Kingsbridge Private Hospital, Belfast - 20 January 2012

rqia.org.uk

Kingsbridge Private Hospital, Belfast - 20 January 2012

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RQIA

Infection Prevention/Hygiene

Announced inspection

Kingsbridge Private Hospital

20 January 2012


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 5

3.0 Inspections 6

4.0 Unannounced Inspection Process 7

4.1 Onsite Inspection 7

4.2 Feedback and Report of the Findings 7

5.0 Audit Tool 8

6.0 Environment 10

6.1 Cleaning 10

6.2 Clutter 11

6.3 Maintenance and Repair 11

6.4 Fixture and Fittings 11

6.5 Information 11

7.0 Patient Linen 13

7.1 Management of Linen 13

8.0 Waste and Sharps 14

8.1 Waste 14

8.2 Sharps 14

9.0 Patient Equipment 16

10.0 Hygiene Factors 17

11.0 Hygiene Practice 19

12.0 Endoscopy Suite 21

12.1 Endoscopy Suite Environment 23

12.2 Specialist Patient Equipment 23

12.3 Policies and Procedures 23

13.0 Key Personnel and Information 24

14.0 Summary of Recommendations 25

15.0 RQIA Hygiene Team Escalation Policy Flowchart 27

16.0 Action Plan 28


1.0 Inspection Summary

A joint inspection of endoscopy units in regulated independent

healthcare facilities was conducted by members of RQIA infection

prevention/hygiene Team (IPHT), estates, and HEIG (Health Estates

Investment Group) inspectors from the DHSSPS.

The purpose of the announced inspection to Kingsbridge Private

Hospital on the 21January 2011 was to provide assurance that facilities

and practices specific to endoscopic procedures within the clinic

complied with current standards.

The clinic was assessed against the Regional Healthcare Hygiene and

Cleanliness standards, with an additional section developed specifically

for endoscopy suites. Inspectors from HEIG also carried out an

inspection using the Flexible Endoscope audit tool produced by

DHSSPS Health Estates and Investment Group (HEIG) the following

area was inspected:

• Specialist Area - Endoscopy Suite/Theatre

The hospital was originally registered 2006, it was re-registered as the

Kings Bridge Private Hospital in November 2011, it is located in South

Belfast and offers a range of both inpatient and out patient procedures.

The endoscopy unit, which operates on an outpatient basis, is a

separate area within the hospital. The endoscopy suite is on the

second floor and is accessed via the main reception by lift or stairs.

There is a small reception area with a consulting room (under

construction), two changing rooms with en-suite, a theatre, clean utility

room and two linked dirty utility rooms.

Inspection Outcomes

The results of the inspection showed an overall compliance level.

However the structure and layout of the endoscopy decontamination

room do not comply with the required standards as evidenced in the

minimally compliant score achieved in this section of the audit tool.

Inspectors also noted that improvement was required in some

associated endoscopic practices.

Observation of staff practice indicated overall compliance with hygiene

and infection prevention and control practices. However more work is

required to ensure effective hand hygiene is carried out by all staff.

The safe management and disposal of waste also requires attention,

and the clinic needs to review the use and supply of personal

protective equipment (PPE).

The inspection resulted in 22 recommendations for Kingsbridge Private

Hospital, a full list of recommendations is listed in Section 14. The

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eport and recommendations will be forwarded to the relevant inspector

for performance management under the following regulations and

standards:

• The HPSS (Quality, Improvement and Regulation) (Northern

Ireland) Order 2003

• The Independent Health Care Regulations (Northern Ireland)

2005

• The Department of Health, Social Services and Public Safety's

(DHSSPS) draft Independent Health Care Minimum Standards

for Hospitals and Clinics March 2005

• The Department of Health, Social Services and Public Safety's

(DHSSPS) Health Estates Investment Group, Flexible

Endoscope Decontamination Audit Tool, January 2010

A report from HEIG inspectors on their findings has been provided in

the format of “key audit findings” and “points of concern”. A copy has

been forwarded to the clinic requesting an action plan to address the

deficiencies identified. The clinic was also asked to provide RQIA with

a position statement regarding their proposal for future service delivery

i.e. upgrading of the existing on-site reprocessing facilities or

outsourcing of endoscope reprocessing.

Notable Practice

The inspection identified the following areas of notable practice:

• Staff displayed a positive attitude to inspection and a

willingness to learn and improve practices.

The RQIA inspection team would like to thank the staff at the

Kingsbridge Hospital for their assistance during the inspection.

The following tables give an overview of compliance scores noted in

areas inspected by RQIA:

Table 1 summarises the overall compliance levels achieved.

Tables 2-7 summarise the individual tables for sections two to seven of

the audit tool as this assists organisation to target areas that require

more specific attention.

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Table 1

Areas Inspected

Environment 84

Patient Linen 91

Waste 86

Sharps 67

General Patient

Equipment

87

Hygiene Factors 88

Hygiene Practices 86

Endoscopy Suite 85

Average Score 84

Table 2

General Environment

Reception 98

Corridors, stairs lift 83

Public toilets 83

Ward/department -

general (communal)

85

Toilet 82

Domestic store 78

General information 77

Average Score 84

Table 3

Patient Linen

Storage of clean linen 90

Storage of used linen 91

Laundry facilities

N/A

Average Score 91

Table 4

Waste and Sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

86

67

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 5

Patient Equipment

Patient equipment 87

Table 6

Hygiene Factors

Availability and

cleanliness of wash hand 96

basin and consumables

Availability of alcohol rub 92

Availability of PPE 82

Materials and equipment

for cleaning

81

Average Score 88

Table 7

Hygiene Practices

Effective hand hygiene

procedures

67

Safe handling and

disposal of sharps

100

Effective use of PPE 83

Correct use of isolation N/A

Effective cleaning of ward 82

Staff uniform and work

wear

97

Average Score 86

Table 8

Endoscopy Suite

Scrub Room

N/A

Endoscopy Theatre 97

Endoscopy

60

decontamination room

Specialist

90

Equipment/practices

Policies and Procedures 93

Average Score 85

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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2.0 Background Information to the Inspection Process

RQIA’s infection prevention and hygiene team was established to

undertake a rolling programme of unannounced inspections of acute

hospitals. The Department of Health Social Service and Public Safety

(DHSSPS) commitment to a programme of hygiene inspections was

reaffirmed through the launch in 2010 of the revised and updated

version of 'Changing the Culture' the strategic regional action plan for

the prevention and control of healthcare-associated infections (HCAIs)

in Northern Ireland.

The aims of the inspection process are:

• to provide public assurance and to promote public trust and

confidence

• to contribute to the prevention and control of HCAI

• to contribute to improvement in hygiene, cleanliness and infection

prevention and control across health and social care in Northern

Ireland

In keeping with the aims of the RQIA, the team will adopt an open and

transparent method for inspection, using standardised processes and

documentation.

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3.0 Inspections

The DHSSPS has devised Regional Healthcare Hygiene and

Cleanliness standards. RQIA has revised its inspection processes to

support the publication of the standards which were compiled by a

regional steering group in consultation with service providers.

The inspections will be undertaken in accordance with the four core

activities outlined in the RQIA Corporate Strategy, these include:

• Improving care: we encourage and promote improvements in the

safety and quality of services through the regulation and review of

health and social care

• Informing the population: we publicly report on the safety,

quality and availability of health and social care

• Safeguarding rights: we act to protect the rights of all people

using health and social care services

• Influencing policy: we influence policy and standards in health

and social care

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4.0 Announced Inspection Process

The hospital received advanced notice of the onsite inspection.

4.1 Onsite Inspection

The inspection team was made up of two inspectors, from RQIA’s

infection prevention/hygiene team, one inspector from RQIA’s estates

team and two inspectors from the DHSSPS Health Estates Investment

Group (HEIG) inspection team. Membership of the inspection team is

outlined in Section 13.

The inspection process involves observation, discussion with staff, and

review of some ward documentation.

4.2 Feedback and Report of the Findings

The process concludes with a feedback of key findings to

organisational representatives and includes examples of notable

practice identified during the inspection. The details of organisational

representatives attending the feedback session is outlined in Section

13.

The RQIA team responsible for the facility is forwarded a copy of the

draft report. The responsible inspector will review the report and

recommendations and devise a Quality Improvement Plan. The draft

report containing the Quality Improvement Plan of the inspection is

forwarded to the organisation for agreement and factual accuracy

checking and returned within two weeks. The Quality Improvement

Plan will be subject to performance management by the inspector

responsible for the facility.

The infection prevention/hygiene team escalation process will be

followed if inspectors/reviewers identify any serious concerns during

the inspection (Section 15).

A number of documents have been developed to support and explain

the inspection process. This information is currently available on

request and will be available in due course on the RQIA website.

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5.0 Audit Tool

The audit tool used for the inspection is based on the Regional

Healthcare Hygiene and Cleanliness standards. The standards

incorporate the critical areas which were identified through a review of

existing standards, guidance and audit tools (Appendix 2 of Regional

Healthcare Hygiene and Cleanliness standards). The audit tool follows

the format of the Regional Healthcare Hygiene and Cleanliness

Standards and comprises of the following sections.

1. Organisational Systems and Governance: policies and

procedures in relation to key hygiene and cleanliness issues;

communication of policies and procedures; roles and

responsibilities for hygiene and cleanliness issues; internal

monitoring arrangements; arrangements to address issues

identified during internal monitoring; communication of internal

monitoring results to staff

2. General Environment: cleanliness and state of repair of public

areas; cleanliness and state of repair of ward/department

infrastructure; cleanliness and state of repair of patient bed area;

cleanliness and state of repair of toilets, bathrooms and

washrooms; cleanliness and state of repair of ward/department

facilities; availability and cleanliness of isolation facilities;

provision of information for staff, patients and visitors

3. Patient Linen: storage of clean linen; handling and storage of

used linen; ward/department laundry facilities

4. Waste and Sharps: waste handling; availability and storage of

sharps containers

5. Patient Equipment: cleanliness and state of repair of general

patient equipment

6. Hygiene Factors: hand wash facilities; alcohol hand rub;

availability of personal protective equipment (PPE); availability of

cleaning equipment and materials.

7. Hygiene Practices: hand hygiene procedures; handling and

disposal of sharps; use of PPE; use of isolation facilities and

implementation of infection control procedures; cleaning of

ward/department; staff uniform and work wear

8. Endoscopy Suite: anaesthetic room, scrub room, endoscopy

theatre/room, endoscopy decontamination room/area, specialist

equipment and policies/procedures.

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Level of Compliance

Percentage scores can be allocated a level of compliance using the

compliance categories below. The categories are allocated as follows:

Compliant

85% or above

Partial compliance 76 to 84%

Minimal compliance 75% or below

Each section within the audit tool will receive an individual and an

overall score, to identify areas of partial or minimal compliance to

ensure that the appropriate action is taken.

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6.0 Environment

STANDARD 2.0

GENERAL ENVIRONMENT

Cleanliness and state of repair of public areas; cleanliness and

state of repair of ward/department infrastructure; cleanliness and

state of repair of patient bed area; cleanliness and state of repair

of toilets, bathrooms and washrooms; cleanliness and state of

repair of ward/department facilities; availability and cleanliness of

isolation facilities; provision of information for staff, patients and

visitors.

General Environment

Reception 98

Corridors, stairs lift 83

Public toilets 83

Ward/department -

general (communal)

85

Toilet 82

Domestic store 78

General information 77

Average Score 84

The above table outlines the findings in relation to the environment of

the facility inspected. The findings indicate that there are some areas

for improvement. The findings in respect of the general environment,

are detailed in the following sections.

At the time of inspection major construction work was under way to

create a new shared recovery bay, to service the endoscopy unit and

theatres. The area had been screened off prior to taking down a wall

however the screens had been removed once this work had finished.

As a result the inspectors were concerned about the amount of dust

that continued to permeate throughout the areas leading to the

endoscopy unit

6.1 Cleaning

At the time of the inspection there was some evidence to indicate

compliance with regional specifications for cleaning. However

inspectors observed that greater attention to detail was required to

ensure effective cleaning mechanisms were in place and implemented

to prevent the build-up of dust and debris. This in turn prevents the

build-up of bacteria and subsequently reduces the potential risk for the

transmission of infection.

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The main hospital reception on the ground floor and the waiting area

for the endoscopy unit were clean and in good decorative order.

Greater attention to detail was required when cleaning the public toilets

on the ground floor to remove splashes and stains from walls, skirting

and the air vent. The inside of the toilet was stained and there was

limescale on the taps. The toilets in the endoscopy unit also required

further cleaning as the inside of both toilets and the vinyl covered back

rest on the disabled toilet were stained.

The walls in the domestic store were splashed and stained and there

was debris on the floor under the low sluice sink. Both the sluice sink

and equipment sink were dirty and the taps had limescale present.

The hand touch points on the door were grubby and the shelving unit

was dusty.

6.2 Clutter

The general areas were clutter free, two large x-ray machines were

observed in the endoscopy waiting area, these were removed during

the inspection.

6.3 Maintenance and Repair

This is a relatively new building and in good repair, however the

inspectors did note that the vinyl flooring in the endoscopy unit was

damaged in places. The flooring outside the endoscopy room has

bubbled and some of the welds at the joins were missing or of poor

finish and there were cracks to plaster work in the patient changing

area.

6.4 Fixtures and Fittings

Unlike the rest of the unit the

chairs in the patient changing

area were old and worn, the

vinyl covering was split and

torn in places and therefore

not impervious to moisture.

6.5 Information

Picture 1: Damaged vinyl on chair

As the hospital has only been registered to the current owners some

policies and guidelines are still being developed. A cleaning policy for

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nursing staff is in place but detailed cleaning schedules are being

formulated. Similarly a support service manager has just been

appointed and is currently re-drafting the domestic cleaning schedule

which was very basic. Information leaflets on MRSA, Clostridium

difficile and common infections were not available. Infection Prevention

and Control policies are being developed for the hospital but staff have

access to the Regional Infection Prevention and Control manual on

line.

Recommendations

1. The hospital should ensure that the systems and processes

in place for environmental cleaning, provide the necessary

assurance that cleaning is carried out effectively, and that all

staff are aware of their responsibilities.

2. The healthcare environment should be repaired and

maintained, and damaged furniture replaced to maintain

public confidence and to help reduce the risk of the spread

of infection.

3. The hospital should review current storage arrangements to

maintaining a clutter free environment.

4. The hospital should continue on developing policies,

guidelines and cleaning schedules.

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7.0 Patient Linen

STANDARD 3.0

PATIENT LINEN

Storage of clean linen; handling and storage of used linen; ward/

department laundry facilities.

7.1 Management of Linen

Patient Linen

Storage of clean linen 90

Storage of used linen 91

Laundry facilities

N/A

Average Score 91

Staff achieved an overall compliant score in this standard.

The bed linen store was clean neat and tidy, however in the store used

for staff scrubs the inspectors noted that some scrub suits were lying

on the floor. In the clean decontamination room off the theatre, a

supply of exposed clean sheets was observed on a trolley, these

sheets should be stored covered or in a linen cupboard to prevent

exposure to airborne contamination.

The used linen baskets in the patient changing areas were made of

wicker and therefore could not be effectively cleaned, and the cloth

bags used as liners were ripped and damaged. Used linen awaiting

collection was stored in a designated area and bags were not over

filled.

Staff advised inspectors that personal protective equipment (PPE) is

used when handling soiled/contaminated linen and that theatre

uniforms are reprocessed by a recognised external laundry contractor.

Recommendations

5. The hospital should ensure that clean linen is stored in a

designated area which is fit for purpose.

6. Equipment used for the storage of used linen should be

cleanable and fit for purpose.

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8.0 Waste and Sharps

STANDARD 4.0

WASTE AND SHARPS

Waste: Effectiveness of arrangements for handling, segregation,

storage and disposal of waste on ward/department

Sharps: Availability, use and storage of sharps containers on

ward/department

Waste and Sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

86

67

8.1 Waste

Although this standard was compliant, several issues were identified

which need to be addressed. Waste was not disposed of appropriately

in accordance with the hospitals waste policy, paper waste was

observed in the sharps box in the endoscopy theatre and

household waste bags were in the large clinical waste euro bins in the

outside compound. The inside of the clinical waste euro bins were dirty

and had loose waste, one of the clinical waste bins was over filled and

the lid could not be locked.

In the endoscopy reception area there was no household waste bin

only a clinical waste bin, the clinical waste bin in the theatre had a

paper label secured with tape and the clinical waste bin in the dirty

utility room had a black household waste liner.

8.2 Sharps

This standard was minimally compliant and improvement is required in

the following areas to ensure safe practice.

The temporary closure mechanism on sharps boxes was not in use,

the sharps box in the theatre had blood splatters and the sharps box on

the dressing trolley was not secured. Not all sharps boxes within the

unit were signed and dated and the inspectors noted this was also the

same for sharps bins which had been disposed of into the large outside

clinical waste euro bin.

Recommendations

7. The hospital should monitor the implementation of its

policies and procedures in respect of the management of

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waste and sharps to ensure safe and appropriate practice is

in place.

8. The hospital should ensure waste bins and sharps boxes are

clean.

9. Systems and processes should be in place to assure that

staff practice is correct in respect of the correct disposal of

waste.

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9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment

Patient equipment 87

The unit achieved compliance in this standard however with attention to

detail and the implementation and monitoring of the nursing cleaning

schedule for patient equipment this score could be improved.

In the endoscope theatre

inspectors observed that

ventilator equipment, oxygen

pipes on the anaesthetic

machine and notes trolley

were dusty and stained. Staff

dealt with these cleaning

issues immediately.

Picture 2: Stained framework of ventilator

The inside of the doors of the dressing procedure trolley were stained

and the top surface was dusty. Tourniquets were made of material and

could not be effectively cleaned, and in the dirty utility room a 50ml

flushing syringe had been removed from it packaging and left on the

side of the double, scope cleaning sink.

Recommendations

10. The hospital and individual staff have a collective

responsibility to ensure that general and specialist

equipment is clean.

11. Staff should ensure sterile equipment is not removed from its

packaging prior to use.

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10.0 Hygiene Factors

STANDARD 6.0

HYGIENE FACTORS

Hand wash facilities; alcohol hand rub; availability of PPE;

availability of cleaning equipment and materials.

Hygiene Factors

Availability and

cleanliness of wash hand 96

basin and consumables

Availability of alcohol rub 92

Availability of PPE 82

Materials and equipment

for cleaning

81

Average Score 88

In this standard overall compliance was achieved.

Alcohol hand rub was generally available, however the portable alcohol

dispenser and holder in the endoscope theatre room was dirty, dusty

and empty.

The section on the availability of personal protective equipment was

partially compliant. Gauntlet sleeves were worn by staff when

manually cleaning the endoscopes, however these were not effective

as they continually slid down exposing the arm.

Different colour single used aprons for clean and dirty work were not

available and a box of vinyl gloves were observed on the shelf in the

endoscope theatre. The Infection Prevention Society advise that these

are used during low risk procedures. It is advised that the type of glove

used is reviewed to ensure staff are use the correct gloves with the

correct protection for all care activities.

Face or eye protection was not worn consistently for the manual

cleaning procedure, reusable goggles were available but stained. Hats

and head gear were not available for use in the endoscope area.

The section on cleaning materials and equipment was also partially

compliant. On inspection of the domestic store, wooden mop handles

and a wooden deck scrubber were noted, the mop buckets were dirty

and water buckets were not colour coded. Not all buckets were

inverted or dry. Equipment such as wet pickup mops, floor polishers

and the domestic trolley were dusty.

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Recommendations

12. The hospital should ensure hand washing facilities are clean

and accessible.

13. The hospital should ensure alcohol rub dispensers and filled

and clean.

14. The hospital should ensure PPE is available, fit for purpose

and worn by staff.

15. The hospital should ensure equipment for general cleaning is

clean and fit for purpose.

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11.0 Hygiene Practices

STANDARD 7.0

HYGIENE PRACTICES

Hand hygiene procedures; handling and disposal of sharps; use

of PPE; use of isolation facilities and implementation of infection

control procedures; cleaning of ward/department; staff uniform

and work wear.

Hygiene Practices

Effective hand hygiene

procedures

67

Safe handling and

disposal of sharps

100

Effective use of PPE 83

Correct use of isolation N/A

Effective cleaning of the

facility

82

Staff uniform and work

wear

97

Average Score 86

In this standard overall compliance was achieved, the safe handling and

disposal of sharps was fully compliant, however a minimally compliant score

was achieved in effective hand hygiene procedures. Staff were observed

entering the dirty utility room on several occasions but failed to use alcohol

hand rub to decontaminate their hands. Staff were also observed not washing

their hands before donning disposable gloves.

Personal protective equipment, disposable gloves and aprons were worn

where appropriate. Staff did not wear the appropriate head protection when in

the endoscope unit, staff in the adjoining theatre were observed wearing their

head protection continuously instead of as a single use item.

Nursing staff when questioned, were not aware of NPSA guidelines for colour

coding of cleaning equipment in relation to theatres.

The information on dilution rates for cleaning and disinfection chemicals was

displayed in the domestic store but was difficult to read, and when domestic

staff were questioned they were they were unable to give the correct dilution

rates for the cleaning agent or disinfectant in use in the hospital.

A dress code policy is in place within the hospital and generally staff were

compliant, however inspectors observed that a member of theatre staff was

wearing hoop earrings.

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Recommendations

16. The hospital and individual staff have a responsibility to

ensure that hand hygiene is carried out in line with the seven

step technique and that all PPE is used appropriately.

17. The hospital and individual staff have a collective

responsibility to ensure that staff knowledge is kept up to

date with regard to the correct dilution rates for chemicals

and colour coded equipment used for cleaning and

decontamination of equipment and specialist patient

equipment.

18. Staff should comply with the hospitals dress code policy.

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12.0 Endoscopy Suite

STANDARD 8.0

ENDOSCOPY SUITE

Endoscopy Suite: anaesthetic room, scrub room, endoscopy

theatre/room, endoscopy decontamination room/area, specialist

equipment and policies/procedures.

12.1 Endoscopy Suite Environment

Endoscopy Suite

Scrub Room

N/A

Endoscopy Theatre 97

Endoscopy

60

decontamination room

Specialist

90

Equipment/practices

Policies and Procedures 93

Average Score 85

The endoscopy unit is a separate area located at one end of the

hospital and accessed by a dedicated stairway or lift which leads to the

first floor unit.

In the endoscope theatre, inspectors observed a blood stain and paper

labels attached to the theatre trolley. The scrub sink is located within

the theatre space, the sink was clean and in good state of repair. The

clean decontamination room is located off the theatre and can only be

accessed through the theatre.

In the clean decontamination room the top of the endoscope storage

unit was dusty and the shelves were cluttered, stained and dusty.

Adhesive tape had been used to secure labels to the drawers of the

dressing trolley, adhesive tape cannot be effectively cleaned and

alternatives should be sourced.

A new drying cabinet had been

installed in the clean

decontamination room was in

the process of being

commissioned.

Picture 3: New drying cabinet

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Picture 4: Blocked access to and washing sink

The dirty decontamination

area, was cluttered and dust

was again an issue, there

was dust on the top of the

endoscope cabinet, air vents,

storage units and skirting.

Access to the hand wash

sink was obstructed by

boxes, the sink also required

cleaning.

There were stains on the

front of the drying cabinet,

adjoining door and the floor.

The low sluice sink was dirty,

and was being used as a

work surface, inspectors

noted that the central wheel

from the endoscope washer

disinfector stored on top of it.

Picture 5: Sluice sink used as storage surface

The double deep sink used to manually clean the scopes was stained

and had signs of rust, and a dirty measuring jug was sitting on the edge

of the sink unit. The double sink in the dirty decontamination room was

not set at the correct high to minimise back injury. There was limescale

deposits on the taps.

The ventilation in the decontamination room did not appear to be

working.

Both the clean and dirty decontamination areas were cluttered with

boxes and plastic bags sitting on the floor. In the dirty decontamination

area the scope storage area was cramped and there was insufficient

work area.

The recovery room was not inspected as it was in constant use

throughout the inspection.

New guidance CFPP 01-06 is to be issued in the near future, all

endoscope decontamination facilities in Northern Ireland will be

required to meet "best practice" requirements of this document in

relation to layout, quality systems and environmental requirements.

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12.1 Specialist Patient Equipment

In the clean decontamination room the storage trolley for the

endoscopes was dusty. In the dirty decontamination room, the second

sink used in the double sink manual cleaning process of the scopes did

not have a fill line.

In relation to effective cleaning, the HEIG inspectors noted that in the

manual wash area the unit dispensing detergent was faulty and an

incorrect ratio of detergent to water was being used. Detergents

should be diluted as per the manufactures guidelines to be effective.

12.2 Policies Procedures and Training

This is a new open facility and while some policies, for example the

decontamination of endoscopy equipment and stand operational

procedures are in place. Others such as, procedures for regular audits

and the hospitals own infection prevention and control policy have still

to receive approval. Staff currently use the Regional Infection

Prevention and Control guidance on line. A training and validation

programme has just been put in place.

Recommendations

19. The environment of the endoscopy suite should be clean and

free of clutter.

20. The decontamination room should be fit for purpose and

comply with relevant standards.

21. Improvements required in the decontamination process

should be addressed and work commenced to comply with

CFPP.

22. All recommendations as outlined by the HEIG inspectors in

their key findings report should be addressed.

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13.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs S O'Connor

Mrs M Keating

Mr C Muldoon

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Inspector Estates Team

Members of the DHSSPS Health Estates Investment Group (HEIG)

inspection team

Mr David Pollock - Inspector, Health Estates Investment Group

Mr Eddie Clarke - Inspector, Health Estates Investment Group

Hospital representatives attending the feedback session

The key findings of the inspection were outlined to the following trust

representatives:

Ms R Wilson - Governance Manager

Mr R Mackinnon - Facilities Manager

Ms Zana O’Neill - GON Cleaning Contractor

Mr P Monaghan - GON Cleaning Contractor

Supporting documentation

A number of documents have been developed to support the inspection

process, these are:

• Infection Prevention/Hygiene Inspection Process (methodology,

follow up and reporting)

• Infection Prevention/Hygiene Team Inspection Protocol (this

document contains details on how inspections are carried out and

the composition of the teams)

• Infection Prevention/Hygiene Team Escalation Policy

• RQIA Policy and Procedure for Use and Storage of Digital Images

This information is currently available on request and will be available

in due course on the RQIA website.

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14.0 Summary of Recommendations

1. The hospital should ensure that the systems and processes

in place for environmental cleaning, provide the necessary

assurance that cleaning is carried out effectively, and that all

staff are aware of their responsibilities.

2. The healthcare environment should be repaired and

maintained, and damaged furniture replaced to maintain

public confidence and to help reduce the risk of the spread of

infection.

3. The hospital should review current storage arrangements to

maintaining a clutter free environment.

4. The hospital should continue on developing policies,

guidelines and cleaning schedules.

5. The hospital should ensure that clean linen is stored in a

designated area which is fit for purpose.

6. Equipment used for the storage of used linen should be

cleanable and fit for purpose.

7. The hospital should monitor the implementation of its

policies and procedures in respect of the management of

waste and sharps to ensure safe and appropriate practice is

in place.

8. The hospital should ensure waste bins and sharps boxes are

clean.

9. Systems and processes should be in place to assure that

staff practice is correct in respect of the correct disposal of

waste.

10. The hospital and individual staff have a collective

responsibility to ensure that general and specialist

equipment is clean.

11. Staff should ensure sterile equipment is not removed from its

packaging prior to use.

12. The hospital should ensure hand washing facilities are clean

and accessible.

13. The hospital should ensure alcohol rub dispensers and filled

and clean.

25


14. The hospital should ensure PPE is available, fit for purpose

and worn by staff.

15. The hospital should ensure equipment for general cleaning is

clean and fit for purpose.

16. The hospital and individual staff have a responsibility to

ensure that hand hygiene is carried out in line with the seven

step technique and that all PPE is used appropriately.

17. The hospital and individual staff have a collective

responsibility to ensure that staff knowledge is kept up to

date with regard to the correct dilution rates for chemicals

and colour coded equipment used for cleaning and

decontamination of equipment and specialist patient

equipment.

18. Staff should comply with the hospitals dress code policy.

19. The environment of the endoscopy suite should be clean and

free of clutter.

20. The decontamination room should be fit for purpose and

comply with relevant standards.

21. Improvements required in the decontamination process

should be addressed and work commenced to comply with

CFPP.

22. All recommendations as outlined by the HEIG inspectors in

their key findings report should be addressed.

26


15.0 Escalation Process

RQIA Hygiene Team: Escalation Process

B

RQIA IPH

Team

Escalation

Process

Concern / Allegation / Disclosure

Inform Team Leader / Head of Programme

MINOR/MODERATE

Has the risk been

assessed as Minor,

Moderate or Major?

MAJOR

Inform key contact and keep a record

Inform appropriate RQIA Director and Chief Executive

Record in final report

Inform Trust / Establishment / Agency

and request action plan

Notify Chairperson and

Board Members

Inform other establishments as appropriate:

E.g.: DHSSPS, RRT, HSC Board, PHA,

Seek assurance on implementation of actions

Take necessary action:

E.g.: Follow-Up Inspection

27


16.0 Action Plan

Reference

number

Recommendations

1. The hospital should ensure that the systems and

processes in place for environmental cleaning, provide

the necessary assurance that cleaning is carried out

effectively, and that all staff are aware of their

responsibilities.

Designated

department

Action required

Date for

completion/

timescale

2. The healthcare environment should be repaired and

maintained, and damaged furniture replaced to

maintain public confidence and to help reduce the risk

of the spread of infection.

3. The hospital should review current storage

arrangements to maintaining a clutter free

environment.

4. The hospital should continue on developing policies,

guidelines and cleaning schedules.

5. The hospital should ensure that clean linen is stored in

a designated area which is fit for purpose.

6. Equipment used for the storage of used linen should

be cleanable and fit for purpose.

7. The hospital should monitor the implementation of its

policies and procedures in respect of the management

of waste and sharps to ensure safe and appropriate

practice is in place.

28


Reference

number

Recommendations

8. The hospital should ensure waste bins and sharps

boxes are clean.

Designated

department

Action required

Date for

completion/

timescale

9. Systems and processes should be in place to assure

that staff practice is correct in respect of the correct

disposal of waste.

10. The hospital and individual staff have a collective

responsibility to ensure that general and specialist

equipment is clean.

11. Staff should ensure sterile equipment is not removed

from its packaging prior to use.

12. The hospital should ensure hand washing facilities are

clean and accessible.

13. The hospital should ensure alcohol rub dispensers

and filled and clean.

14. The hospital should ensure PPE is available, fit for

purpose and worn by staff.

15. The hospital should ensure equipment for general

cleaning is clean and fit for purpose.

16. The hospital and individual staff have a responsibility

to ensure that hand hygiene is carried out in line with

the seven step technique and that all PPE is used

appropriately.

29


Reference

number

Recommendations

17. The hospital and individual staff have a collective

responsibility to ensure that staff knowledge is kept up

to date with regard to the correct dilution rates for

chemicals and colour coded equipment used for

cleaning and decontamination of equipment and

specialist patient equipment.

Designated

department

Action required

Date for

completion/

timescale

18. Staff should comply with the hospitals dress code

policy.

19. The environment of the endoscopy suite should be

clean and free of clutter.

20. The decontamination room should be fit for purpose

and comply with relevant standards.

21. Improvements required in the decontamination

process should be addressed and work commenced

to comply with CFPP.

22. All recommendations as outlined by the HEIG

inspectors in their key findings report should be

addressed.

30

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