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
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Level of Compliance
Percentage scores can be allocated a level of compliance using the
compliance categories below. The categories are allocated as follows:
Compliant
85% or above
Partial compliance 76 to 84%
Minimal compliance 75% or below
Each section within the audit tool will receive an individual and an
overall score, to identify areas of partial or minimal compliance to
ensure that the appropriate action is taken.
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6.0 Environment
STANDARD 2.0
GENERAL ENVIRONMENT
Cleanliness and state of repair of public areas; cleanliness and
state of repair of ward/department infrastructure; cleanliness and
state of repair of patient bed area; cleanliness and state of repair
of toilets, bathrooms and washrooms; cleanliness and state of
repair of ward/department facilities; availability and cleanliness of
isolation facilities; provision of information for staff, patients and
visitors.
General Environment
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