Muckamore Abbey Hospital, Antrim - 25 April 2012 - Regulation and ...

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Muckamore Abbey Hospital, Antrim - 25 April 2012 - Regulation and ...

RQIA

Infection Prevention/Hygiene

Unannounced Follow up Inspection

Belfast Health and

Social Care Trust

Muckamore Abbey Hospital

25 April 2012


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 5

3.0 Inspections 6

4.0 Unannounced Inspection Process 7

4.1 Onsite Inspection 7

4.2 Feedback and Report of the Findings 7

5.0 Audit Tool 8

6.0 Environment 10

6.1 Cleaning 10

6.2 Clutter 12

6.3 Maintenance and Repair 12

6.4 Fixture and Fittings 12

6.5 Information 13

7.0 Patient Linen 14

7.1 Management of Linen 14

8.0 Waste and Sharps 15

8.1 Waste 15

8.2 Sharps 15

9.0 Patient Equipment 16

10.0 Hygiene Factors 17

11.0 Hygiene Practice 19

12.0 Key Personnel and Information 21

13.0 Summary of Recommendations 22

14.0 Unannounced Inspection Flowchart 24

15.0 RQIA Hygiene Team Escalation Policy Flowchart 25

16.0 Action Plan 26


1.0 Inspection Summary

The unannounced inspection undertaken to Muckamore Abbey

Hospital on the 16 February 2012 identified issues of minimal

compliance within standards 2- 7 of the Regional Healthcare Hygiene

and Cleanliness Standards. In line with the follow up process an

unannounced inspection was undertaken on the 25 April 2012.

Inspection Outcomes

The inspection team reviewed the progress and found 78 per cent of

the preliminary findings had been addressed. The majority of those still

requiring action were in relation to the cleaning of windows, radiators

and sanitary areas, replacement of fittings, maintenance and repairs.

On the inspection of 16 February 2012, 26 recommendations were

made in relation to Standards 2-7, 15 have been addressed, 11 have

been repeated and there are 3 new recommendations. The following

area was inspected:

Erne Ward

Improvements and Developments since the Previous Inspection

The infection prevention and control link nurse on the ward has held

various training sessions with staff following the inspection in February,

this included training on a new nursing cleaning schedule, education on

hand hygiene both for patients and for staff and the introduction of

hand hygiene audits.

Staff have been supplied with personal hand held alcohol rub

dispensers

New flooring was being laid in corridors during the visit

Key Area for Improvement

The timeframe for repairs and replacement of fixtures should be

reviewed to ensure the patient’s living spaces are maintained to an

acceptable standard.

A summary of the recommendations following the re-audit is listed in

Section 13.

A detailed list of the findings from the re-audit is forwarded to Belfast

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

action on recurring or new areas which have achieved non compliant

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

1


eport 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.

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

Abbey Hospital for their assistance during the inspection.

The following tables give an overview of compliance scores noted in

areas inspected by RQIA:

Table 1 summarises the overall compliance levels achieved.

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

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

more specific attention.

Table 1

Erne

16 Feb 2012

Erne

25 April 2012

Environment 71 92

Patient Linen 77 84

Waste 79 91

Sharps 86 90

Equipment 44 90

Hygiene Factors 78 93

Hygiene Practices 58 90

Total 70 90

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

2


Table 2

Environment

Erne

16 Feb 2012

Erne

28 April 2012

Reception 84 97

Corridors, stairs lift 65 95

Public toilets 81 100

Ward/department -

68

general(communal)

88

Patient bed area 91 94

Bathroom/washroom 60 79

Toilet 67 82

Clinical

100

81

room/treatment room

Clean utility room N/A N/A

Dirty utility room

N/A

N/A

(Disposal store)

Domestic store 63 86

Kitchen(Servery) 87 96

Equipment store 67 92

Isolation 76 96

General information 39 92

Total 71 92

Linen

Erne

16 Feb 2012

Erne

28 April 2012

Storage of clean linen 61 86

Storage of dirty linen 93 86

Laundry facilities N/A N/A

Total 77 86

Waste and sharps

Handling,

segregation, storage,

waste

Availability, use,

storage of sharps

Erne

16 Feb 2012

79

86

Erne

28 April 2012

91

90

Patient Equipment Erne

Erne

16 Feb 2012 28 April 2012

Patient equipment 44 90

3


Hygiene Factors

Erne

16 Feb 2012

Erne

28 April 2012

Availability and

95

cleanliness of WHB

79

and consumables

Availability of alcohol

100

80

rub

Availability of PPE 67 80

Materials and

95

equipment for

cleaning

85

Total 78 93

Hygiene practices

Erne

16 Feb 2012

Erne

28 April 2012

Effective hand

93

43

hygiene procedures

Safe handling and

100

50

disposal of sharps

Effective use of PPE 73 94

Correct use of

N/A

N/A

isolation

Effective cleaning of

80

56

ward

Staff uniform and

85

70

work wear

Total 58 90

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

6


4.0 Unannounced Inspection Process

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

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

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

inspection flow chart is attached in Section 14.

4.1 Onsite Inspection

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

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

was responsible for guiding the team and ensuring they were in

agreement about the findings reached. Membership of the inspection

team is outlined in Section 12.

The inspection of ward environments is carried out using the draft

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.

Organisations are forwarded a detailed action plan of preliminary

findings within 14 days of the inspection; this does not include the

findings of the overall organisational systems and governance. The

action plan is returned with the agreed draft report. The draft report

contains the high level recommendations of the inspection and is

forwarded to each organisation within 28 days of the inspection for

agreement and factual accuracy checking and returned within two

weeks. The detailed action plan is available on request from RQIA.

The findings of the inspection will be followed up in line with 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 Draft Regional Healthcare Hygiene and Cleanliness

Standards and comprises of the following sections.

1. Organisational Systems and Governance: policies and

procedures in relation to key hygiene and cleanliness issues;

communication of policies and procedures; roles and

responsibilities for hygiene and cleanliness issues; internal

monitoring arrangements; arrangements to address issues

identified during internal monitoring; communication of internal

monitoring results to staff

This standard is not audited when carrying out unannounced

inspections however the findings of the organisational system

and governance at annual announced inspection will be,

where applicable, confirmed at ward level.

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

areas; cleanliness and state of repair of ward/department

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

cleanliness and state of repair of toilets, bathrooms and

washrooms; cleanliness and state of repair of ward/department

facilities; availability and cleanliness of isolation facilities; provision

of information for staff, patients and visitors

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

used linen; ward/department laundry facilities

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

sharps containers

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

patient equipment

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

availability of personal protective equipment (PPE); availability of

cleaning equipment and materials.

7. Hygiene Practices: hand hygiene procedures; handling and

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

implementation of infection control procedures; cleaning of

ward/department; staff uniform and work wear

8


Level of Compliance

Percentage scores can be allocated a level of compliance using the

compliance categories below. The categories are allocated as follows:

Compliant

85% or above

Partial compliance 76 to 84%

Minimal compliance 75% or below

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

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

ensure that the appropriate action is taken.

9


6.0 Environment

STANDARD 2.0

GENERAL ENVIRONMENT

Cleanliness and state of repair of public areas; cleanliness and

state of repair of ward/department infrastructure; cleanliness and

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

of toilets, bathrooms and washrooms; cleanliness and state of

repair of ward/department facilities; availability and cleanliness

of isolation facilities; provision of information for staff, patients

and visitors.

Environment

Erne

16 Feb 2012

Erne

28 April 2012

Reception 84 97

Corridors, stairs lift 65 95

Public toilets 81 100

Ward/department -

68

general(communal)

88

Patient bed area 91 94

Bathroom/washroom 60 79

Toilet 67 82

Clinical room/treatment

100

81

room

Clean utility room N/A N/A

Dirty utility room(Disposal

N/A

N/A

store)

Domestic store 63 86

Kitchen(Servery) 87 96

Equipment store 67 92

Isolation 76 96

General information 39 92

Total 71 92

The above tables outline the findings in relation to the general

environment of the ward inspected during both inspections. The

findings indicate improvement in all areas, in particular the treatment

room which is now fully compliant. The findings in respect of the

general environment are detailed in the following sections.

6.1 Cleaning

The inspection evidenced that there was improvement to indicate

greater compliance with regional specifications for cleaning, however

more attention to detail was still required in sanitary areas. Staff are

10


commended for achieving overall compliant scores and improving the

level of compliance in the

sections within this standard.

All cleaning issues in relation

to the treatment room have

been addressed and there

were no new issues. This

section achieved full

compliance. (Picture 1)

Picture 1: Clean tidy treatment room

In the sanitary areas the inspectors found that more attention to detail

was still required when cleaning. In the single toilet opposite the

equipment store, the toilet bowl was dirty and required descaling,

(Picture 2) the fittings on the toilet seat in the shower room were

stained and or rusted. The shower fittings on the bath and the

underside of the taps in the shower room required cleaning.

Picture 2: Dirty toilet bowl

Cleaning of the large specialist shower chair (Picture 3) had improved,

however crevices required more thorough cleaning, and the plastic

sleeve covering the height adjustment leads held dirty stale water. The

underside of the smaller shower chair was also stained.

11


Picture 3: Large specialist shower chair

The hospital has commenced a programme of cleaning radiators, this

needs to be completed as radiators in the lounge, equipment store and

shower room were still dusty. The external windows throughout the

ward still required cleaning.

6.2 Clutter

The staff on the ward have carried out a de cluttering programme; unused

stock and equipment had been removed, this improved the

overall appearance of the ward and facilitates the cleaning process.

6.3 Maintenance and Repair

A programme of floor replacement scheduled prior to the first

inspection was under way during the visit. It was also noted that in

some areas repairs to wall and wood finishes had been made in

preparation for painting. However, there were still holes in the walls of

both single toilets which have not been repaired. Staff should ensure

that all actions and repairs detailed on the first report are completed

and to an acceptable standard.

The single toilet No. 69 had a very heavy urine smell, this should be

investigated and if necessary the floor replaced.

6.4 Fixtures and Fittings

The hand towel dispenser in toilet No.69 and the toilet roll dispenser in

the toilet opposite the equipment store have still not been replaced,

(Picture 4) although toilet roll was available on a shelf. Staff stated that

dispensers had been ordered, these should be replaced as a matter of

urgency. It is now 9 weeks since the first inspection and the lack of

hand towels prohibits effective hand hygiene for both patients and staff.

12


Picture 4: Damage to paint finish on wall

and the toilet roll dispenser was missing

6.5 Information

A new nursing cleaning schedule, detailing duties and responsibilities

had been introduced; this was completed daily but signed off weekly.

The ward manager advised the trust generic patient equipment

cleaning schedule had just been received and that new cleaning

schedules would be drawn up in line with the guidance.

A library of information leaflets was now available in the office and a list

of the leaflets had been attached to the lobby door at the entrance to

advise visitors and staff to request a copy.

The clip boards in the kitchen and dining room still need to be replaced.

Recommendations

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

for environmental cleaning, provide the necessary assurance

that cleaning is carried out effectively. (Repeated)

2. The trust should ensure suitable supplies are held to ensure

timely replacements of fixtures associated with hand hygiene.

3. The health care environment should be repaired and

maintained, and damaged fixtures and fitting replaced to

maintain public confidence and to help reduce the risk of the

spread of infection. (Repeated)

4. Staff should continue to develop nursing cleaning schedules

in line with the trusts guidelines. (Repeated)

13


7.0 Patient Linen

STANDARD 3.0

PATIENT LINEN

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

department laundry facilities.

Linen

Erne

16 Feb 2012

Erne

28 April 2012

Storage of clean linen 61 86

Storage of used linen 93 86

Laundry facilities N/A N/A

Total 77 86

7.1 Management of Linen

There has been an improvement in this standard, the linen store had

been de-cluttered and inappropriate items such as chairs and handrails

had been removed. The shelving still has to be sealed and the walls

painted.

The frame of the used linen skips were damaged and some of the

reusable linen bags were again torn.

Recommendations

5. The trust should ensure the correct handling and storage of

clean and used linen in a designated area, including

equipment which is clean and fit for purpose.

14


8.0 Waste and Sharps

STANDARD 4.0

WASTE AND SHARPS

Waste: Effectiveness of arrangements for handling, segregation,

storage and disposal of waste on ward/department

Sharps: Availability, use and storage of sharps containers on

ward/department

8.1 Waste

Waste and sharps

Handling, segregation,

storage, waste

Availability, use, storage of

sharps

Erne

16 Feb 2012

79

86

Erne

28 April 2012

91

90

Correct sharps boxes are now in use, the boxes were held in a locked

cupboard in the treatment room along with the black lidded burn box for

pharmaceutical waste. However, the pharmaceutical waste bin

contained medication paper packaging, this should be disposed of in

the household waste stream.

There were still no waste bins available in the two single toilets.

8.2 Sharps

The temporary closure mechanism on sharps boxes in bathrooms was

not in place. Staff stated they have ordered compatible integral sharps

trays to replace the old worn enamel dish currently in use.

Recommendations

6. The trust should monitor the implementation of its policies

and procedures in respect of the management of waste and

sharps to ensure that safe and appropriate practice is in

place. (Repeated)

7. The trust should ensure waste bins are provided at all hand

washing sinks.

15


9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment

Erne

Erne

16 Feb 2012 28 April 2012

Patient equipment 44 90

There has been a significant improvement in the standard of cleaning

patient equipment and staff are to be commended. Staff have carried

out a review of stock held in the treatment room, out of date and

opened single use supplies have been removed and equipment

cleaned. A commode and patient wash bowls which were not used

have been disposed of. Inspectors found that the majority of patient

equipment was clean some attention was required to the hoist and

wheelchairs in the equipment store as these were dusty.

A signing off sheet to show equipment had been cleaned has been

introduced until trigger tape, which identifies equipment is clean and

ready for use, has been sourced. Staff have received infection

prevention control training since the inspection in February, however,

when questioned some staff were not able to give the symbol for single

use items.

Recommendations

8. The trust and individual staff have a collective

responsibility to ensure that patient equipment is clean.

(Repeated)

16


10.0 Hygiene Factors

STANDARD 6.0

HYGIENE FACTORS

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

availability of cleaning equipment and materials.

Hygiene Factors

Erne

16 Feb 2012

Erne

28 April 2012

Availability and cleanliness

95

79

of WHB and consumables

Availability of alcohol rub 80 100

Availability of PPE 67 80

Materials and equipment

95

85

for cleaning

Total 78 93

Improvement was noted in all sections of

this standard. The layout of the clinical

room had been changed and there was

easy access to the clinical hand washing

sink (Picture 5). In the bathroom the

overflow on the hand washing sink was

dirty and a sink in one of the toilets was

worn.

Picture 5: Accessible clinical

hand washing sink

In the shower room, disposable single use aprons and gloves were

stored on wall mounted holders, the glove dispenser was beside the

toilet; this increases the potential risk of aerosol contamination. A new

PPE station had been ordered. Before fitting, staff should consult the

Infection Prevention and Control team, to ensure the placement of PPE

stations conform with the trust guidance.

In the domestic store, some of the inverted buckets stored on shelves

had not been dried out effectively resulting in pools of water on the

wooden units.

17


Recommendations

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

working and in a good state of repair. (Repeated).

10. The trust should ensure that consumables required to carry

out hand hygiene practice are available at all hand washing

sinks. (Repeated)

11. The trust and individual staff have a collective

responsibility to ensure that PPE is stored appropriately.

(Repeated)

12. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of a

ward is stored appropriately. (Repeated)

18


11.0 Hygiene Practices

STANDARD 7.0

HYGIENE PRACTICES

Hand hygiene procedures; handling and disposal of sharps; use

of PPE; use of isolation facilities and implementation of infection

control procedures; cleaning of ward/ department; staff uniform

and work wear.

Hygiene practices

Erne

16 Feb 2012

Erne

28 April 2012

Effective hand hygiene

93

43

procedures

Safe handling and disposal

100

50

of sharps

Effective use of PPE 73 94

Correct use of isolation N/A N/A

Effective cleaning of ward 56 80

Staff uniform and work

85

70

wear

Total 58 90

The training sessions for staff on hygiene practices following the

February inspection has contributed positively to the improved scores

in this standard. Staff now all carry their own personal alcohol rub

dispensers.

Nursing staff confirmed that the infection prevention and control link

nurse had carried out awareness sessions on cleaning practices,

dilution rates for disinfectants and colour coding of cleaning equipment.

However when questioned some staff were still unsure of the correct

dilution rates and colour coding. In response, senior managers

discussed the introduction of a competency assessment to validate

staff training.

There is still a need to remind staff of the trust dress code policy as not

all staff were compliant.

Recommendations

13. The trust and individual staff have a collective

responsibility to ensure that staff knowledge is kept up to

date with regard to cleaning and decontamination of

equipment and the environment. (Repeated)

19


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

familiar with and adhere to the regional dress code policy.

(Repeated)

20


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs L Gawley

Mrs M Keating

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

Trust representatives attending the feedback session

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

representatives:

Ms L Mc Bride

Mr B Mills

Mr C Stewart

Ms H Burke

Mr R Davey

Mr D Hamill

Ms R Wilson

- Co Director Patient and Client Support Services

- Operations Manager

- Operations Manager

- Ward Sister

- Support Services Manager

- Estates Services Manager

- Assistant Support Services Manager

Apologies

Ms B Creaney

Ms E Rafferty

- Executive Director of Nursing

- Service Manager Muckamore Abbey

Supporting documentation

A number of documents have been developed to support the inspection

process, these are:

Infection Prevention/Hygiene Inspection Process (methodology,

follow up and reporting)

Infection Prevention/Hygiene Team Inspection Protocol (this

document contains details on how inspections are carried out and

the composition of the teams)

Infection Prevention/Hygiene Team Escalation Policy

RQIA Policy and Procedure for Use and Storage of Digital Images

This information is currently available on request and will be available

in due course on the RQIA website.

21


13.0 Summary of Recommendations

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

for environmental cleaning, providing the necessary assurance

that cleaning is carried out effectively. (Repeated)

2. The trust should ensure suitable supplies are held to ensure

timely replacements of fixtures associated with hand hygiene.

3. The health care environment should be repaired and

maintained, and damaged fixtures and fitting replaced to

maintain public confidence and to help reduce the risk of the

spread of infection. (Repeated)

4. Staff should continue to develop nursing cleaning schedules in

line with the trusts guidelines. (Repeated)

5. The trust should ensure the correct handling and storage of

clean and used linen in a designated area, including equipment

which is clean and fit for purpose.

6. The trust should monitor the implementation of its policies and

procedures in respect of the management of waste and sharps

to ensure that safe and appropriate practice is in place.

(Repeated)

7. The trust should ensure waste bins are provided at all hand

washing sinks.

8. The trust and individual staff have a collective responsibility to

ensure that patient equipment is clean. (Repeated)

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

working and in a good state of repair. (Repeated).

10. The trust should that consumables required to carry out hand

hygiene practice are available at all hand washing sinks.

(Repeated)

11. The trust and individual staff have a collective responsibility to

ensure that PPE is stored appropriately. (Repeated)

12. Further attention to detail is required to ensure that equipment

used for the general cleaning purposes of a ward is stored

appropriately. (Repeated)

13. The trust and individual staff have a collective responsibility to

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

cleaning and decontamination of equipment and the

environment. (Repeated)

22


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

with and adhere to the regional dress code policy. (Repeated)

23


Reporting & Re-Audit

Episode of Inspection

Plan Programme

14.0 Unannounced Inspection Flowchart

Environmental Scan:

Stakeholders & External

Information

Plan

Programme

Consider:

Areas of Non-Compliance

Infection Rates

Trust Information

RQIA Hygiene Team

Prioritise Themes & Areas for Core Inspections

Prior to Inspection Year

Balance Programme

January/February

Schedule Inspections

Prior to Inspection

Identify & Prepare Inspection Team

Day of Inspection

Inform Trust

Day of Inspection

Carry out Inspection

A

Is there immediate risk

requiring formal escalation?

NO

YES

Invoke

RQIA

IPHTeam

Escalation

Process

Day of Inspection

Feedback Session with Trust

14 days after

Inspection

28 days after

Inspection

Preliminary Findings

disseminated to Trust

Draft Report

disseminated to Trust

NO

Does assessment of

the findings require

escalation?

YES

Invoke

RQIA

IPHTeam

Escalation

Process

A

14 days later

Signed Action Plan

received from Trust

Within 0-3 months

Is a Follow-Up required?

Based on Risk Assessment/key

indicators or Unsatisfactory Quality

Improvement Plan (QIP)?

YES

Invoke

Follow-Up

Protocol

Process enables

only 1 Follow-Up

NO

Open Report published to Website

YES

Is Follow-Up

satisfactory?

NO

DHSSPS/HSC

Board/PHA

PHA

24


15.0 Escalation Process

RQIA Hygiene Team: Escalation Process

B

RQIA IPH

Team

Escalation

Process

Concern / Allegation / Disclosure

Inform Team Leader / Head of Programme

MINOR/MODERATE

Has the risk been

assessed as Minor,

Moderate or Major?

MAJOR

Inform key contact and keep a record

Inform appropriate RQIA Director and Chief Executive

Record in final report

Inform Trust / Establishment / Agency

and request action plan

Notify Chairperson and

Board Members

Inform other establishments as appropriate:

E.g.: DHSSPS, RRT, HSC Board, PHA,

HSENI

Seek assurance on implementation of actions

Take necessary action:

E.g.: Follow-Up Inspection

25


16.0 Action Plan

Reference

number

Recommendations

1. The trust should ensure that systems and processes in

place for environmental cleaning, providing the

necessary assurance that cleaning is carried out

effectively. (Repeated)

Designated

department

Nursing

PCSS

IPC

Action required

‘Roles and responsibilities of Staff in

relation to Environmental Cleanliness and

Cleanliness of Equipment’ policy under

review.

Date for

completion/

timescale

Work / negotiations in relation to the

cleaning manual are still ongoing. In

particular, there is discussion with

nursing/control of infection with reference to

bed cleaning. Once agreement is reached

the manual will be finalised.

Jun 2012

2. The trust should ensure suitable supplies are held to

ensure timely replacements of fixtures associated with

hand hygiene.

Nursing

PCSS

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.

Hand towel and soap dispensers are stock

items and once ordered should be received

within 1 week.

Ongoing

Complete

3. The health care environment should be repaired and

maintained, and damaged fixtures and fitting replaced to

maintain public confidence and to help reduce the risk of

the spread of infection. (Repeated)

4. Staff should continue to develop nursing cleaning

schedules in line with the trusts guidelines. (Repeated)

Estates

IPC

Other

appropriate

staff

Nursing

IPECC

This is ongoing as part of Estate daily

maintenance and refurbishment

programmes.

A sub-group of IPECC (Infection Prevention

& Environment and Cleanliness Committee)

has been set up to review and standardise

cleaning schedules, and will establish any

outstanding issues of audit standardisation

process.

Ongoing

Complete

* indicates stated for a second time 26


Reference

number

Recommendations

Designated

department

Action required

Agree a standardised audit which will be

used in all areas. This will include

standardised responsibilities. To be kept

under review.

Date for

completion/

timescale

Commenced

Feb 2012

Systematic roll out of the agreed

standardised audit using the Maximiser

system.

5. The trust should ensure the correct handling and storage

of clean and used linen in a designated area, including

equipment 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.

6. The trust should monitor the implementation of its

policies and procedures in respect of the management of

waste and sharps to ensure that safe and appropriate

practice is in place. (Repeated)

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

completed Apr

2012

Daniels’ audit completed Oct 2011 and

results disseminated.

Complete

7. The trust should ensure waste bins are provided at all

hand washing sinks.

PCSS

Nursing

This is monitored as part of the

Environmental Cleanliness Audit

Ongoing

* indicates stated for a second time 27


Reference

number

Recommendations

Designated

department

Programme.

Action required

Date for

completion/

timescale

Regional contract for bins at adjudication

stage.

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.

8. The trust and individual staff have a collective

responsibility to ensure that patient equipment is clean.

(Repeated)

Nursing

PCSS

Work / negotiations in relation to the

cleaning manual are still ongoing. In

particular, there is discussion with

nursing/control of infection with reference

bed cleaning. Once agreement is reached

the manual will be finalised.

Jun 2012

9. The trust should ensure that hand washing sinks are

clean, working and in a good state of repair. (Repeated)

PCSS

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.

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

checks, department and managerial audits,

and IPC audits monitor compliance.

* indicates stated for a second time 28


Reference

number

Recommendations

Designated

department

Action required

Where an issue has been highlighted,

action will be taken in conjunction with the

appropriate department to ensure

rectification.

Date for

completion/

timescale

10. The trust should ensure that consumables required to

carry out hand hygiene practice are available at all hand

washing sinks. (Repeated)

PCSS

Regular training is provided to all

appropriate staff.

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

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.

11. The trust and individual staff have a collective

responsibility to ensure that PPE is stored appropriately.

(Repeated)

Nursing

IPC

Regular training is provided to all

appropriate staff.

This is monitored during IPC visits and

audits.

Ward staff will monitor on an ongoing basis.

Ongoing

12. Further attention to detail is required to ensure that

equipment used for the general cleaning purposes of a

ward is stored appropriately. (Repeated)

Nursing

PCSS

Environmental cleanliness audit

programmes, which include daily ward

checks, department and managerial audits,

and IPC audits monitor compliance.

Ongoing

Where an issue has been highlighted,

action will be taken in conjunction with the

* indicates stated for a second time 29


Reference

number

Recommendations

Designated

department

Action required

appropriate department to ensure

rectification.

Date for

completion/

timescale

Regular training is provided to all

appropriate staff.

13. The trust and individual staff have a collective

responsibility to ensure that staff knowledge is kept up to

date with regard to cleaning and decontamination of

equipment and the environment. (Repeated)

Nursing

Work / negotiations in relation to the

cleaning manual are still ongoing. In

particular, there is discussion with

nursing/control of infection with reference

bed cleaning. Once agreement is reached

the manual will be finalised.

Role and responsibilities policy in place.

Cleaning statements document for all wards

and departments to be finalised and

disseminated. This forms part of the

cleaning manual.

Jun 2012

Complete

Jun 2012

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

familiar with and adhere to the regional dress code

policy. (Repeated)

All

Directorates

Trust policy available to all staff on Intranet.

Policy is enforced at local level by senior

staff, e.g., Ward Sisters and Senior

Managers.

Complete

The Ward Sister/Charge Nurse Support

Improvement and Accountability

Framework (SIAF) includes an indicator

relating to compliance with the dress code

policy and this is audited on a quarterly

basis.

Ongoing

* indicates stated for a second time 30


* indicates stated for a second time 31

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