Altnaglevin Hospital, Londonderry - 22 November 2011

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Reference number Recommendations 14 Hand washing sinks in clinical areas should be accessible and comply with current guidelines. Designated department Estates Action required Hand washing sinks comply with requirements with the exception of all taps having elbow operated taps – cost implication but we will review if clinical sinks only can be fitted with these. Date for completion/ timescale March 2012 15 The trust should ensure that all chemicals are stored under locked conditions in accordance with COSHH regulations 16 Equipment used for the general cleaning of a ward should be available, clean, fit for purpose and stored appropriately 17 Systems and processes should be in place to assure that staff knowledge and practice is kept up to date regarding the cleaning and disinfectant process Support Services Support Services Support Services Nursing Staff have been reminded to ensure areas around sinks are kept free from clutter Support Services staff receive induction training which includes COSSH training. The BICS training programme incorporates dilution rates for all cleaning products/disinfectants used. Adherence with the regulation will be monitored through environmental cleanliness Support services cleaning schedules incorporates cleaning equipment and team leader quality control audits includes audit of cleaning equipment. Support Services staff receive induction training which includes COSSH training. The BICS training programme incorporates cleaning procedures and dilution rates for all cleaning products/disinfectants used. There are IPC decontamination guidelines available on the Trust intranet. Decontamination and dilution rates are included in IPC induction and mandatory training for all staff including Nursing Staff training. Commenced and on-going commenced and on-going commenced and on-going Staff knowledge of the correct dilution rates is being addressed through the issue of hand 38
Reference number Recommendations 18 All staff have a responsibility to ensure that hand hygiene is carried out in line with WHO guidelines and that all PPE is used appropriately Designated department Support Services Nursing Action required held laminated cards which states the correct dilution rates as an aid to correct practice. Staff knowledge and processes will be checked monthly on the introduction of the new revised audit tool. Support Services staff induction training/ BICS training programme incorporates hand hygiene and PPE requirements. Hand hygiene is taught at induction and mandatory training and the practice of Nursing and Medical staff is monitored every 2 weeks by their peers, exceptions are reported through robust accountability systems. Date for completion/ timescale Commenced and on-going 19 Systems and processes should be in place to assure that staff knowledge and practice is kept up to date regarding isolation, cleaning and decontamination of equipment Support Services Nursing Hand hygiene scores are reviewed at the monthly accountability meeting and nursing matters are dealt with at that meeting with corrective action taken in terms of repeat hand hygiene until 5 consecutive days scoring 95% is achieved. Staff are advised that where a member of the medical staff fail the hand hygiene this is to escalated to the clinical lead for that area The medical director is to be advised on the occasion that an individual doctor fails three times. Support Services BICS training programme incorporate cleaning procedures for isolation and decontamination of equipment. Attendance at IPC induction and mandatory training on a 2 yearly basis is mandatory for all clinical staff in the Trust. Ad hoc audits of practice related to commodes and other high risk equipment do Commenced and on-going 39
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 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: Reference number damage Recommendat

Altnaglevin Hospital, Londonderry - 22 November 2011

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