Standard Findings/ Non Compliance Action Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Sanitary Facilities not Sanitary Facilities Redesign of shift Cathrina Ryan February 2016 Meetings September 2016 Facilities being checked in the check sheet to be patterns and rosters to A/ODON commenced with Management evening checklists redesigned to reflect have availability of Irene O’Connor Unions and MTAs – not being signed off in National Cleaning Hygiene attendants on Facilities for review of rosters evening standard of 3 cleans duty in afternoons / to facilitate extended and 2 check cleans a evenings to carry out day. day. checks / cleans commenced WTE Deficit Appropriate schedules identified– awaiting designed and to be appointment of same distributed to achieve and maintain hygiene standard. 5 MTAs recruited and 5 further vacancies identified. Interviews April 2016 Monitoring of patients Monthly sanitary Bridget Kelly CNM2 Monthly and Ongoing Ongoing sanitary facilities facility audits ongoing Standard 4 Deficits in Hygiene Recruit and replace Placed on Hospital Cathrina Ryan September 2015 Feb 2016 Human Resource staff WTE identified deficits in hygiene risk register in April A/ODON Ongoing recruitment Management on Medical 2 ward WTE 2014 and escalated to and training across Facilities Josephine Hynes HR ULH Group. Management Irene O’Connor Awaiting further Facilities allocation to Nenagh MARCH 2016 CLOSED – New staff allocated to hospital. Second hygiene MTA allocated to Med 2 Risk submitted to Noreen Spillane Operations COO
Standard Findings/ Non Compliance Action 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 February 2016 Monthly and ongoing Meetings commenced with Unions and MTAs for review of rosters to facilitate extended day. WTE Deficit identified– awaiting appointment of same to achieve and maintain hygiene standard. 5 MTAs recruited and 5 further vacancies identified. Interviews April 2016 Ongoing September 2016 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 Operations Cathrina Ryan A/ODON Josephine Hynes HR Irene O’Connor Facilities Noreen Spillane COO September 2015 Feb 2016 Ongoing recruitment and training across ULH Group. Awaiting further allocation to Nenagh MARCH 2016 – New staff allocated to hospital. Second hygiene MTA allocated to Med 2 CLOSED
nenaghhospitalquipsep2015.docx