Glasgow Western Infirmary failed to make improvements
Health inspectors have found that a number of required improvements at a Glasgow hospital were not made despite being called for in previous reports.
An unannounced visit to the Western infirmary in August found that management still had no time-scale for implementing a Legionella policy.
Other concerns focussed on the disposal of sharp equipment, dirty linen storage and open doors on isolation rooms.
NHS Greater Glasgow and Clyde has drawn up an action plan to address concerns.
A team from the Healthcare Environment Inspectorate (HEI) previously visited the Western Infirmary in July 2012.
That inspection gave rise to four requirements and one recommendation.
The unannounced visit, made on 5 August this year, resulted in five requirements and three recommendations.
The HEI team found that there was no time-scale in place yet for when a Legionella policy would be implemented.
Inspectors were told on a previous visit that NHS Greater Glasgow and Clyde's (GGC) policy for Legionella, the bacteria that causes Legionnaires' disease, was under review and due to be formally approved.
But minutes from a meeting in July this year suggested "no decision had been made on when the draft policy will be approved", the inspectors said.
The health board has now been given a month to provide a time-scale for when a Legionella policy will be approved and put in place.
NHS GGC has also been told to ensure staff on the hospital wards follow the isolation policy, after inspectors noticed a number of isolation rooms had their doors left open.
The inspection report said this "may pose a particular risk of cross-infection to other patients, staff and visitors".
The inspectors pointed out that in July last year the health board was told to ensure the isolation policy was implemented, with monitoring to be carried out of whether doors to isolation rooms were left open.
Their report also revealed that some bins for staff to dispose of sharp equipment were not assembled or labelled correctly and were sometimes not closed properly.
A container for used linen was open when the inspectors visited, instead of being stored in a locked area while awaiting removal.
Overall, inspectors said that NHS GGC was making good progress on standards to protect patients, staff and visitors from the risks of catching hospital infections.
HEI chief inspector Susan Brimelow said: "Staff demonstrated good awareness, knowledge and understanding of their roles and responsibilities for infection prevention and control, and patient equipment was clean.
"However, there are a number of areas for improvement including two requirements that have not been met from our previous inspection.
"We expect NHS Greater Glasgow and Clyde to address these areas as a priority."
Rory Farrelly, the health board's acute director of nursing, said: "We have received the inspector's report and are disappointed that some areas are still falling short of the standards expected in all our hospitals.
"Clearly we need to reinforce some of our policies with staff, including the disposal of sharps, storage of linen and our Legionella policy which, like all our policies, is available to staff on our intranet."
Mr Farrelly said that an action plan had been drawn up to address the requirements and recommendations of the report.
He said NHS GGC was "pleased" that the chief inspector had recognised that "staff demonstrated good awareness, knowledge and understanding of their roles and responsibilities for infection prevention and control, and patient equipment was clean".