Muckamore Abbey Hospital, Antrim - Regulation and Quality ...

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Muckamore Abbey Hospital, Antrim - Regulation and Quality ...

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Belfast Health and Social Care Trust

Muckamore Abbey Hospital

4 January 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 13

6.4 Fixture and Fittings 13

6.5 Information 14

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

12.0 Key Personnel and Information 23

13.0 Summary of Recommendations 24

14.0 Unannounced Inspection Flowchart 25

15.0 RQIA Hygiene Team Escalation Policy Flowchart 26

16.0 Action Plan 27


1.0 Inspection Summary

An unannounced inspection was undertaken to Muckamore Abbey

Hospital, on the 5 January 2012. The hospital was assessed against

the Regional Healthcare Hygiene and Cleanliness standards and the

following areas were inspected:

Finglass Ward

Finglass is a 20 bed male ward situated on the Muckamore Abbey

Hospital site and is part of the Belfast Health and Social Care Trust.

The ward provides single storey accommodation to adult patients with

a learning disability, some of whom also present with challenging

behaviours.

The ward is situated in one of the old ‘villas’ which had been closed in

the past but reopened to accommodate patients from other wards that

have since closed.

Patients range in age from their 30’s to late 60’s and most patients

have been receiving in patient care on the hospital site for several

years, some for decades.

The inspectors were advised by the hospital management team that

the ward is scheduled for closure within the next six months.

Inspection Outcomes

The results of the inspection showed compliance in all but one of the

standards. Greater attention is required in relation to cleaning,

particularly in sanitary areas and the dusting of surfaces. Issues

highlighted in the minimally compliant waste section could be

addressed quickly to achieve a compliant score. The introduction and

monitoring of a nurse cleaning schedule should also improve the

patient equipment cleaning standard.

The maintenance and repair of the ward should still be maintained until

the ward is closed.

The inspection team noted that several of the recommendations

highlighted during an RQIA Mental Health and Learning Disability

Team inspection carried out in September 2011 were still outstanding.

The trust should take action to address these issues as a matter of

urgency.

The inspection resulted in 15 recommendations for Muckamore Abbey

Hospital, a full list of recommendations is listed in Section 13.

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

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

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action on identified areas which have achieved non complaint scores.

The draft report which includes the high level recommendations in a

Quality Improvement Plan is forwarded within 28 days of the inspection

for agreement and factual accuracy. The draft report is agreed and a

completed action plan is returned to RQIA within 14 days from the date

of issue. The detailed list of preliminary findings is available from RQIA

on request.

The final report and Quality Improvement Plan will be available on the

RQIA website. Reports and action plans will be subject to performance

management by the Health and Social Care Board and the Public

Health Agency.

Notable Practice

The inspection identified the following areas of notable practice:

There was good documentation and information available for

support services staff on cleaning practices

The ward manager was in the process of reviewing and

indexing policies and guidelines for easier staff reference

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

Abbey 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 79

Patient Linen 89

Waste 71

Sharps 79

Equipment 77

Hygiene Factors 86

Hygiene Practices 92

Average Score 82

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 2

General Environment

Reception 84

Corridors, stairs lift 82

Public toilets

N/A

Ward/department -

general (communal)

68

Patient bed area 79

Bathroom/washroom 57

Toilet 75

Clinical room/treatment

room

80

Clean utility room 90

Dirty utility room

N/A

Domestic store 76

Kitchen 94

Equipment store

N/A

Isolation

N/A

General information 81

Average Score 79

Table 3

Patient Linen

Storage of clean linen 85

Storage of used linen 92

Laundry facilities

N/A

Average Score 89

Table 4

Waste and Sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

71

79

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 5

Patient Equipment

Patient equipment 77

Table 6

Hygiene Factors

Availability and

cleanliness of wash hand 77

basin and consumables

Availability of alcohol rub 83

Availability of PPE 92

Materials and equipment

for cleaning

93

Average Score 86

Table 7

Hygiene Practices

Effective hand hygiene

procedures

91

Safe handling and

disposal of sharps

100

Effective use of PPE 100

Correct use of isolation

N/A

Effective cleaning of ward 81

Staff uniform and work

wear

88

Average Score 92

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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2.0 Background Information to the Inspection Process

RQIA’s infection prevention and hygiene team was established to

undertake a rolling programme of unannounced inspections of acute

hospitals. The Department of Health Social Service and Public Safety

(DHSSPS) commitment to a programme of hygiene inspections was

reaffirmed through the launch in 2010 of the revised and updated

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

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

in Northern Ireland.

The aims of the inspection process are:

to provide public assurance and to promote public trust and

confidence

to contribute to the prevention and control of HCAI

to contribute to improvement in hygiene, cleanliness and infection

prevention and control across health and social care in Northern

Ireland

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

transparent method for inspection, using standardised processes and

documentation.

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3.0 Inspections

The DHSSPS has devised 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.

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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.

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6.0 Environment

STANDARD 2.0

GENERAL ENVIRONMENT

Cleanliness and state of repair of public areas; cleanliness and

state of repair of ward/department infrastructure; cleanliness and

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

of toilets, bathrooms and washrooms; cleanliness and state of

repair of ward/department facilities; availability and cleanliness of

isolation facilities; provision of information for staff, patients and

visitors.

General Environment

Reception 84

Corridors, stairs lift 82

Public toilets

N/A

Ward/department -

general (communal)

68

Patient bed area 79

Bathroom/washroom 57

Toilet 75

Clinical room/treatment

room

80

Clean utility room 90

Dirty utility room

N/A

Domestic store 76

Kitchen 94

Equipment store

N/A

Isolation

N/A

General information 81

Average Score 79

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 three

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 is required when cleaning. Throughout the

wards the inspectors noted dust and cobwebs on high surfaces, in

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particularly around windows frames. Many of the ceiling light fittings

had debris present, some of the air vents were dusty, and windows

were in general dirty.

In both the dining room and bed dormitory the high and low surfaces

were dusty and the external and internal windows were dirty. In the

dining room inspectors noted tables which had been cleaned after

breakfast were streaked and stained; the edges and underside had

food residue present. The dining room chairs were also stained and

there was dirt in the crevices. In the dormitory the base of the beds

and the portable privacy screen were dusty.

The ward has a lobby area off which are the central toilets, bathroom

and shower room. At the bottom of each of the two dormitories there

are an additional two combined shower and toilet rooms. A single

patient toilet is located off the reception area. In total there are eight

toilets, five showers and a bathroom which is in line with HBN 11-0.

The bathroom/washroom and toilets both received a minimally

compliant score and similar cleaning issues were observed in all

sanitary areas. The tiled walls were stained and the grout between the

tiles was dirty. There was a lack of ventilation in the shower rooms

therefore condensation and mould was noted on the walls and window

frames. The underside of the shower chairs and the bath hoist were

stained. In a shower room the inspectors observed a plastic basket on

the work surface beside the sink, the basket contained numerous

toiletries.

Picture1: Communal toiletries

Some of the toiletries had been labelled in pen with patient initials

others had not, a single comb was observed on the hand washing sink.

The storage of personal toiletries in one basket is not recommended as

it could encourage communal use. This issue had been highlighted

during a RQIA Mental Health and Learning Disability Team inspection

carried out in September 2011.

In the shower room off one of the dormitory’s the vinyl floor coving was

dirty and the grill on the floor drain under the shower had a build up of

debris present. The shower chair was stained and the underside of the

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frame was very badly rusted, the inspectors asked for the chair to be

removed immediately.

In the bathroom there were several denture containers which had

paper identification labels insitu, paper labels are a barrier to an

effective cleaning process. The crevices of a metal framed dining room

chair and the top of a step stool were dirty. The chair is not suitable for

use in a bathroom. A wet bath mat which was stained, and showing

signs of wear was lying on the floor. A plastic water jug was observed

on the bath and was used to hold a bath plug; the inside of the jug was

dirty. A pair of patients slippers were sitting on top of a inco pad on a

shelf.

In the toilet inspected, there was debris in the light fitting and the air

vent was dusty. The vinyl flooring was dirty and discoloured around

and behind the toilet.

The clinical room is small and does not have a dedicated work surface

for clinical procedures. The room has been fitted with metal cupboards

which are in good repair, however the internal surfaces of the lower

shelves and drawers were dusty and the wooden wall mounted shelves

were showing signs of wear. The crevices of a metal frame chair were

dirty. Inspectors noted that the temperature of the drugs fridge was 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.

The kitchen is a good size, and had previously been used as a food

production kitchen. The cupboards and walls were finished in stainless

steel. The cleaning issues identified were in relation to the inaccessible

areas such as skirting under shelves were dusty, there was some

debris on the floor under the kitchen units and there were finger marks

on the internal windows.

In the domestic store the sluice sink required cleaning and personal

staff clothes were observed.

6.2 Clutter

Inspectors observed that the ward was generally clutter free with the

exception of the clinical and clean utility room. The patients bed areas

have been personalised and day spaces were comfortable and well

furnished.

There is sufficient storage for the needs of the ward. However, the

clinical room is small and space limited, the storage of equipment in

this room should be reviewed and unwanted items disposed of. The

clean utility room is a good size and has been well furnished with

cupboards. There was a large amount of stock stored in cupboards,

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drawers and free standing units, boxes of stock were stored on work

surfaces and on the floor. The inspectors recommend that these areas

are de-cluttered and the ordering of stock reviewed to avoid

overstocking.

6.3 Maintenance and Repair

The building has had some refurbishment, sanitary areas were

upgraded but the vinyl flooring was in need of repair as several weld

joints were damaged or missing. When floors are damaged they are

not impervious to water and can not be effectively cleaned. The

painted wood finishes around the hand wash sinks and baths were

flaking and worn, surfaces need to have a cleanable finish. Through

out the ward there were holes in the walls where fitting had been

removed and broken wall tiles in the domestic store had been repaired

with cement but not sealed.

In one of the shower rooms the shower fitting holder was missing and

the shower hose was hanging down. The inspectors were advised this

was under review and being risk assessed. In the other showers the

fittings had been recessed into the plaster work behind the tiles. This

issue had also been raised at the RQIA Mental Health and Learning

Disability Team inspection carried out in September 2011.

Picture 2: Dirty floor drain

Picture 3: Rusted underside of

shower chair

6.4 Fixtures and Fittings

The ward had an eclectic mix of furniture, acquired following closures

of other wards on site. While some was of a good quality other pieces

require re-sealing and varnishing to provide a surface which can be

effectively cleaned.

Notice boards were finished in felt or cork, which can not be effectively

cleaned.

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6.5 Information

Cleaning schedules for nursing staff detailing all equipment and staff

responsibilities were not available. Information leaflets for visitors on

general infections and MRSA and Clostridium difficile were not

available. A poster on the colour coding of cleaning equipment was

displayed at the reception area of the ward, however some nursing

staff were not able to describe the correct colour coding to the

inspectors.

Addition Issues

The RQIA Mental Health and Learning Disability Team inspection

carried out in September 2011 and highlighted the lack of privacy

screens between beds and that the shower rooms did not have

enhanced privacy measures. These recommendations have not been

actioned.

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. Detailed nursing cleaning schedules should be developed.

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

importance of monitoring drug fridge temperature

consistently.

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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.

7.1 Management of Linen

Both sections were compliant in the storage of clean and used linen.

There were some areas identified for improvement such as the storage

of clean linen on unsealed wooden shelves these require sealing to

provide a cleanable surface.

There was a mix of traditional flat white linen and new sleep knit

bedding, some pieces of the flat linen inspected were frayed. The

inspectors observed bundles of towels stored in sanitary areas. The

towels were stored on open trolleys and therefore exposed to possible

aerosol contamination.

Boxes containing freshly laundered patients personal clothes were

noted on the floor of the central sanitary lobby, the boxes were over

flowing and as a result clothing was spilling directly on to the floor.

Used linen skips were also stored in this area, the frame of the skips

were dusty and required cleaning.

Recommendations

Patient Linen

Storage of clean linen 85

Storage of used linen 92

Laundry facilities

N/A

Average Score 89

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

designated area which is clean and fit for purpose.

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8.0 Waste and Sharps

STANDARD 4.0

WASTE AND SHARPS

Waste: Effectiveness of arrangements for handling, segregation,

storage and disposal of waste on ward/department

Sharps: Availability, use and storage of sharps containers on

ward/department

Waste and Sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

71

79

8.1 Waste

The standard on the handling, segregation, storage and disposal of

waste received a minimally compliant score. Inspectors observed that

household waste bins were not available in the bathroom, clean utility

room or shower rooms. Two of the waste bins in the central sanitary

area which leads to the bathroom showers and toilets did not have a

bin liner bag, this was rectified during the morning. The front of these

bins were stained. The lid and base of the waste bin in the shower

room off the dormitory was rusty.

In the treatment room, paper packaging had been disposed of

incorrectly in sharps boxes.

8.2 Sharps

The standard on use and storage of sharps was partially compliant.

None of the sharps boxes inspected had the temporary closure

mechanism in place and a sharps box was not signed. There were

sharps boxes in the bathroom and shower rooms these were used for

the disposal of razor heads, the boxes were sitting on a shelf but were

not secured. Inspectors were advised at the feed back session that

patients do not enter these areas unaccompanied and a risk

assessment had been completed at ward level.

A sharps tray in the clinical room had adhesive tape attached, tape will

act as a barrier to effective cleaning and should be removed.

Recommendations

6 Waste bins should be available, clean and in good repair.

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7 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.

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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 77

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 is held in a small clinical room. The ward has

recently received a resuscitation bag and all the equipment in the bag

was in date and within sterile packaging. However the old resuscitation

tray was still present and contained Magills forceps and a laryngoscope

blade which had been removed from the sterile packaging. An old

ambu bag in an open plastic bag was grubby and stained.

Picture 4: Old cluttered resuscitation tray

The tray should be removed as it is no longer required and may be

used by staff during an emergency situation.

There were three suction machines, one was an old model which sits

on the floor and requires the containers to be cleaned manually. Staff

should review the need for three machines. The underside frame of

the drugs and dressing trolley were dirty and the mask on the portable

nebulizer was stained. The mask and tubing should be single use if

used for more than one patient or cleaned and changed in accordance

with manufactures guidelines.

Recommendations

8 The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean, in a good state of

repair and changed in line with manufactures guidelines.

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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

77

basin and consumables

Availability of alcohol rub 83

Availability of PPE 92

Materials and equipment

for cleaning

93

Average Score 86

While the standard achieved overall compliance the two sections in

relation to the availability and cleanliness of hand wash sinks and

consumables and the alcohol rub dispensers were partially compliant

and the following areas require improvement.

The hand washing sink in the clinical room and the clean utility room

had a plug and overflow present, both sinks required cleaning and

there was a build up of limescale present on the taps. The sink in the

clinical room was worn and had limescale present on the overflow.

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 (HTM 64).

In all wards there were hand wash sinks that were not plug free, as

hands should be washed under running water, a plug should not be

available. 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.

In the clean utility room access to the hand wash sink was blocked by

boxes of supplies and a nail brush was observed on the sink surround.

Nail brushes should be single use and disposed of immediately after

use. There was a paper towel dispenser but no soap dispenser

available.

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Picture 5: Dirty underside of alcohol dispenser

The underside of the alcohol

dispenser in the central

sanitary area leading to the

toilets and showers was very

dirty and encrusted, the

dispenser nozzle in the

bathroom was blocked, the

underside of the dispenser at

reception and outside the

shower room off the right

dormitory bed area was

stained.

The domestic trolley was old and worn and the red bucket on the trolley

required cleaning. The inspectors observed a red mop bucket and mop

in the clean utility room, both had been used and were dirty. The ward

sister confirmed these were used by nursing staff, it is recommended

that they are included in the daily routine for changing mop heads and

that the buckets are cleaned and dried after each use.

Recommendations

9 The trust should ensure that hand washing sinks and

consumables are available, clean and in a good state of

repair.

10 Equipment used for the general cleaning of a ward should be

clean, and fit for purpose.

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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

91

Safe handling and

disposal of sharps

100

Effective use of PPE 100

Correct use of isolation

N/A

Effective cleaning of ward 81

Staff uniform and work

wear

88

Average Score 92

Due to the nature of the ward the inspectors observed minimal hygiene

practices. The inspectors used questions to test staff knowledge.

Compliant scores were achieved in all but one section, the section on

effective cleaning which was partially complaint.

There was no evidence to indicate patient equipment was routinely

cleaned between patient use, the ward sister stated there were no

formal nursing cleaning schedules. Staff duty sheets were used to

indicated staff responsibilities for cleaning ward areas however these

did not detail all equipment used at ward level. Domestic cleaning

schedules were in place, both nursing and domestic cleaning schedules

need to be reviewed and monitored to ensure cleaning issues

highlighted in the environment section are on a cleaning programme

and cleaned appropriately.

In relation to hand hygiene when questioned not all staff were aware of

the seven step technique for hand washing; one staff member stated

four steps. The ward does not carry out hand hygiene audits, but at the

feedback session the member of staff from the Infection Prevention and

Control team advised that a suitable audit tool for areas, where there

would be limited observation opportunities, was under development.

When questioned nursing staff were not fully aware of the correct

dilution rates for disinfectants in use or aware of the correct colour

coding system in place for cleaning equipment.

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There was a staff locker room, but the ward does not have changing

facilities for staff.

Recommendations

11 The trust should ensure that staff knowledge and practice is

kept up to date in relation to the dilution rates for

disinfectants in use.

12 Detailed nursing schedules should be developed to ensure

all equipment and staff responsibilities are defined.

13 Hand hygiene audits should be commenced and the

information displayed.

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12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs S O'Connor - Inspector Infection Prevention/Hygiene Team

Mrs M Keating - Inspector Infection Prevention/Hygiene Team

Trust representatives attending the feedback session

M Mannion - Co - Director Education Nursing

E Rafferty - Service Manager Muckamore Abbey Hospital

E McLarnon - Senior Nurse Manager

R Davey - Support services Manager

D Hamill - Estates Service Manager

M O’Boyle - Ward Sister

R Gillan - Infection Prevention and Control

R Wilson - Assistant Support Service 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. Detailed nursing cleaning schedules should be developed.

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

importance of monitoring drug fridge temperature

consistently.

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

designated area which is clean and fit for purpose.

6. Waste bins should be available, clean and in good repair.

7. 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.

8. The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean, in a good state of

repair and changed in line with manufactures guidelines.

9. The trust should ensure that hand washing sinks and

consumables are available, clean and in a good state of

repair.

10. Equipment used for the general cleaning of a ward should be

clean, and fit for purpose.

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

kept up to date in relation to the dilution rates for

disinfectants in use.

12. Detailed nursing schedules should be developed to ensure

all equipment and staff responsibilities are defined.

13. Hand hygiene audits should be commenced and the

information displayed.

24


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

25


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

26


16.0 Action Plan

Ref No. Recommendations Designated

department

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.

Nursing

PCSS

IPC

Action required

‘Roles and responsibilities of Staff in

relation to Environmental Cleanliness and

Cleanliness of Equipment’ policy under

review.

The consultation process in relation to the

cleaning manual has resulted in requests

for significant changes to the content and

format. Work is ongoing to have a revised

final consultation document by February

2012.

Date for

completion/

timescale

Mar 2012

Feb 2012

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

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.

This is ongoing as part of Estate daily

maintenance and refurbishment

programmes.

Ongoing

Ongoing

3. Detailed nursing cleaning schedules should be

developed.

Nursing

IPECC

A sub-group of IPECC (Infection

Prevention & Environment and

Cleanliness Committee) will be set up to

review and standardise cleaning

schedules, and will establish any

outstanding issues of audit

standardisation process.

Feb 2012

Agree a standardised audit which will be

used in all areas. This will include

standardised responsibilities. To be kept

under review.

Commencing

Feb 2012

27


Ref No. Recommendations Designated

department

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

importance of monitoring drug fridge temperature

consistently.

5. The trust should ensure the correct storage of clean linen

in designated area which is clean and fit for purpose.

Nursing

Nursing

6. Waste bins should be available, clean and in good repair. PCSS

Nursing

Action required

Systematic roll out of the agreed

standardised audit using the Maximiser

system.

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.

Guidance regarding storage of linen is in

the Regional Infection Prevention Manual.

Linen storage and segregation guidance

has been circulated to all Directorates.

This states that all linen must be stored off

the floor in a clean dedicated area that

allows for ease of access and rotation of

stock and that Linen rooms must have

shelving that are easy to clean, and

cleaning frequencies must be at least

quarterly.

This is monitored as part of the

Environmental Cleanliness Audit

Programme.

Regional contract for bins at adjudication

stage.

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial

audits, and IPC audits monitor

compliance.

Date for

completion/

timescale

Ongoing

Complete

Ongoing

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

28


Ref No. Recommendations Designated

department

rectification.

Action required

Date for

completion/

timescale

7. 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.

8. The trust and individual staff have a collective

responsibility to ensure that patient equipment is clean, in

a good state of repair and changed in line with

manufactures guidelines.

PCSS

Nursing

Nursing

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).

Daniels’ audit completed Oct 2011 and

results disseminated.

The consultation process in relation to the

cleaning manual has resulted in requests

for significant changes to the content and

format. Work is ongoing to have a revised

final consultation document by February

2012.

Pilot

completed

Roll-out

programme

across Trust to

be completed

by Apr 2012

Complete

Feb 2012

9. The trust should ensure that hand washing sinks and

consumables are available, clean and in a good state of

repair.

PCSS

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.

This is monitored as part of the

Environmental Cleanliness Audit

Programme. Staff are reminded of the

importance of replenishing dispensers.

Ongoing

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial

audits, and IPC audits monitor

compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

29


Ref No. Recommendations Designated

department

Action required

appropriate department to ensure

rectification.

Date for

completion/

timescale

10. Equipment used for the general cleaning of a ward should

be clean, and fit for purpose.

Nursing

PCSS

Regular training is provided to all

appropriate staff.

The consultation process in relation to the

cleaning manual has resulted in requests

for significant changes to the content and

format. Work is ongoing to have a revised

final consultation document by February

2012.

Feb 2012

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial

audits, and IPC audits monitor

compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

11. The trust should ensure that staff knowledge and practice

is kept up to date in relation to the dilution rates for

disinfectants in use.

12. Detailed nursing schedules should be developed to

ensure all equipment and staff responsibilities are

defined.

Nursing

Nursing

IPECC

Regular training is provided to all

appropriate staff.

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.

A sub-group of IPECC (Infection

Prevention & Environment and

Cleanliness Committee) will be set up to

review and standardise cleaning

schedules, and will establish any

outstanding issues of audit

standardisation process.

Completed and

ongoing

Feb 2012

30


Ref No. Recommendations Designated

department

Action required

Agree a standardised audit which will be

used in all areas. This will include

standardised responsibilities. To be kept

under review.

Date for

completion/

timescale

Commencing

Feb 2012

13. Hand hygiene audits should be commenced and the

information displayed.

Nursing

IPECC

Systematic roll out of the agreed

standardised audit using the Maximiser

system.

Once the audit tool for non-acute wards

and departments has been developed and

agreed, audits will be commenced and

information displayed as appropriate.

Jun 2012

31

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