Whiteabbey Hospital - 31 May 2012 - Regulation and Quality ...

rqia.org.uk

Whiteabbey Hospital - 31 May 2012 - Regulation and Quality ...

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Northern Health and Social Care Trust

Whiteabbey Hospital

31 May 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 8

5.0 Audit Tool 10

6.0 Environment 10

6.1 Cleaning 11

6.2 Clutter 11

6.3 Maintenance and Repair 11

6.4 Fixture and Fittings 11

6.5 Information 11

7.0 Patient Linen 13

7.1 Management of Linen 13

8.0 Waste and Sharps 14

8.1 Waste 14

8.2 Sharps 14

9.0 Patient Equipment 15

10.0 Hygiene Factors 16

11.0 Hygiene Practice 18

12.0 Key Personnel and Information 20

13.0 Summary of Recommendations 21

14.0 Unannounced Inspection Flowchart 22

15.0 RQIA Hygiene Team Escalation Policy Flowchart 23

16.0 Action Plan 24


1.0 Inspection Summary

An unannounced inspection was undertaken to the Whiteabbey

Hospital, on the 31 May 2012. The hospital was assessed against the

Regional Healthcare Hygiene and Cleanliness standards and the

following area was inspected:

Ward 3 (Rehabilitation)

Ward 3 is a 22 bedded medical ward caring for patients with a variety

of conditions. It is a mainly rehabilitation ward complemented by

multidisciplinary services where patients individual daily living skills and

social roles can be improved to achieve health and quality of life.

Inspection Outcomes

The results of the inspection showed compliance in all of the

standards, for which staff are to be commended. Although the ward

inspected was in the process of refurbishment, there was minimal

upheaval for patients and minimal clutter in the ward. Cleaning was of

a good standard and the inspectors were impressed with staff

commitment to providing a safe and clean environment for patients.

While documentation on the care pathway for patients with MRSA was

excellent more detail was required in the care plans for patients with

other known infections.

The inspection resulted in 12 recommendations for the Whiteabbey

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.

1


Notable Practice

The inspection identified the following areas of notable practice:

All staff, were knowledgeable on the decontamination of

equipment and dilution rates for Difficil-S

The ward had devised an informative sharps advice poster to

encourage good practice

All staff were adhering to bare below the elbow and trust uniform

guidelines

There was excellent documentation for the MRSA care pathway

in patient’s notes

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

Whiteabbey 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 organisation to target areas that require

more specific attention.

Table 1

Areas inspected

General environment 89

Patient linen 91

Waste 92

Sharps 91

Equipment 95

Hygiene factors 94

Hygiene practices 98

Average Score 93

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

2


Table 2

General environment

Reception 92

Corridors, stairs lift 93

Public toilets

N/A

Ward/department -

general (communal)

90

Patient bed area 87

Bathroom/washroom 85

Toilet 86

Clinical room/treatment

room

95

Clean utility room 93

Dirty utility room 85

Domestic store 89

Kitchen 96

Equipment store 83

Isolation 86

General information 92

Average Score 89

Table 3

Patient linen

Storage of clean linen 88

Storage of used linen 94

Laundry facilities

N/A

Average Score 91

Table 4

Waste and sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

92

91

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

3


Table 5

Patient equipment

Patient equipment 95

Table 6

Hygiene factors

Availability and

cleanliness of wash hand 93

basin and consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

84

Average Score 94

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 95

Effective cleaning of ward 90

Staff uniform and work

wear

100

Average Score 98

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

6


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 92

Corridors, stairs lift 93

Public toilets

N/A

Ward/department -

general (communal)

90

Patient bed area 87

Bathroom/washroom 85

Toilet 86

Clinical room/treatment

room

95

Clean utility room 93

Dirty utility room 85

Domestic store 89

Kitchen 96

Equipment store 83

Isolation 86

General information 92

Average Score 89

The above table outlines the findings in relation to the general

environment of the facilities inspected. The findings indicate that all

sections except the equipment store achieved a compliant score.

The findings in respect of the general environment are detailed in the

following sections.

6.1 Cleaning

The inspectors observed that in most instances regular and effective

cleaning mechanisms were in place to prevent the build-up of dust and

debris and reduce the potential risk for the transmission of infection.

Further attention to detail was needed in relation to some areas such

as corners and edges of flooring, skirting, grubby pull cords, macerator

10


lid and removing labels and adhesive tape from equipment and fixtures.

The storage of excess toilet rolls was noted in many toilet areas, in the

bathroom, the shower head was grubby and the hand washing sink

plughole was dirty. Limescale was noted at many taps and sinks and

fittings. 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 limescale can interfere with

good cleaning and disinfection, by masking and protecting pathogens.

6.2 Clutter

Despite the on-going refurbishment of the ward, inspectors observed

stores which had been tidied and good use of high density storage

units to provide clutter free ward environments. This promotes

effective cleaning and good hygiene practices.

6.3 Maintenance and Repair

At the time of inspection, inspectors observed maintenance staff

carrying out repairs which should address issues such as damaged

walls, skirting, doors and door frames. It was noted that light bulbs

were not working in the treatment room and equipment store.

6.4 Fixtures and Fittings

The fixtures, fittings and equipment were generally fit for purpose.

However the laminate finish on some bedside lockers and the frame of

tables was damaged; some bedrails were chipped, some wooden arm

chairs were worn at the arm rest. Damaged or missing finish means

that these items are not impervious to moisture. The large specialised

bath had cracks at the plughole and the wooden bar on the sluice bowl

was old and worn. Felt notice boards which cannot be effectively

cleaned were noted throughout the ward.

6.5 Information

Relevant infection prevention and control posters and information

leaflets were in place (Picture 1 and 2), posters for linen segregation

and needle stick injury had been removed for painting and not

replaced.

11


Picture 1: Poster on managing

sharps for staff

Picture 2: Relevant information

information leaflets for patients

and visitors

Recommendations

1. The trust should work to ensure all staff are aware of their

roles and responsibilities to improve and confirm that

environmental cleaning is carried out effectively and that the

environment is in a good state of repair.

2. The trust should ensure the on-going programme of

maintenance and repair for the environment, fixture and

fittings and equipment is completed.

3. The trust should ensure all relevant information leaflets,

posters and signage are available for staff to reference.

12


7.0 Patient Linen

STANDARD 3.0

PATIENT LINEN

Storage of clean linen; handling and storage of used linen; ward/

department laundry facilities.

7.1 Management of Linen

Patient linen

Storage of clean linen 88

Storage of used linen 94

Laundry facilities

N/A

Average Score 91

Overall compliance was achieved for this standard. Repairing and

painting the damage to surfaces in the linen store should address

issues identified during the audit. It was also noted that the frame of a

linen skip was damaged; damaged, unsealed surfaces cannot be

effectively cleaned.

Recommendations

4 The trust should ensure the storage of clean linen in an area

and on equipment which are fit for purpose.

13


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

92

91

8.1 Waste

The inspection evidenced that there were arrangements in place for the

handling, segregation, storage and disposal of waste which generally

complied with local and regional guidance. Issues identified related to

domestic staff practice of attaching a clinical waste bag to their trolley

for use in all areas and the provision of inappropriate waste bins in

clinical areas.

8.2 Sharps

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

and were assembled correctly; labelled with the date, locality and staff

signature. Temporary closures were in place when not in use

throughout the ward with the exception of the large unsecured sharps

box on the phlebotomist trolley. Inspectors noted that disposable foil

trays were being used by the phlebotomist instead of compatible

integral sharps trays.

Recommendations

5 Waste bins and equipment used in the management of waste

should be available in all clinical areas.

6 The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

sharps to ensure that staff knowledge is kept up to date and

safe and appropriate practice is in place.

14


9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient equipment

Patient equipment 95

A high compliant score was achieved in this standard; in general the

equipment at the patient’s bedside was clean and in good repair.

Trigger tape was used to indicate and record when cleaning had taken

place. Staff should ensure labels and adhesive tape are removed from

all equipment and spilled medication is cleaned from drugs’ trolleys.

Inspectors observed a sheepskin leg support brace, which would

present difficulties for cleaning between individual patients, attached to

a newly purchased standing aid. Ward staff advised and trust

representatives confirmed at the feedback that this issue had been

identified with a similar piece of equipment and the standing aid would

be suitably adapted to promote easy cleaning.

Recommendations

7 The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean and in good repair.

15


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 93

basin and consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

84

Average Score 94

In general sinks and consumables were clean and in good repair with

the exception of the hand washing sink and splash back in Bay C

which required more detailed cleaning, it was also noted that there was

a crack in the bowl. Overflows to sinks, basins, baths and bidets are

not recommended, as they constitute a constant infection control risk

much more significant than the possible risk of damage due to water

overflowing (WCs have an internal overflow). This recommendation

does not apply to staff residential accommodation, but does apply to

patient areas including en-suite and general public toilet areas (HTM

64). There were overflows at all hand washing sinks spot checked in

the ward.

A partial compliance was achieved in the section concerning the

availability, storage and use of materials and equipment for general

cleaning of the ward. Issues identified related to staff practice and

repair of equipment. Inspectors noted the mixing of NPSA colour

coded equipment and materials such as a green mop handle in a

cohort bay, yellow cloths with red hand buckets and a wooden handle

bristle brush in the kitchen (Picture 3). The floor burnisher was

chipped, a green dust pan was broken and the domestic trolley was

dirty in the crevices. Constituted Difficil –S was stored on the work

surface in the unlocked dirty utility room breaching COSHH regulations.

16


Recommendations

Picture 3: Mixed NPSA colour coding

red hand bucket and yellow cloth

8. The trust should review the condition and appropriateness of

the hand washing sinks and a risk based approach taken to

their replacement.

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

in line with COSHH regulations.

10. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of the

ward is clean, adheres to the NPSA colour coding system

and is fit for purpose.

17


11.0 Hygiene Practices

STANDARD 7.0

HYGIENE PRACTICES

Hand hygiene procedures; handling and disposal of sharps; use

of PPE; use of isolation facilities and implementation of infection

control procedures; cleaning of ward/department; staff uniform

and work wear.

Hygiene practices

Effective hand hygiene

procedures

100

Safe handling and

disposal of sharps

100

Effective use of PPE 100

Correct use of isolation 95

Effective cleaning of ward 90

Staff uniform and work

wear

100

Average Score 98

The unit achieved high overall compliance in this standard and staff are

commended for achieving full compliance in four sections. Issues

identified were in relation to practice and knowledge. The nursing care

plan of a patient isolated with a known infection needed more detail for

actions taken, COSHH data sheets on Difficil-S were not available for

nursing staff to reference and nursing staff were not aware of the

NPSA colour coding system.

Picture 4: Sinks and consumables in the

dirty utility room. Soap and towel dispenser

located above the deep equipment sink

In the dirty utility room

inspectors observed staff use

the deep equipment sink for

hand washing instead of the

dedicated hand washing sink.

The soap and towel

dispensers were located

above the deep equipment

sink. The placement of the

soap and towel dispensers

needs reviewed in this room

to encourage staff to use the

correct sink (Picture 4).

18


Recommendations

11. The trust and individual staff have a collective responsibility

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

to the isolation of patients and that all relevant

documentation is available.

12. The trust and individual staff should ensure that all care

plans are fully completed and regularly reviewed.

19


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs L Gawley

Mrs M Keating

- 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 M Bermingham - Assistant Director Support Services

Ms A Redmond - Professional Lead for Nursing, Medical and

Unscheduled Care

Mr P Bartley - Service Lead

Mr E Mc Cabe - Estates Services

Ms F Turtle - Senior Infection Prevention and Control nurse

Ms E Campbell - Ward Manager Ward 3

Ms A Hamilton - General Manager Support Services

Mr D Mc Whirter - Support Services Manager

Ms K Mc Elroy - Infection Prevention and Control nurse

Supporting documentation

A number of documents have been developed to support the inspection

process, these are:

Infection Prevention/Hygiene Inspection Process (methodology,

follow up and reporting)

Infection Prevention/Hygiene Team Inspection Protocol (this

document contains details on how inspections are carried out and

the composition of the teams)

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.

20


13.0 Summary of Recommendations

1. The trust should work to ensure all staff are aware of their

roles and responsibilities to improve and confirm that

environmental cleaning is carried out effectively and that the

environment is in a good state of repair.

2. The trust should ensure the on-going programme of

maintenance and repair for the environment, fixture and

fittings and equipment is completed.

3. The trust should ensure all relevant information leaflets,

posters and signage are available for staff to reference.

4. The trust should ensure the storage of clean linen in an area

and on equipment which are fit for purpose.

5. Waste bins and equipment used in the management of waste

should be available in all clinical areas.

6. The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

sharps to ensure that staff knowledge is kept up to date and

safe and appropriate practice is in place.

7. The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean and in good repair.

8. The trust should review the condition and appropriateness of

the hand washing sinks and a risk based approach taken to

their replacement.

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

in line with COSHH regulations.

10. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of the

ward is clean, adheres to the NPSA colour coding system

and is fit for purpose.

11. The trust and individual staff have a collective responsibility

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

to the isolation of patients and that all relevant

documentation is available.

12. The trust and individual staff should ensure that all care

plans are fully completed and regularly reviewed.

21


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

RQIA Hygiene Team

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

22


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

23


16.0 Action Plan

Reference

number

Recommendations

1. The trust should work to ensure all staff are aware of

their roles and responsibilities to improve and confirm

that environmental cleaning is carried out effectively

and that the environment is in a good state of repair.

Designated

department

Trust /

estates ward

3 staff

Action required

To discuss at ward meeting on 24.7.12.

Staff to be reminded of responsibilities

and how to request repairs.

Date for

completion/

timescale

31.7.12

2. The trust should ensure the on-going programme of

maintenance and repair for the environment, fixture

and fittings and equipment is completed.

3. The trust should ensure all relevant information

leaflets, posters and signage are available for staff to

reference.

Domestic

services

department

Trust /

estates

Trust / ward 3

staff

1. All Domestic staff issued with Job

Descriptions.

2. Work schedules in place.

3. Monitoring of cleaning duties takes

place, daily, monthly and annually.

4. Domestic undergo competency

testing.

5. All staff receive induction Training

and on the job refresher training.

6. Leadership walkabouts take place

regularly to highlight improvements

required to the patient environment.

Estates to action. All staff to report when

repairs required.

Staff to be made aware of where to

access info, posters etc and ward clerk to

request same if / as required.

Actioned

16/7/2012

Ongoing

Ongoing

4. The trust should ensure the storage of clean linen in

an area and on equipment which are fit for purpose.

5. Waste bins and equipment used in the management

of waste should be available in all clinical areas.

Trust / ward 3

staff.

Linen cupboard available. To remind

staff at ward meeting 24.7.12 that linen to

be stored on shelves. Deeper shelves

ordered via Estates.

Ward 3 staff Ward manager to ensure that equipment /

store items are ordered as required.

Ongoing.

Ongoing

24


Reference

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 staff knowledge is

kept up to date and safe and appropriate practice is in

place.

Designated

department

Ward 3 staff

Action required

Waste policy printed off and left at nurses’

station. All staff to read and sign. Sharps

information posters taken down by

painters and misplaced. Same have

been re-ordered.

Date for

completion/

timescale

31.7.12

7. The trust and individual staff have a collective

responsibility to ensure that patient equipment is clean

and in good repair.

Ward 3 staff

Staff are aware of cleaning

responsibilities and of how to request

equipment repairs if / as necessary.

Completed

8. The trust should review the condition and

appropriateness of the hand washing sinks and a risk

based approach taken to their replacement.

9. The trust should ensure that all cleaning products are

stored in line with COSHH regulations.

Trust /

estates

Ward 3 staff

Hand washing sinks are monitored for

damage and referred to estates services

where appropriate. Decision to be made

by Trust / Estate services as to whether

or not sinks with waste overflow are to be

replaced.

COSHH policy available to staff. COSHH

cupboard used for safe storage.

31/7/12

Completed

10. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of

the ward is clean, adheres to the NPSA colour coding

system and is fit for purpose.

Domestic

services

department

Ward 3 staff

Domestic

services

department

Domestic staff reminded that all cleaning

products not in use must be kept under

lock and key in the Domestic store

Colour posters downloaded from patient

safety agency website. Same to be

laminated and displayed in kitchen/sluice

areas and areas where equipment is

stored.

Domestic staff reminded to use correct

colour coded equipment and to keep

equipment clean.

This is carried out as part of the daily

domestic supervisory monitoring of

cleaning standards and practices.

Actioned

16/7/12

31.7.12

Actioned

16/7/2012

25


Reference

number

Recommendations

11. The trust and individual staff have a collective

responsibility to ensure that staff knowledge is kept up

to date with regard to the isolation of patients and that

all relevant documentation is available.

Designated

department

Ward 3 staff

Action required

Ward manager to ensure all staff up to

date with Infection Prevention Control

training and use appropriate tool Infection

Risk Assessment Tool (IRATS) for every

patient.

Date for

completion/

timescale

Actioned

Ward clerk to ensure that documentation /

care plans are ordered / copied if and as

required.

12. The trust and individual staff should ensure that all

care plans are fully completed and regularly reviewed.

Nursing staff reminded to use correct

colour coded equipment and to keep

equipment clean

Ward 3 staff To be discussed at ward meeting 24.7.12.

To devise a ‘rota’ between day and night

staff to ensure that this is ongoing

31.7.12

26

More magazines by this user
Similar magazines