Causeway Hospital - 14 June 2012 - Regulation and Quality ...

RQIA
Infection Prevention/Hygiene
Unannounced inspection
Northern Health and Social Care Trust
Causeway Hospital
14 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 12
6.5 Information 13
6.6 Additional Issues 13
7.0 Patient Linen 15
7.1 Management of Linen 15
8.0 Waste and Sharps 16
8.1 Waste 16
8.2 Sharps 16
9.0 Patient Equipment 18
10.0 Hygiene Factors 19
11.0 Hygiene Practice 21
11.1 Additional Issues 22
12.0 Key Personnel and Information 24
13.0 Summary of Recommendations 25
14.0 Unannounced Inspection Flowchart 27
15.0 RQIA Hygiene Team Escalation Policy Flowchart 28
16.0 Action Plan 29

1.0 Inspection Summary
An unannounced inspection was undertaken to Causeway Hospital,
on the 14 June 2012. The hospital was assessed against the Regional
Healthcare Hygiene and Cleanliness standards and the following areas
were inspected:
Elective Surgery
Medical 2
Causeway Hospital is an acute hospital which offers a range of
services including a 24 hour Accident and Emergency Department.
Elective Surgery is a 15 bedded ward, comprising of two patient bed
bays and single room ensuite facilities. Medical 2 incorporates 12
medical beds and a further 15 beds in the Medical Assessment Unit.
Inspection Outcomes
The results of the inspection showed both wards achieved an overall
compliance level and staff are commended for their commitment to
providing a safe and clean environment for patients. However
inspectors observed that whilst the environment was generally clean,
further work is required to ensure cleaning and monitoring is carried out
especially in areas difficult to access. The trust should continue their
work in providing clutter free ward environments, and ensure that there
is an on-going programme of maintenance and repair.
Staff knowledge of products used for the cleaning and decontamination
of equipment and the environment need to improve. Observation of
staff indicated compliance with hygiene and infection prevention and
control practices. However inspectors observed that not all medical
staff adhered to the trust’s dress code policy and trust representatives
indicated that this would be brought to the attention of the Medical
Director.
The inspection resulted in 19 recommendations for Causeway 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
1

management by the Health and Social Care Board and the Public
Health Agency.
Notable Practice
The inspection identified the following areas of notable practice:
Regular audits are carried out; high impact intervention,
mattresses, hand hygiene, environmental cleanliness
In Elective Surgery inspectors were impressed by the
practice and knowledge displayed by three nursing
management level students
Participation in protected meal times
The RQIA inspection team would like to thank the staff at Causeway
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
Ward Elective Surgery Medical 2
Environment 84 85
Patient Linen 97 97
Waste 87 95
Sharps 91 77
Equipment 89 90
Hygiene Factors 98 98
Hygiene Practices 89 93
Total 91 91
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
2

Table 2
Environment Elective Surgery Medical 2
Reception 82 N/A
Corridors, stairs lift 81 N/A
Public toilets N/A 86
Ward/ department -
general(communal)
76 93
Patient bed area 93 83
Bathroom/washroom 96 94
Toilet 93 N/A
Clinical room/ treatment
room
76 84
Clean utility room 79 79
Dirty utility room 89 83
Domestic store 78 84
Kitchen N/A N/A
Equipment store 77 83
Isolation 94 83
General information 76 80
Total 84 85
Table 3
Linen Elective Surgery Medical 2
Storage of clean linen 94 100
Storage of used linen 100 94
Laundry facilities N/A N/A
Total 97 97
Table 4
Waste and sharps Elective Surgery Medical 2
Handling, segregation,
storage, waste
Availability, use, storage of
sharps
87
91
95
77
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
3

Table 5
Patient Equipment Elective Surgery Medical 2
Patient equipment 89 90
Table 6
Hygiene Factors Elective Surgery Medical 2
Availability and cleanliness 99
of WHB and consumables
97
Availability of alcohol rub 100 100
Availability of PPE 100 100
Materials and equipment
92
for cleaning
95
Total 98 98
Table 7
Hygiene practices Elective Surgery Medical 2
Effective hand hygiene
95
procedures
88
Safe handling and disposal 100
of sharps
100
Effective use of PPE 84 100
Correct use of isolation 94 95
Effective cleaning of ward 79 87
Staff uniform and work
84
wear
88
Total 89 93
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 four 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.
Environment Elective Surgery Medical 2
Reception 82 N/A
Corridors, stairs lift 81 N/A
Public toilets N/A 86
Ward/ department -
general(communal)
76 93
Patient bed area 93 83
Bathroom/washroom 96 94
Toilet 93 N/A
Clinical room/
treatment room
76 84
Clean utility room 79 79
Dirty utility room 89 83
Domestic store 78 84
Kitchen N/A N/A
Equipment store 77 83
Isolation 94 83
General information 76 80
Total 84 85
The above table outlines the findings in relation to the general
environment of the facilities inspected. Overall the wards generally
appeared visibly clean, some issues were identified in relation to
domestic and nursing staff cleaning and the maintenance and repair of
the wards. 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 to indicate general
compliance with regional specifications for cleaning. The inspectors
observed that in general regular cleaning mechanisms were in place to
prevent the build-up of dust and debris, which in turn prevents the
10

uild-up of bacteria and subsequently reduces the potential risk for the
transmission of infection.
In the main reception, public toilets and corridor leading to the wards
greater attention to detail was required to remove stains on the wall
underneath soap and alcohol dispensers and to remove dust and
debris from high, low and difficult to reach areas e.g. floor grills and
skylight.
Comparable findings were noted in both wards such as dirty external
windows, dust on high, low and horizontal surfaces, cupboards and
inside storage units.
In the Elective Surgery Ward dust was noted on the chair pedestals
and computers at the nurses’ station. In the domestic store the sluice
and equipment sink and drainer required cleaning and hand bags,
foodstuffs and cleaning products were stored inappropriately together
in a cupboard. In the patient toilet two paper mache urinals with urine
samples were observed on the floor of the toilet throughout the
inspection and the nozzle of the toilet sink taps was grubby.
In Medical 2 limescale was noted on the taps of the sink in Room 6
isolation room, clean utility room and the domestic store. In the dirty
utility room there were splashes and stains on the interior of the slop
hopper and Difficil - S solution was observed on the floor and in the
sink. A more robust checking mechanism is required for the cleaning
of isolation rooms as an empty isolation room, terminally cleaned the
night before the inspection, had dust behind the radiator, splash marks
on the mirror, debris in the floor corners and adhesive tape residue on
the mattress cover.
Additional Issues
Elective Surgery
Medical 2
A large number of the stationery folders were old and worn, with
frayed edges that cannot be effectively cleaned
The deputy ward manager advised that nursing staff do not at
present participate in ward based multidisciplinary
environmental cleanliness audits
Medical staff were observed placing patient notes on the bed
while writing in them, this has the potential for contamination of
the notes
The deputy ward manager advised that nursing staff do not
at present always participate in ward based multidisciplinary
environmental cleanliness audits
11

6.2 Clutter
In both wards the installation of high density storage shows evidence of
an emphasis in providing clutter free environments, this demonstrates
effective utilisation of space. However inspectors observed that in both
wards there was limited storage space available; in some areas
equipment and boxes of
supplies were stored on
floors, on top of shelving units
(Picture 1) and made work
surfaces cluttered in
appearance e.g. the nurses’
station and surrounding area,
dirty utility room. Cluttered
ward environments and the
inability to fully access areas
impede effective cleaning.
Picture 1: Storage on floor and on
top of shelving units
6.3 Maintenance and Repair
Reception, corridors, stairs and wards were generally in a good state of
repair however some chipped paintwork and damaged skirting,
cupboards, door and door frames and flooring was observed. Some
ceiling light bulbs were not working.
In Medical 2 bathroom (Room 1) an extraction fan was not present,
there was a strong smell of urine.
6.4 Fixtures and Fittings
In both wards inspectors observed some worn, damaged furniture,
fixtures and fittings; foot stool, chairs, taps, storage units, shelving and
bedrails. Cork and felt notice boards which cannot be effectively
cleaned were also observed.
In Elective Surgery, bed space privacy curtains and window curtains
were poorly hung, some were old and worn and hooks were not
attached. The outside enamel of the fridge door was chipped and the
supplementary drink fridge required defrosting.
12

6.5 Information
In both wards there were no information leaflets available on
Clostridium difficile or posters for nursing staff to reference on the
National Patient Safety Agency (NPSA) cleaning colour coded system
and the management of an
inoculation injury. Nursing
cleaning schedules while
available did not detail staff
roles and responsibilities and
in Elective Surgery the
domestic services ward
cleaning manual was not
available. Infection control
information was displayed in
both wards for patients and
visitors to view (Picture 2).
Picture 2: Infection control information board
In Elective Surgery some posters at the nurses’ station were attached
to surfaces with adhesive tape and in Medical 2 a poster on the
segregation of linen was not available for staff.
In both wards fridge temperature checks were recorded in a book. The
layout in the book did not allow staff to record action taken in the event
of a cold chain failure. Inspectors also noted that the fridge door was
open. As Elective Surgery closes at the weekend, fridge temperature
checks are not carried out at the weekend to identify a cold chain
failure. In Medical 2 fridge temperature checks were not consistently
recorded; no records since the 06/06/2012 and there were no
temperature records available for the supplementary drink fridge.
6.6 Additional Issues
Elective Surgery
Medical 2
The number on the resuscitation trolley clip is not recorded as
part of the resuscitation trolley checking process
The emergency trolley checklist had not been consistently
recorded
13

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. A robust checking mechanism should be introduced to
ensure that terminal cleaning of isolation rooms is monitored
and carried out effectively.
3. Damaged fixtures and fittings should be replaced to help
reduce the risk of the spread of infection.
4. The trust and staff should work to maintain clutter free ward
environments.
5. The trust should ensure all relevant information leaflets and
posters are available for patients, visitors and staff to
reference and use.
6. Detailed nursing cleaning schedules, outlining staff roles and
responsibilities should further be developed.
7. The trust should ensure a standard drugs fridge temperature
recording sheet is developed for staff to use.
14

7.0 Patient Linen
STANDARD 3.0
PATIENT LINEN
Storage of clean linen; handling and storage of used linen; ward/
department laundry facilities.
Linen Elective Surgery Medical 2
Storage of clean
linen
94 100
Storage of used
linen
100 94
Laundry facilities N/A N/A
Total 97 97
7.1 Management of Linen
Staff within both wards are commended for achieving an overall high
compliance score in this standard. Issues that if addressed would
achieve full compliance are; a dirty pillowcase on the treatment room
pillow in Elective Surgery and a chipped linen skip frame in Medical 2.
In both wards clean linen storage pods were clean and clutter free and
used linen was handled and stored correctly.
Recommendations
8. The trust should ensure that clean linen and linen
equipment are fit for purpose.
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 Elective Surgery Medical 2
Handling, segregation,
87
storage, waste
95
Availability, use, storage of 91
sharps
77
8.1 Waste
In this standard both wards achieved compliance. The inspection
evidenced that there were arrangements in place for the handling,
segregation, storage and disposal of waste which generally comply
with local and regional guidance.
In both wards inspectors observed that waste was segregated and
disposed of incorrectly e.g. household waste into the black lidded burn
bin.
In Elective Surgery a black waste bag was tied to a domestic trolley
and there was no household waste bin in the treatment room. In the
dirty utility room the recycling waste bin required cleaning and there
was slight rust on the underside of the clinical waste bin. Inspectors
observed that the ward waste disposal hold was unlocked and easily
accessible and a clinical waste bag was mixed with laundry bags, this
room required cleaning.
8.2 Sharps
Elective Surgery achieved compliance while Medical 2 achieved partial
compliance in this standard.
Sharps boxes in use conformed to BS7320 (1990)/UN9291 standards.
In both wards sharps boxes were assembled correctly; labelled with the
date, locality and staff signature. On the Elective Surgery resuscitation
trolley and throughout Medical 2 the temporary closure mechanisms on
the sharps boxes were open and in Medical 2 the sharps box on the
phlebotomy trolley at the nurses’ station was overfilled with syringes
16

protruding from the open aperture (Picture 3). In Medical 2 the sharps
box on the resuscitation trolley was not empty or secured safely to the
trolley and a paper label was taped to the box advising staff not to
remove the box from the trolley, this label impedes staff from
accurately filling out the label on the box.
Picture 3: Syringes protruding from a sharps box
In Medical 2 clean utility room a 22 litre sharps box was bracketed to
the wall. When full the box is heavy and difficult to remove from the
bracket, this has potential health and safety implications and should be
reviewed.
In both wards integral sharps trays, used to store a sharps box and
equipment when carrying out a procedure were available however staff
were also using paper mache receivers or disposable foil trays, not
recommended as part of the aseptic non touch technique procedure
(ANTT). In Elective Surgery a sharps tray was blood stained.
Recommendations
9. 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.
10. The trust should ensure that waste bins and equipment used
in the management of waste and sharps are clean and that
waste bins are available and fit for purpose.
11. 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.
17

9.0 Patient Equipment
STANDARD 5.0
PATIENT EQUIPMENT
Cleanliness and state of repair of general patient equipment.
Patient Equipment Elective Surgery Medical 2
Patient equipment 89 90
In this standard both wards are commended for achieving compliance.
Equipment inspected was generally clean and in a good state of repair.
In Elective Surgery a one litre bag of potassium chloride was out of
date; 04/2012, this would suggest stock rotation is not routinely carried
out. Inspectors also noted that some staff when questioned were
unaware of the symbol for single use. The fans on the shelving in the
dirty utility room were not covered to protect against the potential for
contamination in a dirty area.
In Medical 2 a patient wash bowl was not stored inverted in the patient
locker resulting in pooling of water in the bowl and a single use jug was
observed on the drainer in the dirty utility room, suggesting that it was
being reused by staff. One of the commodes spot checked was
labeled with trigger tape to identify it had been cleaned; a faecal stain
was observed on the side of the seat.
Issues identified in both wards for action were paper labels and
chipped frames on some equipment.
Recommendations
12. The trust and individual staff have a collective responsibility
to ensure that patient equipment is clean, used correctly and
in a good state of repair.
13. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
equipment cleaning.
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 Elective Surgery Medical 2
Availability and cleanliness
of WHB and consumables
99 97
Availability of alcohol rub 100 100
Availability of PPE 100 100
Materials and equipment
for cleaning 92
95
Total 98 98
Staff within both wards are commended for achieving an overall high
compliance score in this standard, with full compliance. No issues
were identified in the availability of alcohol rub and PPE.
Hand washing sinks, fixtures and fittings and consumables in both
wards were generally clean, working and in a good state of repair
(Picture 4). In Elective
Surgery there was no soap
present in the dirty utility room
soap dispenser and in
Medical 2 the hand washing
sink in Room 1 was splashed.
In Medical 2 the hand
washing sink in the clean
utility room had a plug, not
recommended as hands
should be washed under
running water.
Picture 4: Typical hand washing sink
In both wards a large container of Difficil - S was stored on a work
surface in the unlocked dirty utility room, not in line with COSHH
regulations. This issue is being reviewed by trust staff and Difficil - S
suppliers. Inspectors noted that not all nursing staff were aware of the
preparation of Difficil - S for routine cleaning.
Inspectors observed that domestic cleaning equipment was clean and
in a good state of repair however in Elective Surgery an inverted green
hand held bucket was stored inappropriately in the domestic store for
hand washing sink.
19

Recommendations
14. The trust should ensure that hand washing sinks and
consumables are clean, adequately stocked and fit for
purpose.
15. The trust should ensure that all cleaning products are stored
in line with COSHH regulations.
16. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date in the use of
general cleaning products.
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 Elective Surgery Medical 2
Effective hand hygiene
95
procedures
88
Safe handling and disposal 100
of sharps
100
Effective use of PPE 84 100
Correct use of isolation 94 95
Effective cleaning of ward 79 87
Staff uniform and work
84
wear
88
Total 89 93
In this standard both wards achieved compliance, with full compliance
and no issues identified in the safe handling and disposal of sharps.
Medical 2 further achieved full compliance in the effective use of PPE.
In both wards staff were aware of the 7 step hand hygiene technique for
use with soap or alcohol rub. However in Medical 2 inspectors
observed that medical staff did not always carry out hand hygiene
appropriately; prior to donning gloves or after leaving the patient’s
environment, part of the World Health Organisation (WHO) 5 moments
of care. In Medical 2 a registered nurse was not aware that alcohol rub
should not be used for hand hygiene when caring for a patient with
Clostridium difficile.
In Elective Surgery there was variation in practice for nursing staff
taking blood pressure; some staff wore gloves and aprons while some
staff did not wear any PPE. Inspectors noted that in Medical 2 a
member of medical staff did not wear an apron or put on gloves prior to
a procedure and after donning gloves inappropriately touched the
environment, contaminating the gloves.
In both wards the use of isolation facilities was satisfactory however in
the Elective Surgery ward nursing care plans, were not available in the
nursing notes for patients with a potential infection. In Medical 2 there
were inconsistencies in staff documentation for the care bundle for
peripheral intravenous lines.
21

Routine cleaning of equipment between use was observed in both
wards. Although information was available on the preparation of Difficil
- S (Picture 5), nursing staff were unsure of the use of Difficil - S for
cleaning blood spillages and
the NPSA cleaning colour
coded system. In Elective
Surgery a COSHH folder was
not available at the time of
inspection for nursing or
domestic staff to reference on
disinfectant used at ward
level.
Picture 5: Information on preparation
and storage of Difficil - S
In both wards work is required, especially with medical staff, to ensure
adherence to the trust and regional dress code policy and the concept
of ‘bare below the elbow’. In Elective Surgery a member of staff wore a
green long sleeved cardigan and had long hair not tied up above collar
length, a member of medical staff wore a lanyard around their neck and
a white coat worn by a member of pharmacy required cleaning. In
Medical 2, two medical staff had long hair not tied up above collar
length and one wore dangling stoned earrings. In both wards medical
staff were observed wearing a stethoscope around their neck with a roll
of surgical tape hooked over the earpieces. This tape cannot be
effectively cleaned.
11.1 Additional Issues
Medical 2
With the introduction of the regional uniform, staff did not have
name badges and patients, visitors and other members of staff
were unable to identify staff by name. Trust representatives
advised that this issue has been identified trust wide and is to be
addressed.
22

Recommendations
17. The trust and individual staff have a collective responsibility
to ensure that hand hygiene is carried out in line with WHO
guidance.
18. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date with regard
to products used for the cleaning and decontamination of
equipment and the environment.
19. The trust should ensure that all members of staff are familiar
with and adhere to the regional dress code policy.
23

12.0 Key Personnel and Information
Members of the RQIA inspection team
Mrs E Colgan
Mrs S O'Connor
Mrs M Keating
Mrs L Gawley
- Senior Officer Infection Prevention/Hygiene Team
- Inspector Infection Prevention/Hygiene Team
- Inspector Infection Prevention/Hygiene Team
- Inspector Infection Prevention/Hygiene Team
Trust representatives attending the feedback session
Ms Rebecca Getty - AD Directorate, Support Services
Ms Ann Hamilton - General Manager, Domestic Services
Ms Donna Hanna - Lead Nurse, Medicine
Ms Linda Millar
- Lead Nurse, Surgery
Ms Doreen Reid - Domestic Services Manager
Ms May Cairns
- Infection Prevention and Control Nurse
Ms Beth Bolton
- Deputy Ward Manager, Elective Surgery
Ms Barbara Ann Maguire - Deputy Ward Manager, Medical 2
Mr Paul Murray - Deputy Ward Manager, Surgical Unit
Ms Judy McNeill - Deputy Ward Manager, Surgery 1
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.
24

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. A robust checking mechanism should be introduced to ensure
that terminal cleaning of isolation rooms is monitored and carried
out effectively.
3. Damaged fixtures and fittings should be replaced to help reduce
the risk of the spread of infection.
4. The trust and staff should work to maintain clutter free ward
environments.
5. The trust should ensure all relevant information leaflets and
posters are available for patients, visitors and staff to reference
and use.
6. Detailed nursing cleaning schedules, outlining staff roles and
responsibilities should further be developed.
7. The trust should ensure a standard drugs fridge temperature
recording sheet is developed for staff to use.
8. The trust should ensure that clean linen and linen equipment are
fit for purpose.
9. 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.
10. The trust should ensure that waste bins and equipment used in
the management of waste and sharps are clean and that waste
bins are available and fit for purpose.
11. 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.
12. The trust and individual staff have a collective responsibility to
ensure that patient equipment is clean, used correctly and in a
good state of repair.
13. The trust and individual staff have a collective responsibility to
ensure that staff knowledge is kept up to date regarding
equipment cleaning.
25

14. The trust should ensure that hand washing sinks and
consumables are clean, adequately stocked and fit for purpose.
15. The trust should ensure that all cleaning products are stored in in
line with COSHH regulations.
16. The trust and individual staff have a collective responsibility to
ensure that staff knowledge is kept up to date in the use of
general cleaning products.
17. The trust and individual staff have a collective responsibility to
ensure that hand hygiene is carried out in line with WHO
guidance.
18. The trust and individual staff have a collective responsibility to
ensure that staff knowledge is kept up to date with regard to
products used for the cleaning and decontamination of equipment
and the environment.
19. The trust should ensure that all members of staff are familiar with
and adhere to the regional dress code policy.
26

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
27

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
28

16.0 Action Plan
Recommendations
Reference
Number
Recommendations
1 The trust should ensure that the systems
and processes are 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
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
Audits are multi disciplinary ie;
involve domestic services,
estates, nursing and infection
prevention control staff and
managers.
2 A robust checking mechanism should be
introduced to ensure that terminal cleaning
of isolation rooms is monitored and carried
out effectively.
3 Damaged fixtures and fittings should be
replaced to help reduce the risk of the
spread of infection.
Domestic and
Infection
Prevention Control
Team & Nursing
Nursing/Domestic/
Estates
High cleaning is carried out by
Estates services on rolling basis
Rooms are checked by nursing
staff following a clean. Checks
are also carried out IPC team.
Issues are raised immediately
with Domestic Services manager
and where necessary staff are
retrained in procedures.
Staff are aware of their
responsibilities to identify and
damage and of the process for
actioning repair/replacement by
Estates staff
Actioned
Checks
ongoing post
cleans
Actioned
Ongoing
29

Reference
Number
Recommendations
4 The trust and staff should work to maintain
clutter free ward environments.
5 The trust should ensure all relevant
information leaflets and posters are
available for patients, visitors and staff to
reference and use.
Designated
Department
Nursing Staff
Corporate
Communications/
Heads of
Departments/Lead
Nurses
Action required
Nursing and Domestic staff
continue to maintain a clutter free
environment.
The ward manager and Deputy
managers monitor daily.
Trust is continuously reviewing
leaflet content and availability
through the analysis of patient
and client experience
questionnaires
Date for
Completion
Timescale
Daily
Monitoring in
place
Actioned
6 Detailed nursing cleaning schedules,
outlining staff roles and responsibilities
should further be developed.
7 The trust should ensure a standard drugs
fridge temperature recording sheet is
developed for staff to use.
8 The trust should ensure that clean linen
and linen equipment are fit for purpose.
Nursing
Pharmacy
Linen
Services/Nursing
Availability of leaflets is also
monitored at ward level during
audits and walkabouts
Lead nurses will support ward
managers to ensure that cleaning
schedules have been developed
and implemented where
necessary
Recording sheet to be developed
and issued to all relevant areas
Ward managers/head of service
to monitor usage
Linen services manager is
responsible for ensuring clean
linen is fit for purpose when
issued. Ward staff are responsible
for identifying items that need
repair/disposal.
September
2012
September
2012
September
2012
Staff to be reminded of their
responsibilities
30

Reference
Number
Recommendations
9 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
Monthly
meetings
Daily/As
required
Discussed at
Safety
Briefings
10 The trust should ensure that waste bins
and equipment used in the management of
waste and sharps are clean and that waste
bins are available and fit for purpose.
11 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.
Domestic/
Nursing
Domestic/
Infection
Prevention
Control/Estates
waste officer
Estates waste manager provides
training on regular basis.
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.
Actioned and
process is
ongoing
Actioned
Ongoing
audits
12 The trust and individual staff have a
collective responsibility to ensure that
patient equipment is clean, used correctly
and in a good state of repair.
Domestic/Nursing
Staff are aware that noncompliance
to policies regarding
this area could result in
disciplinary action
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
Actioned
31

Reference
Number
Recommendations
13 The trust and individual staff have a
collective responsibility to ensure that staff
knowledge is kept up to date regarding
equipment cleaning.
14 The trust should ensure that hand washing
sinks and consumables are clean,
adequately stocked and fit for purpose.
15 The trust should ensure that all cleaning
products are stored in line with COSHH
regulations.
16 The trust and individual staff have a
collective responsibility to ensure that staff
knowledge is kept up to date in the use of
general cleaning products.
Designated
Department
Domestic/Nursing
Domestic
Services/Estates
Services
Action required
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.
Estates services are carry out a
replacement programme of any
sinks found to be unfit for purpose
Domestic Services Domestic supervisors will check
on a daily basis as part of the
daily observational checklist that
all cleaning products are stored in
Domestic/
Nursing
line with COSHH regulations.
Training is given to all relevant
staff in the usage and storage of
cleaning products as part of their
induction.
Additional training is provided if
products change
Date for
Completion
Timescale
Actioned
Actioned
Ongoing
Actioned
Ongoing
Actioned
32

Reference
Number
Recommendations
17 The trust and individual staff have a
collective responsibility to ensure that hand
hygiene is carried out in line with WHO
guidance.
18 The trust and individual staff have a
collective responsibility to ensure that staff
knowledge is kept up to date with regard to
products used for the cleaning and
decontamination of equipment and the
environment.
19 The trust should ensure that all members of
staff are familiar with and adhere to the
regional dress code policy.
Designated
Department
Domestic/
Nursing/
Other disciplines
Nursing/Other
disciplines
All disciplines
Action required
Hand hygiene monitored at ward
level. Performance contained
within Trust Board reports. Staff
found to be non-compliant are
retrained
Relevant directors will 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
Date for
Completion
Timescale
Actioned
August 2012
Actioned
Any revisions to current policy are
issued on a cascade basis via
directors for discussion with staff
at team/ward/departmental
meetings
33