Facilities Management incomplete due to lack of hygiene resources timeframe outlined in equipment log Equipment to be cleaned by staff member who uses it Equipment not in use to be stored off the ward Increase Hygiene Hours logs In progress, equipment cleaned by staff after use i.e. observations machines Equipment moved to the equipment store room off the ward when not in use Hygiene WTE deficit Escalated to Corporate risk register September 2014 5 new MTA’s commenced in Nenagh Hospital since Jan 2016.More positions to be filled. Recruitment on going Bridget Kelly CNM 2 Bridget Kelly CNM2 Bridget Kelly CNM2 Cathrina Ryan A/ODON Josephine Hynes HR Irene O’Connor Facilities Ongoing Ongoing Completed Completed Ongoing process by hygiene staff Equipment being cleaned by staff after use Excess equipment decanted off ward to equipment store room Completed Ongoing process monthly Environmental Hygiene Audit Daily monitoring by ward CNM Daily monitoring by ward CNM Completed Ongoing process Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Facilities Management High levels of dust in 10 bedded Medical 2 Intermittent deep clean as staffing allows Implement deep clean rota of rooms where Staff allocated when available to perform a deep clean to supplement daily cleaning Hygiene Schedule and duties being ADON on duty Cathrina Ryan A/ODON Ongoing April 2016 Intermittent deep cleans carried out at ward level. New Duties, Roles and responsibilities Ongoing Review First quarter 2017
all furniture and beds are pulled out, cleaned, returned to room e.g. Room 1 + 2 every Monday. 3+4 every Tuesday Monitoring of environmental hygiene redesigned in line with recruitment of new staff – same at discussion level with Hospital Management and Union Representation Monthly Hygiene audits being carried out at ward level. Ongoing risk on Hospital Risk Register Irene O’Connor Facilities Bridget Kelly CNM2 Ongoing and Monthly being drafted and discussed by management and Union representation. Meetings ongoing and issues being progressed. . Maintained on Risk register. Ongoing and monthly monitoring Ongoing and monthly monitoring Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Facilities Management Inadequate patient Preparation / waiting area Patients prepped for procedure in post procedure observation area Patient waiting area to be included new plans for remodelled Endoscopy Unit for JAG accreditation Philip Brennan Second quarter of 2017 Upgrade of MAU to commence on ground floor. Plan to move MAU by first quarter of 2017 which will release more floor space to Endoscopy. Second quarter of 2017 Standard 3 Environment and Facilities Management No Endoscopy patient discharge lounge Patients being discharged from bed space Designation of Endoscopy Discharge Lounge with remodelling of Unit Discharge care and advice being provided in observation bed space New Seating area being set up - Celia Dwan CNM2 Philip Brennan Facilities Ongoing Second quarter of 2017 Discharge care and advice being provided in observation bed space Upgrade of MAU to commence on ground floor. Plan to move MAU by first Ongoing Second quarter of 2017
for JAG accreditation quarter of 2017 which will release more floor space to Endoscopy Standard 3 Environment and Facilities Management Clutter on work surfaces in Procedure room 1 Office space adjacent to Endoscopy Procedure Room 1 designated to Endoscopy. New office space provided to Endoscopy Unit. All possible equipment / paperwork decanted to new office space Philip Brennan Facilities Celia Dwan CNM2 Completed Ongoing monitoring and audit Completed Ongoing monitoring and audit Completed Ongoing monitoring and audit Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Facilities Management Failure to remove sterile consumables and clean sharps tray after use Re-education of all staff in Department Education to be carried out by IP&C ADON Barbara Slevin. Education schedule being finalised Celia Dwan CNM2 Barbara Slevin ADON First Quarter 2017 Staff have been updated on relevant policys and awareness created around availability of same by Dept manager First quarter 2017 Standard 3 Environment and Facilities Management Isolation Room Door open Review practices of keeping door open in isolation cases after appropriate patient safety assessment i.e. for slips trips and falls Each patient assessed on an individual basis. Reason for leaving door open to be documented and reported Relevant CNM2 Ongoing IPC Education programme Ongoing, assess on a patient by patient basis Ongoing, assess on a patient by patient basis Standard 6 Hand Hygiene Clinical Hand Wash sinks in Medical 2 do not fully conform with Health Building Note 00-10 Part C Assessment of hand wash sinks in medical 2. Forward business case to Estates re feasibility of replacing Awaited Philip Brennan Facilities February 2016 Awaiting possible ward revamp Suspended June 2017 Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 8 Invasive Medical Improvement in Documentation for Care bundles to be incorporated to Ongoing Audits continued. Local and Relevant CNM2 Barbara Slevin May 2016 Await Guidance from Project Group First quarter 2017
Device related infections are prevented or reduced Peripheral Vascular Care bundles & Urinary Catheter Care bundles required NEWS Chart and become part of patients routine observations HIQA Audit results fed back to staff. QIP in place until documentation streamlined ADON Cathrina Ryan A/ODON Lead Monthly review via Metrics on Medical Floor. New audit tool introduced to audit care bundles on Medical floor. Standard 3 Environment and Facilities Management Blood Glucose Device and container being brought to patient’s bedside All staff reminded for need to make up and clean down individual tray when taking a patients blood glucose Hospital policy re circulated. CNMS requested to monitor and tutor staff in their work areas Cathrina Ryan A/ODON Relevant CNMS January 2017 Reaudit March 2017 Ongoing Monitoring and Audit Outstanding Items From HIQA QIP 2014 Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Facilities Management Sanitary Facilities not being checked in the evening – checklists not being signed off in evening Sanitary Facilities check sheet to be redesigned to reflect National Cleaning standard of 3 cleans and 2 check cleans a day. Monitoring of patients sanitary facilities Redesign of shift patterns and rosters to have availability of Hygiene attendants on duty in afternoons / evenings to carry out checks / cleans commenced Appropriate schedules designed and to be distributed Monthly sanitary facility audits Cathrina Ryan A/ODON Irene O’Connor Facilities Bridget Kelly CNM2 December 2016 Monthly and ongoing Meetings commenced with Unions and MTAs for review of rosters to facilitate extended day. Final draft of rosters circulated to include evening cleaning WTE Deficit identified– awaiting appointment of same to achieve and maintain hygiene standard. 5 MTAs recruited and 7 further vacancies identified. Recruitment ongoing. Ongoing First quarter 2017 Ongoing
Standard 4 Human Resource Management Deficits in Hygiene staff WTE identified on Medical 2 ward Recruit and replace deficits in hygiene WTE Placed on Hospital risk register in April 2014 and escalated to Facilities Management Risk submitted to Chief Operations Officer N Spillane January 2015 Cathrina Ryan A/ODON Josephine Hynes HR Irene O’Connor Facilities Noreen Spillane COO First quarter 2017 Ongoing recruitment and training across ULH Group. Awaiting further allocation to Nenagh MARCH 2016 – 5 New staff allocated to hospital. Second hygiene MTA allocated to Med 2 First quarter 2017