Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...
Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...
Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...
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16.0 Action Plan<br />
Reference<br />
number<br />
Recommendations<br />
1. The trust should ensure that the systems <strong>and</strong> processes in<br />
place for environmental cleaning provide the necessary<br />
assurance that cleaning is carried out effectively, <strong>and</strong> that<br />
all staff are aware of their responsibilities (Repeated).<br />
Designated<br />
department<br />
Nursing<br />
PCSS<br />
IPC<br />
Action required<br />
‘Roles <strong>and</strong> responsibilities of Staff in relation<br />
to Environmental Cleanliness <strong>and</strong><br />
Cleanliness of Equipment’ policy under<br />
review.<br />
Date for<br />
completion/<br />
timescale<br />
Mar 20<strong>12</strong><br />
The consultation process in relation to the<br />
cleaning manual has resulted in requests for<br />
significant changes to the content <strong>and</strong> format.<br />
Work is ongoing to have a revised final<br />
consultation document by February 20<strong>12</strong>.<br />
Feb 20<strong>12</strong><br />
All of these aspects will be monitored through<br />
the programme of Environmental Cleanliness<br />
Audits based on the Cleanliness Matters<br />
Strategy <strong>and</strong> results fed back through<br />
Balanced Scorecards.<br />
Ongoing<br />
2. The healthcare environment should be repaired <strong>and</strong><br />
maintained, <strong>and</strong> damaged fixtures <strong>and</strong> fittings replaced to<br />
maintain public confidence <strong>and</strong> to help reduce the risk of<br />
the spread of infection (Repeated).<br />
3. Detailed nursing cleaning schedules should be developed<br />
(Repeated).<br />
Estates<br />
IPC<br />
Other<br />
appropriate<br />
staff<br />
Nursing<br />
IPECC<br />
This is ongoing as part of Estate daily<br />
maintenance <strong>and</strong> refurbishment programmes.<br />
A sub-group of IPECC (Infection Prevention<br />
& Environment <strong>and</strong> Cleanliness Committee)<br />
will be set up to review <strong>and</strong> st<strong>and</strong>ardise<br />
cleaning schedules, <strong>and</strong> will establish any<br />
outst<strong>and</strong>ing issues of audit st<strong>and</strong>ardisation<br />
process.<br />
Agree a st<strong>and</strong>ardised audit which will be<br />
used in all areas. This will include<br />
st<strong>and</strong>ardised responsibilities. To be kept<br />
under review.<br />
Systematic roll out of the agreed<br />
Ongoing<br />
Feb 20<strong>12</strong><br />
Commencing<br />
Feb 20<strong>12</strong><br />
* indicates stated for a second time 32
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