Ulster Hospital - 15 November 2011 - Regulation and Quality ...
Ulster Hospital - 15 November 2011 - Regulation and Quality ...
Ulster Hospital - 15 November 2011 - Regulation and Quality ...
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RQIA<br />
Infection Prevention/Hygiene<br />
Unannounced inspection<br />
South Eastern Health <strong>and</strong> Social Care<br />
Trust<br />
<strong>Ulster</strong> <strong>Hospital</strong><br />
<strong>15</strong> <strong>November</strong> <strong>2011</strong>
Contents<br />
1.0 Inspection Summary 1<br />
2.0 Background Information to the Inspection Process 6<br />
3.0 Inspections 7<br />
4.0 Unannounced Inspection Process 8<br />
4.1 Onsite Inspection 8<br />
4.2 Feedback <strong>and</strong> Report of the Findings 8<br />
5.0 Audit Tool 9<br />
6.0 Environment 11<br />
6.1 Cleaning 11<br />
6.2 Clutter 14<br />
6.3 Maintenance <strong>and</strong> Repair 16<br />
6.4 Fixture <strong>and</strong> Fittings 16<br />
6.5 Information 18<br />
7.0 Patient Linen 20<br />
7.1 Management of Linen 20<br />
8.0 Waste <strong>and</strong> Sharps 22<br />
8.1 Waste 22<br />
8.2 Sharps 22<br />
9.0 Patient Equipment 24<br />
10.0 Hygiene Factors 27<br />
11.0 Hygiene Practice 30<br />
12.0 Key Personnel <strong>and</strong> Information 34<br />
13.0 Summary of Recommendations 35<br />
14.0 Unannounced Inspection Flowchart 37<br />
<strong>15</strong>.0 RQIA Hygiene Team Escalation Policy Flowchart 38<br />
16.0 Action Plan 39
1.0 Inspection Summary<br />
An unannounced inspection was undertaken to the <strong>Ulster</strong> <strong>Hospital</strong>, on<br />
the <strong>15</strong> <strong>November</strong> <strong>2011</strong>. The hospital was assessed against the<br />
Regional Healthcare Hygiene <strong>and</strong> Cleanliness st<strong>and</strong>ards <strong>and</strong> the<br />
following areas were inspected:<br />
Ward 4 (Haemotology)<br />
Ward 5 (Surgical)<br />
Ward 19 (Orthopaedics)<br />
Ward 23 (Stroke)<br />
The Care of the Elderly Unit, which is separate from the main hospital<br />
block, has been renovated to provide four modern <strong>and</strong> fully refurbished<br />
wards thus enhancing the ward environment for patients <strong>and</strong> staff.<br />
Ward 23 is designated as a stroke ward within the Care of the Elderly<br />
Unit.<br />
Wards 4, 5 <strong>and</strong> 19 are located in the main hospital ward block. Ward<br />
4, located on the first floor, comprises of 14 single rooms, all with ensuite<br />
facilities. The ward had been relocated from Ward 25 the week<br />
prior to the inspection <strong>and</strong> staff <strong>and</strong> patients were in the process of<br />
settling into the new ward surroundings <strong>and</strong> organising placement of<br />
stores <strong>and</strong> supplies in order to create a clutter free environment.<br />
Ward 5, located on the first floor, is a 19 bedded female surgical ward<br />
with two en-suite <strong>and</strong> one, bed only side rooms where patients can be<br />
nursed with isolation precautions. Ward 19 is a 20 bedded ward which<br />
has four single rooms providing en-suite toilets.<br />
Inspection Outcomes<br />
Overall the inspection teams found evidence that the <strong>Ulster</strong> <strong>Hospital</strong><br />
was working to comply with the Regional Healthcare Hygiene <strong>and</strong><br />
Cleanliness st<strong>and</strong>ards. However inspectors found that further<br />
improvement was required in the following areas.<br />
Three of the wards achieved an overall compliant score <strong>and</strong> Ward 4<br />
achieved an overall partially compliant score. Inspectors observed that<br />
the environment in all wards was generally clean, however clutter, <strong>and</strong><br />
at times poor maintenance <strong>and</strong> repair, notably in Wards 5 <strong>and</strong> 19, have<br />
impacted negatively on the scoring.<br />
The trust has identified clutter <strong>and</strong> storage as issues <strong>and</strong> is currently<br />
working to improve these areas. The roles <strong>and</strong> responsibilities for<br />
cleaning patient equipment requires further clarification <strong>and</strong> the<br />
proposed review of detailed cleaning schedules <strong>and</strong> an agreement on<br />
the cleaning disinfectant to be used would increase compliance.<br />
1
Although all wards scored overall compliance for the st<strong>and</strong>ard,<br />
regarding hygiene factors, the section on materials <strong>and</strong> equipment for<br />
cleaning, the low minimal compliance score in Ward 4 <strong>and</strong> the partial<br />
compliance score in the other wards indicates that more work is<br />
required to improve practice. In the hygiene practices st<strong>and</strong>ard, Wards<br />
4 <strong>and</strong> 19 scored a low minimal compliance in the section concerning<br />
effective cleaning of the ward. In all wards, all staff groups must<br />
implement hygiene <strong>and</strong> infection prevention <strong>and</strong> control practices<br />
consistently to minimise the potential risk of transmission of infection to<br />
patients, visitors <strong>and</strong> staff.<br />
An improvement is also required in all wards but notably in Wards 4<br />
<strong>and</strong> 23 in the management of sharps <strong>and</strong> in Wards 19 <strong>and</strong> 23 where<br />
the st<strong>and</strong>ard on patient equipment did not reach an acceptable level.<br />
The inspectors were impressed with staff commitment in the<br />
management of waste <strong>and</strong> the management of linen st<strong>and</strong>ards <strong>and</strong><br />
sections which scored compliant in the Hygiene Factors <strong>and</strong> Hygiene<br />
Practices st<strong>and</strong>ards.<br />
As a result of the findings for Wards 4, 19 <strong>and</strong> 23 a follow up inspection<br />
will be carried out within three months.<br />
The inspection resulted in 23 recommendations for the <strong>Ulster</strong> <strong>Hospital</strong>,<br />
a full list of recommendations is listed in Section 13.<br />
A detailed list of preliminary findings is forwarded to South Eastern<br />
Health <strong>and</strong> Social Care Trust within 14 days of the inspection to enable<br />
early action on identified areas which have achieved non complaint<br />
scores. The draft report which includes the high level<br />
recommendations in a <strong>Quality</strong> Improvement Plan is forwarded within 28<br />
days of the inspection for agreement <strong>and</strong> factual accuracy. The draft<br />
report is agreed <strong>and</strong> a completed action plan is returned to RQIA within<br />
14 days from the date of issue. The detailed list of preliminary findings<br />
is available from RQIA on request.<br />
The final report <strong>and</strong> <strong>Quality</strong> Improvement Plan will be available on the<br />
RQIA website. Reports <strong>and</strong> action plans will be subject to performance<br />
management by the Health <strong>and</strong> Social Care Board <strong>and</strong> the Public<br />
Health Agency.<br />
Notable Practice<br />
The inspection identified the following areas of notable practice:<br />
Care pathways are implemented for patients with<br />
Clostridium difficile infection<br />
Implementation of high impact intervention care bundles<br />
2
Ward 23 is participating in the implementation of a infection<br />
prevention <strong>and</strong> control trial for new nursing cleaning<br />
schedules <strong>and</strong> use of trigger tape<br />
Ward 23 achieved the BICS Regional Team Award for 2010<br />
The RQIA inspection team would like to thank the staff at the <strong>Ulster</strong><br />
<strong>Hospital</strong> for their assistance during the inspection.<br />
The following tables give an overview of compliance scores noted in<br />
areas inspected by RQIA:<br />
Table 1 summarises the overall compliance levels achieved.<br />
Tables 2-7 summarise the individual tables for sections two to seven of<br />
the audit tool as this assists organisation to target areas that require<br />
more specific attention.<br />
Table 1<br />
Areas Inspected Ward 4 Ward 5 Ward 19 Ward 23<br />
General Environment 82 83 76 83<br />
Patient Linen 90 86 95 96<br />
Waste 85 98 98 92<br />
Sharps 72 95 80 71<br />
Equipment 82 86 75 75<br />
Hygiene Factors 89 94 90 90<br />
Hygiene Practices 80 90 87 86<br />
Average Score 83 90 86 85<br />
Level of Compliance<br />
Compliant:<br />
85% or above<br />
Partial Compliance: 76% to 84%<br />
Minimal Compliance:<br />
75% or below<br />
3
Table 2<br />
General Environment Ward 4 Ward 5 Ward 19 Ward 23<br />
Reception N/A 87 N/A 88<br />
Corridors, stairs lift N/A 74 N/A 92<br />
Public toilets N/A 83 N/A 98<br />
Ward/department -<br />
general (communal)<br />
82 78 66 76<br />
Patient bed area 81 85 79 76<br />
Bathroom/washroom 89 78 71 76<br />
Toilet 93 86 70 93<br />
Clinical room/treatment<br />
room<br />
78 N/A 81 88<br />
Clean utility room N/A 65 N/A 77<br />
Dirty utility room 80 98 73 78<br />
Domestic store 68 76 89 76<br />
Kitchen 80 86 82 83<br />
Equipment store 93 79 84 77<br />
Isolation 91 91 87 85<br />
General information 65 89 58 83<br />
Average Score 82 83 76 83<br />
Table 3<br />
Patient Linen Ward 4 Ward 5 Ward 19 Ward 23<br />
Storage of clean linen 89 90 89 92<br />
Storage of used linen 91 81 100 100<br />
Laundry facilities N/A N/A N/A N/A<br />
Average Score 90 86 95 96<br />
Table 4<br />
Waste <strong>and</strong> Sharps Ward 4 Ward 5 Ward 19 Ward 23<br />
H<strong>and</strong>ling, segregation,<br />
storage, waste<br />
85 98 98 92<br />
Availability, use, storage<br />
of sharps<br />
72 95 80 71<br />
Table 5<br />
Patient Equipment Ward 4 Ward 5 Ward 19 Ward 23<br />
Patient equipment 82 86 75 75<br />
Level of Compliance<br />
Compliant:<br />
85% or above<br />
Partial Compliance: 76% to 84%<br />
Minimal Compliance:<br />
75% or below<br />
4
Table 6<br />
Hygiene Factors Ward 4 Ward 5 Ward 19 Ward 23<br />
Availability <strong>and</strong><br />
cleanliness of wash<br />
h<strong>and</strong> basin <strong>and</strong><br />
92 99 100 100<br />
consumables<br />
Availability of alcohol<br />
rub<br />
100 100 90 97<br />
Availability of PPE 100 100 90 86<br />
Materials <strong>and</strong><br />
equipment for cleaning<br />
64 76 80 76<br />
Average Score 89 94 90 90<br />
Table 7<br />
Hygiene Practices Ward 4 Ward 5 Ward 19 Ward 23<br />
Effective h<strong>and</strong> hygiene<br />
procedures<br />
93 94 89 79<br />
Safe h<strong>and</strong>ling <strong>and</strong><br />
disposal of sharps<br />
85 100 100 100<br />
Effective use of PPE 81 88 88 89<br />
Correct use of isolation 85 88 N/A N/A<br />
Effective cleaning of<br />
ward<br />
53 76 67 77<br />
Staff uniform <strong>and</strong> work<br />
wear<br />
85 93 92 84<br />
Average Score 80 90 87 86<br />
Level of Compliance<br />
Compliant:<br />
85% or above<br />
Partial Compliance: 76% to 84%<br />
Minimal Compliance:<br />
75% or below<br />
5
2.0 Background Information to the Inspection Process<br />
RQIA‟s infection prevention <strong>and</strong> hygiene team was established to<br />
undertake a rolling programme of unannounced inspections of acute<br />
hospitals. The Department of Health Social Service <strong>and</strong> Public Safety<br />
(DHSSPS) commitment to a programme of hygiene inspections was<br />
reaffirmed through the launch in 2010 of the revised <strong>and</strong> updated<br />
version of 'Changing the Culture' the strategic regional action plan for<br />
the prevention <strong>and</strong> control of healthcare-associated infections (HCAIs)<br />
in Northern Irel<strong>and</strong>.<br />
The aims of the inspection process are:<br />
to provide public assurance <strong>and</strong> to promote public trust <strong>and</strong><br />
confidence<br />
to contribute to the prevention <strong>and</strong> control of HCAI<br />
to contribute to improvement in hygiene, cleanliness <strong>and</strong> infection<br />
prevention <strong>and</strong> control across health <strong>and</strong> social care in Northern<br />
Irel<strong>and</strong><br />
In keeping with the aims of the RQIA, the team will adopt an open <strong>and</strong><br />
transparent method for inspection, using st<strong>and</strong>ardised processes <strong>and</strong><br />
documentation.<br />
6
3.0 Inspections<br />
The DHSSPS has devised Regional Healthcare Hygiene <strong>and</strong><br />
Cleanliness st<strong>and</strong>ards. RQIA has revised its inspection processes to<br />
support the publication of the st<strong>and</strong>ards which were compiled by a<br />
regional steering group in consultation with service providers.<br />
RQIA's infection prevention/hygiene team have planned a three year<br />
programme which includes announced <strong>and</strong> unannounced inspections<br />
in acute <strong>and</strong> non-acute hospitals in Northern Irel<strong>and</strong>. This will assess<br />
compliance with the DHSSPS Regional Healthcare Hygiene <strong>and</strong><br />
Cleanliness st<strong>and</strong>ards.<br />
The inspections will be undertaken in accordance with the four core<br />
activities outlined in the RQIA Corporate Strategy, these include:<br />
Improving care: we encourage <strong>and</strong> promote improvements in the<br />
safety <strong>and</strong> quality of services through the regulation <strong>and</strong> review of<br />
health <strong>and</strong> social care<br />
Informing the population: we publicly report on the safety,<br />
quality <strong>and</strong> availability of health <strong>and</strong> social care<br />
Safeguarding rights: we act to protect the rights of all people<br />
using health <strong>and</strong> social care services<br />
Influencing policy: we influence policy <strong>and</strong> st<strong>and</strong>ards in health<br />
<strong>and</strong> social care<br />
7
4.0 Unannounced Inspection Process<br />
Trusts receive no advanced notice of the onsite inspection. An email<br />
<strong>and</strong> telephone call will be made by the Chief Executive of RQIA or<br />
nominated person 30 minutes prior to the team arriving on site. The<br />
inspection flow chart is attached in Section 14.<br />
4.1 Onsite Inspection<br />
The inspection team was made up of four inspectors, from RQIA’s<br />
infection prevention/hygiene team <strong>and</strong> four peer reviewers. One<br />
inspector led the team <strong>and</strong> was responsible for guiding the team <strong>and</strong><br />
ensuring they were in agreement about the findings reached.<br />
Membership of the inspection team is outlined in Section 12.<br />
The inspection of ward environments is carried out using the Regional<br />
Healthcare Hygiene <strong>and</strong> Cleanliness audit tool. The inspection<br />
process involves observation, discussion with staff, <strong>and</strong> review of some<br />
ward documentation.<br />
4.2 Feedback <strong>and</strong> Report of the Findings<br />
The process concludes with a feedback of key findings to trust<br />
representatives including examples of notable practice identified during<br />
the inspection. The details of trust representatives attending the<br />
feedback session is outlined in Section 12.<br />
The findings, report <strong>and</strong> follow up action will be in accordance with the<br />
Infection Prevention/ Hygiene Inspection Process (methodology, follow<br />
up <strong>and</strong> reporting).<br />
The infection prevention/hygiene team escalation process will be<br />
followed if inspectors/reviewers identify any serious concerns during<br />
the inspection (Section <strong>15</strong>).<br />
A number of documents have been developed to support <strong>and</strong> explain<br />
the inspection process. This information is currently available on<br />
request <strong>and</strong> will be available in due course on the RQIA website.<br />
8
5.0 Audit Tool<br />
The audit tool used for the inspection is based on the Regional<br />
Healthcare Hygiene <strong>and</strong> Cleanliness st<strong>and</strong>ards. The st<strong>and</strong>ards<br />
incorporate the critical areas which were identified through a review of<br />
existing st<strong>and</strong>ards, guidance <strong>and</strong> audit tools (Appendix 2 of Regional<br />
Healthcare Hygiene <strong>and</strong> Cleanliness st<strong>and</strong>ards). The audit tool follows<br />
the format of the Regional Healthcare Hygiene <strong>and</strong> Cleanliness<br />
St<strong>and</strong>ards <strong>and</strong> comprises of the following sections.<br />
1. Organisational Systems <strong>and</strong> Governance: policies <strong>and</strong><br />
procedures in relation to key hygiene <strong>and</strong> cleanliness issues;<br />
communication of policies <strong>and</strong> procedures; roles <strong>and</strong><br />
responsibilities for hygiene <strong>and</strong> cleanliness issues; internal<br />
monitoring arrangements; arrangements to address issues<br />
identified during internal monitoring; communication of internal<br />
monitoring results to staff<br />
This st<strong>and</strong>ard is not audited when carrying out unannounced<br />
inspections however the findings of the organisational<br />
system <strong>and</strong> governance at annual announced inspection will<br />
be, where applicable, confirmed at ward level.<br />
2. General Environment: cleanliness <strong>and</strong> state of repair of public<br />
areas; cleanliness <strong>and</strong> state of repair of ward/department<br />
infrastructure; cleanliness <strong>and</strong> state of repair of patient bed area;<br />
cleanliness <strong>and</strong> state of repair of toilets, bathrooms <strong>and</strong><br />
washrooms; cleanliness <strong>and</strong> state of repair of ward/department<br />
facilities; availability <strong>and</strong> cleanliness of isolation facilities;<br />
provision of information for staff, patients <strong>and</strong> visitors<br />
3. Patient Linen: storage of clean linen; h<strong>and</strong>ling <strong>and</strong> storage of<br />
used linen; ward/department laundry facilities<br />
4. Waste <strong>and</strong> Sharps: waste h<strong>and</strong>ling; availability <strong>and</strong> storage of<br />
sharps containers<br />
5. Patient Equipment: cleanliness <strong>and</strong> state of repair of general<br />
patient equipment<br />
6. Hygiene Factors: h<strong>and</strong> wash facilities; alcohol h<strong>and</strong> rub;<br />
availability of personal protective equipment (PPE); availability of<br />
cleaning equipment <strong>and</strong> materials.<br />
7. Hygiene Practices: h<strong>and</strong> hygiene procedures; h<strong>and</strong>ling <strong>and</strong><br />
disposal of sharps; use of PPE; use of isolation facilities <strong>and</strong><br />
implementation of infection control procedures; cleaning of<br />
ward/department; staff uniform <strong>and</strong> work wear.<br />
9
Level of Compliance<br />
Percentage scores can be allocated a level of compliance using the<br />
compliance categories below. The categories are allocated as follows:<br />
Compliant<br />
85% or above<br />
Partial compliance 76 to 84%<br />
Minimal compliance 75% or below<br />
Each section within the audit tool will receive an individual <strong>and</strong> an<br />
overall score, to identify areas of partial or minimal compliance to<br />
ensure that the appropriate action is taken.<br />
10
6.0 Environment<br />
STANDARD 2.0<br />
GENERAL ENVIRONMENT<br />
Cleanliness <strong>and</strong> state of repair of public areas; cleanliness <strong>and</strong><br />
state of repair of ward/department infrastructure; cleanliness <strong>and</strong><br />
state of repair of patient bed area; cleanliness <strong>and</strong> state of repair<br />
of toilets, bathrooms <strong>and</strong> washrooms; cleanliness <strong>and</strong> state of<br />
repair of ward/department facilities; availability <strong>and</strong> cleanliness<br />
of isolation facilities; provision of information for staff, patients<br />
<strong>and</strong> visitors.<br />
General Environment Ward 4 Ward 5 Ward 19 Ward 23<br />
Reception N/A 87 N/A 88<br />
Corridors, stairs lift N/A 74 N/A 92<br />
Public toilets N/A 83 N/A 98<br />
Ward/department -<br />
general (communal)<br />
82 78 66 76<br />
Patient bed area 81 85 79 76<br />
Bathroom/washroom 89 78 71 76<br />
Toilet 93 86 70 93<br />
Clinical room/treatment<br />
room<br />
78 N/A 81 88<br />
Clean utility room N/A 65 N/A 77<br />
Dirty utility room 80 98 73 78<br />
Domestic store 68 76 89 76<br />
Kitchen 80 86 82 83<br />
Equipment store 93 79 84 77<br />
Isolation 91 91 87 85<br />
General information 65 89 58 83<br />
Average Score 82 83 76 83<br />
The above table outlines the findings in relation to the general<br />
environment of the facilities inspected. The findings indicate that there<br />
were areas for improvement in all wards, notably Ward 19, where the<br />
poor repair <strong>and</strong> cleaning of the fabric of the building, fixtures <strong>and</strong><br />
fittings have contributed to the minimally compliant areas highlighted in<br />
red. The findings in respect of the general environment are detailed in<br />
the following sections.<br />
6.1 Cleaning<br />
During the inspection, there was evidence, in some of the areas<br />
inspected, to indicate compliance with regional specifications for<br />
cleaning. However, inspectors observed, that while cleaning<br />
mechanisms were in place to prevent the build up of dust, debris <strong>and</strong><br />
bacteria <strong>and</strong> subsequently minimise the potential risk for the<br />
11
transmission of infection, in some instances these were not always<br />
effectively implemented or adhered to by staff.<br />
The entrance <strong>and</strong> main reception to the hospital have been refurbished<br />
<strong>and</strong> were generally clean <strong>and</strong> well presented. In the reception area,<br />
dust was noted on the window sills at the ramp <strong>and</strong> on desk tops; the<br />
glass panels of the minstrel gallery <strong>and</strong> the telephone h<strong>and</strong>sets were<br />
grubby. In the corridor leading to the lifts <strong>and</strong> wards some internal<br />
windows were dirty <strong>and</strong> dust was noted in the corners <strong>and</strong> edges of the<br />
flooring. In the ground floor reception of the Elderly Care Unit, leading<br />
to Ward 23, dust was observed on horizontal surfaces such as in the<br />
skirting corners <strong>and</strong> edges, on the h<strong>and</strong> rails, top of the vending<br />
machine <strong>and</strong> stairwell h<strong>and</strong> rails; dead flies <strong>and</strong> debris were observed<br />
on the stairwell window sills.<br />
There were no cleaning issues identified in the public toilet in Ward 23<br />
however more attention to detail is required in the cleaning of the<br />
disabled toilet in the corridor off the main hospital reception. The<br />
edges <strong>and</strong> corners of the flooring, the radiator <strong>and</strong> the top surface of<br />
the paper towel dispenser were dusty; the exterior surface of the toilet<br />
bowl was stained. It is important that cleaning frequencies take into<br />
consideration areas which are subject to frequent use <strong>and</strong> are<br />
increased accordingly.<br />
In all wards some improvements were required to the cleaning of the<br />
general ward environment. Dust was observed on the leaflet rack,<br />
computer screen <strong>and</strong> table, corners <strong>and</strong> edges of flooring in Ward 4<br />
<strong>and</strong> on a key board <strong>and</strong> table in the corridor of Ward 5. Dust was also<br />
noted in Ward 19, on the leaflet rack, skirting, the floor under the notes<br />
trolleys <strong>and</strong> the free st<strong>and</strong>ing pedestal fan at the reception desk. In<br />
Ward 4 <strong>and</strong> Ward 23, stains were observed in the flooring <strong>and</strong> chairs<br />
required cleaning; in Ward 23 the back of the fire extinguisher was very<br />
dirty.<br />
With the exception of Ward 19 exterior windows in patient bed areas<br />
were dirty, however window blinds in Ward 19 were dusty, a similar<br />
issue was observed in Ward 5. Dust was noted on low <strong>and</strong> high level<br />
surfaces such as on wall trunking in Ward 5, wall casing, chairs <strong>and</strong><br />
bedframes in Ward 4, the arm of the entertainment system in Ward 19<br />
<strong>and</strong> bedframes <strong>and</strong> skirting corners <strong>and</strong> edges in Ward 23. In Ward 5<br />
<strong>and</strong> Ward 23 more attention to detail when cleaning patient bedside<br />
tables was required.<br />
Some cleaning issues were identified in the sanitary areas of all wards.<br />
Wards 4, 5 <strong>and</strong> 23 were generally clean, a few issues were identified.<br />
Dust was noted at high level in the patient toilets of Ward 23 <strong>and</strong> in the<br />
shower room in Ward 5. In Ward 5 finger marks were noted on ceiling<br />
tiles, the shower base had large areas of a black mould or glue residue;<br />
a similar issue identified in a shower base of Ward 23.<br />
12
The sanitary areas in Ward 19 scored minimal compliance. Dust was<br />
observed on high <strong>and</strong> low surfaces <strong>and</strong> particular attention is needed in<br />
the cleaning of the plastic grid of the shower tray, splashes <strong>and</strong> stains<br />
from doors <strong>and</strong> frames, fresh <strong>and</strong> dried in stains from the underside of<br />
raised toilet seats <strong>and</strong> blood splatters or stains on walls. In Ward 23<br />
the underside of wall mounted shower chairs, the portable shower chair<br />
<strong>and</strong> raised toilet seats also required cleaning.<br />
There were no cleaning issues identified in the patient toilets in Ward 4,<br />
however in the bathroom, the wheels of a shower chair required<br />
cleaning, <strong>and</strong> tape was noted on the side of a raised toilet bowl; this<br />
practice impedes the cleaning process.<br />
In the equipment store, treatment room <strong>and</strong> clean utility room of all<br />
wards, dust was observed on some horizontal surfaces at high <strong>and</strong> low<br />
levels; inside cupboards <strong>and</strong> in the drawers of high density storage<br />
units. Similar issues were identified in the dirty utility rooms with the<br />
exception of Ward 5 where staff are to be commended for the st<strong>and</strong>ard<br />
of cleaning.<br />
The domestic stores in Wards 5, 19 <strong>and</strong> 23 were generally clean, some<br />
dust was observed <strong>and</strong> a built in cupboard in Ward 5 was dirty. In<br />
contrast, the domestic store in Ward 4 required detailed cleaning to<br />
flooring, skirting, light switches, doorframes, sinks <strong>and</strong> cupboards.<br />
In Ward 19 kitchen, the only cleaning issue identified was staining on<br />
the ceiling tiles. The fridge in the other wards required cleaning, dust<br />
was noted on horizontal surfaces; the ice machine in Ward 4 <strong>and</strong> the<br />
kitchen trolley in Ward 23. In Wards 5 <strong>and</strong> 23 the external windows<br />
were dirty; in Ward 4 sinks required cleaning. Also in Ward 4 there<br />
were no daily readings of the fridge temperature <strong>and</strong> dishwasher<br />
temperatures had not been recorded for a week. In contrast, the daily<br />
recordings of temperature readings were meticulously completed in<br />
Ward 5 (Picture 1).<br />
Picture 1: Corrective action for kitchen fridge temperatures<br />
13
In all wards inspectors spot checked a single room which has the<br />
potential to be utilised as an isolation room. Similar issues were<br />
identified in all wards; dusty horizontal surfaces such as bedframes,<br />
skirting, entertainment systems, wall trunking <strong>and</strong> external windows. In<br />
Ward 19 the toilet brush was stained, in Ward 4 the drain of the h<strong>and</strong><br />
washing sink was dirty.<br />
6.2 Clutter<br />
A cluttered environment not only impedes the cleaning process but<br />
would not be conducive to providing a safe area to undertake clinical<br />
procedures. The lack of available storage facilities in all wards has<br />
contributed to negative scoring in the general environment st<strong>and</strong>ard.<br />
It was evident that where available there was good use of high density<br />
storage. This provides effective utilisation of space <strong>and</strong> good stock<br />
management, staff were aware that a clutter free environment is an<br />
essential element of effective cleaning <strong>and</strong> good hygiene practices.<br />
Inspectors noted that the staff <strong>and</strong> patients had moved to Ward 4 from<br />
Ward 25 on the 7 <strong>November</strong> <strong>2011</strong>. There was evidence that staff had<br />
yet to utilise space effectively, <strong>and</strong> as this was a smaller ward, reduce<br />
the amount of stock <strong>and</strong> supplies. Due to lack of storage space, two<br />
commodes were stored in the bathroom; a hoist was stored in the toilet,<br />
in the small dirty utility room two commodes <strong>and</strong> two linen skips added<br />
to the cluttered environment <strong>and</strong> excess items were stored on the floor<br />
of the equipment store. The entrance to the ward was cluttered with<br />
cages containing boxes from the recent move <strong>and</strong> trolleys for clinical<br />
procedures which staff had moved due to the treatment room being<br />
located away from the ward area.<br />
There was evidence in Ward 5 that staff were attempting to maintain a<br />
clutter free environment. However the lack of storage space within the<br />
ward contributed to a hoist, floor burnisher, linen trolley <strong>and</strong> a rolled up<br />
mattress waiting collection being stored in the corridor. Inspectors<br />
observed two bedpans stored on the floor under the sink in the toilet,<br />
the clean utility room was very small <strong>and</strong> cluttered with supplies;<br />
equipment <strong>and</strong> an ice machine.<br />
Similar issues were identified in Ward 19. The ward area was cluttered<br />
with equipment, chairs, hoists <strong>and</strong> trolleys (Picture 2), both the<br />
treatment room <strong>and</strong> equipment store were cluttered with equipment<br />
<strong>and</strong>/or stores <strong>and</strong> the lack of a bed pan rack in the dirty utility room<br />
resulted in bedpans left to dry on the drainer of the sink unit.<br />
14
Picture 2: Cluttered ward corridor<br />
In Ward 23, staff maintained a tidy patient bed area <strong>and</strong> ward area<br />
however the large shower room was used to store chairs used by the<br />
Occupational Therapy Department, patient property was stored in the<br />
dirty utility room <strong>and</strong> the telephone exchange was located in the clean<br />
utility room contributing to the cluttered environment.<br />
Patients should be discouraged from leaving their soaps <strong>and</strong> shower<br />
gels in the shower <strong>and</strong> on shelves. This will prevent the use of<br />
communal products <strong>and</strong> help to reduce the risk of contamination <strong>and</strong><br />
possible spread of infection. Evidence of communal shower products<br />
<strong>and</strong> excess toilet rolls were observed in all wards with the exception of<br />
Ward 4.<br />
Particular care is required to ensure that lime scale is removed from<br />
taps <strong>and</strong> fittings as recent evidence has shown that lime scale may<br />
harbour biofilms <strong>and</strong> the build up of limescale can interfere with good<br />
cleaning <strong>and</strong> disinfection, by masking <strong>and</strong> protecting pathogens. Lime<br />
scale was observed on taps in Ward 23 <strong>and</strong> Ward 19 <strong>and</strong> on the hot<br />
water geyser in Ward 5 kitchen.<br />
Additional Issues<br />
Ward 4<br />
The ward was originally designed to care for patients with infections; it<br />
has a staff changing area, including changing cubicles, showers <strong>and</strong><br />
toilets. As previously mentioned the ward transfer had only occurred a<br />
week prior to the inspection. Staff reported this area was now being<br />
used as a h<strong>and</strong>over meeting room <strong>and</strong> a storage area, sanitary<br />
facilities were not routinely used. This area should be reviewed by the<br />
trust to ensure effective use of space <strong>and</strong> water supplies in sanitary<br />
facilities checked to prevent possible legionella.<br />
<strong>15</strong>
Ward 19<br />
Ward 23<br />
Red cloth “medication medic” tabards, worn when administering<br />
medication, were hanging behind the door of the shower room<br />
<strong>and</strong> a large box of washing detergent was on a shelf.<br />
The ward is at present trialing a new bedpan washer. The ward<br />
manager advised that the detergent for this machine was a non<br />
stock item, therefore large bulk orders are placed, adding to the<br />
clutter at ward level.<br />
6.3 Maintenance <strong>and</strong> Repair<br />
Ward 4 was well presented <strong>and</strong> in good repair. The only issue<br />
identified was minor damage to walls.<br />
Inspectors identified themes common to the other wards such as<br />
damage to walls, kitchen cupboards, external window frames <strong>and</strong><br />
loose/missing ceiling tiles. Damage was also observed to the doors,<br />
doorframes <strong>and</strong> formica shelving; in places the damage to doors,<br />
wooden frames/surfaces <strong>and</strong> shelves had resulted in exposed <strong>and</strong><br />
unsealed wood which cannot be effectively cleaned.<br />
In Ward 5 ceiling light covers were missing in the kitchen <strong>and</strong><br />
equipment store, cigarette burns were noted on the floor of the toilet.<br />
Skirting damage was observed in the assisted shower room of Ward 23<br />
<strong>and</strong> in Ward 19 the vinyl flooring was split in places in the patient bed<br />
areas, toilet <strong>and</strong> in the kitchen. Inspectors in Ward 19 spot checked<br />
Room 3 as a room which can be used for isolation purposes. There<br />
was a hole in the wall under the wash h<strong>and</strong> sink unit in the bedroom.<br />
In the toilet there was exposed pipe work <strong>and</strong> holes in the wall <strong>and</strong><br />
floor.<br />
Poorly fitted flooring <strong>and</strong> unsealed surfaces can act as a reservoir for<br />
bacteria <strong>and</strong> also compromise the cleaning process due to the inability<br />
to remove all bacteria by normal damp dusting <strong>and</strong> cleaning processes.<br />
It is imperative that all floors <strong>and</strong> doors are fitted <strong>and</strong> sealed correctly<br />
to prevent the possible build-up of bacteria <strong>and</strong> subsequent<br />
transmission of bacteria, especially during an outbreak situation.<br />
6.4 Fixtures <strong>and</strong> fittings<br />
The fixtures, fittings <strong>and</strong> equipment were generally fit for purpose.<br />
There were some issues common to all wards for example the wipe<br />
boards behind the patients beds in Ward 23 were damaged, in the<br />
other wards some notice boards were finished in felt which cannot be<br />
effectively cleaned.<br />
16
In Ward 4 inspectors noted, that some toilet roll holders were not<br />
enclosed. Some chairs in Ward 5 were damaged, the wooden arms<br />
were worn <strong>and</strong> the fabric was torn exposing the foam underneath.<br />
Hooks were missing from privacy curtains <strong>and</strong> in a sideward the<br />
curtains were shorter than the linings. In the clean utility room, the taps<br />
were old, worn <strong>and</strong> did not have running water.<br />
In the kitchen in Ward 19, there were two equipment sinks, a soap<br />
dispenser, paper towel dispenser <strong>and</strong> no dedicated h<strong>and</strong> washing sink.<br />
Staff reported they did not wash their h<strong>and</strong>s in the kitchen; they used<br />
the sinks in the ward corridor before entering the kitchen. Inspectors<br />
noted in Room 3, spot checked as a room which can be used for<br />
isolation purposes, the screws on the mirror were rusty.<br />
Similar issues were noted in Ward 23. Metal casings on bedside<br />
lockers were worn <strong>and</strong> rusting, disposable bedside curtains were<br />
stained, a fabric chair in the relatives‟ room was torn <strong>and</strong> there was a<br />
fabric chair in the treatment room. Split fabric can act as a reservoir for<br />
bacteria <strong>and</strong> is not easily cleaned therefore any equipment with torn<br />
covering should be repaired/replaced. Non-easily cleaned fabric<br />
compromises the cleaning process due to the inability to remove all<br />
bacteria by normal damp dusting <strong>and</strong> cleaning processes. It is<br />
imperative that all chairs used within a clinical area are covered in<br />
easily cleanable fabric to prevent the possible build-up of bacteria <strong>and</strong><br />
subsequent transmission of bacteria, especially during an outbreak<br />
situation.<br />
In the dirty utility room of Ward 23, a slop hopper was not available to<br />
dispose of bodily waste. Current practice in place for patients requiring<br />
isolation precautions was to use disposable urinals <strong>and</strong> bedpans,<br />
dispose of the contents into the bedpan washer <strong>and</strong> place the<br />
disposable urinals <strong>and</strong> bedpans into clinical waste bins. Inspectors<br />
however observed a student nurse empty the contents of a disposable<br />
urinal into the toilet bowl of the shower room. As none of the patients<br />
in the ward had been identified as having an infection this practice<br />
should not have been carried out. Clear guidance on the disposal of<br />
bodily fluids for non-infectious patients should be in place <strong>and</strong> all staff<br />
advised of the correct procedure to follow at ward level.<br />
Additional Issues<br />
Ward 19<br />
The inspectors noted storage of Osmolite above a toaster <strong>and</strong><br />
were concerned the heat from the toaster may compromise the<br />
safe storage of the food supplement. Some food supplements<br />
were out of date.<br />
17
6.5 Information<br />
Due to the recent move posters had not been displayed in Ward 4 <strong>and</strong><br />
this has impacted on the scoring. With the exception of Ward 4 h<strong>and</strong><br />
hygiene posters were widely displayed throughout the hospital <strong>and</strong> the<br />
areas inspected. Clear instructions were in place, where necessary, to<br />
advise staff <strong>and</strong> visitors of isolation precautions in place. In Wards 5<br />
<strong>and</strong> 19 information leaflets on MRSA, Clostridium difficile <strong>and</strong> general<br />
guidance on infection prevention <strong>and</strong> control were available in the ward<br />
but not displayed in public leaflet racks.<br />
A range of posters were in place for staff to reference, such as waste<br />
<strong>and</strong> sharps management, colour coding <strong>and</strong> segregation of linen.<br />
Inspectors noted that in some instance posters on linen segregation,<br />
waste <strong>and</strong> sharps injury were not available. In Ward 23, there was no<br />
signage on the door to indicate oxygen cylinders were stored in the<br />
clean utility room.<br />
Nursing cleaning schedules while available did not detail all equipment<br />
<strong>and</strong> staff roles <strong>and</strong> responsibilities. Staff in Ward 23 were trialling the<br />
newly developed infection prevention <strong>and</strong> control cleaning schedules.<br />
Trust representatives at the feedback advised that the new cleaning<br />
schedules are under review. In Ward 4 domestic cleaning schedules<br />
<strong>and</strong> the NPSA colour coding poster for domestic staff <strong>and</strong> nursing staff<br />
were not displayed, the NPSA poster was not displayed in the other<br />
wards for nursing staff to reference.<br />
With the exception of Ward 5 not all posters were laminated, some<br />
were attached to surfaces with tape.<br />
There was good daily recording of the drugs fridge temperature in all<br />
wards however in Ward 23 there was no space on the sheet for the<br />
action taken for variations outside temperature ranges to be recorded<br />
<strong>and</strong> the fridge was unlocked. In Ward 4 staff were recording minimum<br />
<strong>and</strong> maximum temperatures <strong>and</strong> not the actual temperature.<br />
Recommendations<br />
1. The trust should ensure that the systems <strong>and</strong> processes in<br />
place for environmental cleaning, provide the necessary<br />
assurance that cleaning is carried out effectively, <strong>and</strong> that all<br />
staff are aware of their responsibilities.<br />
2. The healthcare environment should be repaired <strong>and</strong><br />
maintained, <strong>and</strong> damaged fixtures <strong>and</strong> fittings replaced to<br />
maintain public confidence <strong>and</strong> to help reduce the risk of the<br />
spread of infection.<br />
3. Work should continue on improving storage <strong>and</strong> maintaining<br />
clutter free environments.<br />
18
4. The trust should ensure all relevant information is available<br />
for patients, visitors <strong>and</strong> staff to reference.<br />
5. Detailed nursing cleaning schedules should be reviewed <strong>and</strong><br />
agreed.<br />
6. The trust should ensure that all staff are aware of the<br />
importance of accurately monitoring fridge temperatures.<br />
19
7.0 Patient Linen<br />
STANDARD 3.0<br />
PATIENT LINEN<br />
Storage of clean linen; h<strong>and</strong>ling <strong>and</strong> storage of used linen; ward/<br />
department laundry facilities.<br />
Patient linen Ward 4 Ward 5 Ward 19 Ward 23<br />
Storage of clean linen 89 90 89 92<br />
Storage of used linen 91 81 100 100<br />
Laundry facilities N/A N/A N/A N/A<br />
Average Score 90 86 95 96<br />
7.1 Management of Linen<br />
All wards achieved overall compliance in this section of the toolkit with<br />
Wards 19 <strong>and</strong> 23 achieving full compliance in regard to the storage of<br />
used linen. The wards inspected had effective arrangements in place<br />
for the storage of clean linen however in Ward 4 clean linen was also<br />
stored on a trolley in the assisted shower room <strong>and</strong> in Ward 5 linen<br />
was stored on a trolley in the corridor, the linen was not protected from<br />
potential airborne contamination.<br />
In all wards, except Ward 19, the removal of inappropriate items from<br />
the floor of clean linen stores was required to ensure effective cleaning.<br />
Chairs were stored in the linen store of Ward 4, in Ward 5 mattress<br />
bumpers were stored under the bottom shelf <strong>and</strong> in Ward 23 patient<br />
property was stored in a suitcase under the shelving. Items stored on<br />
the window sill in Ward 4 also impeded the cleaning of the room.<br />
Minor wall damage was noted in the linen store of Ward 23, in Ward<br />
19, the laminate finish to the shelving was damaged; dust <strong>and</strong> debris<br />
were observed on the floor. The linen disposal area in Ward 4 was<br />
also used to store excess items such as chairs, portable bed screen<br />
<strong>and</strong> a trolley.<br />
Practices observed in Ward 5 required improvements. Inspectors<br />
observed a registered nurse carry linen, close to the body, from the<br />
linen trolley to the bedside <strong>and</strong> not wearing PPE, another registered<br />
nurse carried used linen to the skip in the dirty utility room instead of<br />
bringing the skip to the bedside.<br />
Recommendations<br />
7. The trust should ensure the correct storage of clean linen in<br />
a designated area which is clean <strong>and</strong> fit for purpose.<br />
20
8. Systems should be in place to ensure that staff adhere to<br />
regional guidance <strong>and</strong> trust policies <strong>and</strong> that staff knowledge<br />
is kept up to date in respect of h<strong>and</strong>ling <strong>and</strong> storage of linen.<br />
21
8.0 Waste <strong>and</strong> Sharps<br />
STANDARD 4.0<br />
WASTE AND SHARPS<br />
Waste: Effectiveness of arrangements for h<strong>and</strong>ling, segregation,<br />
storage <strong>and</strong> disposal of waste on ward/ department<br />
Sharps: Availability, use <strong>and</strong> storage of sharps containers on<br />
ward/department<br />
8.1 Waste<br />
Waste <strong>and</strong> sharps Ward 4 Ward 5 Ward 19 Ward 23<br />
H<strong>and</strong>ling, segregation,<br />
storage, waste<br />
85 98 98 92<br />
Availability, use, storage<br />
of sharps<br />
72 95 80 71<br />
The inspection evidenced that there are arrangements in place for the<br />
h<strong>and</strong>ling, segregation, storage <strong>and</strong> disposal of waste in the areas<br />
visited, however, in some instances these arrangements did not comply<br />
with local <strong>and</strong> regional guidance. All wards achieved compliance in this<br />
st<strong>and</strong>ard; however the replacement of worn waste bin labels in Ward 5<br />
<strong>and</strong> removing rust from the underside of waste bins in Ward 19 would<br />
have resulted in full compliance for these wards.<br />
Issues affecting compliance in Ward 4 were rusted <strong>and</strong> at times stained<br />
waste bins, inappropriate disposal of waste into a black lidded burn bin,<br />
waste bags tied to a monitor trolley <strong>and</strong> confidential waste left in the<br />
corridor. The waste disposal area was open throughout the inspection<br />
<strong>and</strong> the euro bins were unlocked; an issue also identified in Ward 23.<br />
In Ward 23, other issues identified were in relation to staff practice.<br />
Inappropriate waste was noted in household waste bins, there was<br />
excessive suction waste in a suction canister <strong>and</strong> staff were observed<br />
opening waste bins with their h<strong>and</strong>s rather than the foot pedal.<br />
8.2 Sharps<br />
Staff in Ward 5 are to be commended for the high compliance score<br />
achieved <strong>and</strong> were the only ward to achieve compliance in this<br />
st<strong>and</strong>ard. The issues identified for this ward related to the temporary<br />
closure of the sharps box on the resuscitation trolley being sealed with<br />
a paper label, an issue also identified in Ward 19, <strong>and</strong> staff using the<br />
aseptic non touch technique (ANTT) trays as a sharps tray. The ward<br />
sister confirmed however that compatible trays had been ordered.<br />
22
Wards 4 <strong>and</strong> 23 achieved minimal compliance scores. Although sharps<br />
boxes in use in all wards conformed to BS7320 (1990)/UN9291<br />
st<strong>and</strong>ard <strong>and</strong> were assembled correctly, in Ward 23 <strong>and</strong> Ward 4,<br />
sharps boxes were not all labelled with the date, locality <strong>and</strong> staff<br />
signature.<br />
The correct labelling ensures that if there is a spillage of sharps waste<br />
from the sharps box or an injury to a staff member as a result of<br />
incorrect assembly or disposal, the area the sharps box originated from<br />
can be immediately identified. Identifying the origin of the sharps box<br />
<strong>and</strong> its contents is imperative to assist in the immediate risk<br />
assessment process carried out following a sharps injury <strong>and</strong> also to<br />
ensure that staff who incorrectly assembled/disposed of the sharps box<br />
can receive education on the correct procedures to follow.<br />
In Ward 4 the sharps boxes at the entrance to the ward <strong>and</strong> on the<br />
resuscitation trolley were not secured or out of the reach of vulnerable<br />
people, in Ward 23 the sharps box on the resuscitation <strong>and</strong> the<br />
phlebotomist trolley were not secured with brackets.<br />
With the exception of Ward 5, none of the wards ensured that the<br />
temporary closure mechanisms, to prevent spillage <strong>and</strong> impede<br />
access, were all in place when the sharps boxes were not in use.<br />
Sharps trays also required more attention to detail during the cleaning<br />
process.<br />
Inspectors in Ward 19 observed dusty sharps boxes <strong>and</strong> venepuncture<br />
tubing protruding from a sharps box.<br />
Recommendations<br />
9. Waste bins <strong>and</strong> equipment used in the management of waste<br />
should be available, clean <strong>and</strong> replaced as appropriate.<br />
10. Systems <strong>and</strong> processes should be in place to assure that<br />
staff knowledge <strong>and</strong> practice is kept up to date regarding the<br />
safe <strong>and</strong> the correct h<strong>and</strong>ling <strong>and</strong> disposal of waste <strong>and</strong><br />
sharps.<br />
11. The trust should monitor the implementation of its policies<br />
<strong>and</strong> procedures in respect of the management of waste <strong>and</strong><br />
sharps to ensure that safe <strong>and</strong> appropriate practice is in<br />
place.<br />
23
9.0 Patient Equipment<br />
STANDARD 5.0<br />
PATIENT EQUIPMENT<br />
Cleanliness <strong>and</strong> state of repair of general patient equipment.<br />
Patient equipment Ward 4 Ward 5 Ward 19 Ward 23<br />
Patient equipment 82 86 75 75<br />
While the cleanliness <strong>and</strong> state of repair of patient equipment in Ward<br />
5 was generally good, an improvement in practice is required in the<br />
other wards, especially in Ward 19 <strong>and</strong> Ward 23 where a minimally<br />
compliant score was achieved.<br />
With the exception of Ward 4, inspectors observed equipment such as<br />
hoist frames, IV st<strong>and</strong>s, catheter st<strong>and</strong>s <strong>and</strong> blood pressure monitoring<br />
equipment were damaged.<br />
Some stored equipment in the wards was in need of more detailed<br />
cleaning. In Ward 4, items such as the notes trolley, the resuscitation<br />
trolley <strong>and</strong> the portable suction machine were dusty; the inside of the<br />
blood glucose monitoring machine was splashed <strong>and</strong> stained.<br />
The ECG machine in Ward 19 was shared between wards. Inspectors<br />
noted it was dusty <strong>and</strong> the leads <strong>and</strong> clips were dirty (Picture 3). IV<br />
st<strong>and</strong>s, the inside of the blood glucose monitoring machine <strong>and</strong> the<br />
underside of the drugs trolley frame <strong>and</strong> castors were stained, the<br />
resuscitation trolley <strong>and</strong> a portable monitoring st<strong>and</strong> <strong>and</strong> screen were<br />
dusty. Adhesive tape was noted on the notes trolleys, the covers of<br />
patient files <strong>and</strong> the portable bed screen. Adhesive tape when<br />
removed leaves a sticky residue which is difficult to clean.<br />
Picture 3: Dirty ECG clip<br />
As Ward 23 were trialing the use of trigger tape <strong>and</strong> new cleaning<br />
schedules for the infection prevention <strong>and</strong> control team, it was<br />
disappointing to note that stored equipment such as IV st<strong>and</strong>s, feed<br />
24
pumps, blood pressure cuffs <strong>and</strong> fans were stained or dirty. Dressing<br />
trolleys, the shelving ridges on the phlebotomist trolley <strong>and</strong> the<br />
framework of the wheel chair stored in the large shower room were<br />
dusty.<br />
With the exception of Ward 19 patient wash bowls were not stored<br />
inverted to assist in the drying process. In Wards 4, 5, <strong>and</strong> 19 trigger<br />
tape was not in place to identify if items of equipment were clean <strong>and</strong><br />
ready to use, however, good practice was noted in Ward 5 where staff<br />
placed a laminated label on commodes to identify they had been<br />
cleaned. In Ward 4 commodes spot checked were soiled underneath<br />
<strong>and</strong> around the rim.<br />
Some issues were identified in relation to staff knowledge. Staff<br />
questioned in Ward 23 <strong>and</strong> Ward 5 were not all sure of the symbol for<br />
single use equipment, in Ward 4 the single use jugs in the dirty utility<br />
area were being reused <strong>and</strong> were not being decontaminated correctly<br />
between use.<br />
In Ward 4 the ambu bag <strong>and</strong> laryngoscope blade on the resuscitation<br />
trolley were out of their packaging, in Ward 23 the laryngoscope blades<br />
were out of packaging <strong>and</strong> some suction catheters, removed from their<br />
original packaging, were attached to suction canisters. The<br />
Association of Anaesthetists of Great Britain <strong>and</strong> Irel<strong>and</strong> guidelines<br />
„Infection Control in Anaesthesia‟ states that single use resuscitation<br />
equipment should be kept in a sealed package or should be re -<br />
sterilised between patients according to manufacturer's instructions. It<br />
also states that packaging should not be removed until the point of use<br />
for infection control, identification <strong>and</strong> traceability in the case of a<br />
manufacturer's recall <strong>and</strong> safety (Picture 4).<br />
Picture 4: Laryngoscope h<strong>and</strong>le <strong>and</strong><br />
blade stored in packaging<br />
In Ward 5 staff questioned gave different answers for the changing or<br />
cleaning of nebuliser chambers <strong>and</strong> a phlebotomist advised that reusable<br />
tourniquets were taken home to be steeped in bleach. It is<br />
advised that guidance is sought from infection prevention <strong>and</strong> control<br />
25
concerning the correct decontamination procedure for this item of<br />
equipment<br />
Recommendations<br />
12. The trust <strong>and</strong> individual staff have a collective responsibility<br />
to ensure that patient equipment is clean <strong>and</strong> in good repair.<br />
13. Systems <strong>and</strong> processes should be in place to assure that<br />
staff knowledge <strong>and</strong> practice is kept up to date regarding the<br />
decontamination of patient equipment.<br />
26
10.0 Hygiene Factors<br />
STANDARD 6.0<br />
HYGIENE FACTORS<br />
H<strong>and</strong> wash facilities; alcohol h<strong>and</strong> rub; availability of PPE;<br />
availability of cleaning equipment <strong>and</strong> materials.<br />
Hygiene factors Ward 4 Ward 5 Ward 19 Ward 23<br />
Availability <strong>and</strong><br />
cleanliness of wash<br />
h<strong>and</strong> basin <strong>and</strong><br />
92 99 100 100<br />
consumables<br />
Availability of alcohol<br />
rub<br />
100 100 90 97<br />
Availability of PPE 100 100 90 86<br />
Materials <strong>and</strong><br />
equipment for cleaning<br />
64 76 80 76<br />
Average Score 89 94 90 90<br />
Staff are to be commended for achieving overall compliance in this<br />
st<strong>and</strong>ard, h<strong>and</strong> washing sinks in all wards were generally clean <strong>and</strong> in<br />
good repair.<br />
In Ward 5 a h<strong>and</strong> washing sink in a toilet was damaged, <strong>and</strong> in Ward 4<br />
inspectors observed a few instances were cleaning could be improved.<br />
The h<strong>and</strong> washing sink, the underside of the paper towel <strong>and</strong> soap<br />
dispenser in the dirty utility required cleaning; the soap dispenser also<br />
needed refilled. Inspectors noted that at various h<strong>and</strong> washing sinks in<br />
Ward 4, staff were using baby bath solution for h<strong>and</strong> washing. Staff<br />
advised this was due to the incompatibility between the soap dispenser<br />
<strong>and</strong> the soap refill containers as a result of the move to a new ward.<br />
An order for the correct liquid soap containers had been placed.<br />
Wards 4 <strong>and</strong> 5 achieved full compliance in the availability of alcohol rub<br />
<strong>and</strong> availability of PPE sections. In Ward 19, the alcohol dispenser at<br />
the entrance to the ward was damaged, the metal clips holding the<br />
portable alcohol dispensers on the beds had a sticky residue which<br />
prevents effective cleaning <strong>and</strong> empty boxes of single use gloves had<br />
not been replaced.<br />
A similar issue was identified in Ward 23 where there was only one<br />
size of disposable non-sterile gloves available for use in the dirty utility<br />
room. Eye goggles were not available at ward level for general use<br />
<strong>and</strong> the underside of the alcohol gel dispenser in the dirty utility room<br />
required cleaning.<br />
It is disappointing to note that none of the wards achieved a compliant<br />
score for the section in the st<strong>and</strong>ard relating to materials <strong>and</strong><br />
27
equipment for cleaning; especially Ward 4 where minimal compliance<br />
was observed. The scores for all wards indicate an improvement is<br />
required in staff practices.<br />
With the exception of Ward 19, cleaning solutions were not stored in<br />
accordance with the control of substances hazardous to health<br />
(COSHH) regulations as cupboards were unlocked <strong>and</strong> doors to rooms<br />
left open <strong>and</strong> unlocked. In Ward 5 <strong>and</strong> Ward 23 decanted trigger spray<br />
bottles were also noted on the domestic trolley.<br />
There was no bed pan washer available in Ward 19 <strong>and</strong> staff were<br />
unable to outline the protocol for the decontamination of bedpans.<br />
Some staff questioned used Actichlor Plus to manually decontaminate<br />
bedpans; others stated they would use Haz tabs.<br />
Similarly in Ward 5, a bedpan washer was not available for re-usable<br />
bedpan covers. Staff in Ward 5 reported they filled them with water<br />
<strong>and</strong> added half a Haz tab <strong>and</strong> let them steep. It is advised that<br />
guidance is sought from infection prevention <strong>and</strong> control concerning<br />
the correct decontamination protocol of these items of equipment.<br />
Some equipment used for cleaning was not stored appropriately, was<br />
damaged <strong>and</strong> at times required cleaning, for example the domestic<br />
trolley in each ward was dirty; the trolley in Ward 5 was also damaged.<br />
The floor polisher in Ward 5 was stored in the ward corridor, in Ward<br />
19 it was dirty <strong>and</strong> in Ward 4 it was old <strong>and</strong> worn. Also in Ward 4 the<br />
vacuum <strong>and</strong> the small scrubber drier were dusty <strong>and</strong> in Ward 23 the<br />
vacuum required cleaning.<br />
In Ward 23, mop heads were stored damp on shelving in the domestic<br />
store. Throughout the inspection, a dirty mop head, beside a black<br />
plastic bag containing dirty mop heads, was left on the floor of the<br />
corridor in Ward 5. In Ward 4 there was a bag containing dirty mop<br />
heads in the domestic store. The bag was foul smelling <strong>and</strong> had not<br />
been sent to the laundry prior to the end of the domestic shift.<br />
With the exception of Ward 5 mop buckets required more detailed<br />
cleaning. In Ward 23 <strong>and</strong> Ward 4 buckets were not stored inverted to<br />
assist in the drying process, also in Ward 4 a mop head was not stored<br />
correctly. Inspectors noted Ward 4 was the only ward where buckets<br />
had not been left containing water <strong>and</strong> at times a used mop. Dust pans<br />
in Wards, 4, 5, <strong>and</strong> 23 were not clean <strong>and</strong> colour coded in line with<br />
NPSA guidance.<br />
When cleaning schedules have been completed, all equipment should<br />
be cleaned effectively <strong>and</strong> stored appropriately. It is also essential that<br />
cleaning materials are stored correctly. In Ward 23 inspectors<br />
observed tubs of wipes throughout the ward had been left with their lid<br />
open. This practice has the potential to dry out the wipes, making them<br />
ineffective for use <strong>and</strong> costly for the trust.<br />
28
Recommendations<br />
14. The trust should ensure that h<strong>and</strong> washing sinks <strong>and</strong><br />
consumables are available, clean, <strong>and</strong> in a good state of<br />
repair.<br />
<strong>15</strong>. The trust should ensure that PPE is readily available.<br />
16. The trust should ensure that all cleaning products are stored<br />
in a locked cupboard, in accordance with COSHH<br />
regulations.<br />
17. Equipment used for the general cleaning of a ward should be<br />
are clean, fit for purpose, <strong>and</strong> stored appropriately <strong>and</strong> are fit<br />
for purpose.<br />
29
11.0 Hygiene Practices<br />
STANDARD 7.0<br />
HYGIENE PRACTICES<br />
H<strong>and</strong> hygiene procedures; h<strong>and</strong>ling <strong>and</strong> disposal of sharps; use<br />
of PPE; use of isolation facilities <strong>and</strong> implementation of infection<br />
control procedures; cleaning of ward/department; staff uniform<br />
<strong>and</strong> work wear.<br />
Hygiene practices Ward 4 Ward 5 Ward 19 Ward 23<br />
Effective h<strong>and</strong> hygiene<br />
procedures<br />
93 94 89 79<br />
Safe h<strong>and</strong>ling <strong>and</strong><br />
disposal of sharps<br />
85 100 100 100<br />
Effective use of PPE 81 88 88 89<br />
Correct use of isolation 85 88 N/A N/A<br />
Effective cleaning of<br />
ward<br />
53 76 67 77<br />
Staff uniform <strong>and</strong> work<br />
wear<br />
85 93 92 84<br />
Average Score 80 90 87 86<br />
In Wards 4, 5 <strong>and</strong> 19 inspectors observed that effective h<strong>and</strong> hygiene<br />
procedures were generally undertaken by staff <strong>and</strong> a compliance score<br />
was achieved in this section of the audit tool. There was only one<br />
issue identified in Wards 4 <strong>and</strong> 5, in Ward 4 a doctor did not use the<br />
seven step h<strong>and</strong> washing technique when washing their h<strong>and</strong>s. In<br />
Ward 5 all staff were observed using the correct h<strong>and</strong> hygiene<br />
technique, but two staff questioned quoted it as a five step.<br />
In Ward 19, patients were not offered h<strong>and</strong> hygiene facilities before<br />
meals <strong>and</strong> a member of staff was observed moving between patients<br />
<strong>and</strong> failing to perform h<strong>and</strong> hygiene in line with WHO five moments of<br />
care.<br />
Ward 23 scored partial compliance. This can be attributed to staff<br />
practice in not carrying out the seven step h<strong>and</strong> washing technique<br />
when washing h<strong>and</strong>s or using alcohol gel, not washing h<strong>and</strong>s before<br />
donning gloves <strong>and</strong> not washing h<strong>and</strong>s after leaving a patient having<br />
carried out a procedure.<br />
Staff in Wards 5, 19 <strong>and</strong> 23 are commended for achieving full<br />
compliance in the safe h<strong>and</strong>ling <strong>and</strong> disposal of sharps. Full<br />
compliance would also have been achieved in Ward 4 had staff not resheathed<br />
needles before disposal into a sharps box. This is unsafe<br />
practice <strong>and</strong> has the potential to result in a sharps injury.<br />
30
With little effort <strong>and</strong> an improvement in staff practice in Wards 5, 19<br />
<strong>and</strong> 23, full compliance could easily be achieved in the effective use of<br />
PPE. In Wards 4 <strong>and</strong> 5 domestic staff did not wear protective plastic<br />
aprons when carrying out wet work.<br />
Nursing staff in Ward 4 were observed not wearing PPE when<br />
preparing a patient for a blood transfusion <strong>and</strong> emptying a bedpan. In<br />
Ward 23 nursing staff did not wear an apron when erecting a PEG feed<br />
<strong>and</strong> emptying a urinal. Similarly in Ward 19, two members of nursing<br />
staff did not wear disposable protective aprons when cleaning<br />
commodes.<br />
Wards 19 <strong>and</strong> 23 did not have any patients requiring isolation <strong>and</strong> this<br />
section of the audit was not assessed. An improvement in staff<br />
knowledge in Ward 4 would also improve scores as nursing <strong>and</strong><br />
domestic staff gave varying answers on how to clean an isolation room<br />
<strong>and</strong> nursing staff were unaware of the NPSA colour coding guidance.<br />
In Ward 5 a patient with MRSA, a known healthcare associated<br />
infection (HCAI), did not have a care pathway in place <strong>and</strong> the nursing<br />
care plan required more detail on precautions to be taken.<br />
Additional effort is required in all wards in relation to the effective<br />
cleaning of the ward. Wards 4 <strong>and</strong> 19 scored minimal compliance,<br />
Wards 5 <strong>and</strong> 23 partial compliance.<br />
In all wards the availability of different cleaning disinfectants was<br />
confusing for staff. Staff in Wards 4, 19 <strong>and</strong> 23 reported they used Haz<br />
tabs or Actichlor plus, not all staff were aware there were different<br />
dilution rates for the products available.<br />
In Ward 5 nursing staff only stored <strong>and</strong> used Haz tabs disinfectant<br />
tablets, however domestic staff stated they used Actichlor plus tablets<br />
which they obtained, when required, from nursing staff. This suggests<br />
domestic staff were diluting the Haz tabs solution incorrectly, as per<br />
Actichlor plus dilution rates. In addition, Actichlor plus dilution posters<br />
were displayed in the dirty utility room, Haz tabs dilution posters were<br />
not available.<br />
At the feedback trust representatives advised they were aware <strong>and</strong><br />
agreed that a decision needs to be reached on the disinfectant<br />
cleaning solution to be used.<br />
With the exception of Ward 4 there was no evidence to show<br />
equipment was routinely cleaned between use at ward level. A folder<br />
on COSHH was not available for nursing staff in Ward 23, none was<br />
available in Ward 4 for nursing <strong>and</strong> domestic staff. Nursing staff in all<br />
wards were not aware of the NPSA cleaning colour coding guidance.<br />
31
Picture 5: SEHSCT guidelines<br />
on regional uniform<br />
The South Eastern Health <strong>and</strong> Social<br />
Care Trust has a strict dress code policy<br />
for staff <strong>and</strong> has introduced the Northern<br />
Irel<strong>and</strong> regional uniform (Picture 5). It<br />
was therefore disappointing to note that<br />
staff in some wards were not adhering<br />
to trust policy. Inspectors in Ward 4<br />
observed one nurse with long hair not<br />
tied back above the collar <strong>and</strong> a doctor<br />
wearing a stone ring. Similar issues<br />
were identified in Ward 23 where staff<br />
were observed wearing wrist watches,<br />
necklaces, <strong>and</strong> a member of radiology<br />
staff was not compliant with the policy of<br />
bare below the elbows. In Wards 23<br />
<strong>and</strong> 5 staff were observed with false<br />
nails.<br />
In Ward 19 staff reported they did not have changing facilities <strong>and</strong> staff<br />
in Ward 4 advised that they did not change their uniform on arriving<br />
<strong>and</strong> prior to leaving work.<br />
Additional Issue<br />
Ward 4<br />
Inspectors noted a large roll of cling film in each shower room,<br />
sitting on a shelf beside the toilet, staff stated that this was used<br />
by patients with peripherally inserted central catheters (PICC)<br />
lines to protect the lines when showering (Picture 6). Inspectors<br />
spoke with the acting ward manager <strong>and</strong> this was removed<br />
immediately as there was a risk of contamination from aerosol<br />
spray from the toilet flush.<br />
Picture 6 Clingfilm in toilet<br />
32
Ward 5<br />
Ward 19<br />
Ward 23<br />
The inspectors observed an off duty member of staff still wearing<br />
hospital uniform visit a patient on the ward. The staff member<br />
was wearing a navy cardigan, lifted a clinical waste bin lid with<br />
their h<strong>and</strong>s, washed their h<strong>and</strong>s <strong>and</strong> then pulled their sleeves up<br />
to below the elbow. Inspectors note the member of staff was not<br />
on duty in the ward however it is important that all members of<br />
staff when wearing uniform follow trust policies.<br />
A noticeboard in the office indicated there were three patients with<br />
HCAI therefore domestic staff were carrying out enhanced cleans<br />
in these rooms. Inspectors noted there were no precautionary<br />
notices posted on the doors <strong>and</strong> when questioned nursing staff<br />
confirmed there were no patients being nursed with infections. A<br />
review of the process for informing staff of patients in isolation<br />
should be carried out.<br />
There was no MRSA check list in place for the newly diagnosed<br />
MRSA patient<br />
Recommendations<br />
18. All staff have a responsibility to ensure that h<strong>and</strong> hygiene is<br />
carried out in line with WHO guidance <strong>and</strong> that all PPE is<br />
used appropriately.<br />
19. The trust must ensure that all staff groups implement<br />
st<strong>and</strong>ard infection prevention <strong>and</strong> control precautions<br />
consistently to minimise the risk of infection.<br />
20. Systems <strong>and</strong> processes should be in place to assure that<br />
staff knowledge <strong>and</strong> practice is kept up to date regarding<br />
isolation, cleaning <strong>and</strong> decontamination of equipment.<br />
21. Systems <strong>and</strong> processes should be in place to assure that<br />
staff knowledge <strong>and</strong> practice is kept up to date regarding the<br />
use of disinfectants.<br />
22. A decision should be made on the cleaning solution to be<br />
used.<br />
23. The trust should ensure that all members of staff are familiar<br />
with <strong>and</strong> adhere to the regional dress code policy.<br />
33
12.0 Key Personnel <strong>and</strong> Information<br />
Members of the RQIA inspection team<br />
Mrs E Colgan - Senior Officer Infection Prevention/Hygiene Team<br />
Mrs L Gawley - Inspector Infection Prevention/Hygiene Team<br />
Mrs S O'Connor - Inspector Infection Prevention/Hygiene Team<br />
Mrs M Keating - Inspector Infection Prevention/Hygiene Team<br />
Dr N Baldwin - Senior Infection Prevention <strong>and</strong> Control Nurse<br />
NHSCT<br />
Ms M Armstrong - Senior Manager <strong>Quality</strong> <strong>and</strong> Improvement<br />
BHSCT<br />
Ms S Baird - Deputy Ward Manager North West Independent<br />
Clinic<br />
Ms M Johnston - Senior Domestic Services Manager, SHSCT<br />
Trust representatives attending the feedback session<br />
The key findings of the inspection were outlined to the following trust<br />
representatives:<br />
Ms J Mc Mahon - Clinical Coordinator Surgery Directorate<br />
Ms E Campbell - Governance, Surgery<br />
Ms J Clarke - Manager Patient Experience<br />
Mr C Campbell - Governance <strong>and</strong> Patient Involvement Manager<br />
Mr R Kendall - Ward Manager Ward 24<br />
Ms K Hull - Ward Manager Ward 22<br />
Ms Y Millar - Sister Ward 19<br />
Ms T Kane - Sister Ward 23<br />
Ms L Maxwell - Acting Ward Manager Ward 4<br />
Ms M Hendry - Patient Experience Manager<br />
Ms A Griffiths - Infection Prevention <strong>and</strong> Control Nurse<br />
Ms H Carson - Nursing Auxiliary Ward 19<br />
Supporting documentation<br />
A number of documents have been developed to support the inspection<br />
process, these are:<br />
Infection Prevention/Hygiene Inspection Process (methodology,<br />
follow up <strong>and</strong> reporting)<br />
Infection Prevention/Hygiene Team Inspection Protocol (this<br />
document contains details on how inspections are carried out <strong>and</strong><br />
the composition of the teams)<br />
Infection Prevention/Hygiene Team Escalation Policy<br />
RQIA Policy <strong>and</strong> Procedure for Use <strong>and</strong> Storage of Digital Images<br />
This information is currently available on request <strong>and</strong> will be available<br />
in due course on the RQIA website.<br />
34
13.0 Summary of Recommendations<br />
1. The trust should ensure that the systems <strong>and</strong> processes in<br />
place for environmental cleaning, provide the necessary<br />
assurance that cleaning is carried out effectively, <strong>and</strong> that all<br />
staff are aware of their responsibilities.<br />
2. The healthcare environment should be repaired <strong>and</strong><br />
maintained, <strong>and</strong> damaged fixtures <strong>and</strong> fittings replaced to<br />
maintain public confidence <strong>and</strong> to help reduce the risk of the<br />
spread of infection.<br />
3. Work should continue on improving storage <strong>and</strong> maintaining<br />
clutter free environments.<br />
4. The trust should ensure all relevant information is available<br />
for patients, visitors <strong>and</strong> staff to reference.<br />
5. Detailed nursing cleaning schedules should be reviewed <strong>and</strong><br />
agreed.<br />
6. The trust should ensure that all staff are aware of the<br />
importance of accurately monitoring fridge temperatures.<br />
7. The trust should ensure the correct storage of clean linen in<br />
a designated area which is clean <strong>and</strong> fit for purpose.<br />
8. Systems should be in place to ensure that staff adhere to<br />
regional guidance <strong>and</strong> trust policies <strong>and</strong> that staff knowledge<br />
is kept up to date in respect of h<strong>and</strong>ling <strong>and</strong> storage of linen.<br />
9. Waste bins <strong>and</strong> equipment used in the management of waste<br />
should be available, clean <strong>and</strong> replaced as appropriate.<br />
10. Systems <strong>and</strong> processes should be in place to assure that<br />
staff knowledge <strong>and</strong> practice is kept up to date regarding the<br />
safe <strong>and</strong> the correct h<strong>and</strong>ling <strong>and</strong> disposal of waste <strong>and</strong><br />
sharps.<br />
11. The trust should monitor the implementation of its policies<br />
<strong>and</strong> procedures in respect of the management of waste <strong>and</strong><br />
sharps to ensure that safe <strong>and</strong> appropriate practice is in<br />
place.<br />
12. The trust <strong>and</strong> individual staff have a collective responsibility<br />
to ensure that patient equipment is clean <strong>and</strong> in good repair.<br />
13. Systems <strong>and</strong> processes should be in place to assure that<br />
staff knowledge <strong>and</strong> practice is kept up to date regarding the<br />
decontamination of patient equipment.<br />
35
14. The trust should ensure that h<strong>and</strong> washing sinks <strong>and</strong><br />
consumables are available, clean, <strong>and</strong> in a good state of<br />
repair.<br />
<strong>15</strong>. The trust should ensure that PPE is readily available.<br />
16. The trust should ensure that all cleaning products are stored<br />
in a locked cupboard, in accordance with COSHH<br />
regulations.<br />
17. Equipment used for the general cleaning of a ward should be<br />
are clean, fit for purpose, <strong>and</strong> stored appropriately <strong>and</strong> are fit<br />
for purpose.<br />
18. All staff have a responsibility to ensure that h<strong>and</strong> hygiene is<br />
carried out in line with WHO guidance <strong>and</strong> that all PPE is<br />
used appropriately.<br />
19. The trust must ensure that all staff groups implement<br />
st<strong>and</strong>ard infection prevention <strong>and</strong> control precautions<br />
consistently to minimise the risk of infection.<br />
20. Systems <strong>and</strong> processes should be in place to assure that<br />
staff knowledge <strong>and</strong> practice is kept up to date regarding<br />
isolation, cleaning <strong>and</strong> decontamination of equipment.<br />
21. Systems <strong>and</strong> processes should be in place to assure that<br />
staff knowledge <strong>and</strong> practice is kept up to date regarding the<br />
use of disinfectants.<br />
22. .A decision should be made on the cleaning solution to be<br />
used.<br />
23. The trust should ensure that all members of staff are familiar<br />
with <strong>and</strong> adhere to the regional dress code policy.<br />
36
Reporting & Re-Audit<br />
Episode of Inspection<br />
Plan Programme<br />
14.0 Unannounced Inspection Flowchart<br />
Environmental Scan:<br />
Stakeholders & External<br />
Information<br />
Plan<br />
Programme<br />
Consider:<br />
Areas of Non-Compliance<br />
Infection Rates<br />
Trust Information<br />
RQIA Hygiene Team<br />
Prioritise Themes & Areas for Core Inspections<br />
Prior to Inspection Year<br />
Balance Programme<br />
January/February<br />
Schedule Inspections<br />
Prior to Inspection<br />
Identify & Prepare Inspection Team<br />
Day of Inspection<br />
Inform Trust<br />
Day of Inspection<br />
Carry out Inspection<br />
A<br />
Is there immediate risk<br />
requiring formal escalation?<br />
NO<br />
YES<br />
Invoke<br />
RQIA<br />
IPHTeam<br />
Escalation<br />
Process<br />
Day of Inspection<br />
Feedback Session with Trust<br />
14 days after<br />
Inspection<br />
28 days after<br />
Inspection<br />
Preliminary Findings<br />
disseminated to Trust<br />
Draft Report<br />
disseminated to Trust<br />
NO<br />
Does assessment of<br />
the findings require<br />
escalation?<br />
YES<br />
Invoke<br />
RQIA<br />
IPHTeam<br />
Escalation<br />
Process<br />
A<br />
14 days later<br />
Signed Action Plan<br />
received from Trust<br />
Within 0-3 months<br />
Is a Follow-Up required?<br />
Based on Risk Assessment/key<br />
indicators or Unsatisfactory <strong>Quality</strong><br />
Improvement Plan (QIP)?<br />
YES<br />
Invoke<br />
Follow-Up<br />
Protocol<br />
Process enables<br />
only 1 Follow-Up<br />
NO<br />
Open Report published to Website<br />
YES<br />
Is Follow-Up<br />
satisfactory?<br />
NO<br />
DHSSPS/HSC<br />
Board/PHA<br />
PHA<br />
37
<strong>15</strong>.0 Escalation Process<br />
RQIA Hygiene Team: Escalation Process<br />
B<br />
RQIA IPH<br />
Team<br />
Escalation<br />
Process<br />
Concern / Allegation / Disclosure<br />
Inform Team Leader / Head of Programme<br />
MINOR/MODERATE<br />
Has the risk been<br />
assessed as Minor,<br />
Moderate or Major?<br />
MAJOR<br />
Inform key contact <strong>and</strong> keep a record<br />
Inform appropriate RQIA Director <strong>and</strong> Chief Executive<br />
Record in final report<br />
Inform Trust / Establishment / Agency<br />
<strong>and</strong> request action plan<br />
Notify Chairperson <strong>and</strong><br />
Board Members<br />
Inform other establishments as appropriate:<br />
E.g.: DHSSPS, RRT, HSC Board, PHA,<br />
HSENI<br />
Seek assurance on implementation of actions<br />
Take necessary action:<br />
E.g.: Follow-Up Inspection<br />
38
16.0 Action Plan<br />
Reference<br />
number<br />
Recommendations<br />
1. The trust should ensure that the systems <strong>and</strong><br />
processes in place for environmental cleaning, provide<br />
the necessary assurance that cleaning is carried out<br />
effectively, <strong>and</strong> that all staff are aware of their<br />
responsibilities.<br />
Designated<br />
department<br />
Patient<br />
Experience<br />
Action required<br />
The Trust has environmental cleaning<br />
schedules in place in accordance with<br />
risk. An extensive audit programme is in<br />
place to monitor in accordance with<br />
assessed risk. A system of escalation is<br />
in situ to highlight areas results from<br />
audits.<br />
Cleaning schedules are reviewed<br />
regularly in response to audit results <strong>and</strong><br />
part of the performance management<br />
process <strong>and</strong> governed through the<br />
environmental cleanliness steering<br />
committee.<br />
Date for<br />
completion/<br />
timescale<br />
Ongoing<br />
2. The healthcare environment should be repaired <strong>and</strong><br />
maintained, <strong>and</strong> damaged fixtures <strong>and</strong> fittings<br />
replaced to maintain public confidence <strong>and</strong> to help<br />
reduce the risk of the spread of infection.<br />
Estates<br />
A programme of audits is currently carried<br />
out to identify estate priority areas for<br />
action – in addition an annual programme<br />
for environmental repair work is in place<br />
Ongoing<br />
3. Work should continue on improving storage <strong>and</strong><br />
maintaining clutter free environments.<br />
Patient<br />
Experience<br />
As per environmental cleanliness strategy<br />
staff are encouraged to ensure a clutter<br />
free environment <strong>and</strong> audit activity<br />
monitors compliance<br />
Ongoing<br />
4. The trust should ensure all relevant information is<br />
available for patients, visitors <strong>and</strong> staff to reference.<br />
SET All<br />
The Trust produces <strong>and</strong> makes available<br />
on an ongoing basis an extensive range<br />
of relevant information for patients,<br />
visitors <strong>and</strong> staff.<br />
Ongoing<br />
39
Reference<br />
number<br />
Recommendations<br />
5. Detailed nursing cleaning schedules should be<br />
reviewed <strong>and</strong> agreed.<br />
Designated<br />
department<br />
Nursing<br />
Action required<br />
The Trust has nursing cleaning schedules<br />
in place in accordance with risk. An<br />
extensive audit programme is in place to<br />
monitor in accordance with assessed risk.<br />
A system of escalation is in situ to<br />
highlight areas results from audits.<br />
Cleaning schedules are reviewed<br />
regularly in response to audit results <strong>and</strong><br />
part of the performance management<br />
process <strong>and</strong> governed through the<br />
environmental cleanliness steering<br />
committee.<br />
Date for<br />
completion/<br />
timescale<br />
Ongoing<br />
6. The trust should ensure that all staff are aware of the<br />
importance of accurately monitoring fridge<br />
temperatures.<br />
Nursing<br />
The Trust Medicine Policy provides clear<br />
guidance on the monitoring requirements<br />
for fridge temperatures – work is currently<br />
underway to st<strong>and</strong>ardise the recording<br />
template across the Trust. The Trust<br />
operates communication arrangements<br />
for informing <strong>and</strong> cascading re: policy<br />
information. The Trust‟s RQIA<br />
Improvement Group will ensure that<br />
leadership take action to ensure that the<br />
policy is communicated to all relevant<br />
staff <strong>and</strong> will check staff knowledge<br />
through inclusion in audit arrangements.<br />
Ongoing<br />
40
Reference<br />
number<br />
Recommendations<br />
7. The trust should ensure the correct storage of clean<br />
linen in a designated area which is clean <strong>and</strong> fit for<br />
purpose.<br />
Designated<br />
department<br />
Nursing<br />
Action required<br />
All linen is delivered to the door of the<br />
ward entrance in a covered trolley or<br />
hamper by laundry staff for nursing staff<br />
to deal with. Current linen management<br />
arrangements place responsibility with<br />
Ward Manager / Nursing for maintenance<br />
of the linen cupboards. Storage <strong>and</strong><br />
cleaning arrangements will be highlighted<br />
accordingly.<br />
Date for<br />
completion/<br />
timescale<br />
Ongoing<br />
8. Systems should be in place to ensure that staff adhere<br />
to regional guidance <strong>and</strong> trust policies <strong>and</strong> that staff<br />
knowledge is kept up to date in respect of h<strong>and</strong>ling<br />
<strong>and</strong> storage of linen.<br />
Nursing<br />
IPC<br />
Current linen management arrangements<br />
place responsibility with Ward Manager /<br />
Nursing for maintenance of the linen<br />
cupboards. Training, storage, h<strong>and</strong>ling<br />
<strong>and</strong> cleaning requirements through the<br />
Trust‟s ward manager <strong>and</strong> IPC<br />
arrangements.<br />
Ongoing<br />
9. Waste bins <strong>and</strong> equipment used in the management<br />
of waste should be available, clean <strong>and</strong> replaced as<br />
appropriate.<br />
IPC<br />
The Trust have a clear policy on<br />
management of waste <strong>and</strong> periodic audits<br />
are scheduled to monitor compliance <strong>and</strong><br />
inform improvement action<br />
Ongoing<br />
10. Systems <strong>and</strong> processes should be in place to assure<br />
that staff knowledge <strong>and</strong> practice is kept up to date<br />
regarding the safe <strong>and</strong> the correct h<strong>and</strong>ling <strong>and</strong><br />
disposal of waste <strong>and</strong> sharps.<br />
IPC<br />
The Trust have a clear policy on<br />
management of waste <strong>and</strong> disposal of<br />
sharps <strong>and</strong> periodic audits are scheduled<br />
to monitor compliance <strong>and</strong> inform<br />
improvement action. Staff knowledge<br />
requirement is addressed through ward<br />
<strong>and</strong> clinical management arrangements<br />
<strong>and</strong> checking takes place through audit<br />
arrangements.<br />
Ongoing<br />
41
Reference<br />
number<br />
Recommendations<br />
11. The trust should monitor the implementation of its<br />
policies <strong>and</strong> procedures in respect of the management<br />
of waste <strong>and</strong> sharps to ensure that safe <strong>and</strong><br />
appropriate practice is in place.<br />
12. The trust <strong>and</strong> individual staff have a collective<br />
responsibility to ensure that patient equipment is clean<br />
<strong>and</strong> in good repair.<br />
Designated<br />
department<br />
IPC<br />
Nursing <strong>and</strong><br />
Patient<br />
Experience<br />
Action required<br />
The Trust have a clear policy on<br />
management of waste <strong>and</strong> disposal of<br />
sharps <strong>and</strong> periodic audits are scheduled<br />
to monitor compliance <strong>and</strong> inform<br />
improvement action<br />
The Trust have a policy on the cleaning<br />
<strong>and</strong> management of equipment which<br />
would include storage <strong>and</strong><br />
repair/replacement. Periodic audits are in<br />
place to identify compliance <strong>and</strong> required<br />
action for improvement. The Trust are<br />
currently progressing a st<strong>and</strong>ardised<br />
approach to nursing work schedule for<br />
cleaning <strong>and</strong> decontamination of care<br />
environment <strong>and</strong> equipment as per Trust<br />
Policy – this will be audited to confirm<br />
compliance<br />
Date for<br />
completion/<br />
timescale<br />
Ongoing<br />
Ongoing<br />
13. Systems <strong>and</strong> processes should be in place to assure<br />
that staff knowledge <strong>and</strong> practice is kept up to date<br />
regarding the decontamination of patient equipment.<br />
Nursing <strong>and</strong><br />
Patient<br />
Experience<br />
The Trust have a policy on the cleaning<br />
<strong>and</strong> management of equipment which<br />
would include storage <strong>and</strong><br />
repair/replacement. Periodic audits are in<br />
place to identify compliance <strong>and</strong> required<br />
action for improvement. The Trust are<br />
currently progressing a st<strong>and</strong>ardised<br />
approach to nursing work schedule for<br />
cleaning <strong>and</strong> decontamination of care<br />
environment <strong>and</strong> equipment as per Trust<br />
Policy – this will be audited to confirm<br />
compliance . Ward <strong>and</strong> clinical<br />
management address staff knowledge<br />
requirements <strong>and</strong> checking takes place<br />
through audit arrangements.<br />
Ongoing<br />
42
Reference<br />
number<br />
Recommendations<br />
14. The trust should ensure that h<strong>and</strong> washing sinks <strong>and</strong><br />
consumables are available, clean, <strong>and</strong> in a good state<br />
of repair.<br />
Designated<br />
department<br />
Estates <strong>and</strong><br />
Patient<br />
Experience<br />
Action required<br />
A programme of environmental audits is<br />
currently carried out to identify priority<br />
areas for repair – in addition a<br />
programme for environmental cleanliness<br />
audits would monitor compliance with<br />
st<strong>and</strong>ards <strong>and</strong> identify required action to<br />
address.<br />
Date for<br />
completion/<br />
timescale<br />
Ongoing<br />
<strong>15</strong>. The trust should ensure that PPE is readily available. IPC, Nursing<br />
<strong>and</strong> Patient<br />
Experience<br />
Trust Policy clearly guides on the use of<br />
PPE <strong>and</strong> this issue is highlighted through<br />
team meetings <strong>and</strong> newsletter updates. .<br />
This forms part of Trust training <strong>and</strong> Trust<br />
policy <strong>and</strong> will be audited as part on<br />
internal programme of audits against<br />
recurring non-compliance areas from<br />
RQIA cleanliness <strong>and</strong> hygiene reviews<br />
over next 6 months<br />
Ongoing<br />
16. The trust should ensure that all cleaning products are<br />
stored in a locked cupboard, in accordance with<br />
COSHH regulations.<br />
Nursing <strong>and</strong><br />
Patient<br />
Experience<br />
The Trust has a policy on the<br />
management of products in line with<br />
COSHH regulation. Ward management<br />
address staff knowledge requirements<br />
through staff meetings. Internal audit<br />
programme is in place to monitor level of<br />
compliance <strong>and</strong> areas<br />
Ongoing<br />
17. Equipment used for the general cleaning of a ward<br />
should be are clean, fit for purpose, <strong>and</strong> stored<br />
appropriately <strong>and</strong> are fit for purpose.<br />
Patient<br />
Experience<br />
The Trust has a policy on the<br />
management, cleaning <strong>and</strong> storage of<br />
cleaning. Internal audit programme is in<br />
place to monitor level of compliance <strong>and</strong><br />
areas<br />
Ongoing<br />
43
Reference<br />
number<br />
Recommendations<br />
18. All staff have a responsibility to ensure that h<strong>and</strong><br />
hygiene is carried out in line with WHO guidance <strong>and</strong><br />
that all PPE is used appropriately.<br />
Designated<br />
department<br />
IPC, Nursing<br />
<strong>and</strong> Patient<br />
Experience<br />
Action required<br />
Trust Policy on h<strong>and</strong> hygiene is aligned to<br />
WHO guidance <strong>and</strong> has been addressed<br />
as a Trust priority through comprehensive<br />
training arrangements <strong>and</strong> ongoing audit<br />
<strong>and</strong> accountability arrangements. Trust<br />
Policy clearly guides on the use of PPE<br />
<strong>and</strong> this issue is highlighted through team<br />
meetings <strong>and</strong> newsletter updates. . This<br />
forms part of Trust training <strong>and</strong> Trust<br />
policy <strong>and</strong> will be audited as part on<br />
internal programme of audits against<br />
recurring non-compliance areas from<br />
RQIA cleanliness <strong>and</strong> hygiene reviews<br />
over next 6 months<br />
Date for<br />
completion/<br />
timescale<br />
Ongoing<br />
19. The trust must ensure that all staff groups implement<br />
st<strong>and</strong>ard infection prevention <strong>and</strong> control precautions<br />
consistently to minimise the risk of infection.<br />
IPC, Nursing<br />
<strong>and</strong> Patient<br />
Experience<br />
The Trust operates a range of infection,<br />
prevention <strong>and</strong> control policies <strong>and</strong><br />
addresses training, awareness,<br />
compliance <strong>and</strong> improvement on an<br />
ongoing basis with comprehensive audit,<br />
measurement <strong>and</strong> reporting<br />
arrangements in place.<br />
Ongoing<br />
20. Systems <strong>and</strong> processes should be in place to assure<br />
that staff knowledge <strong>and</strong> practice is kept up to date<br />
regarding isolation, cleaning <strong>and</strong> decontamination of<br />
equipment.<br />
IPC, Nursing<br />
<strong>and</strong> Patient<br />
Experience<br />
The Trust operates a range of infection,<br />
prevention <strong>and</strong> control policies (covering<br />
isolation, cleaning <strong>and</strong> decontamination<br />
of equipment) <strong>and</strong> addresses training,<br />
awareness, compliance <strong>and</strong> improvement<br />
on an ongoing basis with comprehensive<br />
audit, measurement <strong>and</strong> reporting<br />
arrangements in place.<br />
Ongoing<br />
44
Reference<br />
number<br />
Recommendations<br />
21. Systems <strong>and</strong> processes should be in place to assure<br />
that staff knowledge <strong>and</strong> practice is kept up to date<br />
regarding the use of disinfectants.<br />
Designated<br />
department<br />
IPC<br />
Action required<br />
This area has been repeatedly<br />
highlighted to staff through newsletters<br />
<strong>and</strong> staff meetings. This forms part of<br />
Trust training <strong>and</strong> Trust policy <strong>and</strong> will be<br />
audited as part on internal programme of<br />
audits against recurring non-compliance<br />
areas from RQIA cleanliness <strong>and</strong> hygiene<br />
reviews (including the use of COSHH<br />
data sheets.<br />
Date for<br />
completion/<br />
timescale<br />
Ongoing<br />
22. A decision should be made on the cleaning solution to<br />
be used.<br />
IPC<br />
During <strong>November</strong> <strong>2011</strong>, the Trust held<br />
high-level discussion that concluded in<br />
plans for a contract change with the<br />
product provider to take place during<br />
early 2012 to resolve the issue.<br />
Spring 2012<br />
23. The trust should ensure that all members of staff are<br />
familiar with <strong>and</strong> adhere to the regional dress code<br />
policy.<br />
IPC<br />
Regional Dress code policy is available<br />
for all staff <strong>and</strong> awareness raising has<br />
been carried out at team meetings <strong>and</strong><br />
highlighted through a recent newsletter.<br />
Staff are audited regarding compliance<br />
<strong>and</strong> encouraged to challenge peers who<br />
are n adhering to this st<strong>and</strong>ard.<br />
Ongoing<br />
45