Altnaglevin Hospital, Londonderry - 22 November 2011

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Level of Compliance Percentage scores can be allocated a level of compliance using the compliance categories below. The categories are allocated as follows: Compliant 85% or above Partial compliance 76 to 84% Minimal compliance 75% or below Each section within the audit tool will receive an individual and an overall score, to identify areas of partial or minimal compliance to ensure that the appropriate action is taken. 10
6.0 Environment STANDARD 2.0 GENERAL ENVIRONMENT Cleanliness and state of repair of public areas; cleanliness and state of repair of ward/department infrastructure; cleanliness and state of repair of patient bed area; cleanliness and state of repair of toilets, bathrooms and washrooms; cleanliness and state of repair of ward/department facilities; availability and cleanliness of isolation facilities; provision of information for staff, patients and visitors. General Environment Ward 3 Ward 8 Ward 31 Ward 40 Reception N/A N/A 86 92 Corridors, stairs lift 77 76 96 97 Public toilets 94 N/A 88 N/A Ward/department - general 88 76 97 93 (communal) Patient bed area 77 71 81 85 Bathroom/ washroom 96 76 86 94 Toilet 93 86 87 95 Clinical room/treatment 87 60 88 81 room Clean utility room 87 75 84 N/A Dirty utility room 93 77 92 96 Domestic store 98 89 98 91 Kitchen 94 84 N/A 98 Equipment store 96 78 67 77 Isolation 78 86 92 93 General information 73 77 79 74 Average Score 88 78 87 90 The above table outlines the findings in relation to the general environment of the facilities inspected. The findings indicate that there are concerns regarding Ward 8 and in particular the minimally compliant areas highlighted in red. The findings in respect of the general environment are detailed in the following sections. 11
Page 1 and 2: RQIA Infection Prevention/Hygiene U
Page 3 and 4: 1.0 Inspection Summary An unannounc
Page 5 and 6: Table 1 Areas Inspected Ward 3 Ward
Page 7 and 8: Table 7 Hygiene Practices Ward 3 Wa
Page 9 and 10: 3.0 Inspections The DHSSPS has devi
Page 11: 5.0 Audit Tool The audit tool used
Page 15 and 16: also evidence of communal products
Page 17 and 18: Additional Issue In Ward 8 the lift
Page 19 and 20: assurance that cleaning is carried
Page 21 and 22: potential airborne contamination. T
Page 23 and 24: The lift lobby in Ward 8 was being
Page 25 and 26: 9.0 Patient Equipment STANDARD 5.0
Page 27 and 28: 10.0 Hygiene Factors STANDARD 6.0 H
Page 29 and 30: Recommendations 13. The trust shoul
Page 31 and 32: Good practice was observed in effec
Page 33 and 34: 13.0 Summary of Recommendations 1.
Page 35 and 36: Reporting & Re-Audit Episode of Ins
Page 37 and 38: 16.0 Action Plan Reference number R
Page 39 and 40: Reference number damage Recommendat
Page 41 and 42: Reference number Recommendations 18

Altnaglevin Hospital, Londonderry - 22 November 2011

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