Antrim Area Hospital, Antrim - 09 October 2012 - Regulation and ...

RQIA
Infection Prevention/Hygiene
Unannounced Inspection
Northern Health and Social Care Trust
Antrim Area Hospital
9 October 2012

Contents
1.0 Inspection Summary 1
2.0 Background Information to the Inspection Process 5
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 18
8.1 Waste 18
8.2 Sharps 18
9.0 Patient Equipment 20
10.0 Hygiene Factors 22
11.0 Hygiene Practice 24
12.0 Key Personnel and Information 27
13.0 Summary of Recommendations 29
14.0 Unannounced Inspection Flowchart 31
15.0 RQIA Hygiene Team Escalation Policy Flowchart 32
16.0 Action Plan 33

1.0 Inspection Summary
An unannounced inspection was undertaken to the Antrim Area
Hospital, on the 9 October 2012. The hospital was assessed against
the Regional Healthcare Hygiene and Cleanliness Standards and the
following areas were inspected:
Ward C1 - Gynae and Early Pregnancy Unit
Ward C4 - Elective Surgery and ENT
Ward C5 - Surgical
Ward A3 – Renal(Dialysis), Oncology, Haematology,
Rheumatology and general medicine
Inspection Outcomes
The results of the inspection show all wards achieved an overall
compliance level; in particular the staff in Wards C1 and C4 are
commended for achieving compliance with each standard.
Observation of staff in all wards indicated compliance with many
sections within the standards.
The main concern identified on this inspection was the variety of
specialty services provided in Ward A3, such as Renal Dialysis,
Oncology, Haematology, Rheumatology and general medical patients.
This created a large footfall of staff in the ward and has impacted on
some scores achieved. Of particular concern was the size and layout
of Bay 1 where care was delivered to the renal dialysis patients. The
trust should review the suitability of this ward to care for so many
augmented care patients.
Inspectors observed that the environment in general was clean,
however lack of storage within all wards impacted on the ability to
achieve clutter free ward environments. Of note is Ward A3 where the
extremely cluttered environment has impacted negatively on cleaning
practices.
Inspectors found that further improvement was required in Ward A3 in
the handling, storage and segregation of waste and hygiene practices
standards. In the hygiene practices standard, Ward A3 scored a
minimal compliance in the section effective cleaning of the ward and
partial compliance in hand hygiene procedures, safe handling and
disposal of sharps and correct use of isolation sections.
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
Wards A3 and C5. Further work is also required in these wards
concerning correct use of isolation.
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Ward C5 was minimally compliant for the availability, use, storage of
sharps standard indicating that knowledge and practice need to
improve to ensure safe and appropriate practice is in place.
The inspection resulted in 20 recommendations for the NHSCT and the
Antrim Area Hospital, a full list of recommendations is listed in Section
13.
A detailed list of preliminary findings is forwarded to Northern Health
and Social Care Trust within 14 days of the inspection to enable early
action on identified areas which have achieved non complaint scores.
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:
Weekly walkabouts with the ward manager and domestic
supervisor
Deep clean of wards twice a year
Whiteboard displaying audits and IPC staff link staff
Good infection prevention and control practice displayed by
third year nursing students in Ward C5
All patients in Ward C1 are swabbed for MRSA on admission
with results available in 24 hours
The RQIA inspection team would like to thank the NHSCT and in
particular all staff at the Antrim Area 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
Areas inspected C1 A3 C4 C5
General environment 90 80 93 87
Patient linen 97 100 100 100
Waste 92 83 90 97
Sharps 95 90 94 71
Equipment 86 88 97 85
Hygiene factors 95 94 99 91
Hygiene practices 90 84 95 91
Average Score 92 88 95 89
Table 2
General environment C1 A3 C4 C5
92 N/A N/A
Corridors, stairs lift 81 87 92 96
Public toilets 90 N/A N/A N/A
Ward/department -
general (communal)
92 91 97 85
Patient bed area 90 74 90 90
Bathroom/washroom 95 81 92 88
Toilet N/A 91 100 90
Clinical room/treatment
room
N/A 80 93 N/A
Clean utility room 89 N/A 94 83
Dirty utility room 94 84 92 91
Domestic store 100 74 97 81
Kitchen 92 88 94 88
Equipment store N/A 75 N/A 84
Isolation 92 68 90 86
General information 75 69 83 85
Average Score 90 80 93 87
Table 3
Patient linen C1 A3 C4 C5
Storage of clean linen 100 100 100 100
Storage of dirty linen 93 100 100 100
Laundry facilities N/A N/A N/A N/A
Average Score 97 100 100 100
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
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Table 4
Waste and sharps C1 A3 C4 C5
Handling, segregation,
storage, waste
92 83 90 97
Availability, use, storage
of sharps
95 90 94 71
Table 5
Patient equipment C1 A3 C4 C5
Patient equipment 86 88 97 85
Table 6
Hygiene factors C1 A3 C4 C5
Availability and
cleanliness of wash
hand basin and
96 94 95 97
consumables
Availability of alcohol
rub
100 100 100 100
Availability of PPE 92 100 100 86
Materials and
equipment for cleaning
91 83 98 81
Average Score 95 94 98 91
Table 7
Hygiene practices C1 A3 C4 C5
Effective hand hygiene
procedures
93 84 95 95
Safe handling and
disposal of sharps
92 79 100 92
Effective use of PPE 100 100 100 89
Correct use of isolation N/A 83 N/A 79
Effective cleaning of
ward
83 65 95 95
Staff uniform and work
wear
81 95 87 93
Average Score 90 84 95 91
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
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2.0 Background Information to the Inspection Process
RQIA’s infection prevention and hygiene team was established to
undertake a rolling programme of unannounced inspections of acute
hospitals. The Department of Health Social Service and Public Safety
(DHSSPS) commitment to a programme of hygiene inspections was
reaffirmed through the launch in 2010 of the revised and updated
version of 'Changing the Culture' the strategic regional action plan for
the prevention and control of healthcare-associated infections (HCAIs)
in Northern Ireland.
The aims of the inspection process are:
to provide public assurance and to promote public trust and
confidence
to contribute to the prevention and control of HCAI
to contribute to improvement in hygiene, cleanliness and infection
prevention and control across health and social care in Northern
Ireland
In keeping with the aims of the RQIA, the team will adopt an open and
transparent method for inspection, using standardised processes and
documentation.
5

3.0 Inspections
The DHSSPS has devised 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.
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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.
General environment C1 A3 C4 C5
92 N/A N/A
Corridors, stairs lift 81 87 92 96
Public toilets 90 N/A N/A N/A
Ward/department -
general (communal)
92 91 97 85
Patient bed area 90 74 90 90
Bathroom/washroom 95 81 92 88
Toilet N/A 91 100 90
Clinical room/treatment
room
N/A 80 93 N/A
Clean utility room 89 N/A 94 83
Dirty utility room 94 84 92 91
Domestic store 100 74 97 81
Kitchen 92 88 94 88
Equipment store N/A 75 N/A 84
Isolation 92 68 90 86
General information 75 69 83 85
Average Score 90 80 93 87
The above table outlines the findings in relation to the general
environment of the facilities inspected. The findings indicate that there
were some areas for improvement identified in all wards, notably Ward
A3, where clutter and lack of storage impacted on the ability to clean
and 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 most areas to
indicate compliance with regional specifications for cleaning.
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.
In the main reception, public toilet, corridors and stairs, leading to the
wards, some high and low level surfaces including sanitary equipment
were dusty, the external windows required cleaning; there was debris
in light fittings. However in general the cleaning of these areas was
good.
Ward A3 cares for patients with a variety of illnesses and inspectors
noted the extremely busy footfall within the ward itself. The ward did
not achieve compliance for the majority of areas within this standard
and was overall partially compliant. The requirement for specialised
medical equipment necessary for some of these patients and the lack
of storage facilities pose additional difficulties and have impacted on
the ability to effectively clean difficult to reach and cluttered areas of
the ward.
The challenge for domestic staff in cleaning Bay 1 was evident to the
inspectors who had difficultly checking beds and the equipment behind
beds due to this lack of space. Radiators could not be cleaned as
clinical waste bags and personal belongings were stored on top
(Picture 1), chairs and bedside tables also required cleaning, debris
was noted behind beds and in some light fittings.
Picture 1: Untidy ward, clutter affecting cleaning practices
Throughout the wards cleaning in general was of a good standard,
some dust was noted on high and low horizontal surfaces such as high
density storage, floors, skirting and air vents, excess toilet rolls were
noted in sanitary areas and there was debris in some light fittings.
In some areas further work to improve cleaning standards is required.
Shower chairs were stained in the shower rooms of Wards A3, C1 and
C4. In Ward C5 the underside of the raised toilet seat was stained and
in Ward A3 the toilet brush required cleaning. The inside of the
macerator lid in the dirty utility room of Wards C4 and C5, the slop
hopper and domestic sluice bowl in Ward C5 and the sluice, radiators
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and cupboards in Ward A3 domestic store required more thorough
cleaning.
In the treatment room of Ward A3 the inside of the two fridges was
grubby, and there were gaps in the fridge temperature checks.
There was no documentation to record failures in the cold chain and
the fridge containing medication was overfull and unlocked, a similar
issue in Ward C4.
Inspectors in Wards A3, C1 and C5 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.
Cleaning issues such as dusty horizontal surfaces; skirting, windows
frames and excess toilet rolls were identified in rooms designated for
isolation purposes. Additionally in Ward A3 side room, where a patient
had a known infection, the light switch, wall panel, mirror, blind,
underside of the bedside table and bed frame all required a more
detailed clean and the waste pipe below the wash hand basin had a
significant build-up of residue.
Ward kitchens achieved a compliant score however there were some
issues in regard to more attention to detail when cleaning equipment,
horizontal surfaces and flooring that need addressed. In Wards C5
and A3 decanted products were not labelled, in Ward A3 gaps in the
temperature recordings for the fridge were noted.
6.2 Clutter
The provision of clutter free wards and effective utilisation of space and
good stock management assists with effective cleaning.
Of particular note was Bay 1 in Ward A3, a six bedded bay with little
space between beds, either vertically or horizontally, creating a very
cluttered appearance. Similarly in Ward A3, the nurses’ station was
cluttered with equipment, boxes were stored under the reception desk,
the shower room beside Bay 5 was cluttered with 3 raised toilet seats
and two shower chairs which would have created difficultly for patients
accessing the shower. Space was not sufficient to allow for effective
storage of equipment in the domestic store and items were observed
on the floor of the dirty utility room.
In Ward C4, the ENT day procedure clinic is located in the treatment
room and patients for all procedures are required to wait in the corridor
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leading to the ward. The patient lounge is utilized for minor day
procedures; the room was small and cluttered with patients and
equipment.
The clean utility room, dirty utility room and equipment stores in Ward
C5 did not have sufficient space to allow for effective storage of
supplies and equipment. Stock was noted on top of cupboards and on
the floor (Picture 2), the emergency access was blocked with stored
equipment. Inspectors in all wards noted the lack of available storage
facilities however in Ward C1 inspectors were impressed with the
overall clutter free environment.
6.3 Maintenance and Repair
Picture 2: Ward C5 cluttered store room
Wards C1 and C4 had been refurbished in June 2012 and were
generally in good repair (Picture 3). However in all wards inspected
and corridors leading to the wards, inspectors noted wall, skirting, door
and paintwork damage.
Picture 3: Newly renovated shower room
Inspectors in Ward C1 noted stained flooring in some renovated rooms.
The ward manager advised that the recently laid flooring had been
surveyed by the trust architect and estates who agreed that the flooring
was defective. It was expected that the contractor would remove and
13

eplace the flooring. In Ward C4 joins had not been sealed in the floor
coving of the kitchen and patient bed area.
Some of the plastic slats on the ceiling light above the nurses’ station in
Ward C5 were missing and although there had been an attempt to
repair damage to the wall edging in the toilet, plaster was missing.
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 all
wards, wooden bedside tables were showing signs of wear and tear,
the wooden surfaces and edges were worn to the bare wood in places
and some frames were chipped. Ward C1 had plastic bed rails which
were in good repair however inspectors observed chipped paint finish
on some bed rails in the other wards inspected.
With the exception of Ward C4, armchairs were at times worn to the
bare wood; in Ward A3 a chair in a room used for isolation purposes
had a torn seat cover. In a side room of Ward C1 slats were missing
from the vertical blinds, window blinds were frayed at the edges in
Wards C5 and A3, the metal legs of raised toilet seats and shower
chairs were rusty. Also in Ward A3 oxygen cylinders were stored in the
equipment store where there was no safety sign on the door.
There was no toilet roll dispenser in the female public toilet at the main
reception; toilet rolls were stored on a ledge close to the toilet.
Inspectors observed a variety of dispensers throughout the wards.
At the feedback trust representatives advised that the trust was in the
process of tendering for the supply of toilet roll dispensers throughout
facilities.
6.5 Information
A concerted effort had been made by staff in Wards A3 and C4 where
there was minimum use of non-laminated posters. Although cleaning
schedules were available in all wards, in Wards C1 and A3 they lacked
detail of equipment and staff roles and responsibilities.
Only Ward A3 displayed the National Patient Safety Agency (NPSA)
guidelines for nursing staff to reference, however it was not displayed
for domestic staff. With the exception of Ward C5, posters on the
segregation of linen and waste were not displayed for staff to
reference; management of an inoculation injury poster was not
displayed in Wards C4 and C5.
The lack of information leaflets on infection prevention and control,
Clostridium difficile and MRSA for patients, carers and staff to
reference impacted negatively on the audit for Ward A3.
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6.6 Additional Issues
Ward A3
Ward C4
Ward C5
The ward has increased capacity from 24 patients to 31. This
reconfiguration has impacted on patient bed space and
subsequently the amount of equipment and stores needed for the
specialties nursed within the ward.
A variety of specialty services is present in this ward such as
Renal Dialysis, Oncology, Haematology, Rheumatology and
general medicine patients. This ward is considered by the trust
as an augmented care area; it is advised that when the new draft
regional audit tools are disseminated by the DHSSPS the ward
should review its practices. Discussions had also taken place
with the senior management team and estates and a business
plan regarding the ward has subsequently been submitted to the
Board.
Inspectors observed that only one member of support services
staff was on duty to clean this busy and complex ward.
Ward C4 has been opened since July and inspectors have
concerns regarding capacity and space utilisation which could
have a detrimental effect on on the patient’s experience (privacy
and dignity) delivery of service. The ward, at full capacity on the
day of inspection, has 18 beds, 12 surgical and 6 medical and a
small patients’ lounge which has been designated for day
procedures, such as blood transfusions. Minor refurbishment is
planned for this area to improve the lighting and to install six
recliner chairs. In addition an ENT day procedure clinic is located
in the treatment room and patients for these procedures are
required to wait in the corridor leading to the ward.
Staff advised that the ward is be re-configured with the intention
of reducing clutter and increasing storage capacity. Trust
representatives advised that discussions have taken place
concerning increasing the deliveries to the ward to enhance
utilization of space and stock management.
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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 trust should work on the repair and maintenance of ward
and public environments and to replace damaged fixtures
and fittings.
3. The trust and staff should work to improve storage and
maintain clutter free ward environments.
4. The trust should ensure all relevant information is available
for patients, visitors and staff to reference.
5. 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.
Patient linen C1 A3 C4 C5
Storage of clean linen 100 100 100 100
Storage of dirty linen 93 100 100 100
Laundry facilities N/A N/A N/A N/A
Average Score 97 100 100 100
7.1 Management of Linen
Staff in all wards are to be commended for their good practices in the
handling and storage of clean and used linen. Had the frame of linen
skips in Ward C4 not been damaged, all wards would have been fully
compliant in this standard.
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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 C1 A3 C4 C5
Handling, segregation,
storage, waste
92 83 90 97
Availability, use, storage
of sharps
95 90 94 71
8.1 Waste
The inspection evidenced that only Ward A3 did not achieve
compliance for the handling, segregation and storage of waste
standard. Some issues were identified in all wards that require
attention.
In all wards waste was not disposed of into the correct waste stream in
line with trust policy. Examples are blister packs, cotton wool, gloves
and pharmaceutical vials in sharps boxes, disposable forceps and
blood stained dressings into yellow lidded burn bins. With the
exception of Ward C5 paper waste had been disposed into clinical
waste bins.
Household waste bins were not available at all clinical hand wash sinks
in Wards C1 and C4 and in Wards C1 and A3, at least one bin required
more attention to detail when cleaning. Other staff practices affecting
the audit in Ward A3 were the overfilling of the black lidded burn bin
and ward waste bins, the disposal of patients’ clothing into the
confidential waste bin and the disposal area which required cleaning.
8.2 Sharps
It was disappointing to note the minimal compliance score of Ward C5
on the safe handling, segregation, storage and disposal of sharps
standard, the three other wards achieved a high compliant score.
Sharps boxes in use conformed to BS7320 (1990)/UN9291 standards;
however in Ward C5 a large sharps box was not signed or dated.
This is unsafe practice as correct labelling ensures that if there is a
spillage of sharps waste from the sharps box or an injury to a staff
member as a result of incorrect assembly/disposal, the area the sharps
box originated from can be immediately identified. Identifying the origin
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of the sharps box and its contents is imperative to assist in the
immediate risk assessment process carried out following a sharps
injury and also to ensure that staff who incorrectly assembled/disposed
of the sharps box can receive education on the correct procedures to
follow.
With the exception of Ward C4, temporary closure mechanisms on
sharps boxes were not all in place when the box was not in use.
Additional issues which impacted negatively on the audit for Ward C5,
were regarding the dusty sharps box on the resuscitation trolley, a
grubby sharps tray and staff not emptying and cleaning the paper
mache insets and the sharps tray of equipment, after use.
In Ward A3, a sharps box on a procedure trolley was overfilled and a
large unsecured 50litre bin was perched on the top of the Phlebotomy
trolley.
Except for Ward A3, paper mache dishes were inserted into sharps
trays. There are two issues here; the additional cost to the trust and
implications for the aseptic non touch technique (ANTT) practices as
paper mache dishes cannot be effectively cleaned. At the feedback, a
trust representative advised that the trust is considering the use of
cleanable IV trolleys for ANTT procedures. This would also negate the
need for sharps trays.
Recommendations
6. 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.
7. The trust should ensure that waste bins and equipment used
in the management of waste are available and kept clean.
8. 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.
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9.0 Patient Equipment
STANDARD 5.0
PATIENT EQUIPMENT
Cleanliness and state of repair of general patient equipment.
Patient equipment
C1 A3 C4 C5
Patient equipment 86 88 97 85
All wards were compliant for this standard, patient equipment was
generally of a good standard and most equipment was visibly clean.
Full compliance would have been achieved in Ward C4 had the low
frame work of the resuscitation trolley been dust free. With the
exception of Ward C4, trigger tape used to denote equipment, including
commodes, had been cleaned and ready to use, was inconsistently
used.
Some equipment was worn or damaged such as IV stands in Wards
C1 and C5, the notes trolley and underside of the commode lids in
Ward C5 and the frame of the hoist, wheel chair footplate and ice
machine grill in Ward C1. Commodes in Ward A3 did not have a lid as
they had been damaged; the inspectors were informed that new
commodes were on order.
In Ward C5 more attention to detail is required when cleaning fans, the
legs and wheels of the procedure trolleys and the top surface of the
resuscitation trolley. In Wards C5 and C1 single use jugs were being
re-used, in Ward C1 adhesive tape was used to fix labels to the notes
and linen trolleys and nursing staff did not know the symbol for single
use equipment.
Additional Issues
Ward C1
In a drawer of the resuscitation trolley, inspectors observed a
10ml syringe stored out of packaging with the plunger withdrawn
to the 10ml line (Picture 4). The ward manager advised this was
for the insertion of air into a cuffed endotracheal tube.
This practice allows for potential contamination and lack of
traceability issues. The ward manager removed the exposed
syringe immediately.
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Picture 4: Exposed syringe with 10ml inflated air
Ward A3
Ward C5
The phlebotomy trolley was cluttered with notes, and a very large
sharps bin therefore making cleaning difficult, the drawers of the
trolley were damaged. Inspectors were informed that a new
trolley was on order. In the interim the placement of notes and
sharps should be reviewed as these issues create difficulty with
ensuring the optimal infection prevention and control practices are
complied with.
Inspectors observed an open and possibly used patient chest
drain stored in the dirty utility room, this was reported to the ward
manager for action.
Recommendations
9. The trust and individual staff have a collective responsibility
to ensure that equipment is clean, stored correctly and in a
good state of repair.
10. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
equipment cleaning.
21

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 C1 A3 C4 C5
Availability and
cleanliness of wash
hand basin and
96 94 95 97
consumables
Availability of alcohol
rub
100 100 100 100
Availability of PPE 92 100 100 86
Materials and
equipment for cleaning
91 83 98 81
Average Score 95 94 98 91
All wards achieved compliance in this standard and for the section
availability of alcohol rub. Wards A3 and C4 also achieved full
compliance in the availability of PPE.
With the exception of Ward C1, the number of sinks in the bays was
not in line with local and national guidance. In the clean utility room of
Wards C1 and C4, the taps at the clinical hand washing sink were not
elbow or sensor operated, in Ward C1 they were not mixer taps and
the hot water ran at a high temperature.
Some sinks and taps in Ward A3 required more detail cleaning. Issues
affecting compliance in Wards C1, C4 and C5 were in regard to either
empty dispensers or damaged dispensers, and stock including face
and eye protection not always available. Only staff in Ward C1 stored
chemicals in accordance with COSHH regulations.
In Ward C1, RGNs did not know the dilution rate for the disinfectant in
use, decanted disinfectant bottles were not dated and lid of containers
of cleaning wipes were not closed therefore rendering the wipe
ineffective, a similar issue in Ward C5.
Wards C5 and A3 were partially compliant for the section concerning
materials and equipment for cleaning, issues identified were in relation
to staff practice such as equipment needing a more detailed clean, not
stored correctly and in poor repair. In Ward A3, dirty mops were stored
on the domestic cleaning trolley and mop handles were not in line with
NPSA colour coding guidance.
22

Recommendations
11. The trust should ensure that hand washing sinks and
consumables are available, clean, working and in a good
state of repair.
12. The trust should ensure that all cleaning products are stored
in a locked cupboard, in line with COSHH regulations.
13. Further attention to detail is required to ensure that
equipment used for the general cleaning purposes of a ward
is clean, used and stored appropriately and is fit for purpose.
23

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 C1 A3 C4 C5
Effective hand hygiene
procedures
93 84 95 95
Safe handling and
disposal of sharps
92 79 100 92
Effective use of PPE 100 100 100 89
Correct use of isolation N/A 83 N/A 79
Effective cleaning of
ward
83 65 95 95
Staff uniform and work
wear
81 95 87 93
Average Score 90 84 95 91
Only Ward A3 did not achieve overall compliance in this standard,
Ward C4 was fully compliant in two sections and issues were identified
in all wards.
In Wards C1 and C4 inspectors observed a doctor perform hand
decontamination incorrectly while using alcohol rub. Inspectors
observed a number of staff in Ward A3 not using the seven step
technique for hand washing and when using alcohol rub. Some staff in
Ward C5 were observed not washing hands before donning gloves.
Only Ward C4 was fully compliant with the safe handling and disposal
of sharps section. In Wards A3 and C1 re-sheathing of needles was
noted in a sharps box and in Ward A3, sharps were not always
disposed of at the point of care, an issue also identified in Ward C5.
There were no patients with an infection in Wards C1 and C4 therefore
the section, correct use of isolation, was not applicable. Issues
identified in Wards C5 and A3 were in relation to documentation and
practice. In Ward A3, the nursing notes of a patient with Clostridium
difficile were reviewed. The infection prevention and control
assessment had not been updated from admission, the care pathway
was kept in the medical notes therefore it was difficult to determine
infection status from the nursing notes and inspectors noted areas of
the room had not been cleaned properly although the room had been
signed off as being cleaned.
24

Similar issues were identified in Ward C5 where the red alert section
on the nursing documentation did not identify that the patient had
MRSA and there was no care plan present to enable staff to assess the
patients care on a daily basis. Staff had also not completed the section
on the nursing documentation that indicated the patient/family had
received an information leaflet on MRSA.
A detailed trust manual for domestic services is available (Picture 5).
However in the effective cleaning of the ward section, Ward A3 was
minimally compliant, Ward C1 was partially compliant and issues
identified were regarding knowledge and practice. With the exception
of Ward C5, COSHH data sheets on the disinfectant in use were not
available for nursing staff and COSHH data sheets were not available
for domestic staff in Ward A3. Nursing staff in Wards C1 and C5 were
unsure of the NPSA colour coding system, in Wards C1 and A3, some
nursing staff were unsure of the procedure to follow for blood and body
spillages. Nursing staff in Ward A3 were also not fully aware of the
dilution rate for the disinfectant in use for blood and body fluid
spillages.
Picture 5: Domestic Services store Manual
In general dress code was of a high standard. However members of
staff across all disciplines, but more notably in Wards C1 and C4 were
not compliant with the trust dress code policy such as long hair not tied
off the collar, wearing stoned rings and earrings, wrist watches and not
complying with bare below the elbow.
Additional Issues
Ward C5
Inspectors observed three sealed clexane injection packets an
observation monitor trolley.
In Room 25 a tablet had been left in a medicine cup in front of the
sleeping patient rather than administered.
25

Recommendations
14. 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.
15. 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.
16. The trust and individual staff should ensure that all care plan
and care pathway documentation is fully completed and
regularly reviewed.
17. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
the use of disinfectants.
18. The trust and individual staff have a collective responsibility
to ensure COSHH data sheets are readily available for all staff
to reference.
19. The trust should ensure that all members of staff are familiar
with and adhere to the regional dress code policy.
20. The trust and individual staff have a collectible responsibility
to ensure medicines are administered in accordance with the
trust policy and the medicines management standard (2009).
26

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
Melanie Johnston
Christine Goan
Gillian Smyth
Yvonne Black
Domestic Manager SHSCT
Senior Reviewer RQIA
Patient Experience Manager
Assistant Support Services Manager WHSCT
Observors
Damien O’Neill
Gemma Mulholland
Assistant Services Manager BHSCT
Administration Supervisor CSCG, RQIA
Trust representatives attending the feedback session
The key findings of the inspection were outlined to the following trust
representatives:
Valerie Jackson Director Acute Services
Suzanne Pullins Head of Governance and Patient Safety
T. Martin Assistant Director Surgery/ATICS
Linda Linford
Assistant Director NHSCT
Maire Bermingham Assistant Director Corporate Support
Services
Linda Patton
General Manager Medical Specialities
Avril Redmond
Professional Lead for Nursing
Peter Bartley
Service Lead
Mary Neeson
Lead Nurse Surgery
Naomi Baldwin
Lead Nurse Infection Prevention and
Control
Rosaleen Burns Ward Manager C1
Anne-Marie Costello Ward Manager A3
Bernie Irvine
Ward Manager C5
Ann Hamilton
General Manager Domestic Services
Trustwide
Theresa O’Neill
Ward Sister C4
Nuala Mc Cormick Planning Supervisor, Estates Department
A. Anderson Band 6 Ward A3
Alan Steward
Domestic Services Manager Antrim Area
Hospital
27

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.
28

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 trust should work on the repair and maintenance of ward
and public environments and to replace damaged fixtures
and fittings.
3. The trust and staff should work to improve storage and
maintain clutter free ward environments.
4. The trust should ensure all relevant information is available
for patients, visitors and staff to reference.
5. The trust should ensure that all staff are aware of the
importance of monitoring fridge temperatures.
6. 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.
7. The trust should ensure that waste bins and equipment used
in the management of waste are available and kept clean.
8. 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.
9. The trust and individual staff have a collective responsibility
to ensure that equipment is clean, stored correctly and in a
good state of repair.
10. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
equipment cleaning.
11. The trust should ensure that hand washing sinks and
consumables are available, clean, working and in a good
state of repair.
12. The trust should ensure that all cleaning products are stored
in a locked cupboard, in line with COSHH regulations.
29

13. Further attention to detail is required to ensure that
equipment used for the general cleaning purposes of a ward
is clean, used and stored appropriately and is fit for purpose.
14. 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.
15. 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.
16. The trust and individual staff should ensure that all care plan
and care pathway documentation is fully completed and
regularly reviewed.
17. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
the use of disinfectants.
18. The trust and individual staff have a collective responsibility
to ensure COSHH data sheets are readily available for all staff
to reference.
19. The trust should ensure that all members of staff are familiar
with and adhere to the regional dress code policy.
20. The trust and individual staff have a collectible responsibility
to ensure medicines are administered in accordance with the
trust policy and the medicines management standard (2009).
30

Reporting & Re-Audit
Episode of Inspection
Plan Programme
14.0 Unannounced Inspection Flowchart
Environmental Scan:
Stakeholders & External
Information
Plan
Programme
Consider:
Areas of Non-Compliance
Infection Rates
Trust Information
Prioritise Themes & Areas for Core Inspections
Prior to Inspection Year
Balance Programme
January/February
Schedule Inspections
Prior to Inspection
Identify & Prepare Inspection Team
Day of Inspection
Inform Trust
Day of Inspection
Carry out Inspection
A
Is there immediate risk
requiring formal escalation?
NO
YES
Invoke
RQIA
IPHTeam
Escalation
Process
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
14 days later
Signed Action Plan
received from Trust
Within 0-3 months
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
PHA
31

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,
HSENI
Seek assurance on implementation of actions
Take necessary action:
E.g.: Follow-Up Inspection
32

16.0 Action Plan
Antrim Area Hospital, Action Plan, Unannounced Inspection, 09 October 2012
Ref
number
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.
Designated
department
Domestic/
Estates
Action required
Domestic Management and staff have job
descriptions which clarify roles and
responsibilities. Standards of cleaning
are monitored on a daily, monthly and
annual basis.
Date for
completion/
timescale
Actioned and
ongoing
Leadership Walkabouts in place with
Action Plans
Audits are multi disciplinary ie; involve
domestic services, estates, nursing and
infection prevention control staff and
managers.
2. The trust should work on the repair and maintenance
of ward and public environments and to replace
damaged fixtures and fittings.
Estates
High cleaning is carried out by Estates
services on rolling basis
Damaged fixtures and fittings should be
reported to the Estate Services Action
Desk for repair.
A rolling maintenance programme is in
place.
33

Ref
number
Recommendations
3. The trust and staff should work to improve storage and
maintain clutter free ward environments.
Designated
department
Domestic/
Nursing
Action required
Domestic staff and nursing work together
to reduce clutter in wards. Dump the
Junk Days are carried out in trust
hospitals. Info on how to dispose of
unused items on Staff Net. Info re Dump
the Junk on Staff payslips.
Date for
completion/
timescale
February 2013
December
2012
4. The trust should ensure all relevant information is
available for patients, visitors and staff to reference.
5. The trust should ensure that all staff are aware of the
importance of monitoring fridge temperatures.
Corporate
Communicati
ons/Heads of
Departments/
Lead Nurses
Catering/
Nursing/
Domestic
Services
Consideration of appropriate storage is
given as part of planning and design
process as opportunities arise eg: new
builds or refurbishments
Trust is continuously reviewing leaflet
content and availability through the
analysis of patient and client experience
questionnaires
Availability of leaflets is also monitored at
ward level during audits and walkabouts
Directors will issue a reminder to staff
regarding this important issue.
Ongoing
Continual
Actioned and
ongoing
34

Ref
number
Recommendations
6. 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.
Designated
department
Domestic/
Nursing/
Estates
Services
Action required
All staff will be reminded at team
meetings of policy on waste disposal.
Ward Manager and Deputies will monitor
waste management and sharps disposal
taking corrective action as required
Date for
completion/
timescale
Estates waste manager provides training
on regular basis.
7. The trust should ensure that waste bins and
equipment used in the management of waste are
available and kept clean.
8. 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.
Domestic/
Nursing
Domestic/
Infection
Prevention
Control/
Estates
waste officer
Domestic Staff receive Training on waste
as part of Induction and refresher training
is organised as necessary.
Domestic Supervisors and Ward
Managers to identify at Daily/Monthly
audits any unclean bins or bin needing
replaced. Cleaning carried out
immediately and bin replaced
Waste and sharps management is
monitored during ward/service based
environmental cleanliness audits. Any
examples of poor practice are reported
and corrective action taken.
Staff are aware that non compliance to
policies regarding this area could result in
disciplinary action. Memo issued to all
Wards/Departments in Acute Directorate.
Actioned and
Ongoing
Actioned and
ongoing
Actioned on a
Daily basis
35

Ref
number
Recommendations
9. The trust and individual staff have a collective
responsibility to ensure that equipment is clean, stored
correctly and in a good state of repair.
10. The trust and individual staff have a collective
responsibility to ensure that staff knowledge is kept up
to date regarding equipment cleaning.
11. The trust should ensure that hand washing sinks and
consumables are available, clean, working and in a
good state of repair.
Designated
department
Domestic/
Nursing
Domestic/
Nursing
Domestic
Services/
Estates
Services
Action required
Domestic and Nursing staff are aware of
their respective responsibilities in relation
to equipment cleanliness, usage and
state of repair. Equipments found to be
below standard are isolated and either
cleaned again, sent for repair or declared
obsolete if damaged beyond repair.
Domestic and Nursing staff are aware of
which items of equipment they are
responsible for cleaning at through
schedules held at ward level. Standard of
cleaning is monitored through general
daily observations and also as part of
internal IPCEH audits. Where concerns
are identified staff are retained in
procedures.
Domestic services staff have been trained
in the requirements for cleaning and stock
of hand basins.
Cleanliness monitored on a daily basis by
Domestic Supervisors.
Date for
completion/
timescale
Actioned and
ongoing
Actioned and
Ongoing
Ongoing
Actioned
12. The trust should ensure that all cleaning products are
stored in a locked cupboard, in line with COSHH
regulations.
Domestic
Services
Estates services are carry out a
replacement programme of any sinks
found to be unfit for purpose
Domestic supervisors will check on a
daily basis as part of the daily
observational checklist that all cleaning
products are stored in line with COSHH
regulations.
Actioned
36

Ref
number
Recommendations
13. Further attention to detail is required to ensure that
equipment used for the general cleaning purposes of a
ward is clean, used and stored appropriately and is fit
for purpose.
14. 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.
15. 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.
16. The trust and individual staff should ensure that all
care plan and care pathway documentation is fully
completed and regularly reviewed.
Designated
department
Domestic/
Nursing
Domestic/
Nursing/
Other
disciplines
Nursing/
Other
disciplines
Director
Nursing
Action required
Training is given to all relevant staff in the
usage and storage of cleaning equipment
and products as part of their induction.
Additional training is provided if
equipment or products change
Hand hygiene monitored at ward level.
Performance contained within Trust
Board reports. Staff found to be non
compliant are retrained and frequency of
auditing is increased
Relevant Directors to issue a reminder to
staff regarding this important issue
Relevant Directors to issue a reminder to
staff regarding this important issue.
Major project currently underway to
introduce new Nursing Assessment and
Plan of Care documentation to all wards
in acute hospitals.
Date for
completion/
timescale
Actioned
Actioned and
Ongoing
Actioned
Actioned
A Quality Improvement workstream,
including monthly audits, monitors
individual ward compliance with record
keeping indicators. Electronic audit
results are available at ward level for
immediate improvement activity.
37

Ref
number
Recommendations
17. The trust and individual staff have a collective
responsibility to ensure that staff knowledge is kept up
to date regarding the use of disinfectants.
Designated
department
Domestic/
Nursing
Action required
Training is given to all relevant staff in the
usage and storage of cleaning products
as part of their induction.
Date for
completion/
timescale
Actioned and
Ongoing
18. The trust and individual staff have a collective
responsibility to ensure COSHH data sheets are
readily available for all staff to reference.
19. The trust should ensure that all members of staff are
familiar with and adhere to the regional dress code
policy.
Director
Nursing/
Domestic
Services
All disciplines
Additional training is provided if products
change
Relevant Directors to issue a reminder to
staff regarding this important issue.
All staff to be reminded of regional dress
code policy and monitoring of adherence
factored into audit process and general
service management.
Actioned
Actioned
Any revisions to current policy are issued
on a cascade basis via directors for
discussion with staff at team/ward/
departmental meetings.
38

Ref
number
Recommendations
20. The trust and individual staff have a collectible
responsibility to ensure medicines are administered in
accordance with the trust policy and the medicines
management standard (2009).
Designated
department
Medical
Director/
Director
Acute
Services
Action required
Memo issued to all Wards/Departments in
Acute Directorate.
Audits also carried out on regular basis.
Incidents and near misses monitored and
revised at Directorate levels.
Date for
completion/
timescale
Actioned and
completed
Nursing and Midwifery Medicines
Administration Policy is the benchmark
against which all medicines are
administered within the NHSCT.
Pharmacy audits are conducted to review
compliance with elements of same.
Nursing Medication Reflection Tool
completed by staff member when
medicine incident occurs to encourage
reflection on, and learning from, any
incidents.
39