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

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12.0 Key Personnel and Information Members of the RQIA inspection team Mrs E Colgan - Senior Inspector Infection Prevention/Hygiene Team Mrs L Gawley - Inspector Infection Prevention/Hygiene Team Mrs M Keating - Inspector Infection Prevention/Hygiene Team Mrs S O’Connor - Inspector Infection Prevention/Hygiene Team Trust representatives attending the feedback session The key findings of the inspection were outlined to the following trust representatives: Ms Jennifer Welsh - Director, Cancer & Specialist Services Ms Moira Mannion - Co- Director Nursing (representing Director of Nursing) Ms Caroline Leonard - Cancer & Specialist Services Co- Director Ms Gillian Traub - Service Manager, Oncology/Haematology Mr Seamus Trainor - PCSS Manager, BCH Mrs Mandy Armstrong - Regulation & Improvement, Manager Ms Sarah Williamson - Acting Clinical Co-ordinator, Haematology Mr Tony O’Hara - SS Catering Manager Mr Stephen Lawson - Estates Mrs Caroline Smyth - Senior Infection Prevention & Control Nurse Ms Rosie Gray - Ward 6 North, Manager Ms Ruth Finn - Infection Prevention & Control Nurse Ms Joanne Stewart - Ward 10 North, Deputy Ward Manager Ms Patricia Berkery - Domestic Services Apologies Mr Colm Donaghy Ms Brenda Creaney Mr Colin Cairns - Chief Executive - Executive Director of Nursing - Co-Director, PCSS Supporting documentation A number of documents have been developed to support the inspection process, these are: Infection Prevention/Hygiene Inspection Process (methodology, follow up and reporting) Infection Prevention/Hygiene Team Inspection Protocol (this document contains details on how inspections are carried out and the composition of the teams) Infection Prevention/Hygiene Team Escalation Policy RQIA Policy and Procedure for Use and Storage of Digital Images 26
This information is currently available on request and will be available in due course on the RQIA website. 27
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary The unannoun
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: 16. Systems and processes should be
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

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

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