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.
5

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