Human Resource Decontamination Decontamination escalated to Corporate Recruitment program Management Technician Technician Risk Register. in place Recruitment process being undertaken 1 New WTE 1 New WTE Cathrina Ryan CLOSED CLOSED CLOSED appointed to appointed to A/ODON Endoscopy Endoscopy Action Plans Action Taken Lead Responsibility Progress To Date Review Standard Findings/ Non Compliance Target Timeframe Standard 3 Decontamination Reroute waste water Washer plumbed so Philip Brennan Completed Completed Closed Environment and Washer not plumbed for direct disposal waste water is Facilities November 2015 November 2015 November 2015 Facilities for direct disposal of disposed directly Management waste water Standard 6 Hand hygiene sink Hand Hygiene Sink to Re-education and sink Celia Dwan CNM2 Completed Completed Closed Hand Hygiene being used for other be used only for hand labelled as Barbara Slevin November 2015 November 2015 November 2015 ‘Hand purposes washing Hygiene Sink’ ADON Standard 3 Environment and Damage and break to Repair and Replace Flooring Replaced Philip Brennan Completed Completed Closed Facilities flooring in Scope Facilities November 2015 November 2015 November 2015 Management Cleaning Room Standard 3 Environment and Failure to remove Re-education of all Education to be Celia Dwan CNM2 February 2016 IP&C training and September 2016 Facilities sterile consumables in Department carried out by IP&C Barbara Slevin IPC Education education priorities Management and clean sharps tray ADON Barbara ADON Programme discussed with IP&C after use Slevin. Education team schedule for 2016 being finalised Standard 3 Isolation Room Door Review practices of Each patient assessed Relevant CNM2 Ongoing Ongoing, assess on a Ongoing, assess on a Environment and open keeping door open in on an individual IPC Education patient by patient patient by patient Facilities isolation cases after Reason for leaving programme basis Management appropriate patient door open to be safety assessment i.e. documented and for slips trips and falls reported Standard 6 Clinical Hand Wash Assessment of hand Awaited Philip Brennan February 2016 Awaited September 2016 Hand Hygiene sinks in Medical 2 do wash sinks in medical Facilities not fully conform with 2. Forward business Health Building Note case to Estates re 00-10 Part C feasibility of replacing Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review
Human Resource Management Decontamination Technician Decontamination Technician 1 New WTE appointed to Endoscopy escalated to Corporate Risk Register. Recruitment process being undertaken 1 New WTE appointed to Endoscopy Cathrina Ryan A/ODON CLOSED Recruitment program in place CLOSED CLOSED Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Facilities Management Decontamination Washer not plumbed for direct disposal of waste water Reroute waste water for direct disposal Washer plumbed so waste water is disposed directly Philip Brennan Facilities Completed November 2015 Completed November 2015 Closed November 2015 Standard 6 Hand Hygiene Hand hygiene sink being used for other purposes Hand Hygiene Sink to be used only for hand washing Re-education and sink labelled as ‘Hand Hygiene Sink’ Celia Dwan CNM2 Barbara Slevin ADON Completed November 2015 Completed November 2015 Closed November 2015 Standard 3 Environment and Facilities Management Damage and break to flooring in Scope Cleaning Room Repair and Replace Flooring Replaced Philip Brennan Facilities Completed November 2015 Completed November 2015 Closed November 2015 Standard 3 Environment and Facilities Management Failure to remove sterile consumables and clean sharps tray after use Re-education of all in Department Education to be carried out by IP&C ADON Barbara Slevin. Education schedule for 2016 being finalised Celia Dwan CNM2 Barbara Slevin ADON February 2016 IPC Education Programme IP&C training and education priorities discussed with IP&C team September 2016 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 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 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 Awaited September 2016 Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review