Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...

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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 11 6.3 Maintenance and Repair 11 6.4 Fixture and Fittings 12 6.5 Information 13 7.0 Patient Linen 15 7.1 Management of Linen 15 8.0 Waste and Sharps 17 8.1 Waste 17 8.2 Sharps 18 9.0 Patient Equipment 19 10.0 Hygiene Factors 21 11.0 Hygiene Practice 23 12.0 Key Personnel and Information 26 13.0 Summary of Recommendations 28 14.0 Unannounced Inspection Flowchart 30 15.0 RQIA Hygiene Team Escalation Policy Flowchart 31 16.0 Action Plan 32
1.0 Inspection Summary The unannounced inspection of Belfast City Hospital on the 20 October 2011 identified two of the four wards, Ward 6 North and Ward 10 North, had areas of minimal compliance within standards 2-7 of the Regional Healthcare Hygiene and Cleanliness Standards. In line with the follow up process a further unannounced inspection was undertaken to these wards on the 12 December 2011. Inspection Outcomes On the inspection of 20 October 2011, 22 recommendations were made in relation to Standards 2-7. Six have been addressed, 16 have been repeated and there are two new recommendations. Improvements and Developments since the previous Inspection On the12 December 2011 the follow up inspection found that good progress had been made to address areas identified at the inspection in October as outlined below: Ward 6N – 73 per cent of the preliminary findings identified at the previous inspection have been addressed. Ward 10N – 70 per cent of the preliminary findings identified at the previous inspection have been addressed. In both wards there has been significant improvement as all seven standards have now achieved compliance. Improved staff practices were noted in cleaning of the environment and equipment, management of linen, waste, sharps, hygiene factors and hygiene practices In both wards inspected the majority of outstanding issues requiring action are in relation to attention to detail when cleaning, refurbishment, maintenance and repair. Key Areas for Improvement In both wards inspected the majority of outstanding issues requiring action are in relation to attention to detail when cleaning, refurbishment, maintenance and repair. All standards have achieved compliance in both wards, staff are encouraged to maintain this result and improve on existing practice especially in hygiene factors; materials and equipment for cleaning. A summary of the recommendations following the re-audit is listed in Section 13. 1
Page 1: RQIA Infection Prevention/Hygiene U
Page 5 and 6: Table 2 Environment 6N 6N 10N 10N O
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: Staff in both wards are commended f
Page 15 and 16: 6.5 Information Staff in both wards
Page 17 and 18: 7.0 Patient Linen STANDARD 3.0 PATI
Page 19 and 20: 8.0 Waste and Sharps STANDARD 4.0 W
Page 21 and 22: 9.0 Patient Equipment STANDARD 5.0
Page 23 and 24: 10.0 Hygiene Factors STANDARD 6.0 H
Page 25 and 26: 11.0 Hygiene Practices STANDARD 7.0
Page 27 and 28: 16. Systems and processes should be
Page 29 and 30: This information is currently avail
Page 31 and 32: 12. Systems and processes should be
Page 33 and 34: 15.0 Escalation Process RQIA Hygien
Page 35 and 36: Reference number Recommendations 4.
Page 37 and 38: Reference number Recommendations De
Page 39 and 40: Reference number Recommendations De
Page 41: * indicates stated for a second tim

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