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

Reference
number
Recommendations
Designated
department
Action required
Mandatory IPC training is provided, poster
advice issued to wards, staff questioned at
audit.
Date for
completion/
timescale
13. The trust should ensure that all cleaning products are
stored in a locked cupboard, in accordance with COSHH
regulations (Repeated).
PCSS
Locked cupboards are provided.
Ward managers and PCSS supervisors carry
out regular checks to ensure all staff comply
with COSHH procedures. Audited as part of
Belfast Risk Assessment and Audit Tool
(BRAAT).
Complete
14. All staff have a responsibility to ensure that hand hygiene
is carried out in line with WHO guidance and that all PPE
is used appropriately (Repeated).
IPCT
Balance scorecards, which include WHO
Hand Hygiene audits. All of these aspects will
be monitored through the programme of
Environmental Cleanliness Audits based on
the Cleanliness Matters Strategy.
Complete and
Ongoing
The IPCT carried out an independent audit
and results have been fed back.
Independent audits will be carried out 4 times
a year (2 of which will be carried out by
Infection Prevention and Control).
The IPCT is currently devising an educational
tool to remind staff of the appropriate use of
PPE.
15. The trust and all staff have a collective responsibility to
ensure the safe handling and disposal of sharps.
PCSS
There is a training programme available to all
staff.
Complete
Update and refresher training will continue to
be provided.
The Trust will pilot and roll out across all
facilities the use of an electronic tool to audit
Pilot completed
* indicates stated for a second time 36