Antrim Area Hospital, Antrim - 12 October 2011 - Regulation and ...

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Antrim Area Hospital, Antrim - 12 October 2011 - Regulation and ...

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Northern Health and Social Care Trust

Antrim Area Hospital

Laurel House

12 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 11

6.4 Fixture and Fittings 12

6.5 Information 12

7.0 Patient Linen 14

7.1 Management of linen 14

8.0 Waste and Sharps 15

8.1 Waste 15

8.2 Sharps 15

9.0 Patient Equipment 17

10.0 Hygiene Factors 18

11.0 Hygiene Practice 19

12.0 Key Personnel and Information 21

13.0 Summary of Recommendations 22

14.0 Unannounced Inspection Flowchart 23

15.0 RQIA Hygiene Team Escalation Policy Flowchart 24

16.0 Action Plan 25


1.0 Inspection Summary

An unannounced inspection was undertaken to the Antrim Area

Hospital, on the 12 October 2011. The hospital was assessed against

the Regional Healthcare Hygiene and Cleanliness standards and the

following area was inspected:

Laurel House

Laurel House Chemotherapy Unit in Antrim Area hospital, opened in

2005, consists of a fourteen patient treatment area, a Pharmacy Suite,

clean room preparation rooms, a venepuncture room, consulting

rooms, reception and waiting areas and a plant room. Services

available include:

diagnostic/investigative

counselling

screening

supportive and palliative care

treatment

Antrim Area Hospital is one of four Cancer Units in Northern Ireland,

with strong links to the Cancer Centre in Belfast.

Inspection Outcomes

The results of the inspection showed compliance in all of the standards,

for which staff are to be commended. The ward was in good

decorative order, well presented and cleaning was of a good standard.

The inspectors were impressed with staff commitment to providing a

safe and clean environment for patients and overall the observations of

staff indicated compliance with hygiene and infection prevention and

control practices.

The inspection resulted in 13 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 within 14 days of the inspection to enable early

action on identified areas which have achieved non complaint scores.

The draft report which includes the high level recommendations in a

Quality Improvement Plan is forwarded within 28 days of the inspection

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

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

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

on request.

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

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

1


management by the Health and Social Care Board and the Public

Health Agency.

Notable Practice

The inspection identified the following areas of notable practice

High impact intervention care bundle audits for peripheral IV

cannula.

Mattress, commode and environmental cleanliness audits.

Hand hygiene and environmental cleanliness scores were

displayed on a white board at the entrance to the unit for

staff, patients and visitors to reference.

Copies of the DVD on infection prevention and control for

NHSCT staff in the acute setting were available for visitors

and staff to view in the unit.

Inspectors noted the calm and relaxed atmosphere at ward

level and the caring attitude of staff.

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

Areas inspected Laurel House

General environment 92

Patient linen 97

Waste 91

Sharps 89

Equipment 93

Hygiene factors 98

Hygiene practices 90

Average Score 93

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

2


Table 2

General environment

Reception 90

Corridors, stairs lift 84

Public toilets 100

Ward/department -

general (communal)

93

Patient bed area 97

Bathroom/washroom

N/A

Toilet 90

Clinical room/treatment

room

91

Clean utility room 91

Dirty utility room 94

Domestic store 95

Kitchen 92

Equipment store 96

Isolation 87

General information 85

Average Score 92

Table 3

Patient linen

Storage of clean linen 100

Storage of used linen 93

Laundry facilities

N/A

Average Score 97

Table 4

Waste and sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

91

89

Table 5

Patient equipment

Patient equipment 93

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

3


Table 6

Hygiene factors

Availability and

cleanliness of WHB and

96

consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

98

Average Score 98

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

Table 7

Hygiene practices

Effective hand hygiene

procedures

93

Safe handling and

disposal of sharps

77

Effective use of PPE 100

Correct use of isolation

N/A

Effective cleaning of ward 95

Staff uniform and work

wear

86

Average Score 90

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 one inspector, from RQIA’s

infection prevention/hygiene team and one peer reviewer. 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 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.

6.1 Cleaning

General environment

Reception 90

Corridors, stairs lift 84

Public toilets 100

Ward/department -

general (communal)

93

Patient bed area 97

Bathroom/washroom

N/A

Toilet 90

Clinical room/treatment

room

91

Clean utility room 91

Dirty utility room 94

Domestic store 95

Kitchen 92

Equipment store 96

Isolation 87

General information 85

Average Score 92

The inspection of the general environment of the ward evidenced

compliance in all but one of the ward areas and at the time of the

inspection there was good evidence to indicate compliance with

regional specifications for cleaning. It was observed that in most

instances, regular and effective cleaning mechanisms were in place to

prevent the build up of dust and debris which in turn prevents the build

up of bacteria and helps in the reduction of the potential risk for the

transmission of infection.

In the main reception area there was dust at the ceiling pipework, air

vents and grooves in the large signage board. The ward whilst

generally very clean required minor improvements in the cleaning of

external windows, the leaflet rack at the waiting area, the stand of the

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electric kettle in the kitchen, the undercarriage of the patient trolley in a

consulting room and the plughole of sinks.

The inside of the cupboards in the preparation room was grubby, the

inside of the drugs fridge was dusty and medication had spilled onto

the bottom surface. Sticky tape was noted on the mail box storage and

the shelving to the right of the pharmacy hatch. Residue from adhesive

tape impedes the cleaning process.

Limescale was observed on the sink taps in the toilet, dirty utility room,

kitchen and consultation room 3. Particular attention 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.

6.2 Clutter

Picture 1: Neat, tidy and clutter free

treatment area

In Laurel House there was

evidence of a continued

emphasis in providing a clutter

free environment, this

provides effective utilisation of

space and good stock

management which assists

with effective cleaning (Picture

1). Inspectors however noted

staff handbags and outdoor

clothing throughout the ward.

Staff advised the staff lockers

provided in the changing area

are too small to hold these

items therefore they have to

be carried to the ward.

6.3 Maintenance and Repair

The unit has a bright, well presented appearance but on closer

inspection minor damage was noted to some walls, plaster was flaking

in places and holes were noted where fixings had been removed. In

the treatment area there was a hole in the high ceiling which staff

report leaks at times. The main doors to the ward had patches of

yellow coloured stains. The metal doors at the bottom of the stairs on

the ground floor near reception were badly worn and chipped to the

bare metal.

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6.4 Fixtures and fittings

In general the fixtures and fittings were

in good repair, a few issues were

highlighted for action. A wooden CD

storage cabinet was noted in the

treatment area. The door of the cabinet

was of an open lattice panel

construction therefore items stored

inside the cabinet were not protected

from potential airborne contaminants.

Good practice in a high risk clinical

environment is to protect items from

potential contamination and an

alternative storage cabinet should be

sourced.

Picture 2: Felt notice board

Throughout the unit felt notice boards

were fixed to walls (Picture 2). It is

advised that as felt cannot be effectively

cleaned, that an alternative method of

displaying information is investigated.

6.5 Information

Hand hygiene posters were displayed at hand washing sinks and

alcohol gel dispensers. Information leaflets on MRSA, hand hygiene,

common infections and infection prevention and control were available

however the unit had recently run out of a supply of leaflets on

Clostridium difficile infection.

Domestic cleaning schedules were not available on the ward for staff to

reference and inspectors noted some un-laminated posters fixed to

surfaces with adhesive tape.

There was a range of posters

in place for staff to reference

such as waste and sharps

management, National

Patient Safety Agency

(NPSA) colour coding posters

and the management of

linen. A wall mounted

whiteboard provided

information on hand hygiene

and environmental

cleanliness for visitors, staff

Picture 3 Whiteboard with information on and patients (Picture 3).

hand hygiene and environmental

cleanliness audits

12


Recommendations

1. The trust should work to ensure that effective environmental

cleaning is carried out and cleaning schedules are available

for staff.

2. The trust and staff should continue to maintain clutter free

ward environments.

3. The trust should continue to work on the repair and

maintenance of the wards and public environments and to

replace damaged or pervious fixtures and fittings.

13


7.0 Patient Linen

STANDARD 3.0

PATIENT LINEN

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

department laundry facilities.

Linen

Storage of clean linen 100

Storage of used linen 93

Laundry facilities

N/A

Average Score 97

7.1 Management of Linen

The ward is to be commended in achieving a full compliance score in

the storage of clean linen and a high compliance in the storage of used

linen.

Inspectors observed that used linen was stored and segregated

correctly and that clean linen was stored tidily in a covered linen trolley.

Inspectors noted the cloth linen bag attached to the linen skip, which

was stored in the dirty utility room, had a small tear. All linen should be

free from rips and tears.

Observations of the handling of used linen were limited in the unit, as

most patients were treated on treatment couches and chairs. However

staff questioned were knowledgeable on the handling of used linen,

including the use of appropriate colour coded bags at the point of use

and to wear the appropriate personal protective equipment (PPE) when

handling soiled/contaminated linen.

Recommendations

4. Staff should ensure that linen is in good condition and free

from rips and tears.

14


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

91

89

8.1 Waste

The inspection evidenced that there were arrangements in place for the

handling, segregation, storage and disposal of waste which generally

comply with local and regional guidance. Issues identified were in

relation to inappropriate paper waste disposed into sharps boxes and

disposal of a newspaper into a clinical waste bin (Picture 4). The

household waste bin in the kitchen and the clinical waste bin in the

preparation room were rusted and more attention to detail was needed

when cleaning the interior of waste bins, notably in the preparation

room and the dirty utility room.

8.2 Sharps

Picture 4 Newspaper in a clinical waste bin

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

Boxes were assembled correctly; labelled with the date, locality and

staff signature. This is good practice as correct labelling ensures that if

there is a spillage of sharps waste from the sharps box or an injury to a

15


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 the preparation room a number of temporary closures on sharps

boxes was open and it was noted that sharps boxes with integral trays

were stored on the lower shelf of the procedure trolleys for transport to

the bedside. Brackets were not attached to the trolleys to secure the

boxes. With little effort and improvement in staff practice, staff could

achieve full compliance in this standard.

Recommendations

5. The trust should ensure that waste bins are kept clean, in

good repair and replaced as appropriate.

6. 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.

16


9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient equipment

Patient equipment 93

The ward is to be commended in achieving a high compliance score in

this section of the audit tool.

Inspectors observed that the cleaning of patient equipment was of a

very good standard as equipment was visibly clean and generally in a

good state or repair. A few issues were identified for improvement.

The framework of the notes trolley stored at the entrance to the ward

and the shelf of the resuscitation trolley in the preparation room were

chipped and worn to the bare metal. Discussion with staff indicated

that they were aware of the disinfectant in use however some nursing

staff were unsure of the symbol for single use equipment.

The inspectors observed that laryngoscope blades on the resuscitation

trolley were removed from their 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 removed until the point of use for infection control,

identification and traceability in the case of a manufacturer's recall and

safety.

Recommendations

7. The trust and individual staff have a collective responsibility

to ensure that equipment is stored correctly, easily cleaned

and in a good state of repair.

17


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 WHB and

96

consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

98

Average Score 98

Picture 5 Example of hand washing

facilities and PPE station

The unit is to be commended

in achieving full compliance in

the sections regarding

availability of alcohol rub and

personal protective

equipment (PPE) and an

overall high compliance score

in this standard. There was

good provision of hand

washing facilities and PPE

stations in the unit (Picture 5).

Inspectors observed in the preparation room, the underside of the hand

washing sink was dirty, and in the kitchen, the underside of the soap

and paper towel dispensers was dirty. The practice of storing the

dishwasher detergent on the floor beside the dishwasher was not in

accordance with Control of Substances Hazardous to Health (COSHH)

regulations and a green catering dustpan and brush were noted on the

domestic trolley used for cleaning general and sanitary areas. With

minimum staff effort full compliance could be achieved in all sections.

Recommendations

8. The trust should ensure that hand washing sinks and

consumables are clean.

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

in a locked cupboard, in line 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

93

Safe handling and

disposal of sharps

77

Effective use of PPE 100

Correct use of isolation

N/A

Effective cleaning of ward 95

Staff uniform and work

wear

86

Average Score 90

Staff are to be commended for achieving compliance in this standard

and full compliance in the effective use of PPE. The section

concerning the correct use of isolation was not assessed as there were

no patients in the unit being nursed under isolation precautions.

The following issues relating to staff practice, need to be addressed. A

domestic was unsure of the 7 step hand hygiene procedure and there

were a few instances of re-sheathed needles. In one instance a needle

and syringe were not discarded as a single unit. This practice

increases the potential risk of staff receiving a sharps injury when

disconnecting the needle and syringe and should stop immediately.

COSHH data sheets for domestic staff were also not available on the

ward.

The NHSCT has a uniform policy which applies to all staff. Inspectors

were disappointed to note that a doctor was wearing a loose tie, two

members of nursing staff wearing stoned earrings and a domestic

wearing “crocs”.

Staff changing facilities were available for staff to change into and out

of their uniform at work.

Recommendations

10. The trust should ensure that staff receive instructions and

training on the correct hand washing technique.

19


11. The trust and individual staff have a collective responsibility

to ensure safe practice is carried out when handling sharps.

12. The trust should ensure that COSHH data sheets are

available for staff.

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

with and adhere to the regional dress code policy.

20


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs L Gawley - Inspector Infection Prevention/Hygiene

Team

Mrs Melanie Johnston - Domestic Services Manager, SHSCT

Trust representatives attending the feedback session

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

representatives:

Ms P Mc Clelland

Ms A Hamilton

Ms E Deery

Mr E Mc Grattan

Mr A Stewart

Ms S Small

Ms L Surgenor

Ms E Hamilton

- General Manager Cancer Services

- General Manager Domestic Services Trust wide

- Lead Nurse Cancer/OPD

- Principal Pharmacist

- Domestic Services Manager Antrim and Braid

Valley

- Infection Prevention and Control nurse

- Infection Prevention and Control nurse

- Domestic Services Supervisor

Apologies

Mr S Donaghy

Ms Maire Bermingham

Dr N Baldwin

Ms B O‟Neill

- Chief Executive

- Assistant Director Corporate Support

Services

- Senior Infection Prevention and Control

Nurse

- Deputy Ward Manager Laurel House

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 work to ensure that effective environmental

cleaning is carried out and cleaning schedules are available

for staff.

2. The trust and staff should continue to maintain clutter free

ward environments.

3. The trust should continue to work on the repair and

maintenance of the wards and public environments and to

replace damaged or pervious fixtures and fittings.

4. Staff should ensure that linen is in good condition and free

from rips and tears.

5. The trust should ensure that waste bins are kept clean, in

good repair and replaced as appropriate.

6. 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.

7. The trust and individual staff have a collective responsibility

to ensure that equipment is stored correctly, easily cleaned

and in a good state of repair.

8. The trust should ensure that hand washing sinks and

consumables are clean.

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

in a locked cupboard, in line with COSHH regulations.

10. The trust should ensure that staff receive instructions and

training on the correct hand washing technique.

11. The trust and individual staff have a collective responsibility

to ensure safe practice is carried out when handling sharps.

12. The trust should ensure that COSHH data sheets are

available for staff.

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

with and adhere to the regional 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

Reference

number

Recommendations

1. The trust should work to ensure that

effective environmental cleaning is carried

out and cleaning schedules are available

for staff.

2. The trust and staff should continue to

maintain clutter free ward environments.

3. The trust should continue to work on the

repair and maintenance of the wards and

public environments and to replace

damaged or pervious fixtures and fittings.

4. Staff should ensure that linen is in good

condition and free from rips and tears.

5. The trust should ensure that waste bins

are kept clean, in good repair and

replaced as appropriate.

6. The trust should monitor the

implementation of its policies and

procedures in respect of the management

of waste and sharps to ensure that safe

and appropriate practice is in place.

Designated

department

Domestic Services

Nursing Staff

Nursing Services

Domestic Services

Estate Services

Nursing Services

Laundry Services

Domestic

Services/Nursing

Services

Nursing Services

Action required

Domestic Services work schedules are in place.

Domestic Services will monitor the standard of

cleanliness by daily observational audits, monthly

environmental cleanliness audits and annual/

managerial environmental cleanliness audits.

Nursing and Domestic staff continue to maintain a

clutter free environment.

The ward manager and Deputy managers monitor

daily.

Staff will continue monitor the environment in use,

staff to report any damage to the manager or deputy

manager. The ward manager will requisition for

replacement/repair as necessary highlighting risk to

patients. Estate Staff will action in a timely manner.

Staff will continue to monitor linen and will return any

torn linen to the Laundry dept.

Linen Bags for dirty laundry will be returned un used

(were possible without causing build up of dirty

linen),

Laundry manager to contacted and Close liaison

maintained to ensure bags with no tears are supplied

New waste bins replaced if damaged or rusted.

Domestic clean waste bins on daily basis as per

work schedule.

All staff will be reminded at team meetings of policy

on waste disposal. Ward Manager and Deputies will

monitor waste management and sharps disposal

taking corrective action as required

Date for

completion/

timescale

Daily/Monthly/

Annually.

Actioned

Deep Clean in Laurel

House undertaken

18/11/11

Daily Monitoring in

place

Daily/Weekly

Monitoring in place

Daily/As Required

Actioned – Linen

Bags all being

checked prior to

leaving Laundry from

17/11/11

As required.

Daily basis.

Actioned

13/10/11.

Monthly meetings

Daily/As required

Discussed at Safety

Briefings in October

25


Reference

number

Recommendations

7. The trust and individual staff have a

collective responsibility to ensure that

equipment is stored correctly, easily

cleaned and in a good state of repair

Designated

department

Nursing Services

Domestic Services

Action required

Staff will monitor storage and state of equipment and

inform manager of any repairs required. The ward

manager will requisition for replacement/repair as

necessary highlighting risk to patients.

Date for

completion/

timescale

Daily

As required

New Equipment

ordered 19/10/11

8. The trust should ensure that hand

washing sinks and consumables are

clean.

9. The trust should ensure that all cleaning

products are stored in a locked cupboard,

in line with COSHH regulations.

10. The trust should ensure that staff receive

instructions and training on the correct

hand washing technique.

11. The trust and individual staff have a

collective responsibility to ensure safe

practice is carried out when handling

sharps.

12. The trust should ensure that COSHH data

sheets are available for staff.

Domestic Services

Domestic/Nursing

Services

Domestic Services

Nursing Staff and

Medical Staff

Domestic Services

Nursing Services

Cleaning of wash hand sinks to be cleaned daily,

and within toilet areas twice daily by the Domestic

Staff.

Domestic staff reminded of importance of detail

cleaning wash hand basin and underneath soap

dispensers and paper hand towel holders.

Domestic store locked at all times – key pad access

only.

Domestic staff reminded of importance of securing

Domestic Store door and especially keeping

dishwashing detergent secure.

Domestic staff retrained in hand washing technique.

Staff to attend Training as per Trust Policy (face to

face and DVD training)

Monitoring will take place in weekly Hand Hygiene

audits

Sharps to be disposed of correctly as per policy,

Staff reminded at team meetings

SNAP shot audits to be undertaken on an ongoing

basis. And during formal environmental and

managerial audits.

COSHH Data sheets are available in a folder in the

Domestic Store and ward sluice areas.

Cleaned 13/10/11

Monitored by

Domestic

Supervisor/Ward

Manager on a daily

basis.

Actioned13/10/11

Actioned13/10/11

Actioned13/10/11

Actioned15/11/11

Discussed at Safety

Briefings October

Actioned

14/11/11

13. The trust should ensure that all members

of staff are familiar with and adhere to the

regional dress code policy.

Domestic Services

Nursing Services

Domestic and nursing staff reminded of wearing

correct uniform and footwear in accordance with

Dress Code Policy.

Actioned 14/11/11

26

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