Belfast City Hospital, Belfast - 20 October 2011 - Regulation and ...

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Belfast City Hospital, Belfast - 20 October 2011 - Regulation and ...

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Belfast Health and Social Care Trust

Belfast City Hospital

20 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 14

6.3 Maintenance and Repair 15

6.4 Fixture and Fittings 16

6.5 Information 16

7.0 Patient Linen 18

7.1 Management of Linen 18

8.0 Waste and Sharps 20

8.1 Waste 20

8.2 Sharps 21

9.0 Patient Equipment 23

10.0 Hygiene Factors 25

11.0 Hygiene Practice 28

12.0 Key Personnel and Information 32

13.0 Summary of Recommendations 34

14.0 Unannounced Inspection Flowchart 36

15.0 RQIA Hygiene Team Escalation Policy Flowchart 37

16.0 Action Plan 38


1.0 Inspection Summary

An unannounced inspection was undertaken to the Belfast City

Hospital, on the 20 October 2011. The hospital was assessed against

the Regional Healthcare Hygiene and Cleanliness standards and the

following wards were inspected:

• 5 South

• 6 North

• 7 South

• 10 North

Belfast City Hospital is a 529 bedded university teaching hospital

providing local acute services and key regional specialties, including

renal medicine and transplantation and a comprehensive range of

cancer services.

Inspection Outcomes

Overall the inspection teams found evidence that the Belfast City

Hospital is working to comply with the Regional Healthcare Hygiene

and Cleanliness standards. However inspectors found that further

improvement is required in the following areas.

Two of the wards 5 and 7 South achieved an overall compliant score

and two wards 6 and 10 North achieved an overall partially compliant

score. Inspectors observed that, the environment in three of the wards

was generally clean and maintained to a satisfactory standard,

however all wards required some attention to detail when cleaning. A

significant number of issues for improvement was identified in Ward 10

North.

In Wards 6 and 10 North of particular concern were the findings in

relation to Hygiene Factors and Practices. In these two wards all staff

groups must implement hygiene and infection prevention and control

practices consistently to minimise the risk of infection to patients,

visitors and staff.

In all wards improvement is also required in the management of

sharps, and in all wards except for Ward 5 South, the standard on

patient equipment did not reach an acceptable standard.

In Wards 5 and 7 South inspectors were impressed with staff

commitment to providing a safe and clean environment for patients,

this was evidenced by the number of compliant scores, particularly the

hygiene factors and practices sections.

As a result of the findings for Wards 6 and 10 North, there was

escalation to the trust chief executive and a follow up inspection will be

carried out within three months.

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The inspection resulted in 22 recommendations for the Belfast City

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

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

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

action on identified areas which have achieved non complaint scores.

The draft report which includes the high level recommendations in a

Quality Improvement Plan is forwarded within 28 days of the inspection

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

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

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

on request.

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

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

management by the Health and Social Care Board and the Public

Health Agency.

Notable Practice

The inspection identified the following areas of notable practice:

• A joint Infection Control and Environmental Cleanliness

committee has been established with one lead director

• Implementation of the LEAN project and chairman’s award

• Care pathways implemented for patients with an MRSA or

Clostridium difficile infection

• Implementation of high impact intervention care bundles

• Internal infection control and environmental cleanliness

audits

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

City 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.

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Table 1

Ward 5S 6N 7S 10N

General Environment 87 87 85 79

Patient Linen 91 83 92 84

Waste 92 76 85 84

Sharps 74 76 74 84

Patient Equipment 90 80 84 75

Hygiene Factors 94 82 94 83

Hygiene Practices 92 77 98 81

Average Score 89 80 87 81

Table 2

General Environment 5S 6N 7S 10N

Reception N/A 90 N/A N/A

Corridors, stairs lift 93 87 86 83

Public toilets N/A 100 N/A 93

Ward/ department -

general(communal)

78 82 84 76

Patient bed area 86 89 90 83

Bathroom/washroom 96 82 95 67

Toilet 89 89 79 86

Clinical room/ treatment

91 80

room

79

81

Clean utility room 82 N/A 90 72

Dirty utility room 90 84 89 65

Domestic store 78 85 81 79

Kitchen 88 95 92 84

Equipment store 81 77 70 N/A

Isolation 91 94 N/A 89

General information 86 81 85 70

Average Score 87 87 85 79

Table 3

Linen 5S 6N 7S 10N

Storage of clean linen 88 88 83 88

Storage of used linen 93 78 100 79

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

Average Score 91 83 92 84

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance:

75% or below

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Table 4

Waste and sharps 5S 6N 7S 10N

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

Table 5

92 76 85 84

74 76 74 84

Patient Equipment 5S 6N 7S 10N

Patient equipment 90 80 84 75

Table 6

Hygiene Factors 5S 6N 7S 10N

Availability and

cleanliness of WHB and 86 92 96 94

consumables

Availability of alcohol

rub

100 97 100 100

Availability of PPE 93 73 92 87

Materials and

equipment for cleaning

89 65 88 51

Average Score 92 82 94 83

Table 7

Hygiene Practices 5S 6N 7S 10N

Effective hand hygiene

procedures

95 64 95 75

Safe handling and

disposal of sharps

100 77 100 92

Effective use of PPE 100 81 100 90

Correct use of isolation 95 82 100 61

Effective cleaning of

ward

79 73 89 74

Staff uniform and work

wear

100 83 97 93

Average Score 95 77 98 81

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 draft 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.

General Environment 5S 6N 7S 10N

Reception N/A 90 N/A N/A

Corridors, stairs lift 93 87 86 83

Public toilets N/A 100 N/A 93

Ward/ department -

general(communal)

78 82 84 76

Patient bed area 86 89 90 83

Bathroom/washroom 96 82 95 67

Toilet 89 89 79 86

Clinical room/ treatment

91 80

room

79

81

Clean utility room 82 N/A 90 72

Dirty utility room 90 84 89 65

Domestic store 78 85 81 79

Kitchen 88 95 92 84

Equipment store 81 77 70 N/A

Isolation 91 94 N/A 89

General information 86 81 85 70

Average Score 87 87 85 79

The above table outlines the findings in relation to the general

environment of the facilities inspected. The findings indicate that there

are concerns regarding Ward 10 North 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

During the inspection, there was evidence, in some of the areas

inspected, to indicate compliance with regional specifications for

cleaning. However, inspectors observed, that while cleaning

mechanisms were in place to prevent the build up of dust, debris and

bacteria and subsequently minimise the potential risk for the

transmission of infection, these were not always effectively

implemented or adhered to by staff.

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The inspection teams noted, that all wards had issues with cleaning,

however, inspectors had specific concerns about the poor level of

environmental cleaning observed in Ward 10 North particularly in the

bathroom, and clean and dirty utility room.

The outside entrance to the hospital has been refurbished and was

generally clean, however there was evidence of cigarette butts and a

strong odour of cigarette smoke. The reception area carpet was dusty,

stained and marked, the vinyl flooring was worn and had a grubby

appearance in places. The doors at the main lifts and corridors leading

to Ward 10 North had excessive finger marks. It is important that

cleaning frequencies take into consideration areas which are subject to

frequent touch and are increased accordingly. In the corridors, leading

to the wards some additional cleaning is required to light fittings and

under chairs.

In all wards some improvements are required to cleaning the general

ward environment, for example in Ward 10 North some of the computer

stations at the west side nurses station were dusty. In Ward 7 South

adhesive tape was observed on computer display screens and

telephones; in both wards, the inside of the leaflet rack was dusty.

In Wards 6 and 10 North more

attention to detail was

required when cleaning the

corners and edges of floors

and skirtings in most of the

areas within the wards, and in

particular in the isolation

rooms. In Wards 5 and 7

South the floors in most areas

were clean, the areas

identified by inspectors for

more detailed cleaning, were,

for example, the equipment

Picture 1: Soiled floor in a domestic store stores, domestic store and the

treatment room (Picture1).

Throughout the wards inspected, the walls were mostly clean, a few

areas were identified for improvement, for example in Ward 7 South

blood splatters were noted on the wall beside the hand wash sink in a

female toilet. In Ward 10 North blood splashes were observed, on the

wall behind the burn bins in the clean utility room, and there was dust

on the wall trunking at the nurses station. High level dust was also

observed, on the wall plaque above the ice machine. In all wards the

use of posters, notices etc. on the walls attached with adhesive tape

can hinder the cleaning process.

Inspectors noted, that in most areas within all the wards inspected,

attention had been given to the cleaning of hand touch points, such as,

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light fittings and doors, to minimise the risk of transmission of bacteria

from hand contact in frequently used areas. A few issues were

identified for improvement in all wards, however particular attention

needs to be given when cleaning theses areas, in isolation rooms, as in

Ward 10 North, the metal panel touch points of the door of the isolation

room required cleaning.

In all wards more attention was required to the cleaning of fixtures and

fittings such as, cupboards, shelving and high density storage areas.

In Ward 10 North for example, cupboard doors on the central island

were splashed, the inside of some cupboards was dusty and the inside

of shelving tracks and back of the drugs fridge required cleaning. In

Ward 7 South splashes and stains were observed on the outside of

cupboards and there was dust and debris inside the cupboards, high

surfaces were dusty and the outside of the drugs fridge was sticky and

grubby. In all wards the outside of some cupboards were covered in

posters and were therefore unable to be effectively cleaned.

In Ward 5 South, no cleaning issues were identified in the bathrooms.

The bathroom inspected in Ward 10 North received a minimally

compliant score. Inspectors found that the bath, shower head and plug

hole were dirty, there was shaved facial hair/stubble in the hand

washing sink throughout the inspection. The sink was checked three

times during the inspection and remained dirty. In Ward 6 North the

bath hoist and bath steps required cleaning and in Ward 7 South the

high surface above the hand wash sink was dusty.

The cleaning of the ward toilets was mostly completed to a satisfactory

level, however in Ward 7 South more attention to detail when cleaning

is required, for example, the curtain screen rail was dusty and in a

female toilet there was debris on the toilet bowl under the raised toilet

seat. In the male toilet area, the seal around the base of the toilets,

and the toilet brush stand were stained and there was faeces on the

underside of the toilet roll dispenser. In the ward toilet and toilet in the

isolation room in Ward 5 South inspectors observed a urine stain on

the underneath of the toilet seat and raised toilet seat.

Near patient equipment, such as patient lockers and bedside tables

required cleaning, especially at the edges in Ward 6 North and the

bedside entertainment systems were dusty in Ward 7 South. In Ward

10 North a bedside patient fan and a television table were dusty and

high level dust was observed on curtain rails and televisions which

were attached to the ceiling.

The treatment room of Ward 5 South was generally clean and tidy

(Picture 2). In the other three wards more attention to detail was

required.

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Picture 2: Clean and tidy treatment room

In the isolation room inspected in Ward 10 North the television was

dusty and there was tape on the bedside locker. Inspectors noted that

paper waste had been left in the drawer of a patient locker which had

been cleaned and ready for a new admission in Ward 5 South.

In various locations in all wards more detailed cleaning was required to

the cleaning of hand washing sinks at plugs and overflows. Particular

care is required to ensure that lime scale is removed from taps and

fittings as recent evidence has shown that lime scale may harbour

biofilms and the build up of limescale can interfere with good cleaning

and disinfection, by masking and protecting pathogens.

In the dirty utility rooms, whilst generally clean, inspectors noted that

more care was required in cleaning equipment sinks and slop hoppers,

for example, in Ward 6 North the taps of the slop hopper were dirty and

in Ward 7 South faeces was observed on the slop hopper; both sinks

had limescale on the taps. In Ward 10 North some cleaning issues

contributed to the minimally compliant score achieved in this area, in

addition to cleaning the equipment sinks and slop hoppers, inspectors

observed that the front of the bedpan washer and ceiling tiles were

stained.

All domestic stores had issues with cleaning; shelving and cupboards

were dusty, there was dust on high horizontal surfaces, such as the

soap and paper towel dispensers, and in Ward 5 South in the domestic

store the interior fins of three fans were very dusty.

The kitchen areas inspected were generally clean. In Ward 10 North

inspectors noted that the front of the kitchen cupboards had splash

marks, the fire blanket and extinguisher were dusty, and the hand

washing sink plug hole was dirty. In the other wards issues were

observed with the cleaning of appliances such as the fridge, freezer

and the microwave.

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Additional Issues

6.2 Clutter

1. In Ward 5 South isolation room there were two pairs of used

disposable scissors, one pair of scissors still in the wrapping, two

rolls of tape and a small box on the mirror shelf. Inside the small

box were a blood stained soiled dressing, a blood stained

incontinence sheet and clean dressings. These were immediately

removed at sister’s request.

2. A single use jug was in the en-suite. The jug appeared to have

been used, cleaned but not disposed of after use.

There was evidence in some of the wards inspected, particularly wards

5 and 7 South of a continued emphasis to provide a clutter free

environment, with good use of high density storage units and stores.

This provides effective utilisation of space and good stock

management, staff saw a clutter free environment as an essential

element effective cleaning and of good hygiene practices.

In Ward 10 North inspectors noted that the ward entrance foyer and

general ward area appeared cluttered. There were numerous chairs

stacked throughout the ward and boxes of rolls stored on the floor

outside the domestic store. Due to the storage of IV pumps and drip

stands, and the use of some work surfaces for the storage of bandages

and files, the clinical room, was also cluttered in appearance. This not

only impedes the cleaning process but would not be conducive to

providing a safe area to undertake clinical procedures.

Some clutter was observed in the corridors and equipment store of

Ward 6 North, particularly at the side rooms and the corridor leading to

the treatment room. The dirty utility room near the side rooms should

be de-cluttered, inappropriate items removed, and items of equipment

stored in cupboards provided to prevent contamination from aerosol

splashes. The equipment store of Ward 7 South was cluttered to the

point that inspectors had difficulty moving around the store (Picture 3).

Picture 3: Cluttered Equipment store

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6.3 Maintenance and Repair

In all areas inspected, inspectors observed minor paintwork damage to

walls, however in the dirty utility room of Ward 5 South the paintwork

behind the slop hopper and deep equipment sink was damaged and

paint was peeling off the walls. In a toilet, there were holes in the wall

as they had not been repaired when toilet roll holders had been

removed. In Ward 7 South there was a hole in the wall behind the sink

in the domestic store, exposing pipework and a large hole in the wall of

the male toilet. The ward sister informed the inspectors that this had

occurred on the previous evening and a repair request had already

been made to the estates department.

Inspectors also identified other themes common to all wards such as

minor damage to floor and skirting. Damage was also observed to the

doors, frames and formica shelving; in places the damage to doors and

shelves had resulted in exposed and unsealed wood which cannot be

effectively cleaned. In Wards 6 and 10 North doors were damaged, as

a result of the door being propped open by a waste bin.

In all wards except Ward 6 North inspectors observed that ceiling tiles

in some areas within the wards were damaged or missing. The

programme for the cleaning of air vents should be reviewed as a

considerable number of air vents were dusty.

At the time of the inspection, the kitchen of Ward 10 North was

extremely hot and there was limited ventilation, this creates difficulties

for staff who have to work in this environment and should be reviewed

by the estates department to establish what improvements can be

made.

The temperature of the hot water in the sink in a toilet of Ward 5 South

needs to be checked as the water was very hot and not conducive to

hand washing.

In Ward 7 South the toilet

area had been refurbished

creating a spacious shower

and toilet (Picture 4). In Ward

10 North the bathroom on the

east side of the ward is to be

merged with the dirty utility

room and refurbished into a

patient shower room.

Picture 4: Refurbished shower and toilet area

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6.4 Fixtures and Fittings

The fixtures, fittings and equipment in all wards were generally fit for

purpose. There were some issues common to all wards for example

the laminate finish on some bedside lockers and tables was damaged

or missing and some bedrails were chipped. Damaged or missing

finish means that these items are not impervious to moisture. In some

areas fixtures and fittings were old and worn, particularly in the

bathrooms, the dirty utility rooms and the domestic store.

In some areas such as the domestic stores and dirty utility rooms a

designated hand washing sink, or bedpan drip tray were not available.

6.5 Information

Hand hygiene posters were widely displayed throughout the hospital

and the areas inspected. Clear instructions were in place to advise

staff and visitors of isolation precautions in place. There does not

appear to be an agreed set of core HCAI public information leaflets for

patients and visitors for example, in Ward 10 North no information

leaflets were available on hand hygiene or general infection prevention

and control. In Ward 7 South information leaflets on C.difficile and

MRSA were not available.

A range of posters were in place for staff to reference, such as waste

and sharps management, colour coding and segregation of linen.

Inspectors noted that in some instance posters on linen segregation

and sharps injury were not available.

Nursing cleaning schedules while available did not detail all equipment

and staff roles and responsibilities. In Ward 6 North domestic cleaning

schedules were available but not used by staff, and in Ward 5 South

the daily cleaning schedule for the house keeper did not reflect the

amount of items cleaned. Throughout the wards there were excess

posters which were not laminated, and a lack of noticeboards was

observed.

In all wards, except Ward 5 South there were lapses in the recording of

the temperatures of drug fridges. In Wards 6 North and 7 South

temperatures were not consistently recorded and the action taken for

variations outside temperature ranges were not recorded.

16


Recommendations

1. The trust should ensure that the systems and processes in

place for environmental cleaning, provide the necessary

assurance that cleaning is carried out effectively, and that all

staff are aware of their responsibilities.

2. The healthcare environment should be repaired and

maintained, and damaged fixtures and fittings replaced to

maintain public confidence and to help reduce the risk of the

spread of infection.

3. Work should continue on improving storage and maintaining

clutter free environments.

4. An agreed set of core HealthCare Associated Infection (HCAI)

public information leaflets should be available for patients,

visitors, and staff.

5. Detailed nursing cleaning schedules should be developed.

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 5S 6N 7S 10N

Storage of clean linen 88 88 83 88

Storage of used linen 93 78 100 79

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

Average Score 91 83 92 84

7.1 Management of Linen

All wards inspected had effective arrangements in place for the storage

of clean linen. Linen was generally stored in a separate store and was

found to be clean, tidy and free from rips and tears. In Ward 6 North

some linen was stored in an open trolley beside side rooms which are

at times used for isolation purposes. The trolley should be moved or

enclosed to protect the clean linen from airborne contamination.

Some of the reusable linen bags in the linen room of Ward 6 North and

Ward 5 South were torn. In all wards except for Ward 5 South more

attention was required to the cleaning of floors and the removal of

inappropriate items. In Ward 7 South the shelving was also dusty and

there were issues with maintenance and repair.

In Wards 5 and 7 South, good practice was observed in the handling

and storage of used linen, used linen was placed immediately into the

appropriate colour coded bags at the point of use and staff were

observed to be wearing the appropriate personal protective equipment

(PPE) when handling soiled/contaminated linen.

Practices observed in Wards 6 and 10 North required improvement in

the following areas:

• In Ward 10 North staff did not dispose of used laundry at the point

of care, linen was carried through the ward and disposed of into

the linen skip in the dirty utility room. A registered nurse was not

wearing an apron when carrying a bag of infected linen.

• In Ward 6 North two nurses were unaware if water soluble bags

were used for heavily soiled or infected linen and one member of

staff did not remove PPE immediately after handling used linen.

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Recommendations

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

a designated area which is clean and fit for purpose.

8. Systems should be in place to ensure that staff adhere to

regional guidance and trust policies and that staff knowledge

is kept up to date in respect of handling and storage of linen.

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8.0 Waste and Sharps

8.1 Waste

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 5S 6N 7S 10N

Handling, segregation,

storage, waste

92 76 85 84

Availability, use, storage

of sharps

74 76 74 84

The inspection evidenced that there were arrangements in place for the

handling, segregation, storage and disposal of waste in the areas

visited, however, in some instances these arrangements did not comply

with local and regional guidance.

In Wards 7 South and 10 North inappropriate disposal of waste was

observed. In Ward 10 North household waste was disposed of into

clinical waste bins and pharmaceutical waste was disposed of into a

sharps box. In Ward 7 South paper products had been disposed of into

the black lidded pharmaceutical bin.

Picture 5: Inappropriate disposal of waste

In Ward 6 North syringes and

empty saline cartridges were

disposed of into the

household waste bin in the

end bay at the side room area

of the ward (Picture 5), and

inappropriate disposal of

waste was also noted in the

yellow and black lidded burn

bin.

In some wards a clinical or domestic waste bin had not been provided

at hand washing sinks, for example, in Ward 6 North the dirty utility

room near the main ward did not have a household waste bin for the

disposable of paper products and the end bay at the side room area of

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the ward did not have a clinical waste bin. In Ward 10 North there was

no clinical waste bin available in Bay H.

Generally throughout all wards both clinical and household waste bins

were clean and in a good state of repair. Inspectors observed some

instances were bins were stained and beginning to rust in all wards

inspected. For example, in Ward 10 North the clinical waste bin in the

dirty utility was stained and starting to rust under the lid, and the

household waste bin in the staff toilet of Ward 6 North was soiled and

rusting under the lid.

A magpie box was not available in Wards 6 and 10 North. The ward

manager of Ward 10 North advised that she had been unable to

procure magpie boxes. In Ward 6 North waste bags were tied onto the

monitor trolleys.

Each ward had a shared waste hold area which was easily accessible

and not secure. Within the hold area the large clinical waste euro bins

were also open, and in Ward 10 North the hold area was untidy.

8.2 Sharps

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

and were assembled correctly. With the exception of Ward 10 North

bins were labelled with the date, locality and staff signature and

appropriately tagged on disposal. In Ward 10 North the yellow and

black lidded burn bins were not signed to indicate who assembled

them.

The 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.

None of the wards ensured that the temporary closure mechanisms, to

prevent spillage and impede access, were in place when the sharps

boxes were not in use.

In Ward 5 South brackets had been provided for the sharp box on the

drugs trolleys, however staff did not use these, instead a large

unsecured 10 litre box was placed on the lower shelf of the drugs

trolley. In Ward 6 North the sharps boxes in the end bay were not

secured or out of the reach of vulnerable people and one of the small

sharps containers used on the IV trays was filled above the fill line. In

both wards sharps trays in use required more detailed cleaning.

21


In Ward 7 South inspectors identified particular issues with the sharp

box on the phlebotomist trolley, the box had blood splatters, was

locked, but not removed and was not attached securely to the trolley.

Recommendations

9. Waste bins and equipment used in the management of waste

should be available, clean and replaced as appropriate.

10. Systems and processes should be in place to assure that

staff knowledge and practice is kept up to date regarding the

safe and the correct handling and disposal of waste and

sharps.

11. 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.

22


9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment 5S 6N 7S 10N

Patient equipment 90 80 84 75

The cleanliness and state of repair of patient equipment in Ward 5

South was generally good, in the other three wards an improvement is

required especially in Ward 10 North where a minimally compliant

score was achieved.

In all wards, inspectors observed that the resuscitation trolleys were

dusty or had taped labels present, which impedes effective cleaning.

Inspectors also observed that laryngoscope blades on the resuscitation

trolleys had been removed from their sterile packaging. In Ward 6

North the ambu bag had also been removed from its original

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 resterilised

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.

On the resuscitation trolley in Ward 6 North the suction tube had been

used and not disposed of, and in Ward 10 North single use non sterile

gloves were observed on a paper mache kidney dish for use in an

emergency situation. Staff when questioned were unable to identify the

different sizes of the gloves; this practice should be reviewed. In Ward

5 South, the top and back surfaces of the defibrillator were dusty and in

Ward 7 South a paper label and adhesive tape were observed on the

stethoscope on the resuscitation trolley.

Inspectors observed that in some wards, stored equipment such as IV

pumps and drip stands required cleaning or had surface damage,

trigger tape was not in use to indicate that equipment was clean and

ready to use. In Ward 5 South the IV stand and base in use in

Sideward 2 were extremely chipped and in Ward 10 North IV pumps in

use required cleaning. The IV trays in Ward 6 North required more

detailed cleaning as a residue was starting to build up at the edges of

the trays.

There were various types of trolleys in use such as, drugs, notes, and

dressing trolleys, and in all wards there were issues identified for

23


improvement such as, increased cleaning frequencies to improve

cleaning and the removal of label and adhesive marks. In some wards

damage to the trolleys was observed. In Ward 10 North inspectors

noted that dressing trolleys required cleaning as blood stains were

observed on one trolley.

In all wards except Ward 5 South inspectors observed that commodes

had not been cleaned effectively, for example, in Ward 6 North, 10

North and 7 South the underside of the commode was soiled and/or

rust was observed in places. Trigger tape had been used on some but

not all commodes. In Wards 6 North and 7 South, a commode that

was soiled underneath had trigger tape in place to indicate that it was

clean and ready to use. The assurance system for cleaning commodes

should be reviewed. Inspectors also noted in Wards 5 South and 6

North that bedpans were not stored inverted when not in use, to assist

with the drying process and in Ward 7 South some of the bedpans

were old and worn.

In Wards 6 North and 7 South there was no evidence to show that

shared equipment was cleaned between use and in Ward 6 North

inspectors observed that on two occasions the equipment used on the

monitor trolleys was not cleaned between patient use. Again in all

wards except Ward 5 South, some staff, when asked were not aware of

the symbol for single use items.

In Ward 10 North inspectors noted specific problems with the cleaning

of the inside casing of a blood glucose monitor box which was dusty

and the Accurist holder was blood stained. Also nebuliser masks were

hanging loosely and uncovered from the trunking behind the patients

bedside. When questioned, staff gave a variety of answers regarding

the nebuliser equipment changing policy; one staff member changed

the mask daily while another changed the mask weekly.

Recommendations

12. The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean and in good repair.

13. Systems and processes should be in place to assure that

staff knowledge and practice is kept up to date regarding the

decontamination of patient equipment.

24


10.0 Hygiene Factors

STANDARD 6.0

HYGIENE FACTORS

Hand wash facilities; alcohol hand rub; availability of PPE;

availability of cleaning equipment and materials.; staff changing

facilities

Hygiene Factors 5S 6N 7S 10N

Availability and

cleanliness of WHB and 86 92 96 94

consumables

Availability of alcohol

rub

100 97 100 100

Availability of PPE 93 73 92 87

Materials and

equipment for cleaning

89 65 88 51

Average Score 92 82 94 83

All wards were compliant in the section of the audit that relates to the

availability and cleanliness of hand wash facilities.

Hand washing sinks in all wards were generally clean, inspectors

observed a few instances where cleaning could be improved for

example in Ward 6 North the hand washing sinks in the two dirty utility

rooms required cleaning. In Ward 10 North the hand washing sink at

the west side nurses station had a build up of dirt along the back seal.

In Ward 5 South veneer of the hand wash sinks in the treatment room

and Bay D were worn and not all sinks had taps that were sensor or

elbow operated, such as in the clean utility of Ward 10 North and the

dirty utility of Ward 6 North. When elbow operated taps are not

available there should be guidance for staff on the safe use of these

taps. It is good practice to provide sensor or elbow operated taps in

areas where clinical procedures are undertaken.

Hand wash sinks were not all overflow free, overflows to sinks, basins,

baths and bidets are not recommended, as they constitute a constant

infection control risk, much more significant than the possible risk of

damage due to water overflowing (HTM 64). In all wards there were

hand wash sinks that were not plug free, as hands should be washed

under running water, a plug should not be available.

In all wards except for Ward 7 South some of the underside of soap

and paper towel dispensers required cleaning. In Ward 10 North there

was no liquid soap dispenser in Room A or Bay P. The ward manager

advised that these had been removed to carry out maintenance work

25


and had not been put back in place. In Ward 5 South there were no

paper towels in the kitchen paper towel dispenser.

There was good provision of alcohol rub in all wards, in Ward 6 North

there were specific issues identified in relation to availability or use of

PPE. For the size and layout of the ward more dispensers would be

required for the side room area of the ward and the shared corridor.

Disposable plastic aprons were missing from some of the dispensers

and in various locations only one size of disposable glove was

available. Face protection was available but this was not provided on

the resuscitation trolley.

In Wards 10 North and 5 South wall mounted aprons were available in

the dirty utility rooms, this is not advised by the infection prevention and

control team due to the potential risk of aerosol contamination. In the

dirty utility room of Ward 7 South a box of disposable gloves was

stored above the equipment/sluice hopper, disposable aprons were

stored above the waste bins.

Wards 5 and 7 South were compliant in the section of the audit tool

relating to the storage and use of material and equipment for general

cleaning, in contrast Wards 6 and 10 North were minimally compliant.

In all wards Actichlor plus solution or tablets were not stored in

compliance with COSHH regulations. In Ward 10 North Actichlor plus

solution was diluted using hot water rather then luke warm/cold water,

the use of hot water results in the production of toxic chlorine gas. Also

boxes of wipes were open, dried out and therefore not effective for use.

In Ward 6 North there were sheets available to record daily changes of

the Actichlor plus solution, inspectors noted that recording in these

sheets was very inconsistent and no recording had been completed for

some days. In all wards except Ward 7 South there were issues

identified regarding staff knowledge of the correct dilution rate of the

disinfectant used for routine cleaning or for cleaning blood and body

fluid spillages.

Some equipment used for cleaning was not stored appropriately and

required cleaning, for example in Ward 10 North clean mop heads were

stored untidily on the shelving in the domestic store. In all wards mops

when not in use were left in water filled mop buckets until their next

use. In Ward 6 and 10 North, yellow mop buckets and mops were left

sitting outside isolation rooms, and in Ward 10 North domestic

equipment, trolley and red and blue mop buckets, when not in use were

stored in the corridor. Also in Ward 10 North domestic staff advised

inspectors that the supply of mop heads at ward level was insufficient

for their requirements, mop heads were used for multiple tasks and not

changed as required. The mop buckets inspected were dirty and not

stored inverted. A grey coloured bucket was in use by domestic staff to

decant clean and dirty water into the colour coded mop buckets.

26


In all wards there were issues identified regarding the cleaning of

equipment used for general cleaning of the ward, however this was

more evident in Wards 6 and 10 North. Inspectors noted that in Ward

10 North the domestic trolley required cleaning and was in a poor state

of repair, wooden brushes were in use, these were dirty and in poor

repair. Wooden equipment is not easily cleaned and not in line with

NPSA colour coding guidance. In Ward 6 North inspectors also noted

the use of wooden brushes and shafts which were dirty and the

vacuum, buffer and buckets used for cleaning were dusty.

Recommendations

14. The trust should ensure that hand washing sinks and

consumables are available, clean, and in a good state of

repair.

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

clean, and stored appropriately.

16. Systems and processes should be in place to assure that

staff knowledge and practice is kept up to date regarding the

use of disinfectants.

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

in a locked cupboard, in accordance with COSHH

regulations.

18. The trust should ensure that PPE is readily available.

27


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 5S 6N 7S 10N

Effective hand hygiene

procedures

95 64 95 75

Safe handling and

disposal of sharps

100 77 100 92

Effective use of PPE 100 81 100 90

Correct use of isolation 95 82 100 61

Effective cleaning of

ward

79 73 89 74

Staff uniform and work

wear

100 83 97 93

Average Score 95 77 98 81

In Wards 5 and 7 South inspectors observed that effective hand

hygiene procedures were generally undertaken by staff and a high

compliance score was achieved in the section of the audit tool. There

was only one issue identified in Wards 5 and 7 South, in Ward 5 South

a member a staff did not use the seven step hand washing technique

when washing their hands. In Ward 7 South a doctor did not wash their

hands prior to donning gloves when undertaking a clinical procedure.

In contrast Wards 6 and 10 North were minimally compliant and

improvements in practice are required. In both wards practice issues

identified related to:

• not washing hands before putting on gloves

• not washing hands before entering isolation rooms

• not washing hands after leaving isolation rooms

In Ward 10 North specific issues observed by inspectors were, a staff

member did not wash their hands before assisting a patient with a drink

and due to hand/wrist strapping a member of staff was unable to carry

out the correct seven step hand washing technique.

In Ward 6 North, staff observed did use the correct seven step

technique for either washing their hands or when applying alcohol rub.

One doctor washed their hands, then blew their nose, another doctor

did not wash hands after a clinical procedure. Inspectors observed that

patients in bed were not offered hand hygiene before their meal. An

28


improvement is also required in staff knowledge in relation to when it is

appropriate to use alcohol rub and anti-bacterial solution.

All wards except 6 North, were compliant with the safe handling and

disposal of sharps and full compliance was achieved by Wards 5 and 7

South. In Ward 6 North re-sheathing of green and red needles was

observed in two sharps boxes; this is unsafe practice and has the

potential to result in a sharps injury. Staff informed inspectors that the

red needles are blunt and used for teaching purposes. In two sharps

boxes, needles and syringes were not discarded as a complete single

unit.

In Wards 5 and 7 South effective use of PPE was observed. In Ward

10 North inspectors observed that on one occasion staff did not wear

PPE appropriately. A nurse entered an isolation room wearing an

apron and gloves to remove a commode. On leaving the side room,

with the commode, she took the patients clip board/chart hanging from

the dado rail outside the room, handled it, rested it on top of the

commode frame and then brought it into the side room. Once finished

in the side room the nurse replaced the clip board on to the dado rail

and continued to wheel the commode into the dirty utility room. During

this episode of care the nurse wore the same apron and gloves and did

not wash her hands.

On several occasions in Ward 6 North the inappropriate use of PPE

was observed, for example, not wearing an apron when changing and

emptying a catheter bag, on other occasions PPE was not removed

immediately on completing a procedure or prior to leaving an isolation

room.

In Ward 7 South a full compliance score was achieved in the correct

use of isolation and no issues were identified. In the nursing notes

checked in Wards 6 and 10 North improvements in the following areas

were required. In Ward 10 North a patient with Vancomycin - Resistant

Enterococci (VRE), did not have an isolation care plan in place. This

was immediately rectified by the ward manager. In Ward 6 North a

patient with VRE did not have an alert notice visible in their notes or a

care plan in place. Inspectors observed that in both these wards that

PPE was not always worn appropriately when entering and leaving

isolation rooms. In both wards isolation room doors were open

throughout the inspection. In Ward 5 South and 10 North an allied

health professional was observed not wearing a disposable apron or

gloves when entering an isolation room.

Inspectors were concerned that in Ward 10 North re-usable equipment

was not always cleaned after use in an isolation area, for example the

thermometer. Domestic staff informed the inspectors that they used

sani wipes to clean isolation rooms and the domestic equipment used

in isolation areas. In both Wards 6 and 10 North yellow domestic

equipment, mops and buckets, when not in use were stored in the

29


corridor outside isolation side rooms. In Ward 10 North staff did not

clean a yellow bucket that had been used in an isolation room before

using it again.

With the exception of Ward 7 South who were again compliant in this

section of the audit tool, additional effort is required to improve practice

in the effective cleaning at ward level. In all wards inspectors did not

observe equipment being routinely cleaned between patient use, and

COSHH data sheets were not available for domestic staff. Again in all

wards except 7 South staff were not aware of the disinfectant dilution

rate used to clean blood and body fluid spillages.

Nursing staff in Wards 6 and 10 North were unsure of the NPSA

cleaning colour coded system. In both wards inspectors observed that

domestic staff fill mops buckets and hand held buckets at the start of

the morning shift, these were not routinely emptied and the water was

not changed on a regular basis. Also domestic staff left the debris

gathered from sweeping the floor in the corner of the floor for collecting

and disposal at a later time (Picture 6). In Ward 10 North, the domestic

staff advised the inspectors, that there were occasions, when they

finish their shift without completing all scheduled tasks.

Picture 6: Debris left on the floor

In all wards, compliance with regional dress code was good, except for

Ward 6 North where inspectors observed that a doctor did not comply

with bare below elbow policy, or have their long hair tied back. In all

wards except Ward 5 South, staff informed the inspectors that

changing facilities were not available.

Additional Issues

1. Domestic staff in Ward 10 North advised inspectors that they were

not sure when or if they had ever had infection prevention and

control training.

2. The ward manager in Ward 10 North advised that the ward has a

deficit in Band 2 staff and a ward housekeeper.

30


3. Staff also provided feedback on the new uniforms, some staff felt

the V-neck was tight and it was difficult to remove the uniform

when soiled without contaminating their hair. The Band 6 staff

who were previously the Ward Sisters have the same uniform as

a staff nurse and have been asked by visitors if they have been

demoted.

Recommendations

19. The trust must ensure that all staff groups implement

standard infection prevention and control precautions

consistently to minimise the risk of infection.

20. All staff have a responsibility to ensure that hand hygiene is

carried out in line with WHO guidance and that all PPE is

used appropriately.

21. Systems and processes should be in place to assure that

staff knowledge and practice is kept up to date regarding

isolation, cleaning and decontamination of equipment.

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

with and adhere to the regional dress code policy.

31


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs E Colgan - Senior Officer Infection Prevention/Hygiene Team

Mrs L Gawley - Inspector Infection Prevention/Hygiene Team

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

Mrs M Keating - Inspector Infection Prevention/Hygiene Team

Mrs L Watt - Ulster Independent Clinic

Ms S Baird - Northwest Independent Clinic

Mrs Y Black - Western Health and Social Services Trust

Mrs N Donnelly - Western Health and Social Services Trust

Trust representatives attending the feedback session

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

representatives:

Colm Donaghy - Chief Executive

Tony Stevens - Medical Director

Brenda Creaney - Executive Director of Nursing

Jennifer Welsh - Director, Cancer and Specialist Services

Colin Cairns - Co-Director PCSS

Caroline Leonard - Co-Director, Cancer and Specialist Services

David Robinson - Clinical Coordinator and Acting Associate

Director of Nursing

Damien O’Neill - ASM, Medicine

Paul McGarrity - ASM (Gynaecology)

Seamus Trainor - Senior Manager, PCSS

Anne McAuley - Governance Manager, SMWCH

Gerard McCallan - Divisional Estates Manager

Gillian Traub - Service Manager, Oncology and Haematology

Jackie Campbell - Service Manager

Judy Buchanan - Infection Prevention and Control Nurse

Clare Shannon - Ward Manager, 7 South

Alison Millar - Ward Sister, 5 South

Deborah McKelvey - Ward Sister, 10 North

Rosie Gray - Ward Sister, 6 North

Kim Aughey - PCSS Operations Manager

Ian Wilson - Estates Officer

Stephen Lawson - Estates Officer

Aisling Cartin - Estates Officer

Ruth Finn

- Infection Prevention and Control Nurse

Joanne Stewart - Deputy Ward Sister, 10 North

Jason Keys - Estates Officer, Student

32


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.

33


13.0 Summary of Recommendations

1. The trust should ensure that the systems and processes in

place for environmental cleaning, provide the necessary

assurance that cleaning is carried out effectively, and that all

staff are aware of their responsibilities.

2. The healthcare environment should be repaired and

maintained, and damaged fixtures and fittings replaced to

maintain public confidence and to help reduce the risk of the

spread of infection

3. Work should continue on improving storage and maintaining

clutter free environments.

4. An agreed set of core HealthCare Associated Infection (HCAI)

public information leaflets should be available for patients,

visitors, and staff.

5. Detailed nursing cleaning schedules should be developed.

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

importance of monitoring fridge temperatures.

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

a designated area which is clean and fit for purpose.

8. Systems should be in place to ensure that staff adhere to

regional guidance and trust policies and that staff knowledge

is kept up to date in respect of handling and storage of linen.

9. Waste bins and equipment used in the management of waste

should be available, clean and replaced as appropriate.

10. Systems and processes should be in place to assure that

staff knowledge and practice is kept up to date regarding the

safe and the correct handling and disposal of waste and

sharps.

11. 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.

12. The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean and in good repair.

13. Systems and processes should be in place to assure that

staff knowledge and practice is kept up to date regarding the

decontamination of patient equipment.

34


14. The trust should ensure that hand washing sinks and

consumables are available, clean, and in a good state of

repair.

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

clean, fit for purpose, and stored appropriately.

16. Systems and processes should be in place to assure that

staff knowledge and practice is kept up to date regarding the

use of disinfectants.

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

in a locked cupboard, in accordance with COSHH

regulations.

18. The trust should ensure that PPE is readily available.

19. The trust must ensure that all staff groups implement

standard infection prevention and control precautions

consistently to minimise the risk of infection.

20. All staff have a responsibility to ensure that hand hygiene is

carried out in line with WHO guidance and that all PPE is

used appropriately.

21. Systems and processes should be in place to assure that

staff knowledge and practice is kept up to date regarding

isolation, cleaning and decontamination of equipment.

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

with and adhere to the regional dress code policy.

35


Plan Programme

14.0 Unannounced Inspection Flowchart

Environmental Scan:

Stakeholders & External

Information

Prior to Inspection Year

Plan

Programme

Prioritise Themes & Areas for Core Inspections

Balance Programme

Consider:

Areas of Non-Compliance

Infection Rates

Trust Information

RQIA Hygiene Team

January/February

Schedule Inspections

Prior to Inspection

Identify & Prepare Inspection Team

Episode of Inspection

Day of Inspection

Day of Inspection

Inform Trust

Carry out Inspection

Is there immediate risk

requiring formal escalation?

NO

YES

Invoke

RQIA

IPHTeam

Escalation

Process

A

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

Reporting & Re-Audit

14 days later

Within 0-3 months

Signed Action Plan

received from Trust

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

36


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,

Seek assurance on implementation of actions

Take necessary action:

E.g.: Follow-Up Inspection

37


16.0 Action Plan

Ref No Recommendations Designated

department

1. The trust should ensure that the systems and

processes in place for environmental cleaning;

provide the necessary assurance that cleaning

is carried out effectively, and that all staff are

aware of their responsibilities.

Nursing

PCSS

IPC

Action required

‘Roles and responsibilities of Staff in relation

to Environmental Cleanliness and Cleanliness

of Equipment’ policy under review.

The consultation process in relation to the

cleaning manual has resulted in requests for

significant changes to the content and format.

Work is ongoing to have a revised final

consultation document by February 2012.

All of these aspects will be monitored through

the programme of Environmental Cleanliness

Audits based on the Cleanliness Matters

Strategy and results fed back through

Balanced Scorecards.

Date for

completion/

timescale

Mar 2012

Feb 2012

Ongoing

2. The healthcare environment should be repaired

and maintained, and damaged fixtures and

fittings replaced to maintain public confidence

and to help reduce the risk of the spread of

infection.

3. Work should continue on improving storage and

maintaining clutter free environments.

Estates

IPC

Other

appropriate

staff

All

Directorates

This is ongoing as part of Estate daily

maintenance and refurbishment programmes.

Planned programme of de-clutter and deep

cleaning in place. Ongoing space utilisation

and de-cluttering is being driven by Service

Managers.

Ongoing

Ongoing

4. An agreed set of core HealthCare Associated

Infection (HCAI) public information leaflets

should be available for patients, visitors, and

staff.

IPC

The Trust has secured funding from the PHA

to take forward the issue of HCAI

communication.

June 2012

38


Ref No Recommendations Designated

department

5. Detailed nursing cleaning schedules should be

developed.

Nursing

IPECC

Action required

A sub-group of IPECC (Infection Prevention &

Environment and Cleanliness Committee) will

be set up to review and standardise cleaning

schedules, and will establish any outstanding

issues of audit standardisation process.

Agree a standardised audit which will be used

in all areas. This will include standardised

responsibilities. To be kept under review.

Systematic roll out of the agreed standardised

audit using the Maximiser system.

Date for

completion/

timescale

Feb 2012

Dec 2011

Commencin

g Feb 2012

6. The trust should ensure that all staff are aware

of the importance of monitoring fridge

temperatures.

Nursing

The Medicines Code outlines procedures

for use of medicine fridges. A

pharmaceutical refrigerator temperature

log sheet is maintained for each individual

fridge, with records being maintained and

monitored by Ward Managers.

Ongoing

7. The trust should ensure the correct storage of

clean linen in a designated area which is clean

and fit for purpose.

Nursing

Guidance regarding storage of linen is in the

Regional Infection Prevention Manual. Linen

storage and segregation guidance has been

circulated to all Directorates.

Complete

This states that all linen must be stored off

the floor in a clean dedicated area that

allows for ease of access and rotation of

stock and that Linen rooms must have

shelving that are easy to clean, and

cleaning frequencies must be at least

quarterly.

39


Ref No Recommendations Designated

department

8. Systems should be in place to ensure that staff

adhere to regional guidance and trust policies

and that staff knowledge is kept up to date in

respect of handling and storage of linen.

Nursing

Action required

Guidance regarding storage of linen is in the

Regional Infection Prevention Manual. Linen

storage and segregation guidance has been

circulated to all Directorates.

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial

audits, and IPC audits monitor

compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Date for

completion/

timescale

Complete

9. Waste bins and equipment used in the

management of waste should be available,

clean and replaced as appropriate.

PCSS

Nursing

IPC QIT audit will be introduced when

available.

This is monitored as part of the

Environmental Cleanliness Audit Programme.

Regional contract for bins at adjudication

stage.

Ongoing

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial

audits, and IPC audits monitor

compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

40


Ref No Recommendations Designated

department

rectification.

Action required

Date for

completion/

timescale

10. Systems and processes should be in place to

assure that staff knowledge and practice is kept

up to date regarding the safe and the correct

handling and disposal of waste and sharps.

PCSS

There is a training programme available to all

staff.

Update and refresher training will continue to

be provided.

Complete

The Trust will pilot and roll out across all

facilities the use of an electronic tool to audit

waste management compliance against

policy, procedure and RQIA requirements.

This process will supplement the existing

audit tools used by PCSS, IPC and also

existing external audits conducted by Daniels

(sharps box suppliers).

Pilot

completed

Roll-out

programme

across Trust

to be

completed

by Apr 2012

‘Daniels’ audit completed in October 2011

and results have been disseminated

Safer Needle Device Group met again in Dec

2011.

11. 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.

PCSS

Nursing

The Trust will pilot and roll out across all

facilities the use of an electronic tool to audit

waste management compliance against

policy, procedure and RQIA requirements.

This process will supplement the existing

audit tools used by PCSS, IPC and also

existing external audits conducted by Daniels

(sharps box suppliers).

Pilot

completed

Roll-out

programme

across Trust

to be

completed

by Apr 2012

41


Ref No Recommendations Designated

department

12. The trust and individual staff have a collective

responsibility to ensure that patient equipment is

clean and in good repair.

Nursing

PCSS

Action required

Daniels’ audit completed Oct 2011 and

results disseminated.

The consultation process in relation to the

cleaning manual has resulted in requests for

significant changes to the content and format.

Work is ongoing to have a revised final

consultation document by February 2012.

The manual includes roles and

responsibilities of trust staff in relation to

patient equipment. A template will be used

to record all cleaning of equipment.

Date for

completion/

timescale

Complete

Feb 2012

13. Systems and processes should be in place to

assure that staff knowledge and practice is kept

up to date regarding the decontamination of

patient equipment.

Nursing

Role and responsibilities policy in place.

Cleaning statements document for all wards

and departments to be finalised and

disseminated.

Complete

Jan 2012

Regular training is provided to all

appropriate staff through IPC updates and

link nurse meetings.

Equipment Cleaning Guide for clinical

staff has been disseminated.

14. The trust should ensure that hand washing sinks

and consumables are available, clean, and in a

good state of repair.

PCSS

This is monitored as part of the

Environmental Cleanliness Audit Programme.

Staff are reminded of the importance of

replenishing dispensers.

Ongoing

Environmental cleanliness audit

programmes, which include daily ward

42


Ref No Recommendations Designated

department

Action required

checks, department and managerial

audits, and IPC audits monitor

compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Regular training is provided to all

appropriate staff.

Date for

completion/

timescale

15. Equipment used for the general cleaning of a

ward should be clean, fit for purpose, and stored

appropriately.

Nursing

PCSS

The consultation process in relation to the

cleaning manual has resulted in requests for

significant changes to the content and format.

Work is ongoing to have a revised final

consultation document by February 2012.

Feb 2012

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial

audits, and IPC audits monitor

compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Regular training is provided to all

appropriate staff.

43


Ref No Recommendations Designated

department

16.

17.

Systems and processes should be in place to

assure that staff knowledge and practice is kept

up to date regarding the use of disinfectants.

The trust should ensure that all cleaning

products are stored in a locked cupboard, in

accordance with COSHH regulations.

Nursing

PCSS

Action required

All staff have been reminded and made

aware of poster advice.

Mandatory IPC training is provided, poster

advice issued to wards, staff questioned

at audit.

Locked cupboards are provided.

Ward managers and PCSS supervisors

carry out regular checks to ensure all staff

comply with COSHH procedures. Audited

as part of Belfast Risk Assessment and

Audit Tool (BRAAT).

Date for

completion/

timescale

Completed

and ongoing

Complete

18.

The trust should ensure that PPE is readily

available.

Nursing

PCSS

The Trust has a process for the provision of

appropriate PPE.

Complete

All staff must follow information, instruction

and training with regards to disposal of PPE

in compliance with Trust Policy and

Procedure.

Information on correct disposal of PPE is

discussed at ward staff meetings and

displayed in posters. Compliance will be

checked through electronic audit.

Complete

Apr 2012

(Electronic

Audit of

Waste

stream).

19.

The trust must ensure that all staff groups

implement standard infection prevention and

control precautions consistently to minimise the

risk of infection.

IPCT

All staff receive infection prevention training

and regular updates. Link Nurses in all wards

hold regular updates.

Complete

44


Ref No Recommendations Designated

department

20.

All staff have a responsibility to ensure that hand

hygiene is carried out in line with WHO guidance

and that all PPE is used appropriately.

IPCT

Action required

Balance scorecards, which include WHO

Hand Hygiene audits. All of these aspects will

be monitored through the programme of

Environmental Cleanliness Audits based on

the Cleanliness Matters Strategy.

The IPCT carried out an independent audit

and results have been fed back. Independent

audits will be carried out 4 times a year (2 of

which will be carried out by Infection

Prevention and Control).

The IPCT is currently devising an educational

tool to remind staff of the appropriate use of

PPE.

Date for

completion/

timescale

Complete

and

Ongoing

21. Systems and processes should be in place to

assure that staff knowledge and practice is kept

up to date regarding isolation, cleaning and

decontamination of equipment.

IPCT

Mandatory Infection Prevention & Control

training is delivered by IPCN Team.

Staff to be reminded of the link to the regional

Infection Control Manual and the ‘Medical and

Nursing Equipment Cleaning Guide’ has been

re-circulated.

Ongoing

All service managers received email

copies of the cleaning guide poster for

dissemination to all wards and

departments. Assurance is gained through

environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial

audits, and IPC audits monitor

compliance.

45


Ref No Recommendations Designated

department

22. The trust should ensure that all members of staff

are familiar with and adhere to the regional

dress code policy.

Action required

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Trust policy available to all staff on Intranet.

Policy is enforced at local level by senior

staff, e.g., Ward Sisters and Senior

Managers.

Assurance is gained through

environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial

audits, and IPC audits monitor

compliance.

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Date for

completion/

timescale

Complete

46

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