South Tyrone Hospital, 29 May 2012 - Regulation and Quality ...

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South Tyrone Hospital, 29 May 2012 - Regulation and Quality ...

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Southern Health and Social Care Trust

South Tyrone Hospital

29 May 2012


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 5

3.0 Inspections 6

4.0 Unannounced Inspection Process 7

4.1 Onsite Inspection 7

4.2 Feedback and Report of the Findings 7

5.0 Audit Tool 8

6.0 Environment 10

6.1 Cleaning 10

6.2 Clutter 11

6.3 Maintenance and Repair 12

6.4 Fixture and Fittings 12

6.5 Information 12

7.0 Patient Linen 13

7.1 Management of Linen 13

8.0 Waste and Sharps 14

8.1 Waste 14

8.2 Sharps 15

9.0 Patient Equipment 16

10.0 Hygiene Factors 17

11.0 Hygiene Practice 18

12.0 Key Personnel and Information 19

13.0 Summary of Recommendations 20

14.0 Unannounced Inspection Flowchart 21

15.0 RQIA Hygiene Team Escalation Policy Flowchart 22

16.0 Action Plan 23


1.0 Inspection Summary

An unannounced inspection was undertaken to the South Tyrone

Hospital, on the 29 May 2012. The hospital was assessed against the

Regional Healthcare Hygiene and Cleanliness standards and the

following area was inspected:

Ward 2 - Rehabilitation

Ward 2, a twenty two bedded ward, is located in Loane House, the

rehabilitation unit within the grounds of South Tyrone Hospital

Dungannon. Admission to the ward is made through the acute services

and G.P. referrals.

Inspection Outcomes

The inspectors were impressed with the close working relationship

between nursing, domestic services, estates and allied health

professional staff in relation to environmental cleanliness and infection

prevention and control. The results of the inspection showed

compliance in all the standards, for which staff are to be commended.

Cleaning by all staff was of a good standard and all were aware of their

roles and responsibilities in maintaining a clean patient environment.

Ward 2 had been refurbished and was in good decorative order.

The inspection resulted in 12 recommendations for the South Tyrone

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

A detailed list of preliminary findings is forwarded to the Southern

Health and Social Care Trust within 14 days of the inspection to enable

early action on identified areas which have achieved non complaint

scores. The draft report which includes the high level recommendations

in a Quality Improvement Plan is forwarded within 28 days of the

inspection for agreement and factual accuracy. The draft report is

agreed and a completed action plan is returned to RQIA within 14 days

from the date of issue. The detailed list of preliminary findings is

available from RQIA on request.

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

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

management by the Health and Social Care Board and the Public

Health Agency.

1


Notable Practice

The inspection identified the following areas of notable practice:

There were good posters and information on donning and

removing PPE

There was a good process in place for requesting a terminal

clean, signed off by nursing staff when complete

Independent inspections were carried out by trust staff in

January and May 2012, using the Regional Healthcare Hygiene

and Cleanliness Audit tool

Following an outbreak of Norovirus, 18 months ago, a lesson

learned review was undertaken. Staff found this was very

effective and assisted in containing and dealing with a recent

Norovirus outbreak.

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

Tyrone 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 Ward 2

General environment 90

Patient linen 94

Waste 88

Sharps 96

Equipment 96

Hygiene factors 99

Hygiene practices 97

Average Score 94

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

2


Table 2

General Environment

Reception 90

Corridors, stairs lift 86

Public toilets

N/A

Ward/department

general (communal)

90

Patient bed area 93

Bathroom/washroom 90

Toilet 96

Clinical room/treatment

room

89

Clean utility room 85

Dirty utility room 87

Domestic store 98

Kitchen 84

Equipment store 93

Isolation 92

General information 90

Average Score 90

Table 3

Patient Linen

Storage of clean linen 88

Storage of used linen 100

Laundry facilities

N/A

Average Score 94

Table 4

Waste and Sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

88

92

Table 5

Patient Equipment

Patient equipment 96

3


Table 6

Hygiene Factors

Availability and

cleanliness of wash hand 97

basin and consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

98

Average Score 99

Table 7

Hygiene Practices

Effective hand hygiene

procedures

100

Safe handling and

disposal of sharps

100

Effective use of PPE 100

Correct use of isolation 94

Effective cleaning of ward 89

Staff uniform and work

wear

97

Average Score 97

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

4


2.0 Background Information to the Inspection Process

RQIA’s infection prevention and hygiene team was established to

undertake a rolling programme of unannounced inspections of acute

hospitals. The Department of Health Social Service and Public Safety

(DHSSPS) commitment to a programme of hygiene inspections was

reaffirmed through the launch in 2010 of the revised and updated

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

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

in Northern Ireland.

The aims of the inspection process are:

to provide public assurance and to promote public trust and

confidence

to contribute to the prevention and control of HCAI

to contribute to improvement in hygiene, cleanliness and infection

prevention and control across health and social care in Northern

Ireland

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

transparent method for inspection, using standardised processes and

documentation.

5


3.0 Inspections

The DHSSPS has devised Regional Healthcare Hygiene and

Cleanliness standards. RQIA has revised its inspection processes to

support the publication of the standards which were compiled by a

regional steering group in consultation with service providers.

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

programme which includes announced and unannounced inspections

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

compliance with the DHSSPS Regional Healthcare Hygiene and

Cleanliness standards.

The inspections will be undertaken in accordance with the four core

activities outlined in the RQIA Corporate Strategy, these include:

Improving care: we encourage and promote improvements in the

safety and quality of services through the regulation and review of

health and social care

Informing the population: we publicly report on the safety,

quality and availability of health and social care

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

using health and social care services

Influencing policy: we influence policy and standards in health

and social care

6


4.0 Unannounced Inspection Process

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

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

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

inspection flow chart is attached in Section 14.

4.1 Onsite Inspection

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

infection prevention/hygiene team. One inspector led the team and

was responsible for guiding the team and ensuring they were in

agreement about the findings reached. Membership of the inspection

team is outlined in Section 12.

The inspection of ward environments is carried out using the Regional

Healthcare Hygiene and Cleanliness audit tool. The inspection

process involves observation, discussion with staff, and review of some

ward documentation.

4.2 Feedback and Report of the Findings

The process concludes with a feedback of key findings to trust

representatives including examples of notable practice identified during

the inspection. The details of trust representatives attending the

feedback session is outlined in Section 12.

The findings, report and follow up action will be in accordance with the

Infection Prevention/Hygiene Inspection Process (methodology, follow

up and reporting).

The infection prevention/hygiene team escalation process will be

followed if inspectors/reviewers identify any serious concerns during

the inspection (Section 15).

A number of documents have been developed to support and explain

the inspection process. This information is currently available on

request and will be available in due course on the RQIA website.

7


5.0 Audit Tool

The audit tool used for the inspection is based on the Regional

Healthcare Hygiene and Cleanliness standards. The standards

incorporate the critical areas which were identified through a review of

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

Healthcare Hygiene and Cleanliness standards). The audit tool follows

the format of the Regional Healthcare Hygiene and Cleanliness

Standards and comprises of the following sections.

1. Organisational Systems and Governance: policies and

procedures in relation to key hygiene and cleanliness issues;

communication of policies and procedures; roles and

responsibilities for hygiene and cleanliness issues; internal

monitoring arrangements; arrangements to address issues

identified during internal monitoring; communication of internal

monitoring results to staff

This standard is not audited when carrying out unannounced

inspections however the findings of the organisational system

and governance at annual announced inspection will be,

where applicable, confirmed at ward level.

2. General Environment: cleanliness and state of repair of public

areas; cleanliness and state of repair of ward/department

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

cleanliness and state of repair of toilets, bathrooms and

washrooms; cleanliness and state of repair of ward/department

facilities; availability and cleanliness of isolation facilities; provision

of information for staff, patients and visitors

3. Patient Linen: storage of clean linen; handling and storage of

used linen; ward/department laundry facilities

4. Waste and Sharps: waste handling; availability and storage of

sharps containers

5. Patient Equipment: cleanliness and state of repair of general

patient equipment

6. Hygiene Factors: hand wash facilities; alcohol hand rub;

availability of personal protective equipment (PPE); availability of

cleaning equipment and materials.

7. Hygiene Practices: hand hygiene procedures; handling and

disposal of sharps; use of PPE; use of isolation facilities and

implementation of infection control procedures; cleaning of

ward/department; staff uniform and work wear.

8


Level of Compliance

Percentage scores can be allocated a level of compliance using the

compliance categories below. The categories are allocated as follows:

Compliant

85% or above

Partial compliance 76% to 84%

Minimal compliance 75% or below

Each section within the audit tool will receive an individual and an

overall score, to identify areas of partial or minimal compliance to

ensure that the appropriate action is taken.

9


6.0 Environment

STANDARD 2.0

GENERAL ENVIRONMENT

Cleanliness and state of repair of public areas; cleanliness and

state of repair of ward/department infrastructure; cleanliness and

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

of toilets, bathrooms and washrooms; cleanliness and state of

repair of ward/department facilities; availability and cleanliness of

isolation facilities; provision of information for staff, patients and

visitors.

General Environment

Reception 90

Corridors, stairs lift 86

Public toilets

N/A

Ward/department -

general (communal)

90

Patient bed area 93

Bathroom/washroom 90

Toilet 96

Clinical room/treatment

room

89

Clean utility room 85

Dirty utility room 87

Domestic store 98

Kitchen 84

Equipment store 93

Isolation 92

General information 90

Average Score

The above table outlines the findings in relation to the general

environment of the facility inspected. The findings indicate only one

section highlighted in amber which was partially compliant, all other

sections within the standard were compliant. Staff are to be

commended on these scores.

6.1 Cleaning

The inspection evidenced there was good compliance with regional

specifications for cleaning. Inspectors observed that cleaning

mechanisms were implemented to prevent the build up of dust, debris

and bacteria and subsequently reduce the potential risk for the

transmission of infection.

90

10


The ward was bright and well

presented (Picture 1).

Cleaning by domestic, nursing

and occupational therapy staff

was to a good standard. Staff

were aware of their roles and

responsibilities, with the

emphasis on team working,

Picture 1: Clean and tidy side bed room

However there were a few common areas throughout the unit which

required more detailed cleaning. For example in some areas there

were cobwebs in the corners of walls just above skirting and around

light fittings and window frames.

In the treatment room the inside of the drugs fridge was dusty; staff

were unsure of the origin of the dust and were to ask the estates and

pharmacy staff to investigate. The temperature records had not been

completed consistently. It is advised that fridge 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.

In the kitchen, the hand touch points on the fridge door and the outside

of the dishwasher required cleaning. The inside of the fridge also

required cleaning as dried food deposits were noted on the shelves.

The microwave was stained and the frame was rusted, staff advised

that a new microwave had been ordered.

6.2 Clutter

The ward was free of clutter,

staff were aware of the need

to maintain an environment

which facilitates the cleaning

process. (Picture 2)

Picture 2: Clutter free dirty utility room

11


6.3 Maintenance and Repair

The ward had been refurbished approximately two years ago and was

in good decorative order. A number of ceiling strip light bulbs were not

working and there was some minor damage to doors and walls in the

ward. The estates department carry out an on-going programme of

repair and painting. The vinyl floor at the entrance to the unit was

bubbled and lifting in places, staff stated that this was an on going

issue which they were trying to resolve.

6.4 Fixtures and Fittings

In general there were no major issues with fixtures and fittings;

however the inspectors did note that some of the plastic bed rails were

worn. The chairs at the nurse’s station were finished in fabric and were

worn and damaged. A number of notice boards in the ward were also

finished in fabric. Fabric material cannot be effectively cleaned.

6.5 Information

Information leaflets had been removed as part of the terminal clean

carried out following the recent Norovirus outbreak and leaflet racks

were being replenished during the inspection. However there was no

NPSA colour coded guidelines for equipment or advice poster on the

segregation of used linen displayed for nursing staff.

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

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

importance of accurately monitoring the drugs fridge

temperature

3. The trust should ensure all relevant information is available

for patients, visitors and staff

12


7.0 Patient Linen

STANDARD 3.0

PATIENT LINEN

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

department laundry facilities.

Patient linen

7.1 Management of Linen

Storage of clean linen 88

Storage of used linen 100

Laundry facilities

N/A

Average Score 94

Inspectors observed good staff practice in relation to the handling and

disposal of used linen, staff wore the appropriate PPE and brought the

used linen trolley to the bedside. This resulted in full compliance for

this section.

In relation to the clean linen section, the inspectors observed, that there

were worn frayed holes in the sheets of a freshly made up bed. The

linen store was neat and tidy; however damage was noted to both the

wooden door and plaster work on the wall.

Recommendations

4. Staff should ensure bed linen is in good repair.

13


8.0 Waste and Sharps

STANDARD 4.0

WASTE AND SHARPS

Waste: Effectiveness of arrangements for handling, segregation,

storage and disposal of waste on ward/department

Sharps: Availability, use and storage of sharps containers on

ward/department

Waste and sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

88

92

8.1 Waste

This section on handling segregation and disposal of waste was

compliant. However the inspectors did observe inappropriate disposal

of waste which was not in line with the trust’s policy. A cytotoxic burn

bin contained bottles of medication, plastic cups, scissors and paper

packaging; this was removed immediately by staff.

The ward has several bays with two hand washing sinks, while each

bay had two household waste bins in some bays they were not always

located beside the hand wash sink. Some of the lids on bins were

damaged.

Picture 3: Damaged lid of bin

14


8.2 Sharps

In the treatment room, sharps trays were clean however they were

stored under the hand towel dispenser and had become splashed.

Staff immediately relocated the trays to another area away from any

potential contamination.

Recommendations

5. Waste bins should be located appropriately, and in a good

state of repair

6. The trust should ensure staff comply with policies in

relation to the safe disposal of waste

15


9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment

Patient equipment

96

Staff are to be commended for achieving a high compliance score. It

was evident that staff had very good cleaning processes in place for

the cleaning of patient equipment. This includes the group of

occupational therapy staff who play a major part in the rehabilitation of

patients on the ward. A daily decontamination schedule has been

devised which details the designated staff member and the cleaning

task to be carried out. A further additional cleaning schedule detailing

each piece of equipment was in the process of being implemented.

There were only two issues which required attention; adhesive tape

residue was noted on the IV stand at a patient’s bedside and on the

patient’s notes and drugs trolley.

Recommendations

7. Staff should ensure all surfaces are cleanable and free from

adhesive tape

16


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 97

basin and consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

98

Average Score 99

There were only three issues in this standard which if addressed would

make the standard fully compliant. The hand wash sinks and taps

were in good repair and the soap and hand towel dispensers in general

were clean. However in the dirty utility room, there was limescale on

the tap of the hand wash sink, and the underside of the hand towel

dispenser was dirty. The chemical cupboard, also in the dirty utility

room, was not locked in line with COSHH regulations.

Both alcohol rub and PPE

stations were available and

located appropriately. There

were posters on the step by

step process to follow when

donning and removing PPE

during an outbreak.

(Picture 4)

Picture 4: Good posters in the use of PPE

Recommendations

8. The trust should ensure that the hand washing sink and

consumables in the dirty utility room are, clean and free

from limescale

17


9. The trust should ensure that all chemicals are stored under

locked conditions in accordance with COSHH regulations

18


11.0 Hygiene Practices

STANDARD 7.0

HYGIENE PRACTICES

Hand hygiene procedures; handling and disposal of sharps; use

of PPE; use of isolation facilities and implementation of infection

control procedures; cleaning of ward/department; staff uniform

and work wear.

Hygiene Practices

Effective hand hygiene

procedures

100

Safe handling and

disposal of sharps

100

Effective use of PPE 100

Correct use of isolation 94

Effective cleaning of ward 89

Staff uniform and work

wear

97

Average Score 97

The first three sections of this standard were fully compliant, the

inspectors noted good hand hygiene practices by all staff and visitors

to the ward. Good practices were also observed in relation to the

wearing of PPE and the safe handling and disposal of sharps.

Inspectors reviewed a care plan of a patient with a known infection and

found there was insufficient detail on the infection prevention and

control measures to be followed by nursing staff.

In relation to the effective cleaning of the ward, COSHH data sheets

were not available for domestic staff and some nursing staff were not

aware of the NPSA colour coded guidelines for cleaning equipment.

A member of medical staff was not compliant with the trust dress code.

Recommendations

10. The trust should ensure the continued development of care

plans that reflect the infection prevention and control needs

of the patient.

11. The trust should ensure appropriate information is available

for staff.

19


12. The trust should ensure that all members of staff are

familiar with and adhere to the trust’s dress code policy.

20


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs L Gawley

Mrs M Keating

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

Trust representatives attending the feedback session

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

representatives:

Ms A McVeigh - Director Older People and Primary Care

Ms R Toner - Assistant Director, Enhanced Services

Ms G Caldwell - Head of Services, Intensive Care Service, /Stroke

and Non Acute hospital

Ms A Carroll - Assistant Director, Support services

Ms B Cullen - Locality Support Services Manager

Ms J Edgar - Ward Manager Ward 2

Mr J McCaughey - Estates officer

Ms K Kelly - Infection Prevention and Control Nurse

Ms T Jackson - Domestic Services Supervisor

Apologies

Dr G Rankin

- Director of Acute Services

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.

21


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

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

importance of accurately monitoring the drugs fridge

temperature

3. The trust should ensure all relevant information is available for

patients, visitors and staff

4. Staff should ensure bed linen is in good repair.

5. Waste bins should be located appropriately, and in a good

state of repair

6. The trust should ensure staff comply with policies in relation

to the safe disposal of waste

7. Staff should ensure all surfaces are cleanable and free from

adhesive tape

8. The trust should ensure that the hand washing sink and

consumables in the dirty utility room are, clean and free from

limescale

9. The trust should ensure that all chemicals are stored under

locked conditions in accordance with COSHH regulations

10. The trust should ensure the continued development of care

plans that reflect the infection prevention and control needs of

the patient.

11. The trust should ensure appropriate information is available

for staff.

12. The trust should ensure that all members of staff are familiar

with and adhere to the trust’s dress code policy.

22


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

23


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

24


16.0 Action Plan

Recommendations

Reference

number

Recommendations

1. The trust should ensure that the systems and

processes in place for environmental cleaning ,

provide the necessary assurance that cleaning is

carried out effectively

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

importance of accurately monitoring the drugs fridge

temperature

3. The trust should ensure all relevant information is

available for patients, visitors and staff

Designated

department

Domestic/

nursing

Nursing staff/

ward sister

Ward sister/

nursing staff

Action required

Monthly environmental cleaning audits

carried out by ward sister and domestic

services, giving feedback to all domestic and

nursing staff on level of compliance

Ward cleaning schedule in operation to be

signed on a daily basis by domestic staff to

confirm cleaning complete. Areas on noncompliance

will be addressed by Domestic

Lead and Ward sister.

Ward sister to communicate to all staff at next

ward meeting. 9/7/12. All staff who are not

present at meeting to sign they have read

same and record to be kept. Designated

nurse to check on a daily basis

All relevant information leaflets have been

reordered following Norovirus deep clean and

are in situ at door to ward.

4. Staff should ensure bed linen is in good repair. Nursing staff. All nursing staff involved in making beds must

use a high standard of bed linen. To be

communicated to staff at next staff meeting

on 9/7/12 and compliance monitored by Ward

sister

5. Waste bins should be located appropriately, and in a

good state of repair

6. The trust should ensure staff comply with policies in

relation to the safe disposal of waste

7. Staff should ensure all surfaces are cleanable and free

from adhesive tape

Ward sister/

domestic staff

Ward sister/

nursing /

domestic staff

Domestic/

nursing staff

Ward sister walked the ward with domestic

staff to confirm location of waste bins+ new

bins ordered to replace damaged bins

Notice re segregation of waste now in sluice

room for all staff. Ward sister to monitor

segregation of waste.

All staff to be aware off domestic and nursing

cleaning schedule. The schedule will be

discussed at ward meeting on 9/7/12 and

monitored by ward sister

Date for

completion/

timescale

Ongoing

9/7/12

5/7/12

29/5/12 ongoing

29/5/12 ongoing

29/5/12

9/7/12

25


Reference

number

Recommendations

8 The trust should ensure that the hand washing sink

and consumables in the dirty utility room are, clean

and free from limescale

9 The trust should ensure that all chemicals are stored

under locked conditions in accordance with COSHH

regulations

10 The trust should ensure the continued development of

care plans that reflect the infection prevention and

control needs of the patient.

11 The trust should ensure appropriate information is

available for staff.

12 The trust should ensure that all members of staff are

familiar with and adhere to the trust’s dress code

policy.

Designated

department

Action required

Domestic staff Lime scale removed on the 30/5/12.

Domestic services manager and ward sister

will provide feedback on Environmental

cleaning audit results to domestic staff re

noncompliance

Ward sister/all

nursing staff

Infection

/prevention

and control +

ward sister

Ward sister/

nursing staff

Ward sister/

nursing/

medical staff

Cupboard locked on 29/5/12. Estates

provided a hook attached to cupboard at a

high level to store key. Reinforce to all staff

that all chemicals must be locked at all times

ie sluice cupboard to be kept locked at all

times. All staff will be informed at ward

meeting on 9/7/12. Compliance monitored by

sister

Ward sister to ensure that all staff are aware

of current care plans re infection control and

expectations of same. The trust revised

MRSA guidance will be launched on the 12

Sept 2012. A IPC master class will be held

on this date to update staff. Ward 2 STH IPC

link nurse will attend and following this with

the ward sister will ensure information is

disseminated to all staff.

All staff are aware that trust information/

policies is on intranet, and have access to

this. Ward sister informs staff of new

policies. Leaflet information restocked

following Norovirus deep clean

Uniform audits being carried out monthly,

noncompliance being addressed immediately

with staff member and a record will be kept

and monitored. Habitual non-compliance will

be addressed through Trust procedures

Date for

completion/

timescale

30/5/12 ongoing

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12 Sept 12

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