in Med 3. Brown staining was present on the under surface of three patient armchairs and organic matter was noticed under one of these chairs. Light dust was observed on the base of a drip stand and on the undercarriage of two beds. In addition, staining was visible on two electronic thermometer holders. It was observed that patient equipment checklists had not been consistently signed off to indicate that cleaning had been performed. equipment cleanliness check using visual observation and ensuring compliance with the existing tagging system Checklists will be signed off and records maintained. Domestic Supervisor Staff Nurses/Midwives. HCA’s Domestic Staff Heads of Departments Hygiene Audits reviewed by HSAG 2 Environmental Hygiene 2.1 Workstation Cleaning. Light dust was present on surfaces including computer keyboards on the staff workstation in the main Dialysis unit. In Med 3 Light dust was visible on the staff workstation and heavy dust was present on healthcare record trolleys. Cleaning of ward workstations and medical storage trolleys should be included in local cleaning specifications. Roles and responsibilities in this regard should be clearly defined. Working Group established inclusive of all stakeholders to develop a SOP to outline Definitive role and responsibilities To include equipment on Corridor spaces with sub sections outlining responsibilities for each discipline. To be included in SOP for ward cleaning schedule Public service agreement was discussed with Union Working group-Facilities Manager, IPCT Manager, Consultant Microbiologist, Domestic Supervisor, CNM2, HCA, and Ward Receptionist. Everyone’s responsibility Clerical Staff – Public Service Agreement. As per talks with IMPACT union – all ward clerks are responsible for their own working environment. Dec 2016 On Going Environmental Hygiene Audits reviewed by HSAG. 3 Renal Dialysis Unit
with drums of dialysis fluid was located at the main entrance to this unit and a trolley for transporting supplies and a pallet jack were stored along the main unit corridor. 4.3 Waiting Times for Patients It was reported that there were significant waiting times for patients requiring surgery to form an arteriovenous fistula to provide vascular access for dialysis. It is recommended that the hospital accurately quantify the extent of any delays and associated risks. Risks identified should be managed and mitigated within the HSE risk management process. Pathway: All patients are referred to Altnagelvin Hospital, Derry. Delays occur when Altnagelvin are unable to insert due to complexity of individual cases. Complicated cases referred to of up to 1 year. Incidents recorded on data collated and associated risks are being identified and managed. Exploring alternative patient pathway via Sligo University Hospital. Consultant Physician, Associate CD, ADON/SM, GM, DON. On Going capacity issue. July 2017 5 Preventative Measures to Control Nosocomial Aspergillus 5.1 Preventative measures to protect at-risk patients from possible infection due to fungal spores generated during building works had not been fully implemented on the day of inspection. Several windows in the hospital facing an area where soil had been excavated were open despite the finding that keeping 1.The Infection Prevention and Control reporting document (ORG-IC-0023) has been revised 30/06/2016 based on the “National Guidelines for the Prevention of Nosocomial Invasive Aspergillosis during Construction/Renovation - On Going due to extensive rebuild programme. Senior Management safety walks to monitor compliance. external
should include information regarding appropriate indications for glove usage. ‘In the Spotlight’ -plan to hold monthly workshops to raise awareness regarding infection prevention and control. Targeted training in relation to observed non compliances 10 Sterile Supplies Inspectors observed that sterile items were stored in open trolleys on corridors in Medical 3 Ward. Storage of Sterile Supplies should be reviewed across the Hospital. Practice was addressed immediately, sterile supplies are not stored on point of care trolleys CN/MM’s, Staff Nurses/Midwives, HCA’s Complete June 2016 Monitor Environmental Hygiene Audits