Iveagh Centre, Belfast - Regulation and Quality Improvement Authority

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Iveagh Centre, Belfast - Regulation and Quality Improvement Authority

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Belfast Health and Social Care Trust

Iveagh Centre

20 June 2012


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 5

3.0 Inspections 6

4.0 Unannounced Inspection Process 7

4.1 Onsite Inspection 7

4.2 Feedback and Report of the Findings 7

5.0 Audit Tool 8

6.0 Environment 10

6.1 Cleaning 10

6.2 Clutter 12

6.3 Maintenance and Repair 12

6.4 Fixture and Fittings 13

6.5 Information 13

7.0 Patient Linen 14

7.1 Management of Linen 14

8.0 Waste and Sharps 16

8.1 Waste 16

8.2 Sharps 16

9.0 Patient Equipment 17

10.0 Hygiene Factors 19

11.0 Hygiene Practice 21

12.0 Key Personnel and Information 22

13.0 Summary of Recommendations 23

14.0 Unannounced Inspection Flowchart 24

15.0 RQIA Hygiene Team Escalation Policy Flowchart 25

16.0 Action Plan 26


1.0 Inspection Summary

An unannounced inspection was undertaken to the Iveagh Centre, on

the 20 June 2012. The centre was assessed against the Regional

Healthcare Hygiene and Cleanliness standards.

The Iveagh Centre provides assessment and treatment for children

with learning disabilities and is located in the Broadway area of Belfast.

The Centre replaced services previously provided in Muckamore

Abbey Hospital. The centre was open in April 2010. It is a purpose

built, spacious facility, with eight single ensuite bedrooms, there is a

range of well-equipped therapeutic and clinical intervention spaces and

bright recreational areas.

Inspection Outcomes

The overall inspection findings for the Iveagh Centre found that two of

the standards were minimally compliant. Areas of particular concern

related to the handling, segregation and storage of sharps, patient

equipment and effective cleaning of the ward.

The inspectors commend the standard of care provided within the unit

to children with severe behavioural conditions. However, the

concentrated effort on the delivery of this care has caused staff to lose

focus on environmental cleaning and infection prevention and control

issues.

As a result of the findings there was immediate escalation and

feedback to the trust chief executive and a follow up inspection to be

carried out within three months.

The inspection resulted in 16 recommendations for the Iveagh Centre,

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.

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.

1


Notable Practice

The inspection identified the following areas of notable practice:

• The inspectors observed nursing staff dealing with children

with very challenging behaviour and would commend the

caring and professional way they looked after the children.

• The Patient and Client Support Services supervisor showed

a keen interest in improving his practice and those of his

staff.

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

Centre for their assistance during the inspection.

The following tables give an overview of compliance scores noted in

areas inspected by RQIA:

Table 1 summarises the overall compliance levels achieved.

Tables 2-7 summarise the individual tables for sections two to seven of

the audit tool as this assists organisation to target areas that require

more specific attention.

Table 1

Areas inspected

General environment 81

Patient linen 87

Waste 89

Sharps 56

Equipment 66

Hygiene factors 93

Hygiene practices 85

Average Score 80

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

2


Table 2

General environment

Reception 100

Corridors, stairs lift

N/A

Public toilets 93

Ward/department - general

(communal)

82

Patient bed area

N/A

Bathroom/washroom 78

Toilet 83

Clinical room/treatment

room

71

Clean utility room

N/A

Dirty utility room

N/A

Domestic store 81

Kitchen 82

Equipment store

N/A

Isolation/single room 91

General information 44

Average Score 81

Table 3

Patient linen

Storage of clean linen 95

Storage of used linen 88

Laundry facilities 79

Average Score 87

Table 4

Waste and sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

89

56

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

3


Table 5

Patient equipment

Patient equipment 66

Table 6

Hygiene factors

Availability

and

cleanliness of wash hand 87

basin and consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

84

Average Score 93

Table 7

Hygiene practices

Effective hand hygiene

procedures

100

Safe handling and

disposal of sharps

100

Effective use of PPE 100

Correct use of isolation N/A

Effective cleaning of ward 40

Staff uniform and work

wear

86

Average Score 85

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

4


2.0 Background Information to the Inspection Process

RQIA’s infection prevention and hygiene team was established to

undertake a rolling programme of unannounced inspections of acute

hospitals. The Department of Health Social Service and Public Safety

(DHSSPS) commitment to a programme of hygiene inspections was

reaffirmed through the launch in 2010 of the revised and updated

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

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

in Northern Ireland.

The aims of the inspection process are:

• to provide public assurance and to promote public trust and

confidence

• to contribute to the prevention and control of HCAI

• to contribute to improvement in hygiene, cleanliness and infection

prevention and control across health and social care in Northern

Ireland

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

transparent method for inspection, using standardised processes and

documentation.

5


3.0 Inspections

The DHSSPS has devised Regional Healthcare Hygiene and

Cleanliness standards. RQIA has revised its inspection processes to

support the publication of the standards which were compiled by a

regional steering group in consultation with service providers.

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

programme which includes announced and unannounced inspections

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

compliance with the DHSSPS Regional Healthcare Hygiene and

Cleanliness standards.

The inspections will be undertaken in accordance with the four core

activities outlined in the RQIA Corporate Strategy, these include:

• Improving care: we encourage and promote improvements in the

safety and quality of services through the regulation and review of

health and social care

• Informing the population: we publicly report on the safety,

quality and availability of health and social care

• Safeguarding rights: we act to protect the rights of all people

using health and social care services

• Influencing policy: we influence policy and standards in health

and social care

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4.0 Unannounced Inspection Process

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

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

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

inspection flow chart is attached in Section 14.

4.1 Onsite Inspection

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

infection prevention/hygiene team. 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 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 Regional

Healthcare Hygiene and Cleanliness standards. The standards

incorporate the critical areas which were identified through a review of

existing standards, guidance and audit tools (Appendix 2 of Regional

Healthcare Hygiene and Cleanliness standards). The audit tool follows

the format of the Regional Healthcare Hygiene and Cleanliness

Standards and comprises of the following sections.

1. Organisational Systems and Governance: policies and

procedures in relation to key hygiene and cleanliness issues;

communication of policies and procedures; roles and

responsibilities for hygiene and cleanliness issues; internal

monitoring arrangements; arrangements to address issues

identified during internal monitoring; communication of internal

monitoring results to staff.

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.

8


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.

9


6.0 Environment

STANDARD 2.0

GENERAL ENVIRONMENT

Cleanliness and state of repair of public areas; cleanliness and

state of repair of ward/department infrastructure; cleanliness and

state of repair of patient bed area; cleanliness and state of repair

of toilets, bathrooms and washrooms; cleanliness and state of

repair of ward/department facilities; availability and cleanliness of

isolation facilities; provision of information for staff, patients and

visitors.

General environment

Reception 100

Corridors, stairs lift

N/A

Public toilets 93

Ward/department -

general (communal)

82

Patient bed area

N/A

Bathroom/washroom 78

Toilet 83

Clinical room/treatment

room

71

Clean utility room

N/A

Dirty utility room

N/A

Domestic store 81

Kitchen 82

Equipment store

N/A

Isolation/single room 91

General information 44

Average Score 81

The above table outlines the findings in relation to the general

environment of the facility inspected. The findings indicate that the

standard overall was partially compliant; however there are two

sections which have been highlighted in red which are minimally

compliant and require prompt attention.

6.1 Cleaning

During the inspection there was some evidence to indicate compliance

with regional specifications for cleaning. However, inspectors observed

that while cleaning mechanisms were in place these were not always

effectively implemented or adhered to by staff.

Greater attention to detail was required when cleaning; there was a

build up of dust and debris in the corners and edges of the floors.

The air vents had heavy deposits of dust and fluff and hand touch

points on doors such as the bathroom door required cleaning. The

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weigh scales (Picture 1) in both the treatment room and bathroom were

stained and dusty. There was limescale deposit on most of the taps.

Picture 1 Stains on floor and weigh scales

In the treatment room there were splash marks on the wall, stains on

the outside of the perspex cover of the notice board and the doors of

the cupboards. There were sticky dried liquid patches on the floor and

there was a build up of dust under the dressing and drugs’ trolley. The

windowsill, top of the drugs’ fridge, underside of the examination couch

and portable screens were all dusty. The temperatures of the drugs’

fridge were not recorded consistently. It is advised that temperature

checks are carried out on a daily basis to ensure medication is kept at

the correct temperature and to identify if a fridge has failed to reach the

required temperature and a cold chain failure has occurred.

An empty single bedroom was inspected; there was debris on the

corners of the floor beside the bed and debris on the bed base under

the mattress. The handles on the built in drawers under the bed were

dirty and the inside of the wardrobe was dusty. There were scuffmarks

and a small blood stain on the wall.

In the domestic stores both sluice sinks were dusty and dirty and the

hand washing sink in the “dry” store required cleaning.

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6.2 Clutter

With the exception of the

domestic stores and

treatment room, there was no

issue with clutter.( Picture 2)

Picture 2 Clutter free lounge area

Picture 3 Clutter in treatment room

In the treatment room,

(Picture 3) the work counter

was cluttered with equipment

and medicine cups, 50L

sharps bins had been

delivered in error and were

stacked on the floor by the

door. The sharps’ box was

sitting on top of the black

lidded pharmacy box, a foot

spa was on the windowsill

and there were two large

portable suction machines

also on the floor.

In one domestic store, there was a large cage with general supplies to

be returned to the regional supplies depot and in the other store, boxes

of cleaning supplies were stacked on top of cupboards due to a lack of

shelving.

6.3 Maintenance and Repair

In many areas there was damage to paint and plaster work on walls, for

example in the single bedroom there was damage to the plaster work

around the window. In the bathroom inspected, there was a large pool

of water on the floor with dried in tidemarks around the edges. This

would indicate the standing water had been there for some time. Staff

advised that there was a leak in the pipework below the bath and that

the fault had been reported. Actions should be put in place to remove

the standing water each time the bath is used as it is a possible health

and safety hazard.

Staff were not aware of the requirement to run water for unused taps in

line with the trusts Legionella Policy.

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6.4 Fixtures and Fittings

The vinyl covers on some of the chairs and settees were ripped or torn,

the ward manager advised there is a rolling programme to repair

damaged furniture. Furniture which is currently being repaired is due to

be returned to the Centre in July at which time currently identified

damaged furniture will be sent for repair.

The toilet roll dispenser in the single toilet was broken. In the bathroom

the lid and seat of the toilet were missing.

6.5 Information

There was a general lack of information for staff, patient or visitors

which resulted in a minimal compliance score. Up to date cleaning

schedules were not available for domestic staff, cleaning schedules for

nursing staff did not detail all staff roles and responsibilities and did not

comply with the trust generic format. Information on common

infections posters or advice on the segregation of waste, used linen,

management of an inoculation injury and the NPSA guidance on colour

coding of cleaning equipment were not available.

Recommendations

1. The trust should ensure that the systems and processes in

place for environmental cleaning provide the necessary

assurance that cleaning is carried out effectively and that all

staff are aware of their responsibilities.

2. The healthcare environment should be repaired and

maintained, damaged fixtures and fittings replaced to

maintain public confidence and to help reduce the risk of the

spread of infection.

3. To facilate the cleaning process staff should ensure a clutter

free environment in the treatment room.

4. Detailed nursing cleaning schedules should be developed.

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

importance of monitoring drugs’ fridge temperature

consistently.

6. Staff should adhere to the trusts Legionella policy.

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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

Storage of clean linen 95

Storage of used linen 88

Laundry facilities 79

Average Score 87

7.1 Management of Linen

Picture 4 stained bed linen

Both sections on the storage

of clean and used linen were

compliant, and with minor

adjustment could be fully

compliant. The inspectors

noted the bed linen on a bed

inspected was clean;

however there were several

permanent stains on the fitted

sheet. (Picture 4) Linen

should be inspected as part

of the wash process and worn

or stained items should be

removed from use.

Staff should ensure used linen is segregated appropriately. Inspectors

noted wet towels had been disposed of into a red coloured linen bag

which staff confirmed was for the disposal of foul /contaminated linen.

The towels had not been inserted into an alginate bag. Both lids on the

used linen skip were broken.

The Centre has its own laundry facility, which processes the children’s

clothes and bed linen. There were cleaning issues with regard to dust

and debris on the floor and under shelf units and high surfaces, the

outside of the washing machine was dusty and stained and there was

limescale on the taps.

On speaking to support services staff, inspectors were advised there

were no written instructions or guidelines on the laundry process. This

was raised as an additional issue.

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Recommendations

7. Staff should ensure used linen is handled in line with trust policy.

8. Staff should ensure clean linen should be free from stains.

9. Written guidance and training should be provided for all staff

involed in the laundering process.

15


8.0 Waste and Sharps

STANDARD 4.0

WASTE AND SHARPS

Waste: Effectiveness of arrangements for handling, segregation,

storage and disposal of waste on ward/department

Sharps: Availability, use and storage of sharps containers on

ward/department

Waste and sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

89

56

8.1 Waste

The trust is currently changing their process for waste segregation and

disposal. The Centre does not use yellow bags as part of the clinical

waste stream, black and clear bags were in use, some staff when

questioned were unsure of their classification. A universal container

containing a urine sample had been disposed off incorrectly in a sharps

box.

8.2 Sharps

This standard was minimally compliant and requires immediate

attention; observation indicated that staff practice did not comply with

the trust policy for the safe handling of sharps boxes. The lids on both

the used sharps box and the black lidded pharmaceutical waste were

not secure, nor were they signed or dated. The temporary closure

mechanism on the sharps boxes was not in place and there were no

integrated sharps’ trays available. Staff were using a silver metal

kidney dish, the dish was stained.

Recommendations

10. Staff require update training on the safe and correct disposal of

waste and sharps

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9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient equipment

Patient equipment 66

This standard was minimally compliant and issues raised should be

actioned immediately.

As the patients in this ward are generally mobile and physically well

there is no requirement for a large supply of patient equipment. All

patient equipment was held in a small treatment room. There were

several cleaning issues identified. The drugs’ trolleys, dressing trolleys

and weigh scales were dusty and stained. The two suction machines

on the floor were dirty, the machines were covered by black bags which

were also sticky and dirty. The small portable suction machine on the

work bench was dusty and the blood glucose equipment was blood

stained.

The procedure for washing medicine cups should be reviewed. At the

start of the inspection it was noted that used cups, spoons and syringes

were lying in the sink. The cups that had been left to dry on paper

towels at the side of the sink still had a residue of medicine. At

12:45pm the inspectors observed the sink had been filled with soapy

water and more medicine cups were immersed in the water. The cups

on the drainer which the inspectors had noted earlier had not been

removed.

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Single use and sterile equipment had been removed from their

packaging, the laryngoscope handle, laryngoscope blade and Magills

forceps were all exposed in a plastic box on top of the drugs’

fridge.(Picture 5) Exposed oxygen masks and tubing were attached

and hanging on the oxygen cylinder.

The exposed suction catheter was attached to the portable suction

machine, and mask and tubing were attached to the nebuliser. The

mask and tubing should be single use if used for more than one patient

or cleaned and changed in accordance with manufacturer’s guidelines.

The amub bag and mask in the resuscitation bag had also been

removed from its packaging.

Recommendations

Picture 5 Sterile equipment removed from packaging

11. The trust and individual staff have a collective responsibility to

ensure that patient equipment is clean, and that guidelines in

respect of packaging of sterile items are adhered to.

18


10.0 Hygiene Factors

STANDARD 6.0

HYGIENE FACTORS

Hand wash facilities; alcohol hand rub; availability of PPE;

availability of cleaning equipment and materials.

Hygiene factors

Availability and

cleanliness of wash hand 87

basin and consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

84

Average Score 93

Staff are to be commended, the overall standard was compliant and

both the sections on the availablility of alcohol rub and PPE were fully

compliant. With regard to the section on availability and cleanliness of

wash hand sinks and consumables, the hand wash sink in domestic

store and one of the patients’ bathrooms required cleaning. The

underside of the some liquid soap and towel dispensers was dirty.

The clinical hand wash sink in the treatment room had a plug, an

overflow, and the taps were wrist operated.

The section on material and equipment for cleaning was partially

compliant. Staff should ensure cleaning equipment is cleaned and

dried after use. A large blue mop bucket was stored inverted on the

work counter, the bucket was wet and the counter was wet. The green

dust pan was dirty and the long handle shaft of the dust pan brush was

broken.

An additional issue was highlighted in respect of colour coded cleaning

equipment. The correct colour coded hand buckets which were part of

the cleaning trolley were available, however domestic staff were using

a large used and empty wipe container as part of the cleaning

equipment.

Recommendations

12. The trust should ensure that hand washing sinks and

consumables are available, clean and in a good state of repair and

where appropriate comply with clinical guidance.

13. Staff should ensure equipment used for the general cleaning of a

ward is clean, dry and in good repair.

19


14. Staff should ensure the cleaning equipment complies with NPSA

colour coded guidelines.

20


11.0 Hygiene Practices

STANDARD 7.0

HYGIENE PRACTICES

Hand hygiene procedures; handling and disposal of sharps; use

of PPE; use of isolation facilities and implementation of infection

control procedures; cleaning of ward/department; staff uniform

and work wear.

Hygiene practices

Effective hand hygiene

procedures

100

Safe handling and

disposal of sharps

100

Effective use of PPE 100

Correct use of isolation N/A

Effective cleaning of ward 40

Staff uniform and work

wear

86

Average Score 85

The section relating to the effective cleaning of the ward scored a low

minimal compliance. There were variations in nursing staff knowledge

in relation to correct dilution rates for disinfectants and the type of

detergent, disinfectant and alcohol wipes they were using and when

they should be used. Nursing staff were also unsure of the correct

procedures to follow to remove a blood or body spill and were unaware

of the need for a decontamination certificate for equipment prior to

repair or servicing.

Information on the disinfectant currently in use on the ward was not

displayed for either nursing or members of the domestic staff.

Domestic staff were not aware of the current disinfectant product used

by the trust. COSHH data sheets for catering and laundry staff were

displayed in the kitchen and laundry respectively, there were no

COSHH data sheets for domestic staff. COSHH data sheets were

available for nursing staff but required updating.

Recommendations

15. The trust should ensure that staff knowledge and practice is kept

up to date in relation to the dilution rates for disinfectants in use.

16. The trust should ensure information on dilution rates are

displayed and that COSHH date sheets for chemicals are available

and up to date.

21


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs M Keating

Mrs L Gawley

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

Trust representatives attending the feedback session

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

representatives:

Ms B Creaney

Ms E Rafferty

Ms L McBride

Mr T Mc Donagh

Ms R Gillan

Mr P Bradley

Ms P O’Reilley

- Executive Director of Nursing

- Service Manager

- Assistant Director Patient and Client Support

Services

- Senior Manager Patient and Client Support

Services

- Senior Infection Prevention and Control Nurse

- Ward Manager

- Assistant Support Services Manager

Supporting documentation

A number of documents have been developed to support the inspection

process, these are:

• Infection Prevention/Hygiene Inspection Process (methodology,

follow up and reporting)

• Infection Prevention/Hygiene Team Inspection Protocol (this

document contains details on how inspections are carried out and

the composition of the teams)

• Infection Prevention/Hygiene Team Escalation Policy

• RQIA Policy and Procedure for Use and Storage of Digital Images

This information is currently available on request and will be available

in due course on the RQIA website.

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13.0 Summary of Recommendations

1. The trust should ensure that the systems and processes in place

for environmental cleaning provide the necessary assurance that

cleaning is carried out effectively and that all staff are aware of

their responsibilities.

2. The healthcare environment should be repaired and maintained,

damaged fixtures and fittings replaced to maintain public

confidence and to help reduce the risk of the spread of infection.

3. To facilate the cleaning process staff should ensure a clutter free

environment in the treatment room.

4. Detailed nursing cleaning schedules should be developed.

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

of monitoring drugs’ fridge temperature consistently.

6. Staff should adhere to the trusts Legionella policy.

7. Staff should ensure used linen is handled in line with trust policy.

8. Staff should ensure clean linen should be free from stains.

9. Written guidance and training should be provided for all staff

involed in the laundering process.

10. Staff require update training on the safe and correct disposal of

waste and sharps

11. The trust and individual staff have a collective responsibility to

ensure that patient equipment is clean, and that guidelines in

respect of packaging of sterile items are adhered to.

12. The trust should ensure that hand washing sinks and

consumables are available, clean and in a good state of repair and

where appropriate comply with clinical guidance.

13. Staff should ensure equipment used for the general cleaning of a

ward is clean, dry and in good reair.

14. Staff should ensure the cleaning equipment complies with NPSA

colour coded guidelines.

15. The trust should ensure that staff knowledge and practice is kept

up to date in relation to the dilution rates for disinfectants in use.

16. The trust should ensure information on dilution rates are

displayed and that COSHH date sheets for chemicals are available

and up to date.

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Plan Programme

14.0 Unannounced Inspection Flowchart

Environmental Scan:

Stakeholders & External

Information

Prior to Inspection Year

Plan

Programme

Prioritise Themes & Areas for Core Inspections

Balance Programme

Consider:

Areas of Non-Compliance

Infection Rates

Trust Information

RQIA Hygiene Team

January/February

Schedule Inspections

Prior to Inspection

Identify & Prepare Inspection Team

Episode of Inspection

Day of Inspection

Day of Inspection

Inform Trust

Carry out Inspection

Is there immediate risk

requiring formal escalation?

NO

YES

Invoke

RQIA

IPHTeam

Escalation

Process

A

Day of Inspection

Feedback Session with Trust

14 days after

Inspection

28 days after

Inspection

Preliminary Findings

disseminated to Trust

Draft Report

disseminated to Trust

NO

Does assessment of

the findings require

escalation?

YES

Invoke

RQIA

IPHTeam

Escalation

Process

A

Reporting & Re-Audit

14 days later

Within 0-3 months

Signed Action Plan

received from Trust

Is a Follow-Up required?

Based on Risk Assessment/key

indicators or Unsatisfactory Quality

Improvement Plan (QIP)?

YES

Invoke

Follow-Up

Protocol

Process enables

only 1 Follow-Up

NO

Open Report published to Website

YES

Is Follow-Up

satisfactory?

NO

DHSSPS/HSC

Board/PHA

24


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

25


16.0 Action Plan

Reference

number

Recommendations

1. The trust should ensure that the systems and processes in

place for environmental cleaning provide the necessary

assurance that cleaning is carried out effectively and that

all staff are aware of their responsibilities.

Designated

department

Nursing

PCSS

IPC

Action required

‘Roles and responsibilities of Staff in relation

to Environmental Cleanliness and

Cleanliness of Equipment’ policy under

review.

Date for

completion/

timescale

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.

Jun 2012

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.

Ongoing

2. The healthcare environment should be repaired and

maintained, damaged fixtures and fittings replaced to

maintain public confidence and to help reduce the risk of

the spread of infection.

Estates

IPC

Other

appropriate

staff

This is ongoing as part of Estate daily

maintenance and refurbishment programmes.

Ongoing

3. To facilitate the cleaning process staff should ensure a

clutter free environment in the treatment room.

All

Directorates

Planned programme of de-clutter and deep

cleaning in place. Ongoing space utilisation

and de-cluttering is being driven by Service

Managers.

Ongoing

4. Detailed nursing cleaning schedules should be developed. Nursing

IPECC

A sub-group of IPECC (Infection Prevention

& Environment and Cleanliness Committee)

Complete

26


Reference

number

Recommendations

Designated

department

Action required

has been set up to review and standardise

cleaning schedules, and will establish any

outstanding issues of audit standardisation

process.

Date for

completion/

timescale

Agree a standardised audit which will be

used in all areas. This will include

standardised responsibilities. To be kept

under review.

Commencing

Feb 2012

Systematic roll out of the agreed

standardised audit using the Maximiser

system.

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

importance of monitoring drugs’ fridge temperature

consistently.

Nursing

The Medicines Code outlines procedures 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.

Ongoing

6. Staff should adhere to the trusts Legionella policy. Estates The management of water hygiene on Trust

premises is co-ordinated through the multidisciplinary

Water Safety & Usage Group.

This strategy includes training for relevant

staff where appropriate.

Ongoing

7 Staff should ensure used linen is handled in line with trust

policy.

Nursing

PCSS

The Trust has produced a linen storage and

segregation guidance document, which is

displayed in all clinical areas. This provides

guidance on PPE.

Complete

8. Staff should ensure clean linen should be free from stains. Nursing Staff have been reminded to check that linen

is free from stains before use.

Ongoing

27


Reference

number

Recommendations

9. Written guidance and training should be provided for all

staff involved in the laundering process.

Designated

department

Nursing

PCSS

Action required

Guidance to be reviewed and staff training

provided.

Date for

completion/

timescale

Ongoing

10. Staff require update training on the safe and correct

disposal of waste and sharps

PCSS

The Trust will pilot and roll out across all

facilities the use of an electronic tool to audit

waste management compliance against

policy, procedure and RQIA requirements.

This process will supplement the existing

audit tools used by PCSS, IPC and also

existing external audits conducted by Daniels

(sharps box suppliers).

Pilot completed

Roll-out

programme

across Trust

completed Apr

2012

‘Daniels’ audit completed in October 2011

and results have been disseminated

11. The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean, and that

guidelines in respect of packaging of sterile items are

adhered to.

Nursing

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.

Jun 2012

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.

12. The trust should ensure that hand washing sinks and

consumables are available, clean and in a good state of

repair and where appropriate comply with clinical guidance.

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

28


Reference

number

Recommendations

Designated

department

Action required

and managerial audits, and IPC audits

monitor compliance.

Date for

completion/

timescale

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.

13. Staff should equipment used for the general cleaning of a

ward should be clean, dry and in good repair.

Nursing

PCSS

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.

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.

Jun 2012

14. Staff should ensure the cleaning equipment complies with

NPSA colour coded guidelines.

IPCT

All of these aspects will be monitored through

the programme of Environmental Cleanliness

Audits based on the Cleanliness Matters

Complete and

ongoing

29


Reference

number

Recommendations

Designated

department

Strategy.

Action required

Date for

completion/

timescale

The Trust has produced a colour-coded

guidance document based on the NPSA

system, which is displayed in all clinical

areas.

15. The trust should ensure that staff knowledge and practice is

kept up to date in relation to the dilution rates for

disinfectants in use.

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

16. The trust should ensure information on dilution rates are

displayed and that COSHH date sheets for chemicals are

available and up to date.

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

The availability of COSHH data sheets will be

addressed with the roll out of the BRAAT

Risk Assessment Tool.

30

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