Facilities incomplete due to lack timeframe outlined in logs Bridget Kelly CNM 2 Ongoing by hygiene staff monthly Management of hygiene resources equipment log Environmental Hygiene Audit Equipment to be In progress, Equipment being Daily monitoring by cleaned by staff equipment cleaned by cleaned by staff after ward CNM member who uses it staff after use i.e. Bridget Kelly CNM2 Ongoing use observations machines Equipment not in use Equipment moved to Excess equipment Daily monitoring by to be stored off the the equipment store decanted off ward to ward CNM ward room off the ward Bridget Completed equipment store when not in use Kelly CNM2 room Increase Hygiene Hygiene WTE deficit Completed Completed Hours Escalated to Corporate risk register Cathrina Ryan Completed September 2014 A/ODON Ongoing process Ongoing process 5 new MTA’s commenced in Nenagh Hospital since Josephine Hynes HR Ongoing process Jan 2016.More Irene O’Connor positions to be filled. Facilities Recruitment on going Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 High levels of dust in Intermittent deep Staff allocated when ADON on duty Ongoing Intermittent deep Ongoing Review Environment and 10 bedded Medical 2 clean as staffing available to perform a cleans carried out at Facilities allows deep clean to ward level. Management supplement daily cleaning Implement deep clean Hygiene Schedule and Cathrina Ryan April 2016 New Duties, Roles First quarter 2017 rota of rooms where duties being A/ODON and responsibilities
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
hiqa-qip-january-2017.docx