Royal Victoria Hospital, Belfast - 27 September 2012

rqia.org.uk

Royal Victoria Hospital, Belfast - 27 September 2012

The

RQIA

Infection Prevention/Hygiene

Unannounced Follow up Inspection

Belfast Health and

Social Care Trust

Royal Victoria Hospital

27 September 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 13

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 17

10.0 Hygiene Factors 19

11.0 Hygiene Practice 20

12.0 Key Personnel and Information 22

13.0 Summary of Recommendations 24

14.0 Unannounced Inspection Flowchart 25

15.0 RQIA Hygiene Team Escalation Policy Flowchart 26

16.0 Action Plan 27


1.0 Inspection Summary

The unannounced inspection undertaken to the Royal Victoria Hospital

on the 17 July 2012 identified issues of minimal compliance within

standards 2-7 of the Regional Healthcare Hygiene and Cleanliness

Standards in two of the wards inspected. In line with the follow up

process an unannounced inspection was undertaken on the 27

September 2012 the following areas were inspected:

• Ward 4C - Orthopaedic

• Ward 5A - Vascular

Inspection Outcomes

On the inspection of 17 July 2012, 23 recommendations were made in

relation to Standards 2-7. Seventeen have been addressed, two have

been partly achieved, four have been repeated, there are no new

recommendations.

The main reception area still remained minimally compliant; this area

has been highlighted on the three previous inspections and requires

immediate and sustained attention. The inspectors acknowledge that

refurbishment of the main door, which was damaged in January 2011

is scheduled to commence in November. However the following issues

have not been addressed:-

• Dust on the decorative plants, skirting and the sprinklers.

• The public phone was grubby and there were paper labels on the

wall near the telephone.

• In the public toilets of the main reception the access panels under

the hand wash sinks were dirty.

A high standard of cleaning, and well maintained public areas such as

the reception, corridors and public toilets promotes public confidence in

the standards set by the hospital.

Improvements and Developments since the previous Inspection

The follow up inspection found that good progress had been made to

address areas identified at the previous inspection.

Ward 4C -The inspection team found that 77 per cent of the action

points identified for improvement had been addressed.

Ward 5A -The inspection team found that 68 per cent of the action

points identified for improvement had been addressed.

The results of the follow up audit demonstrate that staff have worked

hard to improve both practice and knowledge following the inspection

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in July. Ward 5A was compliant in all standards and staff are to be

commended. However, work is still required by the staff in Ward 4C to

address the recurring issues in relation to the standard on patient

equipment which was partially compliant. In both wards there are

ongoing maintenance and repair issues and in Ward 5A kitchen,

several cleaning issues and repairs to fixtures still need action.

Staff on Ward 5A informed the inspectors of several new initiatives that

have been introduced to the ward. In conjunction with Infection

Prevention and Control (IPC) staff and the ward based IPC link nurses,

training on arterial cardio vascular (ACV) lines has been commenced.

The manufacturer of the Cardiac Monitor used in the ward has also

provided training, both these training programs are competency based

which is certified and signed off on completion. Other initiatives include

a pilot of one stop medication dispensing, a monthly multi-disciplinary

vascular meeting and the practice of permanent night duty staff

working 2 weeks annually on day duty to ensure knowledge and

practice are updated.

In Ward 4C there has been training and awareness sessions in relation

to issues highlighted in the previous inspection for example hand

hygiene and dress code policy. Work remains outstanding on the

updating of nursing cleaning schedules and the validation process.

A summary of the recommendations following the re-audit is listed in

Section 13.

The outstanding issues as a result on this inspection have been

forwarded to Belfast Health and Social Care Trust to enable on going

action on recurring or new areas. The draft report which includes the

high level recommendations in a Quality Improvement Plan is

forwarded within 28 days of the inspection for agreement and factual

accuracy. The draft report is agreed and a completed action plan is

returned to RQIA within 14 days from the date of issue. The detailed

list of preliminary findings is available from RQIA on request.

The final report and Quality Improvement Plan will be available on the

RQIA website. Reports and action plans will be subject to performance

management by the Health and Social Care Board and the Public

Health Agency.

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

Hospital for their assistance during the inspection.

2


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.

Table 1

Ward

4C 4C 5A 5A

17 July 27 Sept 17 July 27 Sept

Environment 80 90 70 88

Patient Linen 87 95 88 96

Waste 88 95 86 94

Sharps 79 85 76 87

Equipment 81 84 76 95

Hygiene Factors 92 98 88 97

Hygiene Practices 81 96 89 96

Total 84 92 82 93

Table 2

Environment

4C 4C 5A 5A

17 July 27 Sept 17 July 27 Sept

Reception N/A N/A N/A 69

Corridors, stairs lift 88 92 83 83

Public toilets 86 85 N/A

Ward/department –

general (communal)

90 97 72 93

Patient bed area 83 91 72 88

Bathroom/washroom 87 91 65 85

Toilet N/A N/A N/A N/A

Clinical room/treatment

room

66 79 50 N/A

Clean utility room 85 94 59 93

Dirty utility room 86 96 71 92

Domestic store 73 90 64 95

Kitchen N/A N/A 57 79

Equipment store 67 81 80 97

Isolation 76 N/A 86 90

General information 60 95 85 90

Total 80 90 70 88

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 3

Patient Linen

4C 4C 5A 5A

17 July 27 Sept 17 July 27 Sept

Storage of clean linen 79 96 81 92

Storage of used linen 94 94 94 100

Laundry facilities N/A N/A N/A N/A

Total 87 95 88 96

Table 4

Waste and sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

4C

17 July

4C

27 Sept

5A

17 July

5A

27 Sept

88 95 86 94

79 85 76 87

Table 5

4C 4C 5A 5A

Patient Equipment

17 July 27 Sept 17 July 27 Sept

Patient equipment 81 84 76 95

Table 6

Hygiene Factors

Availability and

cleanliness of WHB and

consumables

Availability of alcohol

rub

4C

17 July

4C

27 Sept

5A

17 July

5A

27 Sept

94 97 91 97

100 97 100 97

Availability of PPE 94 100 100 100

Materials and

equipment for cleaning

79 100 59 94

Total 92 98 88 97

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 7

Hygiene Practices

4C

17 July

4C

27 Sept

5A

17 July

5A

27 Sept

Effective hand hygiene

procedures

71 100 85 94

Safe handling and

disposal of sharps

100 100 100 100

Effective use of PPE 86 96 100 100

Correct use of isolation 82 N/A N/A 100

Effective cleaning of

ward

76 89 74 88

Staff uniform and work

wear

72 93 86 93

Total 81 96 89 96

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.

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3.0 Inspections

The DHSSPS has devised draft 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.

RQIA's infection prevention/hygiene team have planned a three year

programme which includes announced and unannounced inspections

in acute and non-acute hospitals in Northern Ireland. This will assess

compliance with the DHSSPS Regional Healthcare Hygiene and

Cleanliness standards.

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

Trusts receive no advanced notice of the onsite inspection. An email

and telephone call will be made by the Chief Executive of RQIA or

nominated person 30 minutes prior to the team arriving on site. The

inspection flow chart is attached in Section 14.

4.1 Onsite Inspection

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

infection prevention/hygiene team and two peer reviewers. One

inspector led the team and was responsible for guiding the team and

ensuring they were in agreement about the findings reached.

Membership of the inspection team is outlined in Section 12.

The inspection of ward environments is carried out using the draft

Regional Healthcare Hygiene and Cleanliness audit tool. 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 trust

representatives including examples of notable practice identified during

the inspection. The details of trust representatives attending the

feedback session is outlined in Section 12.

Organisations are forwarded a detailed action plan of preliminary

findings within 14 days of the inspection; this does not include the

findings of the overall organisational systems and governance. The

action plan is returned with the agreed draft report. The draft report

contains the high level recommendations of the inspection and is

forwarded to each organisation within 28 days of the inspection for

agreement and factual accuracy checking and returned within two

weeks. The detailed action plan is available on request from RQIA.

The findings of the inspection will be followed up in line with infection

prevention/hygiene inspection process (methodology, follow up and

reporting).

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 Draft 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

This standard is not audited when carrying out unannounced

inspections however the findings of the organisational

system and governance at annual announced inspection will

be, where applicable, confirmed at ward level.

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

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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

Colour

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.

Environment

4C 4C 5A 5A

17 July 27 Sept 17 July 27 Sept

Reception N/A N/A N/A 69

Corridors, stairs lift 88 92 83 83

Public toilets 86 85 N/A N/A

Ward/department –

general (communal)

90 97 72 93

Patient bed area 83 91 72 88

Bathroom/washroom 87 91 65 85

Toilet N/A N/A N/A N/A

Clinical room/treatment

room

66 79 50 N/A

Clean utility room 85 94 59 93

Dirty utility room 86 96 71 92

Domestic store 73 90 64 95

Kitchen N/A N/A 57 79

Equipment store 67 81 80 97

Isolation 76 N/A 86 90

General information 60 95 85 90

Total 80 90 70 88

The above table outlines the findings in relation to the general

environment of the facilities inspected. The findings indicate that there

was improvement in both wards. The findings in respect of the general

environment are detailed in the following sections.

6.1 Cleaning

Ward staff have worked hard to action issues highlighted in the

previous inspection. The scores in this section indicate good

improvement resulting in both wards achieving overall compliance in

this standard. However continued effort is required in relation to

maintaining a dust free environment in both wards.

In Ward 4C dust observed on the under carriage of patients beds, fans

at the bedside, and air vents were still dusty. In the clinical room dust

11


was observed on shelves, surfaces and in the drawers of the high

density storage cupboards. Dust and debris was observed on the floor

behind bins in the clinical room and under shelves of the equipment

store. The inside of the drugs fridge was stained.

In Ward 5A similar issues with regard to dust and debris were noted in

the clean utility room, the domestic store and the isolation room. High

level dust was observed in a shower room and the equipment store.

Some of the vertical blinds in Ward 5A were worn and dirty.

More detailed cleaning is required in the kitchen of Ward 5A, surfaces

such as skirting, top of the fridge, dado rail, knife storage unit and the

work surface behind the toaster were dusty, or had debris present.

The castors of units were grubby and the food mixer and front of the

fridges and freezers were stained. There was damage to fly screens,

ceiling tiles and the paint finish on the walls.

6.2 Clutter

Storage and clutter still remains an issue in Ward 4C, a ward

reconfiguration project has been developed and work is to commence

which should address some of the issues. The equipment store has

been de-cluttered and tidied pending the reconfiguration of the area.

Ward 5A was generally free of clutter, new shelving was being erected

in the clean utility room and stores were tidy (Picture 1 and 2).

Picture 1: Tidy dirty utility room

Picture 2: Tidy storage area

6.3 Maintenance and Repair

In the public toilets and the lobby area outside Ward 5A and Ward 4C,

there was damage to walls, floors, doors and wood finishes. In the

public toilets of the main reception, the fitting on toilet seats was

incomplete and the access panels under the hand wash sinks were

damaged.

The inspection identified damage to walls, floors, doors and wood

surfaces in ward areas. A programme of maintenance and repair has

12


commenced in Ward 5A, on the day of the inspection the treatment

room was undergoing refurbishment. On completion of work in Ward

5A, work will then start in Ward 4C. A small amount of repairs have

been carried out in Ward 4C as an interim measure, for example, the

damaged floor outside the bathroom in Bay A had been repaired.

6.4 Fixtures and Fittings

The fixtures and fittings in both wards were generally fit for purpose.

In Ward 4C the base of the water dispenser, located opposite the

nurses station was rusted and the floor under and behind the water

dispenser was damaged. In Ward 5A following a risk assessment,

shower curtain rails are to be removed, while in Ward 4C replacement

shower curtains have been ordered. The manager in Ward 4C has

recently assigned staff to carry out mattress audits, but the audits have

not yet been commenced.

6.5 Information

There has been improvement in both wards with regard to the

availability of information. In Ward 4C hand washing posters now

showed the seven step process and information leaflets on infections

were displayed at the entrance to the ward. Nursing cleaning

schedules in Ward 5A had been up dated in line with trust policy;

however Ward 4C schedules still did not list all patient equipment for

cleaning. In Ward 5A National Patient Safety Agency (NPSA)

guidelines were still not clearly displayed for nursing and domestic

staff. In both wards some labels in equipment stores were attached

with adhesive tape.

Four of the seven previous recommendations have been assessed

as having been achieved.

Repeated Recommendations:

1. The trust should continue to work on repair and maintenance

of ward and public environments and replace damaged

fixtures and fittings. Partly completed.

2. The trust and staff should continue to improve storage and

maintain clutter free ward environment. Partly completed.

3. The trust should continue to roll out newly developed

nursing cleaning schedule.

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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.

Patient Linen

4C 4C 5A 5A

17 July 27 Sept 17 July 27 Sept

Storage of clean linen 79 96 81 92

Storage of used linen 94 94 94 100

Laundry facilities N/A N/A N/A N/A

Total 87 95 88 96

7.1 Management of Linen

Both wards improved on the previous overall compliant score.

The clean linen stores were neat and tidy, and there was good staff

practice in relation to the segregation and disposal of used linen.

Whilst there are still minor issues to address in both wards inspectors

have assessed that the previous two recommendations have been

addressed.

Previous Recommendations Achieved.

14


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

4C

17 July

4C

27 Sept

5A

17 July

5A

27 Sept

88 95 86 94

79 85 76 87

8.1 Waste

Staff are to be commended for increasing their compliance score

following the inspection in July. However, the inspectors still found a

common issue on both wards in relation to the incorrect disposal of

waste. In Ward 5A, household waste was incorrectly disposed of into

sharps boxes and clinical waste bins and pharmacy waste was

disposed of into yellow lidded burn boxes. In Ward 4C household

waste had been incorrectly disposed of into clinical waste bins and

paper, blister packs and pharmaceutical waste was found in sharps

boxes.

Some waste bins in Ward 4C have been replaced recently and require

labelling; the labels on older bins were worn and grubby. In Ward 5A

there was no household waste bin in one of the shower rooms.

8.2 Sharps

Staff practice in general had improved in both wards, the temporary

closure mechanism on sharps boxes were in place, however in Ward

5A, following the lunch time drugs administration round by medical staff

the temporary closure of the sharps box on the resuscitation trolley was

open and a used pair of disposable scissors was protruding from the

aperture. The bracket on the resuscitation trolley was broken and the

sharps box was not secure. Also in Ward 5A, a sharps tray had blood

stains, this was an issue raised on the previous inspection.

In Ward 4C, there were only large sharps boxes which were not

compatible with the sharps trays. The large sharps boxes were not

secure on the drugs trolleys; the drugs trolleys were located at the end

15


of each bed bay, which therefore makes the sharps boxes easily

accessible to the public.

Three of the four previous recommendations have been assessed

as having been achieved.

Repeated Recommendation:

4. The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

sharps to ensure that safe and appropriate practice is in

place.

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9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

4C 4C 5A 5A

Patient Equipment

17 July 27 Sept 17 July 27 Sept

Patient equipment 81 84 76 95

Ward 5A staff are to be commended for achieving a high compliance

score in this standard. There were good nursing cleaning schedules

and assurance mechanisms in place to ensure patient equipment was

clean, stored appropriately and ready for use. The issues identified

during the follow up audit were in the main related to chipped or

damaged equipment, there was only one cleaning issue, this was in

relation to a stained commode.

Ward 4C still remains partially compliant. The trust nursing cleaning

schedule has not been fully implemented, only the continuation sheet

was being used, this did not detail all equipment to be cleaned. Trigger

tape, used to identify equipment has been cleaned, was only used for

commodes. The inspectors found equipment; both stored and at the

patient’s bedside required more detailed cleaning. Single use items

such as forceps had been removed from their original packaging and

were lying exposed in the drawers of the resuscitation trolley and in the

treatment room. The ambu bag and a mask had also been removed

from the packaging and were exposed on the top of the resuscitation

trolley. The suction machine located beside the resuscitation trolley

was dusty and the suction catheter was attached and exposed.

The resuscitation trolley is shared between Ward 4C and 4D; therefore

there should be robust cleaning and checking mechanisms in place to

ensure an acceptable standard of cleanliness.

In the dirty utility room of Ward

4C, it was noted that processed

bedpans were still dirty but had

been left on the clean rack

ready for use (Picture 3). Bed

pans and urinals were also old

and worn, and the plastic

coating on some urinal bottle

stands was split.

Picture 3: Dirty bedpan

17


One of the two previous recommendations has been assessed as

having been achieved.

Repeated Recommendation:

5. The trust and individuals have a collective responsibility to

ensure that equipment is clean, and in a good state of repair.

18


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 WHB and

consumables

Availability of alcohol

rub

4C

17 July

4C

27 Sept

5A

17 July

5A

27 Sept

94 97 91 97

100 97 100 97

Availability of PPE 94 100 100 100

Materials and

equipment for cleaning

79 100 59 94

Total 92 98 88 97

Staff are to be commended for their work in addressing issues

highlighted in the previous inspection in July. In Ward 4C the brown

staining on a hand wash sink has been removed and worn and

damaged taps and surrounds are scheduled for replacement.

The domestic store has been tided and equipment was clean and

stored correctly. The only new issue was in relation to a broken alcohol

dispenser in the treatment room.

Similarly, in Ward 5A hand wash sinks were clean and accessible, and

a broken soap dispenser replaced. In the equipment for cleaning

section, the chemical cupboard in the dirty utility room was locked and

air freshener bottles had been removed from shower rooms.

Equipment for cleaning, with the exception of a dust pan and dust mop,

was clean, fit for purpose and stored correctly. However, the cleaning

products in the domestic store were still not stored in line with COSHH

regulations.

Previous Recommendations Achieved.

19


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

4C

17 July

4C

27 Sept

5A

17 July

5A

27 Sept

Effective hand hygiene

procedures

71 100 85 94

Safe handling and

disposal of sharps

100 100 100 100

Effective use of PPE 86 96 100 100

Correct use of isolation 82 N/A N/A 100

Effective cleaning of

ward

76 89 74 88

Staff uniform and work

wear

72 93 86 93

Total 81 96 89 96

Inspectors observed good appropriate hand hygiene practices carried

out in Ward 4C which resulted in this section moving from a minimal

compliant to a fully compliant score. Hand hygiene training sessions

have also been carried out in both wards resulting in an improved

score. In general Personal Protective Equipment (PPE) was worn

appropriately. In Ward 4C the section on effective cleaning could be

improved further, trigger tape was only in use for the cleaning of

commodes, and the disinfectant bottle had a paper label, paper can not

be effectively cleaned. NPSA colour coding guidelines were available

for nursing staff in the dirty utility room, but when questioned not all

nursing staff were aware of them.

In Ward 5A there has been improvement in the section, effective

cleaning of ward resulting in a compliant score. Domestic staff in the

ward have received refresher skills training. Cleaning equipment was

mainly clean, colour coded, fit for purpose and stored correctly;

wooden floor brushes had been removed. However, the chemicals in

the domestic store are still not stored in line with COSHH regulations,

the door to the store was open, and the padlock and key were hanging

from the chemical cupboard (Picture 4).

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Picture 4: Open padlock on chemical cupboard

In Ward 4C the section on correct use of isolation was not assessed as

no patients were in isolation. However, as the main issues in July were

in relation to the cleaning process and preparation of the room for

Vaporized Hydrogen Peroxide (VHP) decontamination process, the

inspectors questioned a member of domestic about the current

practice. The staff member was able to give a detailed description of

the step by step cleaning process.

With regard to the effective cleaning of the ward, in Ward 5A, nursing

staff were now aware of the correct dilution rates for disinfectants and

the NPSA colour coding guidelines. COSHH data sheets were still not

available for either nursing or domestic staff.

Staff on both wards adhered to the staff dress code policy. However,

when questioned staff advised they did not change in and out of

uniform before starting or on completion of a shift.

Three of the four previous recommendations have been assessed

as having been achieved.

Repeated Recommendation:

6. The trust should ensure that all cleaning products are stored

in a locked cupboard, in line with COSHH regulations.

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12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs L Gawley

Mrs M Keating

Peer Reviewers

Mrs S Baird

Mrs G Moore

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Sister, North West Independent Clinic

- Patient Experience Manager, SEHSCT

Trust representatives attending the feedback session

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

representatives:

Ms B Owens - Acting Director, Acute Services

Mr A Dawson - Co-Director, Trauma and Orthopaedics

Ms T McKinney - CCO Specialist Surgery

Ms T Mc Gonagle - Governance Manager

Ms K McClenaghan - Service Manager

Ms A Dowd - Central Nursing Governance

Mr J Thompson - Senior Manager PCSS

Mr D Gibson - Head of Catering Services

Ms C Kearns - Operational Manager PCSS, RVH

Ms P Orr - Ward Sister, 4C

Ms J Clements - Ward Sister, 5A

Ms K Thompson - Infection Prevention and Control

Mr J Ravey - Estates Officer

Apologies

Ms N Patterson

Mr D Robinson

Ms J Callaghan

Mr R Sawney

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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.

23


13.0 Summary of Recommendations

1. The trust should continue to work on repair and maintenance

of ward and public environments and replace damaged

fixtures and fittings. Partly completed.

2. The trust and staff should continue to improve storage and

maintain clutter free ward environment. Partly completed.

3. The trust should continue to roll out newly developed

nursing cleaning schedule.

4. The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

sharps to ensure that safe and appropriate practice is in

place.

5. The trust and individuals have a collective responsibility to

ensure that equipment is clean, and in a good state of repair.

6. The trust should ensure that all cleaning products are stored

in a locked cupboard, in line with COSHH regulations.

24


Plan Programme

14.0 Unannounced Inspection Flowchart

Environmental Scan:

Stakeholders & External

Information

Prior to Inspection Year

Plan

Programme

Prioritise Themes & Areas for Core Inspections

Balance Programme

Consider:

Areas of Non-Compliance

Infection Rates

Trust Information

RQIA Hygiene Team

January/February

Schedule Inspections

Prior to Inspection

Identify & Prepare Inspection Team

Episode of Inspection

Day of Inspection

Day of Inspection

Inform Trust

Carry out Inspection

Is there immediate risk

requiring formal escalation?

NO

YES

Invoke

RQIA

IPHTeam

Escalation

Process

A

Day of Inspection

Feedback Session with Trust

14 days after

Inspection

28 days after

Inspection

Preliminary Findings

disseminated to Trust

Draft Report

disseminated to Trust

NO

Does assessment of

the findings require

escalation?

YES

Invoke

RQIA

IPHTeam

Escalation

Process

A

Reporting & Re-Audit

14 days later

Within 0-3 months

Signed Action Plan

received from Trust

Is a Follow-Up required?

Based on Risk Assessment/key

indicators or Unsatisfactory Quality

Improvement Plan (QIP)?

YES

Invoke

Follow-Up

Protocol

Process enables

only 1 Follow-Up

NO

Open Report published to Website

YES

Is Follow-Up

satisfactory?

NO

DHSSPS/HSC

Board/PHA

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 trust should continue to work on repair and

maintenance of ward and public environments and replace

damaged fixtures and fittings. Partly completed.

2. The trust and staff should continue to improve storage and

maintain clutter free ward environment. Partly completed.

3. The trust should continue to roll out newly developed

nursing cleaning schedule.

Designated

department

Estates

IPC

Other

appropriate

staff

All

Directorates

Nursing

IPECC

Action required

This is ongoing as part of Estate daily

maintenance and refurbishment programmes.

Planned programme of de-clutter and deep

cleaning in place. Ongoing space utilisation

and de-cluttering is being driven by Service

Managers.

A sub-group of IPECC (Infection Prevention

& Environment and Cleanliness Committee)

has been set up to review and standardise

cleaning schedules, and will establish any

outstanding issues of audit standardisation

process.

Date for

completion/

timescale

Ongoing

Ongoing

Complete

Agree a standardised audit which will be

used in all areas. This will include

standardised responsibilities. To be kept

under review.

Commenced

Feb 2012

Systematic roll out of the agreed

standardised audit using the Maximiser

system.

4. The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

sharps to ensure that safe and appropriate practice is in

place.

PCSS

Nursing

The Trust has piloted and rolled out across all

facilities the use of an electronic tool to audit

waste management compliance against

policy, procedure and RQIA requirements.

This process supplements the existing audit

tools used by PCSS, IPC and also existing

external audits conducted by Daniels (sharps

box suppliers).

Complete

* indicates stated for a second time 27


Reference

number

Recommendations

Designated

department

Action required

Daniels’ audit completed Oct 2011 and

results disseminated.

Date for

completion/

timescale

5. The trust and individuals have a collective responsibility to

ensure that equipment is clean, and in a good state of

repair.

Nursing

PCSS

IPC

Work / negotiations in relation to the cleaning

manual are still ongoing. In particular, there

is discussion with nursing/control of infection

with reference bed cleaning. Once agreement

is reached the manual will be finalised.

Ongoing

The manual includes roles and

responsibilities of trust staff in relation to

patient equipment. A template will be used to

record all cleaning of equipment.

Staff have been reminded of protocols in

relation to sterile items.

6. The trust should ensure that all cleaning products are

stored in a locked cupboard, in line with COSHH

regulations.

PCSS

Locked cupboards are provided.

Ward managers and PCSS supervisors carry

out regular checks to ensure all staff comply

with COSHH procedures. Audited as part of

Belfast Risk Assessment and Audit Tool

(BRAAT).

Complete and

ongoing

* indicates stated for a second time 28


* indicates stated for a second time 29

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