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

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15.0 Escalation Process RQIA Hygiene Team: Escalation Process B RQIA IPH Team Escalation Process Concern / Allegation / Disclosure Inform Team Leader / Head of Programme MINOR/MODERATE Has the risk been assessed as Minor, Moderate or Major? MAJOR Inform key contact and keep a record Inform appropriate RQIA Director and Chief Executive Record in final report Inform Trust / Establishment / Agency and request action plan Notify Chairperson and Board Members Inform other establishments as appropriate: E.g.: DHSSPS, RRT, HSC Board, PHA, HSENI Seek assurance on implementation of actions Take necessary action: E.g.: Follow-Up Inspection 28
16.0 Action Plan Reference number Recommendations 1. The trust need to put in place an effective maintenance programme to ensure air vents and light fittings are cleaned regularly. Designated department Action required Date for completion/ timescale Estates High level cleaning contract in place. Ongoing 2. The trust need to ensure an effective window cleaning programme is in place for both the external and internal windows. Estates Cleaning contract in place with outside contractors. Ongoing 3. Nursing staff need introduce mattress audit checks in line with Infection Prevention and Control’s guidance. Nursing Mattress audit now in place. Will be completed on a monthly basis. Ongoing from 01/05/11 4. Greater attention is required to detailed cleaning tasks. 5. The ward manger in consultation with the other two ward managers needs to review and define communal room use to ensure a clutter free environment. 6. The trust need to consider an urgent refurbishment of the domestic store. 7. The trust need to ensure a programme of repair is in place to ensure the fabric of the ward is maintained. 8. The trust need to ensure staff follow the policy and run water in relation to the prevention of Legionella. Domestic & Nursing Nursing Estates & Maintenance Estates & Maintenance Nursing Weekly cleaning schedule in place for nurses & domestics. Environmental audit undertaken monthly by nurse in charge & domestic supervisor. A protocol is now in place to monitor the communal area & a weekly audit is undertaken to ensure a clutter free environment. A works programme has been agreed to refurbish the domestic store & a minor works request for funding has been completed on 16/05/11. A programme has been agreed to address painting, floors & outstanding maintenance issues. Minor works request for capital completed 16/05/11. The Trust policy on Legionella will be adhered to in consultation with maintenance. Twice weekly checks now in place. Ongoing Ongoing from 01/05/11 31/08/11 31/08/11 Ongoing from 16/05/11 29
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
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: Reporting & Re-Audit Episode of Ins
Page 33: Reference number Recommendations 18

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

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