2 November 2011 - Regulation and Quality Improvement Authority

rqia.org.uk

2 November 2011 - Regulation and Quality Improvement Authority

RQIA

Infection Prevention/Hygiene

Unannounced inspection

Western Health and Social Care Trust

Altnagelvin Hospital

Ward 43 Sperrin Ward

2 November 2011


Contents

1.0 Inspection Summary 1

2.0 Background Information to the Inspection Process 5

3.0 Inspections 6

4.0 Unannounced Inspections 7

4.1 Onsite Inspection 7

4.2 Feedback and Report of the findings 7

5.0 Audit Tool 8

6.0 Environment 10

6.1 Cleaning 10

6.2 Clutter 11

6.3 Maintenance and Repair 11

6.4 Fixture and Fittings 12

6.5 Information 12

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 17

10.0 Hygiene Factors 19

11.0 Hygiene Practice 21

12.0 Key Personnel and Information 23

13.0 Summary of Recommendations 24

14.0 Unannounced Inspection Flowchart 26

15.0 RQIA Hygiene Team Escalation Policy Flowchart 27

16.0 Action Plan 28


1.0 Inspection Summary

An unannounced inspection was undertaken to the Altnagelvin

Hospital, on the 2 November 2011. The hospital was assessed

against the Regional Healthcare Hygiene and Cleanliness standards

and the following area was inspected:

Ward 43

The Sperrin Suite, located in the South Wing, is a purpose-built

chemotherapy unit with 21 treatment chairs, an inpatient ward, Ward 43

with 14 beds, an outpatient facility with nine consulting rooms and

facilities for rehabilitation specialist palliative care and support services.

The facilities in Ward 43 are of the highest standard, with all single

rooms with ensuite facilities. Four of the rooms are specialist in that

they have positive air pressure to offer protection for patients with a

severely compromised immune system.

Inspection Outcomes

The results of the inspection showed compliance in all but one of the

standards, for which staff are to be commended. The ward inspected

was well presented, in good decorative order, and cleaning was of a

good standard. Inspectors were impressed with staff commitment to

providing a safe and clean environment for patients and overall the

observations of staff indicated compliance with hygiene and infection

prevention and control practices.

The inspection resulted in 15 recommendations for the Altnagelvin

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

A detailed list of preliminary findings is forwarded to the 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

management by the Health and Social Care Board and the Public

Health Agency.

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Notable Practice

The inspection identified the following areas of notable practice:

Staff report that carrying out the Releasing Time to Care has

proven beneficial for staff and patients and has contributed

to improved practices concerning infection prevention and

control

The intregity and effective cleaning of surfaces and walls was

promoted by the minimal use of paper labels and adhesive

tape

Audits are carried out on care bundles for peripheral IV lines

and urinary catheters, hand hygiene and environmental

cleanliness

Inspectors noted the calm and relaxed atmosphere at ward

level and the caring attitude of staff

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

Altnagelvin 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

Ward 43

Environment 91

Patient Linen 95

Waste 87

Sharps 82

Equipment 89

Hygiene Factors 97

Hygiene Practices 91

Average score 90

Level of Compliance

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

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Table 2

Environment

Reception 81

Corridors, stairs lift 86

Public toilets 91

Ward/department –

general (communal)

97

Patient bed area

N/A

Bathroom/washroom 94

Toilet

N/A

Clinical room/treatment

room

86

Clean utility room

N/A

Dirty utility room 98

Domestic store 93

Kitchen 84

Equipment store 93

Isolation 93

General information 90

Average score 91

Table 3

Linen

Storage of clean linen 96

Storage of used linen 93

Laundry facilities

N/A

Total 95

Table 4

Waste and sharps

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

87

82

Table 5

Patient Equipment

Patient equipment 89

Level of Compliance

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance:

75% or below

3


Table 6

Hygiene Factors

Availability and

cleanliness of WHB and 96

consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

90

Average score 97

Table 7

Hygiene practices

Effective hand hygiene

procedures

89

Safe handling and

disposal of sharps

86

Effective use of PPE 88

Correct use of isolation 100

Effective cleaning of ward 80

Staff uniform and work

wear

100

Average score 91

Level of Compliance

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

4


2.0 Background Information to the Inspection Process

RQIA’s infection prevention and hygiene team was established to

undertake a rolling programme of unannounced inspections of acute

hospitals. The Department of Health Social Service and Public Safety

(DHSSPS) commitment to a programme of hygiene inspections was

reaffirmed through the launch in 2010 of the revised and updated

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

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

in Northern Ireland.

The aims of the inspection process are:

to provide public assurance and to promote public trust and

confidence

to contribute to the prevention and control of HCAI

to contribute to improvement in hygiene, cleanliness and infection

prevention and control across health and social care in Northern

Ireland

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

transparent method for inspection, using standardised processes and

documentation.

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3.0 Inspections

The DHSSPS has devised 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 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 Regional

Healthcare Hygiene and Cleanliness audit tool. The inspection process

involves observation, discussion with staff, and review of some ward

documentation.

4.2 Feedback and Report of the Findings

The process concludes with a feedback of key findings to trust

representatives including examples of notable practice identified during

the inspection. The details of trust representatives attending the

feedback session is outlined in Section 12.

The findings, report and follow up action will be in accordance with the

Infection Prevention/Hygiene Inspection Process (methodology, follow

up and reporting).

The infection prevention/hygiene team escalation process will be

followed if inspectors/reviewers identify any serious concerns during

the inspection (Section 15).

A number of documents have been developed to support and explain

the inspection process. This information is currently available on

request and will be available in due course on the RQIA website.

7


5.0 Audit Tool

The audit tool used for the inspection is based on the Regional

Healthcare Hygiene and Cleanliness standards. The standards

incorporate the critical areas which were identified through a review of

existing standards, guidance and audit tools (Appendix 2 of Regional

Healthcare Hygiene and Cleanliness standards). The audit tool follows

the format of the Regional Healthcare Hygiene and Cleanliness

Standards and comprises of the following sections.

1. Organisational Systems and Governance: policies and

procedures in relation to key hygiene and cleanliness issues;

communication of policies and procedures; roles and

responsibilities for hygiene and cleanliness issues; internal

monitoring arrangements; arrangements to address issues

identified during internal monitoring; communication of internal

monitoring results to staff

This standard is not audited when carrying out unannounced

inspections however the findings of the organisational

system and governance at annual announced inspection will

be, where applicable, confirmed at ward level.

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

areas; cleanliness and state of repair of ward/department

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

cleanliness and state of repair of toilets, bathrooms and

washrooms; cleanliness and state of repair of ward/department

facilities; availability and cleanliness of isolation facilities;

provision of information for staff, patients and visitors

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

used linen; ward/department laundry facilities

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

sharps containers

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

patient equipment

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

availability of personal protective equipment (PPE); availability of

cleaning equipment and materials.

7. Hygiene Practices: hand hygiene procedures; handling and

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

implementation of infection control procedures; cleaning of

ward/department; staff uniform and work wear

8


Level of Compliance

Percentage scores can be allocated a level of compliance using the

compliance categories below. The categories are allocated as follows:

Compliant

85% or above

Partial compliance 76 to 84%

Minimal compliance 75% or below

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

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

ensure that the appropriate action is taken.

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6.0 Environment

STANDARD 2.0

GENERAL ENVIRONMENT

Cleanliness and state of repair of public areas; cleanliness and

state of repair of ward/department infrastructure; cleanliness and

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

of toilets, bathrooms and washrooms; cleanliness and state of

repair of ward/department facilities; availability and cleanliness

of isolation facilities; provision of information for staff, patients

and visitors.

Environment

Reception 81

Corridors, stairs lift 86

Public toilets 91

Ward/department –

general (communal)

97

Patient bed area

N/A

Bathroom/washroom 94

Toilet

N/A

Clinical room/treatment

room

86

Clean utility room

N/A

Dirty utility room 98

Domestic store 93

Kitchen 84

Equipment store 93

Isolation 93

General information 90

Average score 91

The above table outlines the findings in relation to the general

environment of the facilities inspected. Compliance was demonstrated

in the majority of areas within the ward, with the regional specifications

for cleaning standards. The findings in respect of the general

environment are detailed in the following sections.

6.1 Cleaning

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

with regional specifications for cleaning. It was observed that regular

and effective cleaning mechanisms were in place to prevent the build

up of dust and debris which in turn prevents the build up of bacteria

and helps in the reduction of the potential risk for the transmission of

infection.

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There were some issues identified that require more attention to detail

in the cleaning process. Inspectors noted evidence of dust on the

glass shelving of the display cabinets in the South Wing corridor and on

some high level surfaces and shelving in the ward. External windows

in the South Wing corridor and in the ward required cleaning and the

nozzle of automated taps in the ward was dirty. In the small pantry, the

interior of the freezer used by relatives, was dirty and temperature

checks for the fridge and freezer had not been consistently recorded.

Additional Issue

Ice cream and ice lollies were observed in the freezer of the small

pantry. It is advised to seek guidance from the catering department

concerning the safe storage of food purchased and transported to the

ward by relatives.

6.2 Clutter

In Ward 43 there was evidence of a continued emphasis in providing a

clutter free environment, this provides effective utilisation of space and

good stock management which assists with effective cleaning (Picture

1). Inspectors found that the bathroom was cluttered with a hoist,

slings and a mattress (Picture 2). Staff reported that the bathroom is

used as a storage area as all bed rooms are en-suite. Staff confirmed

that the water is run daily to prevent legionella,Trust representatives

confirmed that when a functional purpose for this room is agreed, the

room use can be converted through capital funding.

Picture 1: Tidy and well presented

dirty utility room

Picture 2: Cluttered, unused

bathroom

6.3 Maintenance and Repair

The main entrance and reception to the hospital were showing signs of

age, wear and tear. Walls and skirting were damaged, paintwork was

chipped and the glass panel of the back entrance sliding door was

broken; plastic sheeting had been placed over the glass to prevent it

from shattering and causing injury.

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The public toilets in the main reception area have been refurbished and

were clean and tidy. Some damage to the flooring was noted at the

entrance to the toilets and laminate was chipped on a cubicle door.

The ward itself had a bright well presented appearance and was

generally in good repair with some minor damage to walls and doors

noted. It was evident that staff practice in propping doors open with

waste bins or storing equipment against walls has in some part

attributed to the wall and door damage observed. In the treatment

room, the drugs fridge lock was broken resulting in easy access to

medication and in the kitchen, the top exterior surface of the fridge was

broken. Staff confirmed both these items had been reported for repair.

Limescale was noted on taps throughout the ward.

6.4 Fixtures and fittings

At the main entrance to the hospital, the fabric chairs at the back

entrance were slightly stained and the wooden arms were worn to the

bare wood. At the front entrance, the public telephones were in a poor

state of repair. Staff reported the telephones were to be removed.

In general, fixtures and fittings in the ward were in a good state of

repair, some furniture, such as bedrails were chipped and in the

bathroom a toilet seat lid, to prevent aerosol contamination, had not

been fitted.

Inspectors noted the use of notice boards made from fabric which

cannot be effectively cleaned throughout the ward areas and a PPE

station was located in the dirty utility room. It is advised that guidance

is sought from the infection prevention and control team concerning the

placement of PPE in a dirty utility room, due to the potential for aerosol

contamination spray from the slop hopper.

6.5 Information

An agreed set of core healthcare associated infection (HCAI) public

information leaflets were available for patients and visitors, hand

hygiene posters were displayed throughout the hospital and the areas

inspected. Clear instructions were in place outside isolation rooms to

advise staff and visitors of isolation precautions.

An agreed set of core healthcare associated infection (HCAI) public

information leaflets were available for patients and visitors, hand

hygiene posters were displayed throughout the hospital and the areas

inspected. Clear instructions were in place outside isolation rooms to

advise staff and visitors of isolation precautions.

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A few issues were identifed for action. A

NPSA colour coding poster for nursing staff

was not available and nursing staff cleaning

schedules need more detail regarding

equipment in use and staff responsibility.

Cleaning schedules and a NPSA poster were

available for domestic staff (Picture 3).

Picture 3 Domestic cleaning schedules

and NPSA colour coding poster

Recommendations

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

place for environmental cleaning, provide the necessary

assurance that cleaning is carried out effectively, and that all

staff are aware of their responsibilities.

2. The healthcare environment should be repaired and

maintained, and damaged fixtures and fittings replaced to

maintain public confidence and to help reduce the risk of the

spread of infection.

3. Work should continue on improving storage and maintaining

clutter free environments.

4. Detailed nursing cleaning schedules should be developed.

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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.

7.1 Management of Linen

Linen

Storage of clean linen 96

Storage of used linen 93

Laundry facilities

N/A

Total 95

Staff are to be commended for achieving overall compliance in this

section of the audit tool. A few issues were identified which need

addressed. Inspectors observed that clean linen was stored in a

separate store from used linen. The linen was stored neat and tidy

however there was a large stain on the ceiling tile above the light fitting.

Used linen was placed immediately into the appropriate colour coded

bags at the point of care however a member of nursing staff was

observed handling used linen in the lobby of an isolation room and not

wearing appropriate PPE.

Recommendations

5. The trust should ensure that the linen store is in good repair.

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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

Handling, segregation,

storage, waste

Availability, use, storage

of sharps

87

82

8.1 Waste

Picture 4: Pharmaceutical waste

in a magpie box

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. Issues were

identified in relation to staff

practice,such as household

waste in clinical waste bins,

pharmaceutical waste in a

magpie box(Picture 4) and non

pharmaceutical waste in a black

lidded burn bin.

In some waste bins the underside of some lids was starting to rust,

there was no household waste provision in the dirty utility room. There

was a disposal area at the entrance to the ward, the door to the area

was unlocked and the large eurobin for the containment of waste was

unlocked.

8.2 Sharps

A partial compliance score was achieved in this section of the audit

tool, the issues identified were in relation to staff practice. The sharps

box on the drugs trolley was dirty, none of the temporary closures on

the sharps boxes were in place when the boxes were not in use and

sharps trays were not compatible with the sharps boxes. The process

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in place for the disposal of sharps near to the bedside has resulted in

staff having to wait on a free venepuncture trolley which has a sharps

box attached. The ward manager confirmed that following aseptic non

touch technique (ANTT) training, the ward sister had ordered

compatible sharps trays which should address this issue.

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

All boxes, with the exception of the sharps box on a venepuncture

trolley, were assembled correctly; labelled with the date, locality and

staff signature. This is good practice as correct labelling ensures that if

there is a spillage of sharps waste from the sharps box or an injury to a

staff member as a result of incorrect assembly/disposal, the area the

sharps box originated from can be immediately identified.

Identifying the origin of the sharps box and its contents is imperative to

assist in the immediate risk assessment process carried out following a

sharps injury and also to ensure that staff who incorrectly

assembled/disposed of the sharps box can receive education on the

correct procedures to follow. With little effort and improvement in staff

practice, staff could easily achieve compliance in this standard.

Recommendations

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

should be available, clean and replaced as appropriate.

7. 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.

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9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

Patient Equipment

Patient equipment 89

Inspectors observed that the cleaning of patient equipment was of a

good standard as equipment was visibly clean, generally in a good

state of repair and labelled with trigger tape to indicate when clean. A

few issues were identified for improvement.

A drugs trolley had a chipped frame and a sticky label on the lid, one of

the covers on the mobile linen trolley was starting to split and the top

surface of the emergency trolley was badly cracked. Equipment which

is compromised or damaged cannot be effectively cleaned. Staff

confirmed a new top covering for the resuscitation trolley had been

ordered.

Picture 5: Laryngoscope blades out

of their packaging

Laryngoscope blades on the

resuscitation trolley were

removed from their sterile

packaging (Picture 5). The

Association of Anaesthetists of

Great Britain and Ireland

guidelines ‘Infection Control in

Anaesthesia’ states that single

use resuscitation equipment

should be kept in a sealed

package or should be re-sterilised

between patients according to

manufacturer's instructions.

It also states that packaging should not be removed until the point of

use for infection control, identification and traceability in the case of a

manufacturer's recall and safety.

Other issues were identified in relation to staff practice. Adhesive tape

residue was noted on one of the portable nebulisers in the equipment

store, the blue plastic medicine kardexes were dirty and a member of

nursing staff was unsure of the symbol for single use equipment. The

ice machine in the kitchen is scored under this section of the audit tool.

The ice machine dispenser nozzle was dirty and cleaning records were

inconsistently recorded.

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Recommendations

8. The trust and individual staff have a collective responsibility

to ensure that equipment is stored correctly, easily cleaned

and in a good state of repair.

18


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

Availability and

cleanliness of WHB and 96

consumables

Availability of alcohol rub 100

Availability of PPE 100

Materials and equipment

for cleaning

90

Average score 97

The ward achieved a high overall compliance score for this standard

and full compliance in the sections relating to availability of alcohol rub

and PPE. Although hand washing sinks were clean and in a good state

of repair, (Picture 6) staff should also ensure all hand towel dispensers

and liquid soap dispensers are cleaned effectively.

Picture 6: Example of handwashing facilities,

clean and in a good state of repair

Some issues were identified in relation to nursing staff practice and

knowledge concerning the correct preparation, storage and dilution

rates of Actichlor plus. Cleaning agents were not stored in accordance

with control of substances hazardous to health (COSHH) regulations.

Actichlor plus containers were stored in an unlocked cupboard in the

dirty utility room and cleaning spray had been left on a dado rail at the

entrance to the ward and detergent had been left on a table. These

were removed immediately by a member of support services.

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Recommendations

9. The trust should ensure that hand washing consumables are

clean.

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

staff knowledge and practice is kept up to date regarding the

use of disinfectants.

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

in a locked cupboard, 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

Effective hand hygiene

procedures

89

Safe handling and

disposal of sharps

86

Effective use of PPE 88

Correct use of isolation 100

Effective cleaning of ward 80

Staff uniform and work

wear

100

Average score 91

Staff are to be commended in achieving compliance in this standard and full

compliance in the section relating to correct use of isolation and staff uniform

and work wear. Hand hygiene practices observed complied with WHO (World

Health Organisation) guidance on the correct technique to use for hand

washing and appliance of hand rub.

The following issues relate to staff practice and knowledge. One member of

nursing staff did not know it was incorrect to use alcohol rub if a patient has

Clostridium difficile. Another nurse advised inspectors they used alcohol gel

directly after washing their hands with soap and water. Staff should be

advised that this is unnecessary practice. Sharps were not disposed of into a

sharps box at the bedside and there was one incidence of re-sheathing of

needles observed.

Inspectors noted that nursing staff did not wear aprons when serving meals.

At the feedback session trust representatives confirmed that they were aware

this practice required action and was to be addressed.

The following issues were identified in the section concerning effective

cleaning of the ward. When questioned, some nursing staff were unsure of

the cleaning solution dilution rate for blood spillage, had no knowledge of the

NPSA colour coding system for cleaning and a nurse reported that Hydrex, an

antibacterial skin cleansing solution, was used to clean equipment.

21


Recommendations

12. The trust and individual staff have a collective responsibility

to ensure handwashing practices are in line with trust policy.

13. The trust should ensure that staff practice in relation to the

safe handing and disposal of sharps is in line with trust

policy.

14. The trust and individual staff have a collectice responsibility

to ensure PPE is worn according to policy.

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

staff knowledge and practice is kept up to date regarding

isolation, cleaning and decontamination of equipment.

22


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs L Gawley - Inspector Infection Prevention/Hygiene Team

Mrs S O'Connor - 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 A. Witherow - Assitant Director of Nursing

Mr S Gibson - Head of Operations and Maintenance

Ms M Kelly - Head of Support Services

Mr M Quinn - Head of Service Adult Disability Services/Lead

Nurse

Ms E England - Lead Nurse/General Manager Cancer Services

Ms S Gormley - Support Services Manager

Ms S Glenn - Ward Manager, Ward 43 Sperrin Ward

Ms C Brown - Ward Manager, Spruce House

Ms U Cardin - Ward Manager, Sperrin Unit

Ms Y Black - Assistant Manager Support Services

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.

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13.0 Summary of Recommendations

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

place for environmental cleaning, provide the necessary

assurance that cleaning is carried out effectively, and that all

staff are aware of their responsibilities.

2. The healthcare environment should be repaired and

maintained, and damaged fixtures and fittings replaced to

maintain public confidence and to help reduce the risk of the

spread of infection.

3. Work should continue on improving storage and maintaining

clutter free environments.

4. Detailed nursing cleaning schedules should be developed.

5. The trust should ensure that the linen store is in good repair.

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

should be available, clean and replaced as appropriate.

7. 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.

8. The trust and individual staff have a collective responsibility

to ensure that equipment is stored correctly, easily cleaned

and in a good state of repair.

9. The trust should ensure that hand washing consumables are

clean.

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

staff knowledge and practice is kept up to date regarding the

use of disinfectants.

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

in a locked cupboard, in line with COSHH regulations.

12. The trust and individual staff have a collective responsibility

to ensure handwashing practices are in line with trust policy.

13. The trust should ensure that staff practice in relation to the

safe handing and disposal of sharps is in line with trust

policy.

14. The trust and individual staff have a collectice responsibility

to ensure PPE is worn according to policy.

24


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

staff knowledge and practice is kept up to date regarding

isolation, cleaning and decontamination of equipment.

25


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

26


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

27


16.0 Action Plan

Reference

number

Recommendations

1 The trust should ensure that the systems and

processes in place for environmental cleaning, provide

the necessary assurance that cleaning is carried out

effectively, and that all staff are aware of their

responsibilities.

Designated

department

Nursing

Action required

The Trust has cleaning programmes in

place and support staff have all receive

training on BICS.

Cleaning schedules for patient equipment

are in development and will be re-issued

January 2012

Date for

completion/

timescale

Commenced

and on going

2 The healthcare environment should be repaired and

maintained, and damaged fixtures and fittings

replaced to maintain public confidence and to help

reduce the risk of the spread of infection.

Estates

Defects to be reported to Estates Help

Desk.

Environmental Cleanliness audits to be

monitored to assess areas needing

attention. Backlog Maintenance Funding

to be secured from General Capital to

address audit issues

On going

3 Work should continue on improving storage and

maintaining clutter free environments.

Estates

Nursing

The Productive ward series will be

implemented from February onwards

which using lean methodologies will help

to bring focus to the aspect of stock

management

Work is also on-going in relation to the

development of a de-clutter programme

for staff to have access to regular

disposal opportunities etc.

February

2012

January

2012

4 Detailed nursing cleaning schedules should be

developed.

Nursing

Corporate nursing cleaning schedules are

currently being developed and will be

audited in the monthly environmental

cleanliness audits

Jan 2012

onwards

28


Reference

number

Recommendations

5 The trust should ensure the correct storage of clean

linen in a designated area which is clean and fit for

purpose.

Designated

department

Nursing

Estates

Action required

Training work- shops are being scheduled

for staff Jan- March and this will be

addressed in the programme.

Ward managers have been asked to

identify where a problem with linen

storage exists and to raise through their

governance and estates meetings.

Date for

completion/

timescale

Jan2012

6 Waste bins and equipment used in the management

of waste should be available, clean and replaced as

appropriate.

Support

Services

Nursing

This will be included in the training

programmes Jan-March and will be

included in the Environmental Cleanliness

audits process The cleaning schedules

for each location include waste bins

Jan 2012

On going

7 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.

Estates

Annual Sharps Safety Audit Altnagelvin

and Erne recently completed by Daniels

Heathcare, findings due to be circulated

by 20 th December 2011.

Dec 2011

8 The trust and individual staff have a collective

responsibility to ensure that equipment is stored

correctly, easily cleaned and in a good state of repair.

Estates

Nursing

The Trust has an equipment /

decontamination policy and all directors

have been written to advising them of the

measures they must take to ensure that

this is followed.

This is part of the equipment controls

assurance standard and will be monitored

again in spring 23012

On going

9 The trust should ensure that hand washing

consumables are clean.

Support

Services

The cleaning schedules include the

cleaning and replenishing of hand towels,

toilet rolls and soap dispensers

On going

29


Reference

number

Recommendations

10 Systems and processes should be in place to assure

that staff knowledge and practice is kept up to date

regarding the use of disinfectants.

Designated

department

Nursing

Action required

IPC Mandatory Training Slides updated

All Ward Managers have received a

reminder email with insructions for how to

access disinfectant training DVD.

Actichlor disinfectant representative to

provide training ward to ward within the

next month.

In addition a laminated information card

will be developed for staff reference.

Date for

completion/

timescale

On going

11 The trust should ensure that all cleaning products are

stored in a locked cupboard, in line with COSHH

regulations.

Support

Services

Support Services staff receive training on

COSHH as part of their induction. Also

BICS training incorporates COSHH

training.

Commenced

and on going

12 The trust and individual staff have a collective

responsibility to ensure hand washing practices are in

line with trust policy.

13 The trust should ensure that staff practice in relation to

the safe handling and disposal of sharps is in line with

trust policy.

Nursing

Nursing

Estates

Services

The Trust has very strict accountability

systems which include very close

monitoring of hand hygiene compliance.

Staff receive mandatory training on

Sharps and this will also be included in

the training during Jan-_March 2012

Commenced

and on going

Jan 2012

14 The trust and individual staff have a collective

responsibility to ensure PPE is worn according to

policy.

15 Systems and processes should be in place to assure

that staff knowledge and practice is kept up to date

regarding isolation, cleaning and decontamination of

equipment.

Nursing

Support

Services

Nursing

Support

Services

All staff will be issued with a pocket held

card outlining the correct use of the PPE

This is included in the mandatory

infection prevention control training and

will be included in the updated

environmental cleanliness audit tool

scheduled for use in February 2012 in all

Trust facilities

Jan 2101

Jan-March

2012

30

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