Altnagelvin Hospital, Londonderry - 2 November 2011

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11.0 Hygiene Practices STANDARD 7.0 HYGIENE PRACTICES Hand hygiene procedures; handling and disposal of sharps; use of PPE; use of isolation facilities and implementation of infection control procedures; cleaning of ward/ department; staff uniform and work wear. Hygiene practices Effective hand hygiene procedures 100 Safe handling and disposal of sharps 100 Effective use of PPE 91 Correct use of isolation 87 Effective cleaning of ward 69 Staff uniform and work wear 96 Average Score 91 Five out of the six sections achieved compliance. Two of those sections, hand hygiene procedures and safe disposal of sharps, were fully compliant. In the section on effective cleaning of the ward, it was disappointing to note a minimally compliant score. The inspectors noted that on questioning nursing staff in both the practical application on how to make up disinfectants and correct disinfectant dilution rates, staff needed to update their knowledge. Information posters on correct dilution rates of disinfectants for staff to reference were not available, however, copies of dilution rate charts were obtained and displayed by the end of the inspection. The inspectors were told by a member of domestic staff that Actichlor Plus, a disinfectant with detergent, was not used as part of the daily cleaning process for an isolation room; only detergent was used. Actichlor Plus was only used when the room was empty and being terminally cleaned. This practice should be clarified with the domestic services manager and infection prevention and control staff to ensure that this practice is in accordance with the local policy and procedure. In relation to the correct use of isolation a review of patients’ nursing notes with known infections was carried out. Staff should ensure that care pathways are fully completed and reviewed within the set timescale. In one of the patient’s nursing notes, a care plan was also available, this enabled staff to record daily in the progress notes. In the other notes it was observed that nursing interventions that had occurred on the day of the inspection, in relation to the on going care for their infection, had not always been recorded. 22
Recommendations 13 Systems and processes should be in place to assure that staff knowledge and practice is kept up to date regarding the use of disinfectants. 14 Staff should ensure that care pathways are fully completed and reviewed within the set timescale. 23
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
Page 5 and 6: The following tables give an overvi
Page 7 and 8: Table 7 Hygiene practices Effective
Page 9 and 10: 3.0 Inspections The DHSSPS has devi
Page 11 and 12: 5.0 Audit Tool The audit tool used
Page 13 and 14: 6.0 Environment STANDARD 2.0 GENERA
Page 15 and 16: The main patient areas were general
Page 17 and 18: 7.0 Patient Linen STANDARD 3.0 PATI
Page 19 and 20: Recommendations 7. Systems and proc
Page 21 and 22: Recommendations 9 The trust and ind
Page 23: Recommendations 11 The trust should
Page 27: 13.0 Summary of Recommendations 1.
Page 30 and 31: 15.0 Escalation Process RQIA Hygien
Page 32 and 33: Reference number Recommendations 4.
Page 34: Reference number Recommendations 13

Altnagelvin Hospital, Londonderry - 2 November 2011

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