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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

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