Altnaglevin Hospital, Londonderry - 22 November 2011

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Recommendations

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Recommendations 10. Waste bins and equipment used in the management of waste should be available, clean and free from damage. 11. 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. 22
9.0 Patient Equipment STANDARD 5.0 PATIENT EQUIPMENT Cleanliness and state of repair of general patient equipment. Patient Equipment Ward 3 Ward 8 Ward 31 Ward 40 Patient Equipment 84 72 76 84 Improvement is required across all wards with regard to the cleanliness, state of repair of patient equipment and staff practice. Ward 3 and Ward 40 were partially compliant, Ward 31 had a low partial compliance score and Ward 8 was minimally compliant. Trust staff use a system of green trigger tape to indicate that equipment has been cleaned. The inspectors found in Wards 3 and 31 that while tape was in place equipment was not clean. In Ward 3 the portable nebuliser in room L was very dirty, especially in the crevices of the handle. This piece of equipment had tape attached indicating it had been cleaned on the 19 November 2011. A commode with tape in Ward 31 was heavily stained and a BP monitor stand in use was dusty and had trigger tape attached dated July 2011. The use of trigger tape was not consistent in Ward 8, two commodes checked had no trigger tape and not all stored IV stands had tape insitu. In all four wards, dust and sticky tape was noted on portable equipment such as IV stands, ECG, suction machines, resuscitation trolleys and dressing trolleys. In both Ward 3 and Ward 31 there was no tracking system for reusable hoist slings to indicate which patient was using the sling. The slings were stored over the hoist in the shower room in Ward 3 and over the hoist stored in the corridor of Ward 31. In Ward 40, Ward 31, and Ward 3 the ambu bag had been removed from the original packaging, and in Ward 8 the laryngoscope blade had also been removed from its’ packaging. In Ward 3, three nasal tubes with a pin attached were stored out of packaging in a drawer of the resuscitation trolley. The Association of Anaesthetist of Great Britain and Ireland guidelines "Infection Control in Anaesthesia "states that single use resuscitation equipment should be kept in a sealed package or should be re-sterilised between patients according to manufacturer's instructions. It also states that packaging should not be removed until the point of use for infection control, identification, traceability in the case of a manufacturer's recall and safety. 23
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 and 12: 5.0 Audit Tool The audit tool used
Page 13 and 14: 6.0 Environment STANDARD 2.0 GENERA
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: The lift lobby in Ward 8 was being
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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