Annual Report and Clinical Governance Report 2008 to 2009

Accreditations
Sandyford ensures that services, including those that support clients, meet quality
standards. In the last year the following accreditations were achieved:
• Clinical Pathology accreditation (CPA) remains active until our next inspection
due April 2009.
• EPASS (Educational Providers Accreditation Scheme Scotland) Training for GPs –
As an EPASS provider all the educational events held within our period
accreditation are now EPASS accredited until March 2010.
• Consultant posts form part of Deanery-approved higher medical training
schemes in Genitourinary (Sexual Health & HIV) Medicine and Sexual &
Reproductive sub-specialist training for Obstetrics & Gynaecology.
Infection Control
The aim of the infection control audit tool is to assist with ensuring that the Clinical
Standards Board for Scotland’s standards for health care associated infection are
met and to ensure a high standard of infection control.
The tool, developed by NHS Greater Glasgow Primary Care Trust Infection Control
nurses in 2003, defines acceptable standards for a managed environment which
minimises the risk of infection to patients and staff.
The audit is completed in 19 sections to audit infection control standards with reaudit
timeframe being dependent on the previous audit scores. Standards of
cleanliness, following infection control guidelines and clinical practice have
improved since the introduction of the audit. In most areas the audit is carried out
annually indicating acceptable scores in the previous audits.
As well as the infection control audit there is also the cleaning services audit
developed to comply with the NHS Scotland National Framework for Cleaning
Services Specification. This audit is carried out by the hotel services staff who work
closely with Sandyford to monitor standards of cleanliness. As part of the induction
of new staff training in infection control is carried out. Regular sessions on infection
control updates are arranged throughout the year for Sandyford staff and is
mandatory for staff to attend annually.
Summary
This section has provided information on where the Sandyford seeks published
evidence in ensuring clinical effectiveness. It indicates the wide range of national
guidelines that are available which influences care and standards within the
organisation. The following section details the training programme that is in place
to support staff in delivering quality care to clients who attend the service.
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