Report of the announced monitoring assessment at Bantry ... - hiqa.ie

Report of the announced monitoring assessment at Bantry General Hospital, CorkHealth Information and Quality Authority3.2. Theme 1: Leadership, Governance and ManagementTheme 1: Leadership, Governance and ManagementRobust leadership, governance and management structures and processes underpinwhat hospitals should have in place to assure the public and themselves that thearrangements for the prevention and control of Healthcare Associated Infections(PCHCAI) are effective.There are robust local, monitoring and reporting arrangements in place therebyensuring infection control is managed at a consistently high level of quality withminimal variation in the delivery of that care. There are effective regional andnational PCHCAI reporting arrangements in place, infection control activitiesprovided are compliant with the relevant legislation, clinical care programmes andevidenced-based practice, and the organisation is acting on national standards andrecommendations from statutory bodies.Essential Element 1(a). A comprehensive corporate and PCHCAI governancestructure supported by an integrated organisational framework is in place. Thegovernance arrangements will include PCHCAI specific strategies, aligned costeffective initiatives and defined responsibilities for externally contracted services.Findings Essential Element 1(a).At the time of the inspection, Bantry General Hospital was a stand-alone hospitalwith informal working arrangements with Cork University Hospital Group (CUHG).PCHCAI GovernanceThe Hospital’s governance structure includes a general manager, a hospitalmanager, a director of nursing and a clinical director (who is also the ClinicalDirector for Cork University Hospital Group). The Hospital Manager and Director ofNursing report to the General Manager, who reports to the Area Manager, HSESouth. The Clinical Director reports to the Area Manager, HSE South.Infection Prevention and Control TeamAn Infection Prevention and Control Team (IPCT) is in place, which is accountable tothe Hospital Infection Control Committee, as documented in the submitted terms ofreference. The team comprises the Infection Control Nurse, a nursing representativeand a consultant physician.5