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
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 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.
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5.0 Audit Tool
The audit tool used for the inspection is based on the Regional
Healthcare Hygiene and Cleanliness standards. The standards
incorporate the critical areas which were identified through a review of
existing standards, guidance and audit tools (Appendix 2 of Regional
Healthcare Hygiene and Cleanliness standards). The audit tool follows
the format of the Regional Healthcare Hygiene and Cleanliness
Standards and comprises of the following sections.
1. Organisational Systems and Governance: policies and
procedures in relation to key hygiene and cleanliness issues;
communication of policies and procedures; roles and
responsibilities for hygiene and cleanliness issues; internal
monitoring arrangements; arrangements to address issues
identified during internal monitoring; communication of internal
monitoring results to staff
This standard is not audited when carrying out unannounced
inspections however the findings of the organisational
system and governance at annual announced inspection will
be, where applicable, confirmed at ward level.
2. General Environment: cleanliness and state of repair of public
areas; cleanliness and state of repair of ward/department
infrastructure; cleanliness and state of repair of patient bed area;
cleanliness and state of repair of toilets, bathrooms and
washrooms; cleanliness and state of repair of ward/department
facilities; availability and cleanliness of isolation facilities;
provision of information for staff, patients and visitors
3. Patient Linen: storage of clean linen; handling and storage of
used linen; ward/department laundry facilities
4. Waste and Sharps: waste handling; availability and storage of
sharps containers
5. Patient Equipment: cleanliness and state of repair of general
patient equipment
6. Hygiene Factors: hand wash facilities; alcohol hand rub;
availability of personal protective equipment (PPE); availability of
cleaning equipment and materials.
7. Hygiene Practices: hand hygiene procedures; handling and
disposal of sharps; use of PPE; use of isolation facilities and
implementation of infection control procedures; cleaning of
ward/department; staff uniform and work wear
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