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