Ulster Independent Clinic, Belfast - 31 January 2012

rqia.org.uk

Ulster Independent Clinic, Belfast - 31 January 2012

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Private Clinic

Ulster Independent Clinic

31 January 2012


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 6

3.0 Inspections 7

4.0 Unannounced Inspection Process 8

4.1 Onsite Inspection 8

4.2 Feedback and Report of the Findings 8

5.0 Audit Tool 9

6.0 Environment 11

6.1 Cleaning 11

6.2 Clutter 12

6.3 Maintenance and Repair 12

6.4 Fixture and Fittings 12

6.5 Information 13

7.0 Patient Linen 14

7.1 Management of Linen 14

8.0 Waste and Sharps 15

8.1 Waste 15

8.2 Sharps 15

9.0 Patient Equipment 16

10.0 Hygiene Factors 17

11.0 Hygiene Practice 18

12.0 Endoscopy Suite 20

12.1 Endoscopy Suite Environment 20

12.2 Specialist Patient Equipment 21

12.3 Policies and Procedures 22

13.0 Key Personnel and Information 24

14.0 Summary of Recommendations 25

15.0 RQIA Hygiene Team Escalation Policy Flowchart 26

16.0 Action Plan 27


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, independent health care

team (IHCT) and HEIG (Health Estates Investment Group) inspectors

from the DHSSPS.

The purpose of the announced inspection to the Ulster Independent

Clinic on the 31 January 2012 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 Ulster Independent Clinic is located in South Belfast, and is

registered to provide care for 74 in-patients. Endoscopy procedures

are performed in Theatre Block A-Theatre 4, current treatments include

gastroscopy, colonoscopy, bronchoscopy, flexible cystoscopy and

uteroscopy. The new updated endoscopy unit opened in January 2012

now incorporates a separate ‘clean’ decontamination room and a ‘dirty’

decontamination room.

Inspection Outcomes

The results of the inspection showed an overall compliance level and

compliance in all but one of the standards, for which staff are to be

commended. An improvement in practice regarding the management

of sharps should easily raise the compliance level for this standard.

Inspectors were impressed with staff commitment to providing a safe

and clean environment for patients, this was evidenced by the number

of compliant scores, particularly the Linen, Patient Equipment and

Hygiene Practices section. The low minimally compliant score for the

domestic store can be contributed to untidy storage of equipment and

supplies impeding the cleaning process and the poor maintenance and

repair of the room and its fixtures.

The inspection resulted in 14 recommendations for the Ulster

Independent Clinic, a full list of recommendations is listed in Section

14.

1


The report 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.

• A detailed Infection Prevention and Control file was available

for staff within the Endoscopy Unit.

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

Independent Clinic 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 2-8 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.

2


Table 1

Areas Inspected

General Environment 91

Patient Linen 100

Waste 98

Sharps 81

Equipment 88

Hygiene Factors 94

Hygiene Practices 95

Endoscopy Suite 91

Average Score 92

Table 2

General Environment/

Reception 98

Corridors, stairs lift 100

Public toilets 91

Communal Theatre Area N/A

Patient Bed

Area/Recovery

98

Dirty utility room 91

Domestic store 41

General information 94

Average Score 88

Table 3

Patient Linen

Storage of clean linen 100

Storage of used linen 100

Laundry facilities

N/A

Average Score 100

Table 4

Waste and Sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

98

81

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

3


Table 5

Patient Equipment

Patient equipment 88

Table 6

Hygiene Factors

Availability and

cleanliness of wash hand 95

basin and consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

82

Average Score 94

Table 7

Hygiene Practices

Effective hand hygiene

procedures

100

Safe handling and

disposal of sharps

85

Effective use of PPE 100

Correct use of isolation N/A

Effective cleaning of ward 100

Staff uniform and work

wear

90

Average Score 95

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

4


Table 8

Endoscopy Suite

Anaesthetic Room 96

Scrub Room

N/A

Endoscopy Theatre 4 91

Decontamination Area

(Dirty)

96

Decontamination Area

(Clean)

91

Specialist

Equipment/practices

83

Policies & Procedures 90

Average Score 91

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

5


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.

6


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 Unannounced 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.

8


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 100

Public toilets 91

Communal Theatre Area N/A

Patient Bed

Area/Recovery

98

Dirty utility room 91

Domestic store 41

General information 94

Average Score 88

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

the facility inspected. High compliance was achieved in all areas

except for the domestic store where an improvement is required. The

findings in respect of the general environment are detailed in the

following sections.

6.1 Cleaning

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

with regional specifications for cleaning. The inspectors observed that

regular cleaning mechanisms were in place to prevent the build up of

dust and debris which in turn prevents the build up of bacteria and

subsequently reduces the potential risk for the transmission of

infection.

The Clinic presented as generally very clean with some minor

improvements required in the cleaning of some pull cords and ensuring

debris is removed from sink overflows. Cleaning issues identified

related to stained walls in the clean utility and dirty and stained shelving

and sluice bowl in the domestic store where the corners and edges of

the flooring also contained debris.

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Inspectors observed in the dirty utility room, the interior of the slop

hopper base was badly stained from possible chemical or detergent

disposal.

Particular attention is required to ensure that limescale is removed from

taps and fittings as recent evidence has shown that limescale may

harbour biofilms and the build up of limescale can interfere with good

cleaning and disinfection by masking and protecting pathogens. Lime

scale was noted on taps in the public toilets, dirty utility room and

domestic store.

6.2 Clutter

There was evidence in most areas of a continued emphasis in

providing clutter free environments. In the domestic store however, the

untidy storage of equipment and supplies within the room, on the floor

and the cluttered untidy shelves have significantly contributed to the

minimally compliant score for this room.

6.3 Maintenance and Repair

Damage was noted to some walls, doors, and skirting. The doors to

the clean utility were damaged at times to the bare wood, the door of

the clean utility also had loose and missing seal. There was damaged

wall plaster in the domestic store and at the corner of the wall beside

and below the dumb waiter in the clean utility room. Ceiling tiles were

displaced in the domestic store.

Unsealed walls and wood can act as a reservoir for bacteria and also

compromise the cleaning process due to the inability to remove all

bacteria by normal damp dusting and cleaning processes.

6.4 Fixtures and Fittings

Picture 1: Stain on interior base of slop hopper

The fixtures, fittings and

equipment were generally fit

for purpose, some fixtures

such as metal and melamine

shelving were showing signs

of age. Staff contributed the

staining on the interior base of

the slop hopper to the

disposal of chemical or

cleaning detergents (Picture

1).

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6.5 Information

A wide range of posters was

displayed on waste

segregation (Picture 2), linen,

management of an inoculation

injury and the NPSA colour

coding system.

Picture 2 Waste segregation posters

Inspectors noted the clinic has adapted the NPSA colour coding

system for use in theatres and the endoscopy unit. The information

poster appeared to advise staff to mix colours such as mops and

cleaning cloths. It is advised that a review of the current colour coding

system is carried out to standardise the NPSA system throughout the

clinic.

Information leaflets for patients and visitors on hand hygiene and

infection prevention and control, were not available.

Recommendations

1. The clinic 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 clinic and staff should work to maintain a clutter free

environment.

3. The healthcare environment should be repaired and

maintained, and damaged fixtures and fittings replaced to

maintain public confidence and to help reduce the risk of the

spread of infection.

13


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 100

Storage of used linen 100

Laundry facilities

N/A

Average Score 100

Staff are commended for achieving full compliance in this standard.

No issues were identified with the storage of clean and used linen.

The linen store was clean, neat and tidy, used linen was stored in a

designated area prior to collection. Used linen bags were not overfilled

and linen skips were clean and in a good state of repair.

Staff advised inspectors that personal protective equipment (PPE) is

used when handling soiled/contaminated linen and that theatre

uniforms are reprocessed in a local trust laundry.

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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

98

81

8.1 Waste

The unit achieved high compliance in this standard. The inspection

evidenced that there were arrangements in place for the handling,

segregation and storage of waste which generally comply with local

and regional guidance.

Inspectors observed that overall waste was segregated and disposed

of correctly. Full compliance would have been achieved if disposable

gloves and paper waste had not been disposed of into the sharps box

in Theatre 4.

8.2 Sharps

The unit achieved partial compliance in this standard.

Sharps boxes in use conformed to BS7320 (1990)/UN9291 standards

however two sharps box in Theatre 4 were not signed or dated. This is

unsafe practice, sharps boxes should be labelled correctly to ensure

that the origin can be identified in the event of spillage or injury and

assist in the immediate risk assessment process.

Inspectors observed that compatible sharps trays were not available,

staff used single use foil trays and the temporary closure mechanisms,

to prevent spillage and impede access, were not always in place when

sharps boxes were not in use.

Recommendations

4. Systems should be in place to assure the safe handling and

disposal of waste and sharps.

15


9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment

Patient equipment 88

The unit achieved compliance in this standard, a few issues were

identified for improvement. In the anaesthetic room, a 20ml syringe

and a laryngoscope blade were stored out of packaging on the

anaesthetic trolley and at the nurses station, the ambu bag and mask

were hanging out of packaging on the resuscitation trolley. The

Association of Anaesthetists of Great Britain and Ireland guidelines

"Infection Control in Anaesthesia" states that single use resuscitation

equipment should be kept in a sealed package or should be resterilised

between patients according to manufacture's instructions. It also states

that packaging should not be removed until the point of use for

infection control, identification, traceability in the case of a

manufacturer's recall and safety.

Trigger tape was not in in place to identify cleaned equipment ready for

use, adhesive tape was noted on some IV stands and the re-usable

tourniquets in Theatre 4 were stained. Inspectors noted some

damaged items of equipment. The top surface of the resuscitation

trolley was cracked, the underneath of an arm rest in Theatre 4 was

rusted and lime scale was present on the castors of the trolley used for

endoscopy cleaning in Theatre 4.

Recommendations

5. The clinic and individual staff must ensure that patient

equipment is checked, in good repair, stored correctly and

trigger tape is used to identify if equipment is clean and

ready for 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 95

basin and consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

82

Average Score 94

In this standard overall compliance was achieved and full compliance

in the availability of alcohol rub and PPE sections. Hand washing sinks

and fixtures and fittings were generally clean, working and in a good

state of repair.

More attention to detail was required in cleaning the underneath of the

of the soap, alcohol and moisturizer dispensers in recovery,

underneath the soap dispenser and the hand washing sink located

outside the clean room and the hand washing sink in the “dirty”

decontamination room. In Theatre 4 the nozzle of a soap dispenser

had congealed soap and the underneath of a paper towel dispenser

was dirty.

Some improvement was required in the section concerning materials

and equipment for cleaning. Inspectors observed spray bottles with

decanted fluid on the domestic trolley and in the domestic store some

mop buckets were not stored inverted and the cone, floor burnisher,

vacuum and some buckets were dirty. In the dirty utility room, two

mops were stored in buckets containing a solution.

Recommendations

6. The clinic should ensure that consumable dispensers are

clean.

7. The clinic should ensure that all cleaning products are stored

in a locked cupboard, in line with COSHH regulations.

8. Equipment used for the general cleaning purposes should be

clean and stored appropriately.

17


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

100

Safe handling and

disposal of sharps

85

Effective use of PPE 100

Correct use of isolation N/A

Effective cleaning of ward 100

Staff uniform and work

wear

90

Average Score 95

A high overall compliance was achieved in this standard. Full

compliance was achieved in three sections and staff should be

commended.

Re-sheathed needles were noted in a sharps box in Theatre 4 and

Recovery. Re-sheathing needles is unsafe practice and has the

potential to cause a sharps injury, therefore should not be carried out.

Staff questioned were

knowledgeable on the

solutions used for routine

cleaning, removing blood and

body spillages and the

dilution rates of the

disinfectant in use (Picture 3).

Picture 3: Disinfectant dilution rate poster

It was disappointing to note two endoscopy staff wore wrist watches

and a member of staff wore stoned ear rings during the inspection.

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Recommendations

9. The clinic and individual staff have a collective responsibility

to ensure the safe handling and disposal of sharps.

10. The clinic should ensure that all members of staff are familiar

with and adhere to the regional dress code policy.

19


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

Anaesthetic Room 96

Scrub Room

N/A

Endoscopy Theatre 4 91

Decontamination Area

(Dirty)

96

Decontamination Area

(Clean)

91

Specialist

Equipment/practices

83

Policies & Procedures 90

Average Score 91

The new endoscopy decontamination unit was opened in January

2012. A new Automated Endoscope Reprocessing (AER) machine has

been installed and there are plans to purchase a second drying

cabinet. Plans are in place to upgrade the stand alone ventilation to

Class 8 quality airflow.

The endoscopy unit has not implemented the Quality Management

System EN 13485:2003 but it is working towards ISO 23845 with

anticipated completion in December 2012.

New guidance is to be issued in the near future, all endoscope

decontamination facilities in N Ireland will be required to meet "best

practice" requirements of CFPP 01-06 and NI specific layout, quality

system and environmental requirements

Throughout the theatre area damage was noted to some walls, doors,

and skirting. Unsealed walls and wood can act as a reservoir for

bacteria and also compromise the cleaning process due to the inability

to remove all bacteria by normal damp dusting and cleaning processes.

The doors to Theatre 4, were damaged at times to the bare wood.

In the anaesthetic room there was lime scale on the taps and staff were

inconsistently recording temperature readings for the drugs fridge. The

shelving and containers in Endoscopy Theatre 4 were cluttered with a

20


large amount of supplies (Picture 4). At the feedback hospital

representatives advised that as the theatre can be used for different

specialities, a large amount of supplies are needed. However there

needs to be a systematic approach to the storage of supplies to ensure

areas remain clutter free.

Picture 4: Clutter on shelving in Theatre 4

The new decontamination unit was well presented and in good repair

however a gowning room, domestic store and set down area specific to

the unit were not available. In the new ‘clean’ decontamination room,

the lack of storage facilities resulted in paper work and documentation

being stored on the window sill. There was dust on the electric

trunking, the “clean” endoscopes hung vertically on the wall but were

not locked away.

Electric leads were noted stretched across the wash hand basin for the

leak tester in the “dirty” decontamination room and pipes under the

floor required capping.

12.2 Specialist Patient Equipment

The HEIG inspectors advised that the paint finish on the inside of one

of the older Wassenburg AER chambers which is due to go out of

commission was bubbling with the potential for paint to flake off and

enter the endoscope. There was no back up electrical supplies to the

endoscope drying/storage cabinet, to ensure storage data of scopes is

not lost.

Maintenance contracts, testing and validation procedures are in place

for all decontamination equipment. All endoscopic accessories are

processed with each individual endoscope in the AER. Reusable

valves are decontaminated in accordance with manufacturers’

instructions and processed with their corresponding endoscope in the

AER.

21


A manual method for patient traceability had recently been introduced

and the system is in the process of being updated to facilitate the new

AERs.

Inspectors noted endoscopes were transported by trolley in a basket

without a hard lid, also the lack of a set down area resulted in “dirty”

scopes being placed on the same trolley as manually washed scopes.

Two trolleys were available for transporting clean and dirty scopes but

as the trolleys were not labeled there was the potential for staff to use

the wrong trolley and take the empty dirty trolley into the “clean” room.

On observing manual decontamination of a scope in the “dirty”

decontamination room, HEIG inspectors advised staff to add detergent

to water after the leak test had been completed. Detergent was

dispensed via Automated Eco-Lab dispenser, this is to be tested and

documented weekly to ensure correct product release and it is required

that the log book for chemicals used is kept up to date.

HEIG inspectors advised that the equipment batch process record was

not adequate during the release of reprocessed endoscopes. The

independent monitoring system on the AER i.e. Eurotherm is capable

of being upgraded to achieve the product release automatically.

ENT flexible endoscopes were not decontaminated on the unit. Daily

cleaning was carried out by Outpatients staff before and after each

clinic. Single disposable sheaths for each patient were provided for

use by the Consultants.

12.3 Policies and Procedures

The unit had a decontamination lead however the Estates manager

had not attended the authorized person for decontamination (APD)

course. Following attendance at the course in April 2012, the estates

manager can fulfill the AP (D) role.

Infection prevention and control and environmental cleanliness audits

were carried out and action plans were available.

Endoscopy/decontamination training was provided for staff and there

was evidence of a structured induction programme and a written

training and revalidation programme.

Recommendations

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

well maintained.

12. Work should continue on improving storage and maintaining

a clutter free environment in all rooms.

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13. Improvements required in the decontamination process

should be addressed and work commenced to comply with

CFPP01-06.

14. All recommendations as outlined by the HEIG inspectors in

their key findings report should be addressed.

23


13.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs L Gawley

Mrs S O'Connor

Mrs E Connolly

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Senior Inspector Dental and Independent

Healthcare

Mr P Cunningham - Senior Inspector Estates RQIA

Mr K Monaghan - Inspector Estates RQIA

Members of the DHSSPS Health Estates Investment Group (HEIG)

inspection team

Mr David Pollock

Mr Eddie Clarke

- Inspector, Health Estates Investment Group

- Inspector, Health Estates Investment Group

Hospital representatives attending the feedback session

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

representatives:

Ms D Graham

Ms B Mc Coy

Mr S Dunlop

Ms L Watt

- Matron/Chief Executive

- Decontamination Lead

- Estates Manager

- Infection Control Sister

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.

24


14.0 Summary of Recommendations

1. The clinic 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 clinic and staff should work to maintain a clutter free

environment.

3. The healthcare environment should be repaired and

maintained, and damaged fixtures and fittings replaced to

maintain public confidence and to help reduce the risk of the

spread of infection.

4. Systems should be in place to assure the safe handling and

disposal of waste and sharps.

5. The clinic and individual staff must ensure that patient

equipment is checked, in good repair, stored correctly and

trigger tape is used to identify if equipment is clean and

ready for use.

6. The clinic should ensure that consumable dispensers are

clean.

7. The clinic should ensure that all cleaning products are stored

in a locked cupboard, in line with COSHH regulations.

8. Equipment used for the general cleaning purposes should be

clean and stored appropriately.

9. The clinic and individual staff have a collective responsibility

to ensure the safe handling and disposal of sharps.

10. The clinic should ensure that all members of staff are familiar

with and adhere to the regional dress code policy.

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

well maintained.

12. Work should continue on improving storage and maintaining

a clutter free environment in all rooms.

13. Improvements required in the decontamination process

should be addressed and work commenced to comply with

CFPP01-06.

14. All recommendations as outlined by the HEIG inspectors in

their key findings report should be addressed.

25


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

26


16.0 Action Plan

Reference

number

Recommendations

1. The clinic 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 clinic and staff should work to maintain a clutter

free environment.

3. The healthcare environment should be repaired and

maintained, and damaged fixtures and fittings

replaced to maintain public confidence and to help

reduce the risk of the spread of infection.

4. Systems should be in place to assure the safe

handling and disposal of waste and sharps.

5. The clinic and individual staff must ensure that patient

equipment is checked, in good repair, stored correctly

and trigger tape is used to identify if equipment is

clean and ready for use.

6. The clinic should ensure that consumable dispensers

are clean.

7. The clinic should ensure that all cleaning products are

stored in a locked cupboard, in line with COSHH

regulations.

8. Equipment used for the general cleaning purposes

should be clean and stored appropriately.

27


Reference

number

Recommendations

9. The clinic and individual staff have a collective

responsibility to ensure the safe handling and disposal

of sharps.

Designated

department

Action required

Date for

completion/

timescale

10. The clinic should ensure that all members of staff are

familiar with and adhere to the regional dress code

policy.

11. The environment of the endoscopy suite should be

clean and well maintained.

12. Work should continue on improving storage and

maintaining a clutter free environment in all rooms.

13. Improvements required in the decontamination

process should be addressed and work commenced

to comply with CFPP01-06.

14. All recommendations as outlined by the HEIG

inspectors in their key findings report should be

addressed.

28

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