Antrim Area Hospital, Antrim - 26 October 2011 - Regulation and ...

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Antrim Area Hospital, Antrim - 26 October 2011 - Regulation and ...

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Northern Health and Social Care Trust

Antrim Area Hospital

26 October 2011


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 5

3.0 Inspections 6

4.0 Unannounced Inspections 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 13

6.5 Information 13

6.6 Additional Issues 14

7.0 Patient Linen 16

7.1 Management of Linen 16

8.0 Waste and Sharps 17

8.1 Waste 17

8.2 Sharps 18

9.0 Patient Equipment 20

10.0 Hygiene Factors 22

11.0 Hygiene Practice 24

12.0 Key Personnel and Information 27

13.0 Summary of Recommendations 29

14.0 Unannounced Inspection Flowchart 31

15.0 RQIA Hygiene Team Escalation Policy Flowchart 32

16.0 Action Plan 33


1.0 Inspection Summary

An unannounced inspection was undertaken to the Antrim Area

Hospital, on the 26 October 2011. The hospital was assessed against

the Regional Healthcare Hygiene and Cleanliness standards and the

following areas were inspected:

A1 – Stroke Unit

A4 – Medicine

B2 – Medicine

C5 – Surgical

Antrim Area Hospital is the largest hospital in the Northern Health and

Social Care Trust (NHSCT) providing a 24 hour Accident and

Emergency Department, inpatient wards and a full range of outpatient

services including diagnostics and rehabilitation.

Inspection Outcomes

The results of the inspection showed all wards achieved an overall

compliance level. Inspectors observed that the environment in general

was clean, however further work is required within the trust to achieve

clutter free ward environments. Observation of staff indicated

compliance with hygiene and infection prevention and control practices

and staff are commended for their commitment to providing a safe and

clean environment for patients.

The inspection resulted in 23 recommendations for the Antrim Area

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

A detailed list of preliminary findings is forwarded to Northern Health

and Social Care Trust (NHSCT) within 14 days of the inspection to

enable early action on identified areas which have achieved non

complaint scores. The 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 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.

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Notable Practice

The inspection identified the following areas of notable practice:

A ward deep cleaning programme is carried out twice yearly

Infection prevention and control link staff are

multidisciplinary; nursing and nursing auxiliary staff

The domestic services staff manual contained useful

information

Implementation of high impact intervention care bundles

An infection prevention and control notice board at ward

entrances displayed scores on environmental cleanliness

and hand hygiene audits for visitors and patients

Feeding assessment aids above patients beds provided

information and a visual trigger for staff on each patient’s

requirements

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

Hospital for their assistance during the inspection.

The following tables give an overview of compliance scores noted in

areas inspected by RQIA:

Table 1 summarises the overall compliance levels achieved.

Tables 2-7 summarise the individual tables for sections two to seven of

the audit tool as this assists organisation to target areas that require

more specific attention.

Table 1

Ward A1 A4 B2 C5

Environment 92 83 87 79

Patient Linen 94 91 100 90

Waste 92 87 86 84

Sharps 79 87 92 76

Patient

Equipment

97 88 87 76

Hygiene Factors 98 94 92 94

Hygiene

Practices

94 93 96 95

Total 92 89 91 85

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 2

Environment

A1 A4 B2 C5

Reception N/A N/A N/A 82

Corridors, stairs lift 93 93 85 86

Public toilets N/A N/A N/A 87

Ward/ department -

general(communal)

96 93 88 78

Patient bed area 96 86 88 80

Bathroom/washroom 96 87 83 78

Toilet N/A 86 95 82

Clinical room/

treatment room

79 79 88 59

Clean utility room 94 N/A N/A N/A

Dirty utility room 91 71 83 78

Domestic store 90 79 93 76

Kitchen 92 71 92 81

Equipment store N/A 70 71 82

Isolation 97 91 91 89

General information 80 93 89 72

Total 91 83 87 79

Table 3

Linen A1 A4 B2 C5

Storage of clean

linen

88 88 100 100

Storage of used

linen

100 93 100 80

Laundry facilities N/A N/A N/A N/A

Total 94 91 100 90

Table 4

Waste and sharps A1 A4 B2 C5

Handling,

segregation,

storage, waste

Availability, use,

storage of sharps

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

92 87 86 84

79 87 92 76

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Table 7

Table 5

Patient Equipment A1 A4 B2 C5

Patient equipment 97 88 87 76

Table 6

Hygiene Factors

A1 A4 B2 C5

Availability and

cleanliness of WHB 97 90 95 95

and consumables

Availability of

alcohol rub

100 100 100 100

Availability of PPE 100 100 93 100

Materials and

equipment for

96 87 78 79

cleaning

Total 98 94 92 94

Hygiene Practices

A1 A4 B2 C5

Effective hand

hygiene procedures

100 86 95 100

Safe handling and

disposal of sharps

88 100 100 92

Effective use of

PPE

94 100 100 100

Correct use of

isolation

100 85 90 85

Effective cleaning

of ward

89 86 90 90

Staff uniform and

work wear

93 100 100 100

Total 94 93 96 95

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 four inspectors, from RQIA’s

infection prevention/hygiene team and four peer reviewers. 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.

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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.

Environment A1 A4 B2 C5

Reception N/A N/A N/A 82

Corridors, stairs lift 93 93 85 86

Public toilets N/A N/A N/A 87

Ward/ department -

general(communal)

96 93 88 78

Patient bed area 96 86 88 80

Bathroom/washroom 96 87 83 78

Toilet N/A 86 95 82

Clinical room/

treatment room

79 79 88 59

Clean utility room 94 N/A N/A N/A

Dirty utility room 91 71 83 78

Domestic store 90 79 93 76

Kitchen 92 71 92 81

Equipment store N/A 70 71 82

Isolation 97 91 91 89

General information 80 93 89 72

Average Score 91 83 87 79

The above table outlines the findings in relation to the general

environment of the facilities inspected. The findings indicate that there

are some areas for improvement in Wards A4 and C5 and in particular

the minimally compliant areas highlighted in red. The findings in

respect of the general environment are detailed in the following

sections.

6.1 Cleaning

At the time of the inspection there was good evidence to indicate

compliance with regional specifications for cleaning. The inspectors

observed that in general regular cleaning mechanisms were in place to

prevent the build-up of dust and debris. This in turn prevents the buildup

of bacteria and subsequently reduces the potential risk for the

transmission of infection.

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In the main reception, corridors and stairs, leading to the wards, some

high and low level surfaces were dusty and the external windows

required cleaning, however in general the cleaning of these areas was

good.

Greater attention to detail was required in all wards to remove sticky

labels and tape residue from surfaces and dust and debris from some

high and low surfaces, floor corners and edges. The underside of

raised toilet seats in toilet and bathroom areas and the cleaning of

external windows also required more detailed cleaning. It was also

noted that felt notice boards in ward areas could not be effectively

cleaned. In Ward C5 flies were noted in ceiling light fittings, some

doors and the inside of storage units were stained. In places the

skirting and the inside of the drugs fridge required cleaning, an issue

also identified in Ward B2.

In Ward A4 and C5 attention to detail was required when cleaning

shelving, sinks, kitchen appliances and the slop hopper and macerator

in the dirty utility room.

Particular care is required to ensure that limescale is removed from

taps and fittings as recent evidence has shown that limescale may

harbour biofilms and the build-up of limescale can interfere with good

cleaning and disinfection by masking and protecting pathogens.

Limescale was noted on taps in the dirty utility room, bathrooms and

domestic stores of all wards.

The cleaning of isolation areas inspected was generally good however

attention to detail should be improved upon to ensure dust, debris and

stains are removed from floor corners and edges, windows and ceiling

lights.

6.2 Clutter

In all wards the installation of high density storage shows evidence of

an emphasis in providing clutter free environments, this demonstrates

effective utilisation of space. However inspectors observed that in all

wards there was limited storage space available for equipment and

some rooms and surfaces were cluttered in appearance. The nursing

station at the entrance and corridors in A4 were cluttered.

Inspectors noted insufficient storage with equipment or boxes stored

on top of cupboards (Picture 1) and on floors, impeding effective

cleaning. Excess toilet rolls were observed in toilet and bathrooms.

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Picture 1: Storage on top of cupboards

In Ward A1 there was no equipment store available, equipment was

stored in designated patient areas at the end of each bay. In Ward A4

inspectors observed excess supplies and patient property bags on the

floor and windowsills. In Ward C5 the ward entrance was cluttered

with kitchen trolleys and cages of surplus equipment stores. Excess

ordering of stores or ineffective stock management has attributed to

cluttered ward environments and the inability to fully access areas,

therefore impeding effective cleaning.

6.3 Maintenance and Repair

All wards inspected had areas where maintenance and repair were

required.

Picture 2: Shower room

in poor repair

In the main reception, corridors and

stairs leading to the wards there was

minor paintwork and door damage and

in all wards there was minor damage

and, or scuff marks to walls, doors,

floors and some skirting. Damaged,

non intact surfaces cannot be

effectively cleaned and impede the

cleaning process. In Ward A1 clinical

room, the oxygen cylinder trolleys were

rusty, damaging the vinyl floor and in

Ward A4 the paintwork on some

radiators was chipped and the grouting

in the kitchen tiles needed replaced. In

Ward B2 gaffer tape was used to

temporarily repair a damaged door and

areas of bare plaster were noted in the

shower room; a result of the external

wall surface peeling off (Picture 2). In

Ward C5 some chipped skirting and

wall damage were observed.

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In the isolation rooms spot checked issues to be addressed include

damaged flooring, skirting, doors and frames.

6.4 Fixtures and fittings

In some wards, fixtures, fittings and equipment were not fit for purpose

and required updating in all wards.

Inspectors observed worn and damaged shelving/storage units,

furniture and equipment such beside tables, lockers, bed frames and

shower chairs.

In Ward A4 the pipework between the macerator and slop hopper was

not enclosed, the seal of the join at the hand washing sink in the dirty

utility room needed repaired and some plugholes were tarnished.

There was no bedpan rack or drip tray for the reusable bedpans

present and the overflow of the domestic sluice sink was blocked.

In Ward B2 male toilet, the soil pipe behind the toilet bowl was cracked,

the plastic covering had not been removed from the macerator,

allowing water to collect behind it and discolour the metal surface and

the veneer of the domestic sluice bowl was chipped.

In Ward C5 the formica finish on the nurses’ station was starting to

wear. The doors of the cupboard, beside the resuscitation trolley, did

not fit and therefore did not close correctly, and the printer table was

extensively damaged, with exposed MDF. Some window blinds were

frayed, toilet seats were missing and kitchen cupboards were old and

worn; formica was split.

Issues to be addressed in the isolation rooms spot checked, include a

worn bedside table, chipped bedframe and bedrails, removing the plug

from a handwashing sink in Ward A4, in Ward B2 fixing the dripping tap

and in Ward A1 resolving the slow drainage of the handwashing sink in

the isolation room lobby.

6.5 Information

With the exception of Ward C5 there were information leaflets available

on hand hygiene and general infection prevention and control.

However there were no posters displayed on linen segregation and/or

inoculation injury for staff to reference.

In all wards posters on hand hygiene and MRSA and Clostridium

difficile information leaflets were available (Picture 3). With the

exception of Ward C5, clear instructions were in place on isolation

room doors to advise staff and visitors of isolation precautions. This

was rectified by staff during the inspection.

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Picture 3: Information leaflets on display

In Wards A4 and C5 some posters were frayed, not laminated and

attached to surfaces with sticky tape.

Nurse cleaning schedules while available in Wards A1, B2 and C5

were not detailed enough to cover all equipment used at ward level.

Detailed nursing cleaning schedules are required which outline all

equipment to be cleaned.

Inspectors noted in all wards that the drugs and/or kitchen

fridge/freezer temperatures had not been consistently taken or

recorded and there was no temperature range available on the

recording sheets for staff to reference. It is imperative that fridge

temperature checks are taken and recorded on a daily basis to ensure

medication or foodstuff are stored at the correct temperature and that

appropriate action is taken in the event of a cold chain failure. It was

also noted in Wards B2 and C5 that the drugs fridge was opened and

in Ward C5 there was jelly and rice stored in the fridge. In Ward A4

and C5 food in the kitchen fridge was not labelled correctly with the

patient’s name. Inspectors also noted that there was no signage on

the door of the clinical room to indicate the storage of oxygen cylinders.

6.6 Additional Issues

Ward A4

There is no treatment room on the ward, the clinical preparation

area is small, cramped and will be under further pressure when

the additional seven beds are opened.

There is no private area for speaking to relatives to discuss issues

or for breaking bad news.

There is a pharmacy room on each side of the ward, the kitchen

facility is shared. The trust could explore this possibility of

creating more space by developing a shared pharmacy room.

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Ward B2

Ward C5

Prior to the opening of the new beds a space utilization exercise

should be undertaken.

There are two toilets in the ward and a bathroom and shower

room containing a toilet. Staff had labelled one toilet for male

patients and one toilet for female patients. At the time of

inspection there were 24 male patients on the ward, with the use

of only one full time toilet.

Due to lack of storage facilities in Bay 4, a hoist, portable screens

and chairs were blocking a fire exit. In the bed bays chairs were

stored at fire doors also blocking the fire exit.

The patient welcoming service advised inspectors that the board

in the front reception indicating ward levels and ward names was

not detailed enough for patients.

Recommendations

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

roles and responsibilities to improve and confirm that

environmental cleaning is carried out effectively and that the

environment is in a good state of repair.

2. The trust and staff should work to maintain clutter free ward

environments.

3. The trust should ensure an on-going programme of

maintenance and repair for the environment, fixture and

fittings and equipment is carried out.

4. The trust should ensure all relevant information leaflets,

posters and signage are available for patients, visitors and

staff to reference.

5. The trust should develop detailed nursing cleaning

schedules.

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

importance of monitoring fridge temperatures.

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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.

Linen A1 A4 B2 C5

Storage of clean

linen

88 88 100 100

Storage of used

linen

100 93 100 80

Laundry

facilities

N/A N/A N/A N/A

Average Score 94 91 100 90

7.1 Management of Linen

Wards A1, A4 and C5 are commended for achieving an overall high

compliance score in this standard, with Ward B2 achieving overall full

compliance. In Ward C5 partial compliance was achieved in the

storage of used linen.

In Ward A1 clean linen room, there was minor wall damage, the room

was small and cluttered with pillows stored on top of boxes and some

pillows were stained. In Ward A4 excess pillows were stored on top of

the linen storage trolley. In Wards B2 and C5 there were no issues

with the storage of clean linen.

In Wards A1, A4 and B2 good practice was observed in the handling of

used linen, and staff were observed to wear the appropriate personal

protective equipment (PPE) when handling soiled/contaminated linen.

However in Ward C5 two members of staff were observed handling

used linen without wearing a disposable protective apron. In Wards A4

and C5 the frame or top of the linen skip was either stained or rusted.

Recommendations

7. The trust should ensure the storage of stain free linen in an

uncluttered environment.

8. The trust and individual staff have a collective responsibility

to ensure the correct use of PPE when handling used linen.

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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

8.1 Waste

Waste and sharps A1 A4 B2 C5

Handling,

segregation,

storage, waste

Availability, use,

storage of sharps

92 87 86 84

79 87 92 76

The inspection evidenced that there were arrangements in place for the

handling, segregation, storage and disposal of waste which generally

complied with local and regional guidance. Wards A1, A4 and B2 are

commended for achieving compliance in this standard, Ward C5

achieved partial compliance.

In all wards inspectors observed that waste was segregated and

disposed of incorrectly. Household waste was disposed of into clinical

waste bins, pharmaceutical waste or wipes, paper, tourniquets and

gloves were disposed of into the sharps boxes, and in Ward C5 a

clinical waste bag and scissors were disposed of into a magpie box,

which should be used to dispose of broken crockery, bottles, aerosols

and tin cans. In all four wards it was noted that there was no

household waste bin in the dirty utility room and the clinical room or

domestic store. There was no sanitary waste bin in the female visitors’

toilet at the main hospital reception, beside outpatients.

In all wards, inspectors observed a number of waste bins were stained,

damaged or rusted. In Ward A4 waste bags were tied onto monitor

trolleys (Picture 4) and in Wards B2 and C5 the ward waste hold area

was untidy. In Ward C5 the clinical waste bin in the clinical room was

more than 2/3 full and a black lidded burn bin was overfilled; an IV fluid

bag was protruding from the bin.

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8.2 Sharps

Picture 4: Clinical waste bag attached to monitor trolley

Wards A4 and B2 are commended for achieving compliance in this

standard, Wards A1 and C5 achieved partial compliance.

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

In Wards A4, B2 and C5 sharps boxes were assembled correctly;

labelled with the date, locality and staff signature. However in Ward A1

the large sharps box in the clinical room was not signed or dated. This

is unsafe practice as correct labelling ensures that if there is a spillage

of sharps waste from the sharps box or an injury to a staff member as a

result of incorrect assembly/disposal, the area the sharps box

originated from can be immediately identified. Identifying the origin of

the sharps box and its contents is imperative to assist in the immediate

risk assessment process carried out following a sharps injury and also

to ensure that staff who incorrectly assembled/disposed of the sharps

box can receive education on the correct procedures to follow.

In Wards B2 and C5 inspectors observed sharps boxes in the clinical

room were not secured with safety brackets and in Ward A4 two

locked, tagged and signed sharps boxes were left in the corridor

waiting disposal. In Wards A1, A4 and C5 it was observed that integral

sharps trays were dirty or had tape residue present. It was also noted

that paper mache kidney dishes were inset into the integral sharps

trays when in use.

It was observed in all wards that the temporary closure mechanisms, to

prevent spillage and impede access, were not always in place when

the sharps boxes were not in use. In Ward A1 the sharps box on the

resuscitation trolley was not empty.

Recommendations

9. The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

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sharps to ensure that safe and appropriate practice is in

place.

10. The trust should ensure that waste bins and equipment used

in the management of waste and sharps are clean and that

waste bins are available and fit for purpose.

11. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

the safe and the correct handling and disposal of waste and

sharps.

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9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment A1 A4 B2 C5

Patient equipment 97 88 87 76

In this standard Wards A1, A4 and B2 are commended for achieving

compliance, patient equipment was generally of a good standard and

most equipment was visibly clean. Ward C5 achieved partial

compliance however with attention to detail this score could be

improved upon.

In all wards some equipment was either chipped, damaged or required

cleaning; notes trolleys, ECG machine, hoist frame, ice machine.

Inspectors observed in all wards commodes inspected were either

rusting, soiled or the lids were starting to perish. In Ward A4 one

commode was broken and while a certificate of decontamination, dated

the 8 August 2011, was insitu, the commode had not yet been

repaired. In Wards A4 and C5 stored IV stands or pumps and dressing

trolleys required cleaning, in Ward C5 trigger tape used to identify if

equipment had been cleaned and ready for use, was not consistently in

use. In Ward B2 the frame and shelf of the resuscitation trolley were

chipped and damaged and in Wards B2 and C5 the resuscitation trolley

was dusty and equipment on the resuscitation trolley required cleaning;

equipment was cleaned in Ward B2 before the inspection ended.

In Ward A4 bedpans were not stored inverted when not in use and

none of the staff questioned were aware of the symbol for single use

equipment. In Ward B2 equipment store there was a hole in the cover

of the therapy mattress, adhesive tape on the mattress cover corner

join, and wooden walking sticks present were unable to be effectively

cleaned.

In Ward C5, some in use IV stands and pumps, the casing of the blood

glucose monitors and the hand pump on the pressure infusor cuff

required cleaning. It was also noted by inspectors that single use jugs

were being re-used and that the laryngoscope blade on the

resuscitation trolley was uncovered and had been removed from its

original sterile packaging. The Association of Anaesthetists of Great

Britain and Ireland guidelines ‘Infection Control in Anaesthesia’ states

that single use resuscitation equipment should be kept in a sealed

package or should be re-sterilised between patients according to

manufacturer's instructions. It also states that packaging should not be

20


emoved until the point of use for infection control, identification and

traceability for safety and in the case of a manufacturer's recall.

Recommendations

12. The trust and individual staff have a collective responsibility

to ensure that equipment is clean, stored correctly and in a

good state of repair.

13. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

equipment cleaning.

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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

A1 A4 B2 C5

Availability and

cleanliness of WHB 97 90 95 95

and consumables

Availability of alcohol

rub

100 100 100 100

Availability of PPE 100 100 93 100

Materials and

equipment for

96 87 78 79

cleaning

Average Score 98 94 92 94

In this standard all wards are commended for achieving overall

compliance; compliance or full compliance scores were achieved in the

majority of sections.

In Wards B2 and C5 inspectors noted

that the 1:6 ratio of handwashing sinks

to patients was not in line with local and

national guidelines of 1:4. Hand

washing sinks and fixtures and fittings

in all wards were generally clean,

working and in a good state of repair

(Picture 5), however greater attention to

detail was required in cleaning the hand

washing sink in Bay 1 in Ward C5 and

removing limescale from the hand

washing sink taps in Ward A4 dirty

utility room and clinical room.

Picture 5: Typical hand washing sink

In Ward A4 it was also observed that the hand washing sink taps in the

dirty utility room and clinical room continued to drip when turned off and

some plugholes and taps were tarnished.

22


Inspectors observed that in Wards A4, B2 and C5 the clinical hand

washing sink in the clinical room was not fit for purpose; taps were not

mixer, elbow or sensor operated.

In Wards A1, B2 and C5 some soap dispensers required cleaning and

in Ward A1 there were no hand towels available in the dispenser in the

domestic store.

There were no issues identified in relation to availability or use of

alcohol rub. Inspectors observed a range of PPE available in the wall

mounted dispensers for staff to easily access, however in Ward B2

there was no face protection available for general use.

In Wards A1, A4 and C5 cleaning products were not stored in line with

Control of Substances Hazardous to Health (COSHH) regulations in a

locked area; dirty utility room and/or kitchen. In Wards B2 and C5 the

lid on tubs of cleaning wipes was not always closed, drying out the

contents and therefore making the wipes ineffective. In Ward A4 staff

when questioned were unaware of the dilution rate for using Difficil – S

and gave varying answers for the use of colour coded bottles used for

decanting Difficil – S.

In Wards B2 and C5 the cleaning and storage of equipment used for

general cleaning required attention as inspectors observed dirty, not in

use, domestic equipment and mop buckets filled with solution.

Inspectors also noted in Ward B2, mop handles did not correspond to

the National Patient Safety Agency (NPSA) cleaning colour coded

system and a small wooden brush hanging from the domestic trolley

was not colour coded. This cannot be effectively cleaned as over time

worn wood is not impervious to moisture.

Recommendations

14. The trust should ensure that hand washing sinks are clean,

working and in a good state of repair.

15. The trust should ensure that consumable dispensers are

clean and that dispensers are adequately stocked.

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

in a locked cupboard, in line with COSHH regulations.

17. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date in the use of

disinfectants.

18. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of a ward

is clean, fit for purpose and stored appropriately.

23


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

A1 A4 B2 C5

Effective hand hygiene

procedures

100 86 95 100

Safe handling and

disposal of sharps

88 100 100 92

Effective use of PPE 94 100 100 100

Correct use of isolation 100 85 90 85

Effective cleaning of

ward

89 86 90 90

Staff uniform and work

wear

93 100 100 100

Average Score 94 93 96 95

In this standard all wards are commended for achieving overall

compliance; compliance or full compliance scores were achieved in all

sections.

The results of the audit indicate that in all wards effective hygiene

practices were in place. Hand hygiene practices observed showed all

wards generally complied with WHO (World Health Organisation)

guidance on the correct technique to use for hand washing and

appliance of hand rub. Observations indicated that staff generally

performed hand hygiene at the appropriate moments for hand hygiene,

using the correct seven step technique as displayed. However in Ward

A4 a member of staff was observed not washing their hands after

cleaning a commode, prior to food service, and two members of staff

did not wash their hands after cleaning commodes and before

completing and applying trigger tape. In Ward B2 a medical student

did not perform the seven step hand washing technique.

There were no issues identified in Wards A4 and B2 with the safe

handling and disposal of sharps. In Ward A1 inspectors observed a resheathed

needle in a sharps box on the resuscitation trolley and in

Ward C5 a re-sheathed needle was observed in a sharps box in the

clinical room. Re-sheathing needles is unsafe practice, it increases

staffs potential risk of receiving a sharps injury and should stop

immediately.

24


There were no issues identified in

Wards A4, B2 and C5 in the effective

use of PPE section (Picture 6).

Inspectors observed that single use

aprons and gloves were worn by staff

when carrying out clinical care and

changed as appropriate. In Ward A1

inspectors observed a member of staff,

wearing gloves and an apron, entering

the dirty utility room, collecting an item

from a cupboard, and leaving; items

should be collected prior to donning

aprons and gloves.

Picture 6: Typical PPE station

In all wards nursing practices observed in relation to the application of

isolation precautions were generally good and in line with current

practice guidance. However in Ward A4 the doors of two patients with

Clostridium difficile were open throughout the inspection and in Ward

C5 a member of staff was observed, when serving food, entering two

consecutive side rooms with the same green apron insitu and not

removing or changing it. It was also noted in Ward A4 staff were

unsure of the colour of bottle used when cleaning an isolation area and

whether to take the bottle into an isolation room when cleaning or to

leave it outside.

A review of documentation evidenced that in Ward B2 decisions

concerning precautions taken for patients in isolation were not

documented in the patient careplans. In Ward C5 there was no MRSA

patient centred care pathway and daily documentation of infection

prevention and control precautions. In Ward A4 the infection control

advice sheet for a Clostridium difficile patient was not fully completed.

Discussion with nursing staff in Ward A4 identified that they were not

aware of the appropriate disinfectant dilution rate to use for cleaning

blood and body fluid spillage and in all wards nursing staff were

unfamiliar with the NPSA cleaning colour coding system. In Ward A1

and B2 there were no Difficil – S, disinfectant COSHH data sheets

available and inspectors noted in Ward B2 that a commode which had

trigger tape insitu to identify that it had been cleaned, was dirty

underneath; suggesting staff did not follow trust cleaning guidelines.

Overall inspectors observed good adherence to the regional dress

code policy and the concept of ‘bare below the elbow’. In Ward A1 a

member of medical staff had long hair, which was not tied up, and was

wearing strappy velcro sandals, inappropriate in a ward environment

due to the potential injury from a dropped sharp item. Staff changing

facilities were available for staff to change into and out of their uniform

at work.

25


Additional Issues

Ward A1

A nurse was observed leaving the clinical room carrying a sharps

box, sharps tray and a plastic bottle of liquid close to her body.

Inspectors observed that prior to entering an isolation room the

nurse placed the equipment on the side of the hand washing sink

rather than on the work surface and washed her hands.

Recommendations

19. The trust and individual staff have a collective responsibility

to ensure that hand hygiene is carried out in line with WHO

guidance and that all PPE is used appropriately.

20. The trust and individual staff have a collective responsibility

to ensure safe practice is carried out when handling sharps.

21. The trust and individual staff have a collective responsibility

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

to the isolation of patients and that all relevant

documentation is fully completed.

22. The trust and individual staff have a collective responsibility

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

to cleaning and decontamination of equipment.

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

with and adhere to the regional dress code policy.

26


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs E Colgan

Mrs L Gawley

Mrs S O'Connor

Mrs M Keating

- Senior Officer Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

Peer Reviewers

Sonia Gormley - Support Services Manager, WHSCT

Janice Clarke - Senior Manager, Patient Experience, SEHSCT

Helen Hamilton - Project Manager, RQIA

Bernie McQuade - Inspector, Nursing Team, RQIA

Trust representatives attending the feedback session

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

representatives:

Mrs Olive MacLeod

Ms Valerie Jackson

Dr Olivia Dornan

Mrs Suzanne Pullins

Ms Maire Bermingham

Ms Linda Millar

Ms Judy Nelson

Mrs Linda Patton

Ms Stephanie Greenwood

Mr Alan Stewart

Mr Peter Thompson

Mrs Pat McKee

Ms Angela McErlane

Mrs Naomi Baldwin

Ms Marie Morrison

Ms Martina Ward

Ms Bernie Irvine

Ms Diane Russell

Ms Wilma Wilson

- Director of Nursing

- Director, Acute Hospital Services

- AMD, Acute Hospital Services

- Assistant Director, Medicine & Unscheduled

Care

- Assistant Director, Corporate Support

Services

- General Manager, Surgery

- General Manager, Portering and Site

Support Services

- General Manager, Medical Services

- General Manager, Unscheduled Care &

Cardiology

- Domestic Services Manager

- Senior Engineer, Estate Services

- Lead Infection Prevention & Control Nurse

- Lead Nurse

- Senior Infection Prevention & Control Nurse

- A4, Ward Manager

- B2, Ward Manager

- C5, Ward Manager

- A1, Ward Manager

- A1, Deputy Ward Manager

Apologies

Mr Sean Donaghy

Ms Ann Hamilton

- Chief Executive

- General Manager, Domestic Services

27


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.

28


13.0 Summary of Recommendations

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

roles and responsibilities to improve and confirm that

environmental cleaning is carried out effectively and that the

environment is in a good state of repair.

2. The trust and staff should work to maintain clutter free ward

environments.

3. The trust should ensure an on-going programme of

maintenance and repair for the environment, fixture and

fittings and equipment is carried out.

4. The trust should ensure all relevant information leaflets,

posters and signage are available for patients, visitors and

staff to reference.

5. The trust should develop detailed nursing cleaning

schedules.

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

importance of monitoring fridge temperatures.

7. The trust should ensure the storage of stain free linen in an

uncluttered environment.

8. The trust and individual staff have a collective responsibility

to ensure the correct use of PPE when handling used linen.

9. The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

sharps to ensure that safe and appropriate practice is in

place.

10. The trust should ensure that waste bins and equipment used

in the management of waste and sharps are clean and that

waste bins are available and fit for purpose.

11. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

the safe and the correct handling and disposal of waste and

sharps.

12. The trust and individual staff have a collective responsibility

to ensure that equipment is clean, stored correctly and in a

good state of repair.

29


13. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

equipment cleaning.

14. The trust should ensure that hand washing sinks are clean,

working and in a good state of repair.

15. The trust should ensure that consumable dispensers are

clean and that dispensers are adequately stocked.

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

in a locked cupboard, in line with COSHH regulations.

17. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date in the use of

disinfectants.

18. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of a ward

is clean, fit for purpose and stored appropriately.

19. The trust and individual staff have a collective responsibility

to ensure that hand hygiene is carried out in line with WHO

guidance and that all PPE is used appropriately.

20. The trust and individual staff have a collective responsibility

to ensure safe practice is carried out when handling sharps.

21. The trust and individual staff have a collective responsibility

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

to the isolation of patients and that all relevant

documentation is fully completed.

22. The trust and individual staff have a collective responsibility

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

to cleaning and decontamination of equipment.

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

with and adhere to the regional dress code policy.

30


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

31


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

32


16.0 Action Plan

Reference

number

Recommendations

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

roles and responsibilities to improve and confirm that

environmental cleaning is carried out effectively and that

the environment is in a good state of repair.

2. The trust and staff should work to maintain clutter free ward

environments.

3. The trust should ensure an on-going programme of

maintenance and repair for the environment, fixture and

fittings and equipment is carried out.

4. The trust should ensure all relevant information leaflets,

posters and signage are available for patients, visitors and

staff to reference.

5. The trust should develop detailed nursing cleaning

schedules.

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

importance of monitoring fridge temperatures.

Designated

department

Domestic

Domestic/

Nursing

Estate

Services

Corporate

Comms/

Nursing

Nursing

Catering/

Nursing

Action required

Domestic Management and staff have job

descriptions which will clarify roles and

responsibilities. Standards of cleaning are

monitored on a daily monthly and annual

basis.

Domestic staff and nursing work together to

reduce clutter in wards. Dump the Junk Days

are carried out in trust hospitals. Info on how

to dispose of unused items on Staff Net.

All Estate Services issues raised in Section

16 this report being actioned.

Estates backlog maintenance programme in

place Trust wide

Trust is continuously reviewing leaflet content

and availability through analysis of Patient &

Client Experience questionnaires and

implementation of appropriate actions.

Lead nurses will support ward managers to

ensure that cleaning schedules are

developed and implemented where

necessary

Relevant directors will issue a reminder to

staff regarding this important issue

Date for

completion/

timescale

Actioned

Actioned

February 2012

Ongoing

Actioned

March 2012

December 2011

7. The trust should ensure the storage of stain free linen in an

uncluttered environment.

8. The trust and individual staff have a collective responsibility

to ensure the correct use of Personal Protective Equipment

(PPE) when handling used linen.

Linen

Services/

Nursing

Infection

Prevention

Control (IPC) /

Nursing

Relevant directors will issue a reminder to

staff regarding this important issue

Clear protocols and guidance for clinical staff

in use and disposal of Personal Protective

Equipment (PPE) available. Infection

Prevention and Control (IPC) Nurses

reinforce best practice on clinical visits.

Wearing of PPE covered in Mandatory

December 2011

December 2011

33


Reference

number

Recommendations

9. The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

sharps to ensure that safe and appropriate practice is in

place.

10. The trust should ensure that waste bins and equipment

used in the management of waste and sharps are clean

and that waste bins are available and fit for purpose.

11. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

the safe and the correct handling and disposal of waste and

sharps.

Designated

department

Nursing/Estate

s Services

Domestic/

Nursing

Nursing/

Estates

Services

Action required

training for nursing and Health Care Assistant

(HCA) staff.

Refresher training to be provided on waste

management by Estates staff in the form of

Healthcare Waste Audits.

Domestic Supervisors and Ward Managers to

identify at Daily/Monthly audits any unclean

bins or bin needing replaced. Cleaning

carried out immediately and bin replaced

Waste classification and segregation training

is conducted through Corporate Induction,

individual refresher training, Auxiliary Nursing

training and training when procedures and

policies are updated. The policy will be

updated and a training scheduled for all staff

when the Department has finalised the 'Safe

management of healthcare waste' formally

know as HTM07-01.

Date for

completion/

timescale

C5 and A1 by

10 January

2012 and any

other wards on

request

Actioned and

Process is

ongoing

C5 and A1 by

February 2012

and any other

wards on

request

12. The trust and individual staff have a collective responsibility

to ensure that equipment is clean, stored correctly and in a

good state of repair.

Domestic/

Nursing

Domestic staff follow work schedules to

ensure equipment is clean and stored

correctly

Actioned

13. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date regarding

equipment cleaning.

Domestic

Domestic staff have been reminded of

importance of keeping equipment clean.

Actioned

14. The trust should ensure that hand washing sinks are clean,

working and in a good state of repair.

15. The trust should ensure that consumable dispensers are

clean and that dispensers are adequately stocked.

Estate

Services

Domestic

All items regarding Wash Hand Basins

(WHBs) have been identified and are being

investigated and repaired as necessary`

Domestic staff have been reminded to

thoroughly clean consumable dispensers

February 2012

Actioned

34


Reference

number

Recommendations

16. The trust should ensure that all cleaning products are

stored in a locked cupboard, in line with COSHH

regulations.

Designated

department

Domestic/

Nursing

Action required

Domestic staff have been reminded to keep

all disinfectants/cleaning products locked

away

Date for

completion/

timescale

Actioned

17. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date in the use

of disinfectants.

Domestic/

Nursing

Training is given to staff on use of

disinfectants. Staff practices monitored by

domestic supervisor.

Actioned

18. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of a

ward is clean, fit for purpose and stored appropriately.

Domestic

Domestic staff reminded of need for

thoroughly cleaning. Cleaning equipment –

on work schedule

Actioned

19. The trust and individual staff have a collective responsibility

to ensure that hand hygiene is carried out in line with WHO

guidance and that all PPE is used appropriately.

20. The trust and individual staff have a collective responsibility

to ensure safe practice is carried out when handling sharps.

Domestic/

Nursing/

Other

disciplines

IPC Nurses /

Nursing

All staff have received training on hand

hygiene and hand hygiene audits are carried

out in all clinical areas each week. Staff who

fail to meet the standard are spoken to and

retrained where necessary

Relevant directors will issue a reminder to

staff regarding this important issue

Actioned

December 2011

21. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date with

regard to the isolation of patients and that all relevant

documentation is fully completed.

22. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date with

regard to cleaning and decontamination of equipment.

IPC Nurses /

Nursing

Nursing/Other

disciplines

Isolation requirements and isolation

precautions are included in IPC training for all

clinical staff. IPC nurses monitor isolation

practice and provide challenge and support

where practice does not reflect trust

guidance. All patients have infective status

assessed on admission to hospital and the

Isolation Risk Assessment Tool and

Hierarchy of Organisms Tool are used by

Patient Flow, Ward Managers and IPC

Nurses on a daily basis to ensure appropriate

patient isolation.

Relevant directors will issue a reminder to

staff regarding this important issue

December 2011

December 2011

35


Reference

number

Recommendations

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

familiar with and adhere to the regional dress code policy.

Designated

department

Domestic/

Nursing/

Medical

Action required

All staff have been reminded of Dress Code

and individuals who do not adhere will be

subject to appropriate disciplinary action

Date for

completion/

timescale

Actioned

36

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