQIA within 14 days from the date of issue. The detailed list of preliminary findings is available from RQIA on request. The final report and Quality Improvement Plan will be available on the RQIA website. Reports and action plans will be subject to performance management by the Health and Social Care Board and the Public Health Agency. Notable Practice The inspection identified the following areas of notable practice The trust have approved an individual ward manager’s post for each ward. The newly appointed ward manager for Sperrin Ward took up the post on the 4 April 2011. 1
Page 1: RQIA Infection Prevention/Hygiene U
Page 5 and 6: Table 2 General environment Sperrin
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: Picture 1: Clean and tidy reception
Page 15 and 16: 6.2 Clutter The patient areas of th
Page 17 and 18: 6.4 Fixtures and fittings Some of t
Page 19 and 20: 7.0 Patient Linen STANDARD 3.0 PATI
Page 21 and 22: 9.0 Patient Equipment STANDARD 5.0
Page 23 and 24: The very low score in the PPE secti
Page 25 and 26: Inspectors noted wooden brushes 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: Reference number Recommendations 18

Longstone Hospital, Armagh - Regulation and Quality Improvement ...

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