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

Reference
number
Recommendations
Designated
department
Action required
Environmental cleanliness audit programmes,
which include daily ward checks, department
and managerial audits, and IPC audits
monitor compliance.
Date for
completion/
timescale
Where an issue has been highlighted, action
will be taken in conjunction with the
appropriate department to ensure
rectification.
8. The trust should monitor the implementation of its policies
and procedures in respect of the management of waste
and sharps to ensure that safe and appropriate practice is
in place (Repeated).
PCSS
Nursing
The Trust will pilot and roll out across all
facilities the use of an electronic tool to audit
waste management compliance against
policy, procedure and RQIA requirements.
This process will supplement the existing
audit tools used by PCSS, IPC and also
existing external audits conducted by Daniels
(sharps box suppliers).
Pilot completed
Roll-out
programme
across Trust to
be completed by
Apr 2012
9. The trust and individual staff have a collective
responsibility to ensure that patient equipment is clean
and in good repair (Repeated).
Nursing
PCSS
Daniels’ audit completed Oct 2011 and
results disseminated.
The consultation process in relation to the
cleaning manual has resulted in requests for
significant changes to the content and format.
Work is ongoing to have a revised final
consultation document by February 2012.
Complete
Feb 2012
The manual includes roles and
responsibilities of trust staff in relation to
patient equipment. A template will be used to
record all cleaning of equipment.
10. The trust should ensure that hand washing sinks and
consumables are available, clean, and in a good state of
repair (Repeated).
PCSS
This is monitored as part of the
Environmental Cleanliness Audit Programme.
Staff are reminded of the importance of
replenishing dispensers.
Ongoing
* indicates stated for a second time 34