Royal Victoria Hospital, Belfast - 17 July 2012 - Regulation and ...

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Royal Victoria Hospital, Belfast - 17 July 2012 - Regulation and ...

RQIA

Infection Prevention/Hygiene

Unannounced Inspection

Belfast Health and Social Care Trust

Royal Victoria Hospital

17 July 2012


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 6

3.0 Inspections 6

4.0 Unannounced Inspections 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 12

6.3 Maintenance and Repair 13

6.4 Fixture and Fittings 14

6.5 Information 14

6.6 Additional Issues 15

7.0 Patient Linen 17

7.1 Management of Linen 17

8.0 Waste and Sharps 19

8.1 Waste 19

8.2 Sharps 19

8.3 Additional Issue Ward 7B 20

9.0 Patient Equipment 22

10.0 Hygiene Factors 24

11.0 Hygiene Practice 25

12.0 Key Personnel and Information 29

13.0 Summary of Recommendations 31

14.0 Unannounced Inspection Flowchart 33

15.0 RQIA Hygiene Team Escalation Policy Flowchart 34

16.0 Action Plan 35


1.0 Inspection Summary

An unannounced inspection was undertaken to the Royal Victoria

Hospital, on the 17 July 2012. The hospital was assessed against the

Regional Healthcare Hygiene and Cleanliness Standards and the

following areas were inspected:

• Ward 4C - Orthopaedic

• Ward 5A - Vascular

• Ward 6A - Gastro-intestinal Surgery

• Ward 7B - Medical Respiratory

Inspection Outcomes

Overall the inspection teams found evidence that the Royal Victoria

Hospital was working to comply with the Regional Healthcare Hygiene

and Cleanliness standards. Improvements in the overall levels of

compliance have been noted since the previous inspection, three of the

wards achieved an overall partially compliant score and Ward 6A

achieved an overall compliant score.

Inspectors found that further improvement was required in the following

areas. The environment in all wards required attention to detail where

cleaning; clutter, and at times poor maintenance and repair, notably in

Ward 5A, have impacted negatively on the scoring.

Although all wards scored overall compliance for the standard

regarding hygiene factors, the section on materials and equipment for

cleaning, indicates that more work is required to improve practice. In

the hygiene practices standard, Ward 4C scored a minimal compliance

in the section hand hygiene procedures and none of the wards were

compliant for the section concerning effective cleaning of the ward. In

all wards, all staff groups must implement hygiene and infection

prevention and control practices consistently to minimise the potential

risk of transmission of infection to patients, visitors and staff. As a

result of the findings for Wards 4C and 5A a follow up inspection will be

carried out within three months.

The inspectors noted that good practice by staff resulted in compliance

in the following sections of the audit tool; the management of waste

and used linen and within the Hygiene Factors and Hygiene Practices

standards.

The inspection resulted in 22 recommendations for the BHSCT and the

Royal Victoria Hospital, a full list of recommendations is listed in

Section 13.

A detailed list of preliminary findings is forwarded to Belfast Health and

Social Care Trust within 14 days of the inspection to enable early

action on identified areas which have achieved non complaint scores.

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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.

Notable Practice

The inspection identified the following areas of notable practice:

• Care bundles are performed for insertion and maintenance of

peripheral IV lines, maintenance of central lines and urinary

catheterization

• Audits are carried out on; hand hygiene, peripheral vascular

catheters, central venous catheters, urinary catheter care

• Ward 5A has implemented a care bundle for the acutely ill

patient

• Vapourised hydrogen peroxide cleans are carried following

discharge of patients with VRE (Vancomycin Resistant

Enterococcus) infection

• Ward 6A has initiated a “Body Chart” for use with each

patient. This is a good visual trigger for staff to quickly

identify catheters, cannulae, wounds, pressure areas

• In Ward 6A and 7B, the use of the electronic handover tool

has shortened handover time to approximately 10 minutes

and can highlight IPC issues for staff

The RQIA inspection team would like to thank the BHSCT and in

particular all staff at the Royal Victoria 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 the organisation to target areas that

require more specific attention.

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Table 1

Ward 4C 5A 6A 7B

Environment 80 70 81 80

Patient Linen 87 88 89 83

Waste 88 86 89 86

Sharps 79 76 94 79

Equipment 81 76 88 86

Hygiene Factors 92 88 91 87

Hygiene Practices 81 89 90 90

Total 84 82 89 84

Table 2

Environment 4C 5A 6A 7B

Reception N/A N/A 70 N/A

Corridors, stairs lift 88 83 81 95

Public toilets 86 N/A 84 N/A

Ward/department –

general (communal)

90 72 79 80

Patient bed area 83 72 84 77

Bathroom/washroom 87 65 79 94

Toilet N/A N/A 87 79

Clinical room/treatment

room

66 50 96 74

Clean utility room 85 59 76 80

Dirty utility room 86 71 75 73

Domestic store 73 64 81 79

Kitchen N/A 57 78 67

Equipment store 67 80 81 81

Isolation 76 86 79 73

General information 60 85 81 85

Total 80 70 81 80

Table 3

Linen 4C 5A 6A 7B

Storage of clean linen 79 81 83 65

Storage of used linen 94 94 94 100

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

Total 87 88 89 83

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 4

Waste and sharps 4C 5A 6A 7B

Handling, segregation,

storage, waste

88 86 89 86

Availability, use,

storage of sharps

79 76 94 79

Table 5

Patient Equipment 4C 5A 6A 7B

Patient equipment 81 76 88 86

Table 6

Hygiene Factors 4C 5A 6A 7B

Availability and

cleanliness of WHB and 94 91 91 85

consumables

Availability of alcohol

rub

100 100 97 93

Availability of PPE 94 100 93 93

Materials and

equipment for cleaning

79 59 83 77

Total 92 88 91 87

Table 7

Hygiene Practices 4C 5A 6A 7B

Effective hand hygiene

procedures

71 85 94 80

Safe handling and

disposal of sharps

100 100 100 100

Effective use of PPE 86 100 94 100

Correct use of isolation 82 N/A 88 86

Effective cleaning of

ward

76 74 76 80

Staff uniform and work

wear

72 86 90 93

Total 81 89 90 90

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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2.0 Background Information to the Inspection Process

RQIA’s infection prevention and hygiene team was established to

undertake a rolling programme of unannounced inspections of acute

hospitals. The Department of Health Social Service and Public Safety

(DHSSPS) commitment to a programme of hygiene inspections was

reaffirmed through the launch in 2010 of the revised and updated

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

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

in Northern Ireland.

The aims of the inspection process are:

• to provide public assurance and to promote public trust and

confidence

• to contribute to the prevention and control of HCAI

• to contribute to improvement in hygiene, cleanliness and infection

prevention and control across health and social care in Northern

Ireland

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

transparent method for inspection, using standardised processes and

documentation.

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3.0 Inspections

The DHSSPS has devised 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 four inspectors from RQIA’s

infection prevention/hygiene team along with four 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.

The findings, report and follow up action will be in accordance with the

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.

7


5.0 Audit Tool

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

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 5A 6A 7B

Reception N/A N/A 70 N/A

Corridors, stairs lift 88 83 81 95

Public toilets 86 N/A 84 N/A

Ward/department –

general (communal)

90 72 79 80

Patient bed area 83 72 84 77

Bathroom/washroom 87 65 79 94

Toilet N/A N/A 87 79

Clinical room/treatment

room

66 50 96 74

Clean utility room 85 59 76 80

Dirty utility room 86 71 75 73

Domestic store 73 64 81 79

Kitchen N/A 57 78 67

Equipment store 67 80 81 81

Isolation 76 86 79 73

General information 60 85 81 85

Total 80 70 81 80

The above table outlines the findings in relation to the general

environment of the facilities inspected where none of the wards

achieved compliance in this standard. The findings indicate that there

were areas for improvement in all wards, notably Ward 5A, where

clutter, the poor repair and cleaning of the fabric of the building, fixtures

and fittings have contributed to the minimally compliant areas

highlighted in red. 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 in some areas to

indicate compliance with regional specifications for cleaning. However,

the inspectors observed that while cleaning mechanisms were in place

to prevent the build up of dust, debris and bacteria and subsequently

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educe the potential risk for the transmission of infection, they were not

always implemented or adhered to.

Ward 5A was minimally compliant for the majority of criteria within this

standard with an overall minimally compliant score. A concentrated

effort is required by staff in all wards to improve cleaning practice.

In the main reception area, walls and flooring were stained, the edges

of the stairs and ceiling air vents had a build up of dust, external

windows were smeared, public telephones were dirty and had paper

labels attached to the wall mounted frame. Dust was also noted on the

plants, the wooden panelling housing the plants and on the window sill

and in the radiator cover of the public toilet. Similar issues were noted

in the public toilet of Ward 4C where the vinyl flooring was grubby, the

air vent was dusty and the door was stained.

In the corridors leading to Wards 4C, 5A and 7B green algae was

present on some window panels and cobwebs were observed in the

lobby outside Wards 6A and 5A. Greater attention to detail when

cleaning window sills, external windows, stained flooring, corners and

edges of flooring was required in the lobby of Ward 6A. Similarly, in

Ward 5A, the lift doors and ceiling tiles were stained, sticky hand marks

were noted on windows and sticky adhesive residue on the public

telephone.

In all wards inspected greater attention to detail was required when

cleaning, to ensure dust, debris and stains are removed from all high

and low horizontal surfaces, such as skirting, radiators, walls and

flooring. The interior and exterior of high density shelving, windows,

lights and vents, all fixtures and fittings, including sanitary, dirty utility

and disposal areas required attention. Inspectors observed that

adhesive tape was used to attach labels or posters to surfaces which in

some instances had left a sticky residue, impeding the cleaning

process.

Lime scale was observed on taps. Particular care is required to ensure

that lime scale is removed from taps and fittings as recent evidence

has shown that lime scale may harbour biofilms and the build-up of

lime scale can interfere with good cleaning and disinfection by masking

and protecting pathogens.

In Wards 6A and 7B shower chairs were stained, in Ward 5A, the

inside and outside of the toilet bowl, the underneath of the toilet seat

and the toilet brush and holder required cleaning.

Wards 4C, 5A and 6A require further work to ensure that the inside/

outside of the drugs’ fridges and door touch points throughout the

wards are clean. In Wards 4C, 5A and 7B temperature recordings

were inconsistent and record sheets did not all provide evidence for

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ecord variations outside recommended temperature ranges or actions

taken.

Cleaning issues such as dust on horizontal surfaces, debris in corners

and edges of flooring, grubby pull cords and hand washing facilities

and excess toilet rolls were identified in rooms designated for isolation

purposes. In Ward 4C a room had been treated with Vaporised

Hydrogen Peroxide (VHP) however, the cleaning process had not been

completed to an acceptable standard. Surfaces were still dusty, the

suction canister, disposable ear phones, soap and hibiscrub dispensers

had not been removed prior to the treatment and there were footprints

on the patient wash chair. In Ward 7B the rim of the toilet bowl and the

shower chair were stained, in Ward 6A the shower drain, shower panel

and toilet seat were dirty.

Catering kitchens were inspected on Levels 5, 6 and 7. Level 6 was

partially compliant; Levels 5 and 7 were minimally compliant. Flooring,

skirting, horizontal surfaces, taps and sinks, some fixtures and fittings

required more in depth cleaning. In Level 5, the hot water geyser, the

exterior of cleaned water jugs and the inside of the dishwasher were

dirty. Opened food was not stored in sealed, airtight containers, work

surfaces were grubby. In Level 7, surfaces were untidy and cluttered,

many kitchen appliances were stained, the Gastnorm tray was on the

floor, fly screens and the dishwasher were dirty and catering staff were

observed not wearing head gear when plating up chicken.

6.2 Clutter

The provision of clutter free wards and effective utilisation of space and

good stock management assists with effective cleaning in the wards

(Picture 1). Inspectors however noted in Ward 4C a cage containing

stores, a mattress and a bed were in the corridor outside the ward and

the equipment store, also used as a staff locker room and domestic

store was disorganised and very cluttered (Picture 2). The on going

refurbishment of Ward 6A contributed to the storage of domestic

equipment cluttering the dirty utility room and unfixed shelving littering

the floor of the equipment store and reducing storage capabilities within

the room.

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Picture 1: Tidy mail box storage

Picture 2: Cluttered locker room

in Ward 4C

The clean utility rooms and domestic stores of Wards 5A and 7B did

not have sufficient space to allow for effective storage of equipment

and patient equipment was stored in both treatment rooms. In Ward

7B, the 6 bedded bays appeared cramped with little space between

beds and the displaying of cards on wall trunking created a cluttered

environment. There was inadequate shelving in the dirty utility room

and patient equipment was stored in the en-suite of a room used for

isolation purposes.

The lobby of Ward 5A was cluttered with a bicycle, chair, transport

cage and pharmacy boxes, the latter two blocking access to the public

telephone. Shelving units in the equipment store were cluttered and

untidy, communal toiletries were present in shower rooms. Excess

toilet rolls were noted in toilet areas of Wards 5A, 6A and 7B.

6.3 Maintenance and Repair

Inspectors observed that in the main reception, the entrance doors

were damaged, there was minor wall damage, and the wooden

panelling, reception desk and internal frame at the glass brick window

were worn, exposing bare wood.

In all wards inspected, inspectors noted wall, door and paintwork

damage. It was evident that staff practice in propping doors open with

waste bins or storing equipment against walls has in some part

contributed to the wall and door damage observed. In Ward 4C

inspectors observed holes in the shower room wall from removed

fixtures and skirting poorly joined in the treatment room. Flooring was

damaged in Wards, 4C, 5A and 6A, water leaks were noted in the

kitchens of Levels 5 and 7 and damaged formica or veneer was

observed on work surfaces and at the nurses’ station in Wards 5A and

6A.

Wall repairs of a poor standard were noted in Ward 7B. Wall trunking

was damaged, electrical flex was hanging from a ceiling light in a toilet

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and some lights did not work. An issue also observed in Ward 5A

treatment room.

Damaged fly screens and radiator covers, displaced or damaged

ceiling tiles, split covers on pull cords and rusted shelving in the

chemical cupboard of the domestic store contributed to the minimally

compliant score achieved in Ward 5A for this standard. The drugs’

fridge was old, worn and damaged, an issue also identified in Ward 6A.

In Ward 6A, wiring was exposed on a hand held call bell, wall trunking

in the bays and the sealant at some hand washing sinks were

damaged. Some caps used to cover mirror screws were missing

resulting in rusted screw heads.

6.4 Fixtures and Fittings

The fixtures, fittings and equipment in all wards were generally fit for

purpose however common issues were identified for action. In Wards

4C, 5A and 6A, shower rail fittings were available but there was no

curtain to protect patient’s privacy and dignity. The lack of bedpan drip

trays and chipped bedrails were noted in Wards 5A, 6A and 7B,

bedpan holders were overstocked in Ward 7B.

Vertical blinds and wooden chairs were damaged in Wards 6A and 7B

and there was no sign on the treatment door alerting the storage of

oxygen cylinders. Pillows in Ward 7B did not have plastic protective

covering, inspectors observed stained pillows.

In Ward 6A the leaflet rack in the waiting area was badly damaged and

the fabric covers on the seating benches were badly stained. At the

feedback trust representatives confirmed these would be replaced.

Also observed were damaged toilet seats and worn plugholes, the blue

storage containers in the treatment room were worn and damaged.

A mattress spot checked in Ward 4C was damaged, the undercarriage

of a bed was broken and privacy curtains were not dated. Privacy

curtains in Ward 5A required changing.

6.5 Information

With the exception of Ward 6A, the trust’s new nursing cleaning

schedules outlining responsibility, equipment and frequency of cleaning

were not in place for staff to reference and document. Due to on-going

refurbishment of the domestic store in Ward 6A, domestic cleaning

schedules had been removed.

Hand washing posters in Ward 4C demonstrated a 6 step procedure

instead of the recommended 7 step, information leaflets on MRSA,

Clostridium difficile, general infections or hand hygiene were not

available, MRSA leaflets were also not available in Ward 7B.

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In Wards 4C and 5A National Patient Safety Agency (NPSA) guidelines

were not clearly displayed for nursing staff to reference and in Ward 6A

there was no poster available on the segregation of linen. In all wards

inspectors observed posters and labels which were not laminated and

posters attached to surfaces with adhesive tape.

6.6 Additional Issues

• User friendly information on hand hygiene and environmental

cleanliness audits and evidence on care bundle performance

(Picture 3) were not displayed in all wards, for example Wards 6A

and 7B. Staff in Ward 6A confirmed that the notice board for

displaying the information had been removed for the ongoing

refurbishment.

Picture 3: Notice board displaying audits,

information and mandatory training dates

• In Ward 6A the original linen store had been spit into a smaller

linen store and a domestic sluice room. The sluice room was still

under construction therefore staff were using the domestic store

in Ward 6B to store equipment, material and supplies and the

nursing sluice to empty buckets.

Recommendations

1. The trust should work to improve, monitor and ensure that

environmental cleaning is carried out effectively, that patient

equipment is fit for purpose and that the environment is in a

good state of repair.

2. The senior management within trust should ensure that all

staff are aware of their roles and responsibilities in

environmental cleaning.

3. The trust should work on the repair and maintenance of ward

and public environments and to replace damaged fixtures

and fittings.

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4. The trust and staff should work to improve storage and

maintain clutter free ward environments.

5. The trust should ensure all relevant information is available

for patients, visitors and staff to reference.

6. The trust should continue to roll out the newly developed

nursing cleaning schedules.

7. The trust should ensure that all staff are aware of the

importance of monitoring fridge temperatures.

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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.

Linen 4C 5A 6A 7B

Storage of clean linen 79 81 83 65

Storage of used linen 94 94 94 100

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

Total 87 88 89 83

7.1 Management of Linen

The poor repair of the linen store affected the levels of compliance in

all wards. Ward 6A was the only linen store which appeared tidy and

organised, non-linen items contributed to the cluttered environment in

Wards 5A and 7B. Shelving was damaged in Ward 5A and 7B, wall

damage was noted in all stores except in Ward 7B, although inspectors

noted a wall mounted wooden plinth which could not be effectively

cleaned and a missing light cover.

The wooden door frame of Ward 4C was damaged preventing full

closure of the door; the door handle in Ward 7B was broken. In Wards

6A and 7B debris was noted on the corners and edges of the flooring,

sticky labels were posted untidily on the door.

Washed in stains were noted on bed sheets of two beds in Ward 6A;

staff confirmed that this was an ongoing issue. In Ward 5A the ward

sister advised that on occasions cleaned ‘wet’ sheets were returned to

the ward from the laundry services. At the feedback trust

representatives advised that the laundry company responsible for

laundering linen would be contacted and that staff on the wards were to

record and inform of any further incidents.

The storage and segregation of used linen was generally good, no

issues were identified in Ward 7B where good practices were

observed. In Ward 4C, had the frames of the linen skips been in good

repair full compliance would also have been achieved for this section of

the audit.

Staff practice affected scores in Wards 5A and 6A. In Ward 5A

although not observed, nursing staff advised inspectors that they did

not wear personal protective equipment when washing and changing a

bed. In Ward 6A inspectors noted used linen which had not been

placed into an alginate bag in a red linen laundry bag designated for

contaminated linen. Staff questioned confirmed the linen was not

17


contaminated and had been incorrectly disposed of into the wrong linen

skip.

Recommendations

8. The trust should ensure the correct storage of clean linen in

a designated area which is clean and fit for purpose.

9. The trust should monitor the implementation of its policies

and procedures in respect of the handling and storage of

linen to ensure that safe and appropriate practice is in place.

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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 4C 5A 6A 7B

Handling, segregation,

storage, waste

88 86 89 86

Availability, use,

storage of sharps

79 76 94 79

8.1 Waste

The inspection evidenced that all wards were compliant for the

handling, segregation and storage of waste standard. Some issues

however were identified that require attention.

With the exception of Ward 4C damage was noted to waste bins and at

least one waste bin in all wards inspected required cleaning.

To encourage good hand hygiene practices in all wards inspected, it is

essential that household waste bins are available at all hand washing

sinks and the placement does not affect patient privacy and dignity.

In Bay B Ward 4C the waste bins were located under privacy curtains.

In all wards waste was not disposed of into the correct waste stream

and in line with trust policy. The magpie box in Ward 7B designated for

aerosols, broken crockery and glass contained a dirty dust pan.

There was pharmacy waste in the magpie boxes of Wards 4C, 5A and

6A, in Ward 5A pharmacy waste had also been disposed into a yellow

lidded burn bin and in Ward 6A into a large sharps box. Ward 4C did

not have a black lidded burn bin.

Incorrect disposal of household waste into the clinical waste stream

was noted in Wards 5A and 6A. A sharps box in Ward 5A also

contained household waste, in Ward 4C a sharps box contained used

dressings. Inspectors observed in Ward 7B a clinical waste bag

incorrectly placed in a black lidded household waste bin.

8.2 Sharps

The inspection evidenced that only Ward 6A achieved compliance on

the safe handling, segregation, storage and disposal of sharps

standard. The ward shares the emergency trolley with Ward 6B.

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Inspectors were disappointed to note that in this ward the sharps box

on the emergency trolley was not labeled, signed or secure and the

temporary closure was open.

Common themes were observed in the other three wards. Temporary

closure mechanisms were not all in place on the sharps boxes when

not in use, sharps boxes on the emergency or drugs trolleys were not

secure or empty and sharps trays were stained in Wards 4C and 5A.

Inspectors in Wards 5A and 7B

observed items such as IV tubing and

syringe plungers, protruding from

sharps boxes (Picture 4). In Ward 7B

the sharps box on the resuscitation

trolley was not dated, or signed and

sharps were not disposed of at the

point of care as there were no

compatible sharps boxes for the IV

trays in use.

Picture 4: Protruding plunger in sharps box

8.3 Additional Issue Ward 7B

On entering the treatment room during the inspection the inspector

observed that IV/IM medication had been drawn up and left sitting in

trays, this is unsafe practice and was addressed immediately by the

nurse and brought to the attention of the ward manager. It is

concerning that this issue was also identified on the re-audit of a

different ward last year; this may be a training issue for the trust.

Recommendations

10. 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.

11. The trust should ensure that waste bins and equipment used

in the management of waste are available, kept clean and

replaced as appropriate.

12. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

the safe and the correct handling and disposal of waste and

sharps is adhered to.

20


13. The trust need to review staff practice in relation to the

administration of medications and provide training if required.

21


9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment 4C 5A 6A 7B

Patient equipment 81 76 88 86

Wards 6A and 7B achieved compliance for this standard; Wards 4C

and 5A were partially compliant, issues were identified in all wards

inspected.

Common themes were noted. Trigger tape to denote equipment had

been cleaned and was ready to use was not in use in Wards 5A and

4C, it was sporadically used in Ward 7B. In Ward 7B disposable

tourniquets were not in use, in Ward 6A used disposable tourniquets

had been left on sharps trays, these were discarded immediately by a

senior staff nurse. With the exception of Ward 7B, staff questioned

were unaware of the symbol for single use equipment.

Greater attention to detail when cleaning patient equipment such as the

underside of commodes, walking aids, IV stands, suction machines,

drugs’ and resuscitation trolleys and re-usable blood pressure cuffs

was required in Wards 4C and 7B. Staff in Ward 4C should ensure

stock is regularly rotated and adhesive tape and plasters removed from

all equipment; in Ward 7B there was no filter on the portable suction

machine. In both wards patient washbowls were not stored inverted to

aid the drying process.

The low partially compliant score in Ward 5A is indicative of patient

equipment which required cleaning, was in poor repair or stored out of

packaging. Items such as Magills forceps, ambu bags and masks out

of packaging did not have traceability labels to denote expiry date and

lot number; some IV bags were also stored out of original packaging.

Detailed cleaning of stored equipment such as IV stands, IV pumps

and observation monitors and in use drugs’, notes’ and dressing

trolleys was required. Some equipment had minor damage such as

chipped framework, the undercarriage of a commode was rusted, the

plastic protective coating on some urinal holders or catheter stands

was missing in places exposing the metal underneath and the casing of

a glucose monitor was held together with adhesive tape (Picture 5).

Inspectors noted two bedpans which had been processed by the

washer disinfector had faecal stains present. Staff should ensure

effective cleaning processes are in place.

22


Picture 5: Glucose monitor casing and

dirty adhesive tape

Patient equipment in Ward 6A was generally visibly clean and in good

condition although some bedpans and IV stands were old and worn.

Blood stains were noted on the glucose monitoring machine and the

interior lid of its container.

Recommendations

14. The trust and individual staff have a collective responsibility

to ensure that equipment is clean, stored correctly and in a

good state of repair.

15. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

equipment cleaning.

23


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 4C 5A 6A 7B

Availability and

cleanliness of WHB and 94 91 91 85

consumables

Availability of alcohol

rub

100 100 97 93

Availability of PPE 94 100 93 93

Materials and

equipment for cleaning

79 59 83 77

Total 92 88 91 87

All wards were compliant for this standard; Wards 4C and 5A were fully

compliant for the sections concerning availability of alcohol rub.

Hand washing sinks and fixtures and fittings in all wards were generally

clean, working and in a good state of repair however, greater attention

to detail could further improve scoring. In Wards 4C and 6A although

clean, some hand washing sinks were old, worn or stained, in Ward 4C

the laminate surround was badly worn. Staff in Ward 6A and 7B were

unsure who had responsibility for running the sink in the shared

disposal area in line with the trust Legionella control measures.

In Ward 7B the hand washing sinks in the clean and dirty utility rooms

were not draining properly, the surface was tarnished and drainage

holes were dirty. The hand washing sink in the treatment room was not

visibly clean, the seal was stained and peeling away from the splash

back. There was no soap dispenser in the dirty utility room and

Chlorhexidine hand wash was supplied at all hand washing sinks, a

similar issue in Ward 6A.

It is imperative that in order to promote effective hand hygiene for staff

and visitors that hand hygiene consumables are available for use.

There was one alcohol rub dispenser in Ward 6A which was empty, the

hand rub container at the entrance to Ward 7B was missing and

Hydrex dispenser plungers were dirty.

None of the wards was compliant in the section materials and

equipment for cleaning, Ward 5A was minimally compliant. With the

exception of Ward 7B, inspectors noted chemicals stored in unlocked

cupboards breaching COSHH regulations, in Ward 6B disinfectant

24


tablets were decanted into an unlabelled foil dish, in Ward 6A out of

date cleaning chemicals were in the unlocked equipment store waiting

collection. Trigger spray bottles of air freshener were hanging in

shower rooms in Wards 5A and 6A.

In Wards 4C, 5A and 6A, some mop buckets were dirty in the crevices,

not all were stored inverted. Mops buckets in Wards 5A and one

bucket in Ward 6A were observed stored in the domestic store filled

with solution. In Ward 5A some contained used mop heads, in both

wards some mop heads were soaking in the solution and therefore not

laundered after use.

Picture 6: Cloths and mops left soaking

in solution

In Ward 5A, a red hand held

bucket filled with solution and

a cloth had been left in the

domestic store and not

discarded after use (Picture

6). Mop handles were stored

propped against the wall as

holders were not available.

Dirty, wooden floor brushes,

which cannot be effectively

cleaned were observed, and

the brushes were not colour

coded in line with NPSA

guidelines.

Dustpans were dirty in Wards 5A, 6A and 7B, brushes in Ward 7B also

required cleaning. Cleaning equipment such as burnishers, high

dusters, vacuums were dirty or had minor damage in Ward 5A, floor

polishing pads were dirty in Ward 4C, and the polisher was dusty. Dirty

or damaged equipment was observed in Ward 7B, the flex of the

burnisher and the vacuum hose was damaged, the castors and base of

the burnisher were dusty.

Recommendations

16. The trust should ensure that hand washing sinks and

consumables are available, clean, working and in a good

state of repair.

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

in a locked cupboard, in line with COSHH regulations.

18. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of a ward

are clean, used and stored appropriately and are fit for

purpose.

25


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 5A 6A 7B

Effective hand hygiene

procedures

71 85 94 80

Safe handling and

disposal of sharps

100 100 100 100

Effective use of PPE 86 100 94 100

Correct use of isolation 82 N/A 88 86

Effective cleaning of

ward

76 74 76 80

Staff uniform and work

wear

72 86 90 93

Total 81 89 90 90

With the exception of Ward 4C overall compliance was achieved in this

standard. Poor hand hygiene practices were observed in Ward 4C.

Many staff did not carry out all seven steps of the hand wash

technique, staff did not comply with hand hygiene in line with the World

Health Organisation (WHO) five moments of care and patients were

not offered hand hygiene prior to meals. In Ward 7B the majority of

staff observed evidenced effective hand hygiene practice however on

two occasions staff did not undertake the seven step technique

properly and all but one member of staff used antibacterial hand wash

in preference to soap.

Staff in all wards are commended for achieving full compliance for the

section relating to safe handling and disposal of sharps. Wards 5A and

7B were fully compliant with effective use of PPE. In Ward 4C

domestic staff confirmed they did not wear aprons for wet work and a

member of staff was observed not removing gloves after completing an

activity. In Ward 6A a nursing auxiliary was observed leaving an

isolation room having removed PPE and not decontaminating their

hands outside the room.

There were no patients requiring isolation precautions in Ward 5A

therefore this section of the tool kit was not scored. In Wards 4C and

7B inspectors reviewed the notes of a patient with a known infection;

the care pathway was in place however the infection prevention and

control assessment had not been completed. Additionally, in Ward 7B

26


dust in the isolation room would suggest that cleaning was not being

carried out effectively on a daily basis, while in Ward 4C patients and

relatives were not provided with relevant information leaflets. A review

of the notes in Ward 6A identified that both the care pathway and the

infection, prevention and control assessment had not been completed.

To improve practice and knowledge in the effective cleaning at ward

level further effort is required in all wards inspected, and notably Ward

5A which was minimally compliant in this section. In Ward 5A

registered nursing staff did not routinely clean patient equipment

between use however nursing auxiliary staff did. Some nursing staff

questioned were unaware of the dilution rates for the disinfectant in use

for routine cleaning, none knew the dilution rate for cleaning blood and

body spillages and the NPSA (National Patient Safety Agency) colour

coded system for cleaning.

In Ward 4C there was little evidence to demonstrate patient equipment

was cleaned between use as detergent wipes were exposed and dry in

their canisters. Individual bottles of constituted disinfectant bottles

were not dated, NPSA colour coding guidelines were not available for

nursing staff and staff were unaware of the need for a decontamination

certificate for equipment needing repaired, serviced or maintained.

Staff in Wards 6A and 7B were unable to outline the correct procedure

for cleaning blood and body fluid spillage as they did not know the

correct disinfectant dilution rate. Data sheets for the disinfectant in use

were not available in Ward 6A and not all nursing staff were aware of

the NPSA colour coding system.

Inspectors observed that the trust has in general implemented the

concept of ‘bare below the elbow’ for staff delivering care. However, in

Ward 4C two members of staff did not comply with the policy, two

members of medical staff wore wrist watches, two members of staff

wore unsecured clothing. In Ward 5A medical staff were observed with

stethoscopes hanging around their necks, a student nurse in Ward 6A

wore false nails. These were removed before the end of the

inspection.

Designated staff changing facilities were not available for nursing and

domestic staff to change into and out of their uniform at work.

Recommendations

19. The trust and individual staff have a collective responsibility

to ensure that hand hygiene is carried out in line with WHO

guidance and that all PPE is used appropriately.

20. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date with regard

to isolation, cleaning and decontamination of equipment.

27


21. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

the use of disinfectants.

22. The trust should ensure that all members of staff are familiar

with and adhere to the regional dress code policy.

28


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs E Colgan

Mrs L Gawley

Mrs S O’Connor

Mrs M Keating

- Senior Officer Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

Peer Reviewers

Janice Clarke

Colin Clarke

Shirley Baird

Noelle Donnelly

- Senior Manager, Patient Experience, SEHSCT

- Lead Nurse, Infection Prevention & Control,

SHSCT

- Sister, North West Independent Clinic

- Assistant Support Services Manager, WHSCT

Trust representatives attending the feedback session

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

representatives:

Ms B Creaney

Mr R Sowney

Ms L Linford

Mr C Thomas

Ms K Ms Clenaghan

Ms E McDonald

Ms L Symington

Ms C Lecky

Ms D Cunningham

Ms J Callaghan

Ms R Gillen

Ms S Douthart

Ms J Ms Keown

Ms K Browne

Ms N Scott

Ms C Kearns

Ms K Thompson

- Executive Director of Nursing

- Co Director A/S

- Senior Manager & ADN A/S

- Service Manager Surgery

- Service Manager Specialist Surgery

- Fracture Services Manager

- Assistant Service Manager Surgery

- Assistant Service Manager Medicine

- Acting Ward Manager Ward 6A

- CCO

- Senior Infection Prevention and Control Nurse

- Deputy Ward Manager Ward 4C

- Ward Sister 5A

- Ward Sister 7B

- Senior Manager PCSS

- PCSS Operational Manager

- Infection Prevention and Control Nurse

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)

29


• 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.

30


13.0 Summary of Recommendations

1. The trust should work to improve, monitor and ensure that

environmental cleaning is carried out effectively, that patient

equipment is fit for purpose and that the environment is in a

good state of repair.

2. The senior management within trust should ensure that all

staff are aware of their roles and responsibilities in

environmental cleaning.

3. The trust should work on the repair and maintenance of ward

and public environments and to replace damaged fixtures and

fittings.

4. The trust and staff should work to improve storage and

maintain clutter free ward environments.

5. The trust should ensure all relevant information is available

for patients, visitors and staff to reference.

6. The trust should continue to roll out the newly developed

nursing cleaning schedules.

7. The trust should ensure that all staff are aware of the

importance of monitoring fridge temperatures.

8. The trust should ensure the correct storage of clean linen in a

designated area which is clean and fit for purpose.

9. The trust should monitor the implementation of its policies

and procedures in respect of the handling and storage of linen

to ensure that safe and appropriate practice is in place.

10. 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.

11. The trust should ensure that waste bins and equipment used

in the management of waste are available, kept clean and

replaced as appropriate.

12. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding the

safe and the correct handling and disposal of waste and

sharps is adhered to.

13. The trust need to review staff practice in relation to the

administration of medications and provide training if required.

31


14. The trust and individual staff have a collective responsibility

to ensure that equipment is clean, stored correctly and in a

good state of repair.

15. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

equipment cleaning.

16. The trust should ensure that hand washing sinks and

consumables are available, clean, working and in a good state

of repair.

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

in a locked cupboard, in line with COSHH regulations.

18. Further attention to detail is required to ensure that equipment

used for the general cleaning purposes of a ward are clean,

used and stored appropriately and are fit for purpose.

19. The trust and individual staff have a collective responsibility

to ensure that hand hygiene is carried out in line with WHO

guidance and that all PPE is used appropriately.

20. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date with regard to

isolation, cleaning and decontamination of equipment.

21. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding the

use of disinfectants.

22. The trust should ensure that all members of staff are familiar

with and adhere to the regional dress code policy.

32


14.0 Unannounced Inspection Flowchart

Plan Programme

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

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

33


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

34


16.0 Action Plan

Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

1. The trust should work to improve, monitor and ensure

that environmental cleaning is carried out effectively,

that patient equipment is fit for purpose and that the

environment is 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 to

bed cleaning. Once agreement is reached

the manual will be finalised.

Ongoing

All of these aspects will be monitored

through the programme of Environmental

Cleanliness Audits based on the

Cleanliness Matters Strategy and results

fed back through Balanced Scorecards.

2. The senior management within trust should ensure

that all staff are aware of their roles and

responsibilities in environmental cleaning.

Nursing

PCSS

IPC

‘Roles and responsibilities of Staff in

relation to Environmental Cleanliness and

Cleanliness of Equipment’ policy under

review.

Ongoing

Work / negotiations in relation to the

cleaning manual are still ongoing. In

particular, there is discussion with

nursing/control of infection with reference to

bed cleaning. Once agreement is reached

the manual will be finalised.

All of these aspects will be monitored

through the programme of Environmental

Cleanliness Audits based on the

Cleanliness Matters Strategy and results

fed back through Balanced Scorecards.

35


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

3. The trust should work on the repair and maintenance

of ward and public environments and to replace

damaged fixtures and fittings.

4. The trust and staff should work to improve storage

and maintain clutter free ward environments.

Estates

IPC

Other

appropriate

staff

All

Directorates

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.

Ongoing

Ongoing

5. The trust should ensure all relevant information is

available for patients, visitors and staff to reference.

6. The trust should continue to roll out the newly

developed nursing cleaning schedules.

IPC

Nursing

Nursing

IPECC

All relevant information is now displayed (or

will be displayed following refurbishment).

The Trust has secured funding from the

PHA to take forward the issue of HCAI

communication.

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.

Complete

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.

7. The trust should ensure that all staff are aware of the Nursing The Medicines Code outlines procedures Ongoing

36


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

importance of monitoring fridge temperatures.

for use of medicine fridges. A

pharmaceutical refrigerator temperature log

sheet is maintained for each individual

fridge, with records being maintained and

monitored by Ward Managers.

A dishwasher temperature log sheet is

maintained for each individual dishwasher,

where possible, with records being

maintained and monitored by Ward

Managers. Not all dishwasher

temperatures can be recorded.

8. The trust should ensure the correct storage of clean

linen in a designated area which is clean and fit for

purpose.

Nursing

Guidance regarding storage of linen is in

the Regional Infection Prevention Manual.

Linen storage and segregation guidance

has been circulated to all Directorates.

Complete

This states that all linen must be stored off

the floor in a clean dedicated area that

allows for ease of access and rotation of

stock and that Linen rooms must have

shelving that are easy to clean, and

cleaning frequencies must be at least

quarterly.

9. The trust should monitor the implementation of its

policies and procedures in respect of the handling and

storage of linen to ensure that safe and appropriate

practice is in place.

Nursing

Guidance regarding storage of linen is in

the Regional Infection Prevention Manual.

Linen storage and segregation guidance

has been circulated to all Directorates.

Complete

10. The trust should monitor the implementation of its PCSS The Trust has piloted and rolled out across Complete

37


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

policies and procedures in respect of the

management of waste and sharps to ensure that safe

and appropriate practice is in place.

Nursing

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).

Daniels’ audit completed Oct 2011 and

results disseminated.

11. The trust should ensure that waste bins and

equipment used in the management of waste are

available, kept clean and replaced as appropriate.

PCSS

Nursing

This is monitored as part of the

Environmental Cleanliness Audit

Programme.

Ongoing

Regional contract for bins at adjudication

stage.

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial audits,

and IPC audits monitor compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

12. The trust and individual staff have a collective

responsibility to ensure that staff knowledge is kept up

to date regarding the safe and the correct handling

and disposal of waste and sharps is adhered to.

PCSS

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

Complete

38


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

requirements. This process supplements

the existing audit tools used by PCSS, IPC

and also existing external audits conducted

by Daniels (sharps box suppliers).

Daniels’ audit completed Oct 2011 and

results disseminated.

13. The trust need to review staff practice in relation to

the administration of medications and provide training

if required.

Nursing

The administration of medications is a

statutory and mandatory training

requirement for nursing staff.

Ongoing

The administration of medications is in the

annual mandatory training study days and

staff are required to complete pre-course

information prior to attendance. Staff must

adhere to the Trust’s Medicines

Management Code.

14. The trust and individual staff have a collective

responsibility to ensure that equipment is clean,

stored correctly 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.

39


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

15. The trust and individual staff have a collective

responsibility to ensure that staff knowledge is kept up

to date regarding equipment cleaning.

Nursing

Role and responsibilities policy in place.

Cleaning statements document for all

wards and departments to be finalised and

disseminated. This forms part of the

cleaning manual.

Complete

Ongoing

16. The trust should ensure that hand washing sinks and

consumables are available, clean, working and in a

good state of repair.

PCSS

This is monitored as part of the

Environmental Cleanliness Audit

Programme. Staff are reminded of the

importance of replenishing dispensers.

Ongoing

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial audits,

and IPC audits monitor compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Regular training is provided to all

appropriate staff. Training is being updated

following recent guidance.

17. 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

Complete and

ongoing

40


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

18. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of

a ward are clean, used and stored appropriately and

are fit for purpose.

Nursing

PCSS

Audit Tool (BRAAT).

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial audits,

and IPC audits monitor compliance.

Ongoing

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Regular training is provided to all

appropriate staff.

19. The trust and individual staff have a collective

responsibility to ensure that hand hygiene is carried

out in line with WHO guidance and that all PPE is

used appropriately.

IPCT

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.

Balance scorecards include WHO Hand

Hygiene audits. All of these aspects will be

monitored through the programme of

Environmental Cleanliness Audits based on

the Cleanliness Matters Strategy.

Complete and

ongoing

The IPCT carried out an independent audit

and results have been fed back.

Independent audits will be carried out 4

times a year (2 of which will be carried out

by Infection Prevention and Control).

The IPCT is currently devising an

41


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

educational tool to remind staff of the

appropriate use of PPE.

The Trust has produced a colour-coded

guidance document based on the NPSA

system, which is displayed in all clinical

areas.

20. The trust and individual staff have a collective

responsibility to ensure that staff knowledge is kept up

to date with regard to isolation, cleaning and

decontamination of equipment.

IPCT

Mandatory Infection Prevention & Control

training is delivered by IPCN Team.

Staff to be reminded of the link to the

regional Infection Control Manual and the

‘Medical and Nursing Equipment Cleaning

Guide’ has been re-circulated.

Ongoing

All service managers received email copies

of the cleaning guide poster for

dissemination to all wards and

departments. Assurance is gained through

environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial audits,

and IPC audits monitor compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

42


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

21. The trust and individual staff have a collective

responsibility to ensure that staff knowledge is kept up

to date regarding the use of disinfectants.

Nursing

All staff have been reminded and made

aware of poster advice.

Mandatory IPC training is provided, poster

advice issued to wards, staff questioned at

audit.

Complete and

ongoing

22. The trust should ensure that all members of staff are

familiar with and adhere to the regional dress code

policy.

All

Directorates

Trust policy available to all staff on Intranet.

Policy is enforced at local level by senior

staff, e.g., Ward Sisters and Senior

Managers.

Complete

The Ward Sister/Charge Nurse Support

Improvement and Accountability

Framework (SIAF) includes an indicator

relating to compliance with the dress code

policy and this is audited on a quarterly

basis.

Ongoing

43

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