South West Acute Hospital - 13 November 2012 - Regulation and ...

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South West Acute Hospital - 13 November 2012 - Regulation and ...

RQIA

Infection Prevention/Hygiene

Unannounced Inspection

Western Health and Social Care Trust

South West Acute Hospital

13 November 2012


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 5

3.0 Inspections 6

4.0 Unannounced Inspections 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 11

6.2 Clutter 11

6.3 Maintenance and Repair 12

6.4 Fixture and Fittings 13

6.5 Information 13

6.6 Additional Issues 13

7.0 Patient Linen 15

7.1 Management of Linen 15

8.0 Waste and Sharps 16

8.1 Waste 16

8.2 Sharps 16

9.0 Patient Equipment 18

10.0 Hygiene Factors 20

11.0 Hygiene Practice 22

12.0 Key Personnel and Information 24

13.0 Summary of Recommendations 25

14.0 Unannounced Inspection Flowchart 27

15.0 RQIA Hygiene Team Escalation Policy Flowchart 28

16.0 Action Plan 29


1.0 Inspection Summary

An unannounced inspection was undertaken to the South West Acute

Hospital, on the 13 November 2012. The hospital was assessed

against the Regional Healthcare Hygiene and Cleanliness Standards

and the following areas were inspected:

Ward 1 - Medical and Surgical Admissions Unit

Ward 5 - Stroke

The South West Acute Hospital, opened in June 2012, provides a wide

range of major acute hospital services to patients living within the

catchment area of Fermanagh, Tyrone and beyond. It is the first

hospital within Northern Ireland to have 100 percent single en-suite

rooms and provides up to date facilities, equipment and technologies to

deliver patient care.

Inspection Outcomes

The results of the inspection showed both wards achieved an overall

compliance level and staff are commended for their commitment to

providing a safe and clean environment for patients. However

inspectors observed that whilst the environment was generally clean,

further work is required to ensure cleaning and monitoring is carried out

especially in areas difficult to access. Nursing staff knowledge of the

systems and products used for the cleaning and decontamination must

also be improved. The trust should continue their work in providing

clutter free ward environments, and ensure that there is an on-going

programme of maintenance and repair.

In both wards the standard on the availability, use and storage of

sharps achieved partial compliance and requires further work and

attention by ward staff. Observation of staff indicated compliance with

hygiene and infection prevention and control practices.

The inspection resulted in 12 recommendations for the South West

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

A detailed list of preliminary findings is forwarded to Western 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

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management by the Health and Social Care Board and the Public

Health Agency.

Notable Practice

The inspection identified the following areas of notable practice:

Regular audits – Visual Infusion Phlebitis Score, Early

Warning Score, Malnutrition Universal Screening Tool,

Falls, Armbands, hand hygiene, peripheral IV lines, catheter

care, commodes

Implementation of high impact interventions

In Ward 1 the ward sister was emailing information to staff

to reduce paper notices

In Ward 1 the PPE pyramid was displayed for staff to

reference

In Ward 5, good domestic services documentation;

enhanced cleaning sheet

In Ward 5 a proactive ward Consultant, with a keen interest

in infection prevention and control. Consultant participates

in long line ward audits, microbiology ward rounds,

appraisals, root cause analysis and formal infection

prevention and control

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

Acute 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 the organisation to target areas that

require more specific attention.

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Table 1

Ward Ward 1 Ward 5

Environment 93 91

Patient Linen 92 88

Waste 88 88

Sharps 82 80

Equipment 92 88

Hygiene Factors 96 95

Hygiene Practices 90 96

Total 90 89

Table 2

Environment Ward 1 Ward 5

Reception N/A 82

Corridors, stairs lift 87 93

Public toilets 98 N/A

Ward/ department –

general (communal)

93 95

Patient bed area N/A N/A

Bathroom/washroom N/A 89

Toilet 95 98

Clinical room/ treatment

room

N/A

N/A

Clean utility room 92 77

Dirty utility room 98 98

Domestic store 97 100

Kitchen 96 93

Equipment store 92 90

Isolation 99 95

General information 81 81

Total 93 91

Table 3

Linen Ward 1 Ward 5

Storage of clean linen 91 88

Storage of used linen 93 88

Laundry facilities N/A N/A

Total 92 88

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 4

Waste and sharps Ward 1 Ward 5

Handling, segregation,

88 88

storage, waste

Availability, use, storage of

sharps

82 80

Table 5

Patient Equipment Ward 1 Ward 5

Patient equipment 92 88

Table 6

Hygiene Factors Ward 1 Ward 5

Availability and cleanliness 99 99

of WHB and consumables

Availability of alcohol rub 97 97

Availability of PPE 87 86

Materials and equipment

100 98

for cleaning

Total 96 95

Table 7

Hygiene practices Ward 1 Ward 5

Effective hand hygiene

94 95

procedures

Safe handling and disposal 85 100

of sharps

Effective use of PPE 100 100

Correct use of isolation 89 100

Effective cleaning of ward 76 84

Staff uniform and work

97 97

wear

Total 90 96

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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2.0 Background Information to the Inspection Process

RQIA‟s infection prevention and hygiene team was established to

undertake a rolling programme of unannounced inspections of acute

hospitals. The Department of Health Social Service and Public Safety

(DHSSPS) commitment to a programme of hygiene inspections was

reaffirmed through the launch in 2010 of the revised and updated

version of 'Changing the Culture' the strategic regional action plan for

the prevention and control of healthcare-associated infections (HCAIs)

in Northern Ireland.

The aims of the inspection process are:

to provide public assurance and to promote public trust and

confidence

to contribute to the prevention and control of HCAI

to contribute to improvement in hygiene, cleanliness and infection

prevention and control across health and social care in Northern

Ireland

In keeping with the aims of the RQIA, the team will adopt an open and

transparent method for inspection, using standardised processes and

documentation.

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3.0 Inspections

The DHSSPS has devised draft Regional Healthcare Hygiene and

Cleanliness standards. RQIA has revised its inspection processes to

support the publication of the standards which were compiled by a

regional steering group in consultation with service providers.

RQIA's infection prevention/hygiene team have planned a three year

programme which includes announced and unannounced inspections

in acute and non-acute hospitals in Northern Ireland. This will assess

compliance with the DHSSPS Regional Healthcare Hygiene and

Cleanliness standards.

The inspections will be undertaken in accordance with the four core

activities outlined in the RQIA Corporate Strategy, these include:

Improving care: we encourage and promote improvements in the

safety and quality of services through the regulation and review of

health and social care

Informing the population: we publicly report on the safety,

quality and availability of health and social care

Safeguarding rights: we act to protect the rights of all people

using health and social care services

Influencing policy: we influence policy and standards in health

and social care

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4.0 Unannounced Inspection Process

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

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

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

The inspection flow chart is attached in Section 14.

4.1 Onsite Inspection

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

infection prevention/hygiene team and one peer review from RQIA’s

project management 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.

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 draft 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

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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.

Environment Ward 1 Ward 5

Reception N/A 82

Corridors, stairs lift 87 93

Public toilets 98 N/A

Ward/ department -

general(communal)

93 95

Patient bed area N/A N/A

Bathroom/washroom N/A 89

Toilet 95 98

Clinical room/ treatment

room

N/A

N/A

Clean utility room 92 77

Dirty utility room 98 98

Domestic store 97 100

Kitchen 96 93

Equipment store 92 90

Isolation 99 95

General information 81 81

Total 93 91

The above table outlines the findings in relation to the general

environment of the facilities inspected. Overall the wards appeared

visibly clean; some issues were identified in relation to domestic and

nursing staff cleaning. The findings in respect of the general

environment are detailed in the following sections.

The new hospital opened in June 2012 (Picture 1) provides a modern

and pleasant environment for patients and visitors. The inspection

team identified some issues during the inspection that should be

rectified as part of a „snagging‟ list and settling in period.

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Picture 1: Patient waiting area

6.1 Cleaning

At the time of the inspection there was evidence to indicate compliance

with regional specifications for cleaning. The inspectors observed that

in most instances regular cleaning mechanisms were in place to

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

build-up of bacteria and subsequently reduces the potential risk for the

transmission of infection.

In the main reception and corridors leading to the wards greater

attention to detail was required to remove splash marks from the floor,

hand prints from glass panelling and dust and debris from high, low

and difficult to reach surfaces e.g. top of signage boards.

Comparable findings were noted in wards such as dirty external

windows, dust inside the drugs‟ fridge, limescale on kitchen taps and

faecal staining on the inside of the slop hopper.

In Ward 5 some additional cleaning issues were identified such as

builders‟ dust in some floor corners and edges and a dirty toilet brush

in the bathroom. Greater attention to detail is needed when cleaning

the clean utility room; as dust and debris were noted in the top and

inside of storage cupboards and the equipment sink was stained.

A more robust checking mechanism is required for the cleaning of

rooms. In Ward 5, Room 10, an empty room ready for use, had dust

on the under carriage of the bed frame, the ceiling light above the bed

was dirty and the inside of the toilet bowl was stained.

6.2 Clutter

Inspectors observed minimum clutter in both wards. The installation of

high density storage assists in providing clutter free environments, and

provides effective utilisation of space.

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Areas for improvement were noted in both wards for example in

Ward 1 the equipment store was disorganised and overstocked with

boxes of supplies on the floor. Staff advised that this was being

addressed.

In Ward 5 the clean utility room and clinical work surface was untidy

and cluttered with equipment, supplies and stationery; storage space

appeared insufficient. Inspectors were advised that a review of the

empty, underutilised near patient testing room was being carried out

with the potential to decant some of the supplies e.g. IV fluid storage.

In the equipment store, incontinence pads on shelves, were out of their

packaging and equipment was stored in the floor corner.

6.3 Maintenance and Repair

The main reception, corridors and stairs were in a good state of repair.

Some issues were identified in reception with scuff marks and damage

to the wall edging, notably in beside the wheelchair storage area

(Picture 2), and cracks and damage to the flooring leading to Ward 1.

Picture 2 - Wall damage in reception

In Ward 1 flooring at the ward reception, the nurses‟ station and in the

toilet were in the process of being repaired. The hinge on a wall

cupboard in the clean utility room was loose and the door was ill fitting.

There was wall damage in the domestic store and in Room 11 there

was sealant dripping from the sides of the ceiling access panel in the

en-suite.

In Ward 5 sitting room, there was minor wall paintwork damage behind

chairs; a ceiling tile in the bathroom was displaced. In Room 10, the

base of the shower, where the wall and floor join, was bulging.

6.4 Fixtures and Fittings

Fixtures and fittings were in a good state or repair. However in the

main reception, outside the Outpatient Department, the end of the

water cooler pipework was dirty and a pipe coming out of the ground

had been stuffed with paper rather than sealed off. In both wards, felt

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notice boards which cannot be effectively cleaned, were also observed.

Staff advised at the feedback session that this issue was being

addressed.

In Ward 5 the privacy curtain in the bathroom had no date to identify

when it had to be changed. There was no toilet roll holder available on

the wall or on the disabled handrail and the bottom inside seal on the

fridge door was split.

6.5 Information

In both wards there were no posters for nursing staff to reference on

the National Patient Safety Agency (NPSA) cleaning colour coded

system, linen and waste segregation. Nursing cleaning schedules

while available need to be developed further and in Ward 5 staff were

ticking rather than signing their name when completing cleaning

schedule records.

Infection control information was not displayed in both wards for

patients and visitors to view, staff advised at the feedback session that

this was being addressed. Inspectors also noted that there was no

signage in place to indicate restricted access to the kitchen and in

Ward 5, there was no signage on the door of the equipment store to

denote the storage of oxygen cylinders.

In Ward 1 some posters were attached to waste bins with adhesive

tape and temperatures for the drugs‟ fridge had been inconsistently

recorded. In Ward 5 there were no DHSSPS general infection

prevention and control leaflets available for visitors.

6.6. Additional Issues

Ward 1

Adhesive tape was used to fix notices (“Please pull”) to doors in the

corridor leading to the ward.

The wash hand basin in the dirty utility room on the right side of

ward was very slow to empty.

Audits are not displayed for visitors, staff to view.

Ward 5

Discussion with physiotherapy staff indicated that there were no

cleaning schedules for the cleaning of patient equipment.

Environmental cleaning scores while available in the domestic store

were not on display for the general public to view. Inspectors were

advised at the feedback that the IPCT are addressing this issue and

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a white board is to be erected at the entrance to all wards

displaying relevant IPC and cleaning information.

Regular mattress audits have not been undertaken since moving to

the new hospital site. Previously these had been done by the tissue

viability nurse.

Frequently touched telephones should be easily cleaned, with no

sticky labels present.

Recommendations

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

place for environmental cleaning, including terminal cleaning

of rooms, provide the necessary assurance that cleaning is

carried out effectively and that all staff are aware of their

responsibilities.

2. The trust and staff should work to maintain clutter free ward

environments.

3. A regular programme of maintenance and repair should be

developed and carried out to maintain the new fabric of the

building; ‘snagging’ issues identified during the new hospital

settling in period are addressed.

4. The trust should improve documentation and the provision of

information in the following areas, relevant information

leaflets and posters for patients, visitors and staff, detailed

nursing cleaning schedules and consistent recording of

drugs’ 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 Ward 1 Ward 5

Storage of clean

linen

91 88

Storage of used

linen

93 88

Laundry facilities N/A N/A

Total 92 88

7.1 Management of Linen

Staff within both wards are commended for achieving an overall

compliance score in this standard.

Clean linen was stored neat and tidy; however in Ward 1 linen bags

were stored on the floor of the clean linen store and black hand marks

were noted on the door. In Ward 5 clean linen store, minor wall scuff

marks, debris in a ceiling light fitting and door lock damage were issues

to be addressed. Inspectors also noted a staff member carrying clean

linen against their uniform.

In Ward 1 used linen disposed of into a red linen skip, for

contamination/infection, was not bagged in an alginate bag. In Ward 5

used linen bags were more than 2/3 full on the linen trolley.

Recommendations

5. The trust should ensure that clean and used linen is handled

and disposed of correctly and stored in a maintained area.

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8.0 Waste and Sharps

STANDARD 4.0

WASTE AND SHARPS

Waste: Effectiveness of arrangements for handling, segregation,

storage and disposal of waste on ward/department

Sharps: Availability, use and storage of sharps containers on

ward/department

Waste and sharps Ward 1 Ward 5

Handling, segregation,

88 88

storage, waste

Availability, use, storage of

sharps

82 80

8.1 Waste

In this standard both wards achieved compliance. The inspection

evidenced that there were arrangements in place for the handling,

segregation, storage and disposal of waste which generally comply

with local and regional guidance.

In both wards inspectors observed that waste was disposed of

incorrectly e.g. household waste into sharps‟ boxes and clinical waste

bins. It was also noted that there was no household/ recycling waste

bin available in dirty utility rooms.

In Ward 1, batteries and unused cannula, syringes and needles, in their

original packaging, were disposed of into sharps boxes. In Ward 5,

Room 10 lobby, there was no household/recycling waste or clinical

waste bin available. The underside of the clinical waste bin in the dirty

utility room was stained.

8.2 Sharps

In this standard both wards achieved partial compliance.

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

In both wards sharps boxes were assembled correctly; labelled with the

date, locality and staff signature. However in both ward blood splashes

were noted on sharps‟ boxes.

In Ward 1 the majority of sharps‟ box temporary closure mechanisms

was open, a 50 litres sharps box stored on the phlebotomy trolley was

not secure and there was adhesive tape residue on a sharps‟ tray.

In Ward 5 all integral sharps‟ trays examined required cleaning; one

tray had adhesive tape present. The temporary closure mechanism on

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the sharps‟ box on the resuscitation trolley was open and there was

sharps waste insitu; the box had not been changed since 31/05/12.

Recommendations

6. The trust should ensure that policies and procedures in

respect of the management of waste and sharps are

implemented to ensure that safe and appropriate practice is in

place, including the availability, cleaning of equipment used in

the management of waste and sharps and staff knowledge in

relation to the management of sharps.

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9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment Ward 1 Ward 5

Patient equipment 92 88

In this standard both wards are commended for achieving compliance.

In both wards trigger tape was used to identify equipment that had

been cleaned (Picture 3).

Picture 3 - Trigger tape on equipment

However staff were unaware of the symbol for single use, communal

patient wash products were stored on the linen trolley and procedure

trolleys were either dusty, stained or had rusted wheels and castors.

In Ward 5 other issues to be addressed included; a faecally stained

bedpan that had been cleaned in the bedpan washer remained dirty,

stained and grubby IV trays and dusty, stained or damaged equipment

e.g. glucometer taped together, dusty portable suction machine on the

resuscitation trolley.

Inspectors also noted that in the physiotherapy room cardboard covers

had not been removed from zimmer frames.

Additional Issues

Ward 5

Inspectors observed a patient sitting in an arm chair, a hoist sling

remained insitu behind his back and had not been removed. This

practice should be reviewed by the tissue viability nurse.

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Recommendations

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

ensure that staff knowledge is kept up to date and that and

patient equipment is clean, used correctly and in a good state

of repair.

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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 Ward 1 Ward 5

Availability and cleanliness of 99 99

WHB and consumables

Availability of alcohol rub 97 97

Availability of PPE 87 86

Materials and equipment for 100 98

cleaning

Total 96 95

Staff in both wards are commended for achieving an overall high

compliance score in this standard. Ward 1 achieved full compliance in

materials and equipment used for cleaning.

Picture 4 - Typical hand washing sink

Hand washing sinks, fixtures and fittings and consumables in both

wards were clean, working and in a good state of repair (Picture 4). In

Ward 1, Room 11 lobby, an opened bottle of chlorhexidine was stored

on the sink and in Ward 5 paper labels were noted on taps throughout

the ward.

In both wards there were no alcohol gel dispensers and posters

present at the entrance/exit to the ward. At the feedback session

representatives from the Infection Prevention and Control team advised

that this was being addressed.

Personal protective equipment (PPE) was widely available throughout

both wards however in Ward 1, there were no disposable aprons in one

of the portable PPE dispensers. In both wards eye protection, although

20


listed on the checklist, was not available on the resuscitation trolley. In

Ward 5, eye or face protection was not available for general use.

Inspectors observed that domestic cleaning equipment was clean and

in a good state of repair, no issues were identified in Ward 1. In Ward

5, cleaning solutions were stored in an unlocked cupboard, in the

unlocked kitchen, easily accessible and not in line with Control of

Substances Hazardous to Health (COSHH) regulations.

Recommendations

8. The trust should ensure that alcohol gel dispensers and PPE

are readily available for use.

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

line with COSHH regulations.

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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 Ward 1 Ward 5

Effective hand hygiene

94

procedures

95

Safe handling and disposal 85

of sharps

100

Effective use of PPE 100 100

Correct use of isolation 89 100

Effective cleaning of ward 76 84

Staff uniform and work wear 97 97

Total 90 96

In this standard both wards achieved compliance, with full compliance

and no issues identified in the effective use of PPE. Ward 5 further

achieved 100 per cent and full compliance in the safe handling and

disposal of sharps and correct use of isolation.

Due to the 100 per cent single room ward layout, observation of practice

was limited however those staff observed did carry out hand hygiene in

line with the World Health Organisation (WHO) 5 moments of care. In

both wards staff were aware of the 7 step hand hygiene technique for

use with soap or alcohol rub. Staff did not always know that alcohol gel

should not be used for hand hygiene when caring for a patient with

Clostridium difficile.

In Ward 1 there were two

instances where re-sheathing

of needles was observed; this

is unsafe practice which has

the potential to cause the staff

member a sharps‟ injury

(Picture 5).

Picture 5 - Re-sheathed needles

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The use of isolation facilities in both wards was satisfactory. However

in Ward 1, patients admitted to the ward with a history of MRSA,

although being nursed with infection control precautions, have no

overarching infection control nursing care plan initiated until the results

of the admission swabs are available. In Ward 5, care pathways for

MRSA and Clostridium difficile had been initiated and completed daily.

In both wards work is required in the effective cleaning of the ward as

only partial compliance was achieved. Nursing staff in both wards were

unfamiliar with the National Patient Safety Agency (NPSA) cleaning

colour coded system. Nursing COSHH data sheets on cleaning

solutions were either not available or available and last updated in

2007.

In Ward 1 there were inconsistencies in staff practice when carrying out

the same routine cleaning; some used alcohol wipes, some used

detergent wipes. Not all nursing staff were aware of the disinfectant

dilution rate for cleaning blood and body fluid spillages. In Ward 5, the

equipment file with manufacturer‟s instructions on use and cleaning

was unable to be located during the inspection.

Inspectors noted that in both wards adherence to the trust and regional

dress code policy and the concept of „bare below the elbow‟ was

overall very good. However in Ward 1 a member of nursing staff was

wearing stoned earrings and in Ward 5 a member of staff was wearing

nail polish.

Additional Issues

Ward 1

Staff reported they were not all up to date with mandatory infection

prevention and control training. Trust representatives advised due

to the move to the new hospital, training had been suspended, there

was now a backlog which they were aware of and additional

training places are now available

Recommendations

10. The trust and individual staff need to ensure that sharps are

disposed of in a safe manner

11. The trust and individual staff should ensure that care plans for

the delivery of all patient care is available.

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

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

the systems and products used for the cleaning and

decontamination of equipment and the environment.

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12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs L Gawley

Mrs S O’Connor

Mrs M Keating

Mrs H Hamilton

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Inspector Infection Prevention/Hygiene Team

- Project Manager, RQIA

Trust representatives attending the feedback session

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

representatives:

Joe Lusby - Deputy Chief Executive

Maeve Brown - Divisional Nurse EC&M

Siobhan Love - Support Services Manager

Allison MacLaine - Assistant Support Services Manager

Tracey Hill - Sister, Ward 1

Jacqueline Teague - Patient Flow Co-ordinator

Karen Martin - Infection Prevention & Control Nurse

Shiree McGlone - Infection Prevention & Control Nurse

Mary Robinson - Deputy Ward Sister, Ward 5

Denis Ryan - Ward Manager, Ward 6

Karena Ferguson - Support Services Co-ordinator,

Housekeeping

Norma Ron - Sister, Ward 2

Angela McCarville - Acting Sister, Ward 7

Mary Melley - Assistant Nurse Service Manager

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.

24


13.0 Summary of Recommendations

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

place for environmental cleaning, including terminal

cleaning of rooms, provide the necessary assurance that

cleaning is carried out effectively and that all staff are aware

of their responsibilities.

2. The trust and staff should work to maintain clutter free ward

environments.

3. A regular programme of maintenance and repair should be

developed and carried out to maintain the new fabric of the

building; ‘snagging’ issues identified during the new

hospital settling in period are addressed.

4. The trust should improve documentation and the provision

of information in the following areas, relevant information

leaflets and posters for patients, visitors and staff, detailed

nursing cleaning schedules and consistent recording of

drugs’ fridge temperatures.

5. The trust should ensure that clean and used linen is handled

and disposed of correctly and stored in a maintained area.

6. The trust should ensure that policies and procedures in

respect of the management of waste and sharps are

implemented to ensure that safe and appropriate practice is

in place, including the availability, cleaning of equipment

used in the management of waste and sharps and staff

knowledge in relation to the management of sharps

7. The trust and individual staff have a collective responsibility

to ensure that staff knowledge is kept up to date and that

and patient equipment is clean, used correctly and in a

good state of repair.

8. The trust should ensure that alcohol gel dispensers and

PPE are readily available for use.

9. The trust should ensure that all cleaning products are

stored in line with COSHH regulations.

10. The trust and individual staff need to ensure that sharps are

disposed of in a safe manner

11. The trust and individual staff should ensure that care plans

for the delivery of all patient care is available.

25


12. The trust and individual staff have a collective responsibility

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

to the systems and products used for the cleaning and

decontamination of equipment and the environment.

26


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

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

27


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

28


16.0 Action Plan

Reference

Number

Recommendations

1 The trust should ensure that the systems

and processes in place for environmental

cleaning, including terminal cleaning of

rooms, provide the necessary assurance

that cleaning is carried out effectively and

that all staff are aware of their

responsibilities.

Designated

Department

Support

Services

Action required

All new housekeeping staff receive

Support Services Induction before

commencing employment.

The updated Infection Control

Support Services Guidelines are

now approved and all relevant

Housekeeping Support Services

Assistants will receive refresher

training.

Terminal Cleaning Audit Sheet is

completed and signed off by

Nursing following any terminal

clean.

All Housekeeping staff to complete

BICS training.

Cleaning work schedules are

revised regularly to meet changing

demands on the ward.

Regular Quality controls completed

by Housekeeping Supervisors

Departmental and Managerial

Environmental Audits on-going.

Date for

Completion

Timescale

Commenced

and on-going

March 2013

Jan 2013

2 1. The trust and staff should work to maintain

clutter free ward environments.

Estates

A draft Waste Manual is scheduled

to be tabled at the corporate

management team January 2013 for

approval.

This manual outlines the correct

process for staff to follow in terms of

January 2013

29


Reference

Number

Recommendations

Designated

Department

Action required

de-cluttering and disposal of

equipment

Date for

Completion

Timescale

3 2. A regular programme of maintenance and

repair should be developed and carried

out to maintain the new fabric of the

building; „snagging‟ issues identified

during the new hospital settling in period

are addressed.

3.

Estates

Hard FM services to the hospital are

provided by Interserve FM under a

PFI contract. Procedures are in

place to provide for reactive and life

cycle maintenance.

All faults/defects in regard to the

building and its fabric are to be

promptly reported via the helpdesk

to Interserve FM. The contract sets

out time frames in which matters

should be resolved.

On-going

4 4. The trust should improve documentation

and the provision of information in the

following areas, relevant information

leaflets and posters for patients, visitors

and staff, detailed nursing cleaning

schedules and consistent recording of

drugs fridge temperatures.

5.

5 The trust should ensure that clean and

used linen is handled and disposed of

correctly and stored in a maintained area.

Nursing

Nursing IP&C

This has been raised with ward

managers and will be included on

the Nursing Matters Newsletter in

January/Feb 2013

Posters are available which provide

guidance in respect of this.

Ward Manager advised to ensure

they have these on display and

monitor practice of staff.

Feb 2013

On-going

30


Reference

Number

Recommendations

6 The trust should ensure that policies and

procedures in respect of the management

of waste and sharps are implemented to

ensure that safe and appropriate practice

is in place including the availability,

cleaning of equipment used in the

management of waste and sharps and

staff knowledge in relation to the

management of sharps.

Designated

Department

Nursing IP&C

Action required

Policies and guidelines are in place

In October 2012 The Trust adopted

RQIA EC audit tool for all Trust

audits and this process will begin to

monitor this aspect of practice

Date for

Completion

Timescale

On-going

7 The trust and individual staff have a

collective responsibility to ensure that staff

knowledge is kept up to date and that and

patient equipment is clean, used correctly

and in a good state of repair.

Nursing

A „core trainor model‟ in use and a

scoping will be completed to locate

Core Trainers in the newly

reconfigured wards and recruit to

areas where this core trainor is not

available

A system to monitor the requests for

repair processed during the

warranty period will be commenced.

Cleaning and decontamination of

medical equipment must in

accordance with manufacturers

guidelines and is largely addressed

in the Trust IP&C Policy.

Commenced

8 The trust should ensure that alcohol gel

dispensers and PPE are readily available

for use.

Nursing IP&C

These were requested verbally by

Head of IPC through „Developing

Better Services Team‟ on 10 th

August followed by an email in

September 2012.

An exercise to determine with Ward

Commenced

February

2013

31


Reference

Number

Recommendations

Designated

Department

Action required

Manager that there are now

sufficient numbers for safe care will

be carried out.

Date for

Completion

Timescale

9 The trust should ensure that all cleaning

products are stored in line with COSHH

regulations.

Support

Services

Guidance is available on the correct

storage of cleaning products in line

with CPOSH recommendations

On-going

Request has been made to have

locks fitted to cupboards in ward

pantries for storage of chemicals.

Jan 2013

10 The trust and individual staff need to

ensure that sharps are disposed of in a

safe manner.

11 The trust and individual staff should

ensure that care plans for the delivery of

all patient care is available.

Nursing

Nursing

Policies and guidelines on the

management of Sharps are in place

to guide staff on the correct

processes.

Work commenced in SWAH in

relation to nursing record keeping

and care planning. The regional

NIPEC evidence based audit tool in

in use and an audit has been

undertaken during November to

record baseline scores for the acute

adult wards including acute elderly

care wards.

Improvement programmes are

currently being developed and the

SWAH is implementing the new

regional nursing assessment

booklet.

On-going

Commenced

and on-going

32


Reference

Number

Recommendations

12 The trust and individual staff have a

collective responsibility to ensure that staff

knowledge is kept up to date with regard

to the systems and products used for the

cleaning and decontamination of

equipment and the environment.

Designated

Department

Nursing

Action required

Policies and guidelines are in place

in relation to cleaning of equipment

Individual specialist pieces of

equipment not covered by the IP&C

manual will have written guidelines

for the decontamination according

to the manufacturers

recommendations

Date for

Completion

Timescale

Commenced

and on-going

33

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