Altnagelvin Hospital, Londonderry - 2 November 2011

RQIA
Infection Prevention/Hygiene
Unannounced inspection
Western Health and Social Care Trust
Altnagelvin Hospital
Brain Injury Unit
2 November 2011
[Type text]

Contents
1.0 Inspection Summary 1
2.0 Background Information to the Inspection Process 6
3.0 Inspections 7
4.0 Unannounced Inspections 8
4.1 Onsite Inspection 8
4.2 Feedback and Report of the findings 8
5.0 Audit Tool 9
6.0 Environment 11
6.1 Cleaning 11
6.2 Clutter 12
6.3 Maintenance and Repair 13
6.4 Fixture and Fittings 13
6.5 Information 13
7.0 Patient Linen 15
7.1 Management of Linen 15
8.0 Waste and Sharps 16
8.1 Waste 16
8.2 Sharps 16
9.0 Patient Equipment 18
10.0 Hygiene Factors 20
11.0 Hygiene Practice 22
12.0 Key Personnel and Information 24
13.0 Summary of Recommendations 25
14.0 Unannounced Inspection Flowchart 26
15.0 RQIA Hygiene Team Escalation Policy Flowchart 28
16.0 Action Plan 29

1.0 Inspection Summary
An unannounced inspection was undertaken to the Altnagelvin Hospital, on
the 2 November 2011. The hospital was assessed against the Regional
Healthcare Hygiene and Cleanliness standards and the following area was
inspected:
Spruce House - Brain Injury Unit
Spruce House is a 24 bedded purpose built Neurodisability unit located within
the grounds of Altnagelvin hospital. Opened in 2004, only part of the building
is in use as just 18 beds have been commissioned. Beds are allocated
equally among long stay, respite and slow stream rehabilitation.
The building is well decorated and
maintained; bedrooms are spacious
which allows staff room to provide
care to the patient unhindered
(Picture 1).
Picture 1 Spacious bed area
All rooms have been fitted with ceiling
tracking for handling equipment.
Corridors are wide and contribute to a
light bright environment. The unit has
a Snoezelen room, with specialist
multisensory equipment (Picture 2).
Picture 2 Snoezelen, multisensory room
1

Inspection Outcomes
The results of the inspection showed compliance in all but two of the
standards, for which staff are commended. The inspectors were impressed
with staff commitment to providing a safe and caring environment for patients
who require specialised one to one care. The two partial compliant standards
in relation to safe handling of sharps and cleanliness and repair of patient
equipment could easily become compliant if staff received update training or
awareness sessions.
The inspection resulted in14 recommendations for the Brain Injury Unit of
Altnagelvin Hospital, a full list of recommendations is listed in Section 13.
A detailed list of preliminary findings is forwarded to Western Health and
Social Care Trust /organisation within 14 days of the inspection to enable
early action on identified areas which have achieved non complaint scores.
The draft report which includes the high level recommendations in a Quality
Improvement Plan is forwarded within 28 days of the inspection for agreement
and factual accuracy. The draft report is agreed and a completed action plan
is returned to RQIA within 14 days from the date of issue. The detailed list of
preliminary findings is available from RQIA on request.
The final report and Quality Improvement Plan will be available on the RQIA
website. Reports and action plans will be subject to performance
management by the Health and Social Care Board and the Public Health
Agency.
Notable Practice
The inspection identified the following areas of notable practice:
An new waste streaming project was being rolled out in the unit to
take into account recycling of paper waste
The integrity and effective cleaning of surfaces and walls was
promoted by the minimal use of paper labels and adhesive tape
Inspectors noted a calm and relaxed atmosphere at ward level and
the caring attitude of staff
The RQIA inspection team would like to thank the staff at Altnagelvin Hospital
for their assistance during the inspection.
2

The following tables give an overview of compliance scores noted in areas
inspected by RQIA:
Table 1 summarises the overall compliance levels achieved.
Tables 2-7 summarise the individual tables for sections two to seven of the
audit tool as this assists organisation to target areas that require more specific
attention.
Table 1
Areas inspected
General environment 89
Patient linen 87
Waste 88
Sharps 79
Equipment 84
Hygiene factors 95
Hygiene practices 91
Average Score 88
Table 2
General environment
Reception 98
Corridors, stairs lift
N/A
Public toilets
N/A
Ward/department -
general (communal)
95
Patient bed area 93
Bathroom/washroom 84
Toilet 93
Clinical room/treatment
room
93
Clean utility room 87
Dirty utility room 86
Domestic store 82
Kitchen 98
Equipment store 68
Isolation 91
General information 88
Average Score 89
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
3

Table 3
Patient linen
Storage of clean linen 83
Storage of used linen 87
Laundry facilities 90
Average Score 87
Table 4
Waste and sharps
Handling, segregation,
storage, waste
Availability, use, storage
of sharps
88
79
Table 5
Patient equipment
Patient equipment
84
Table 6
Hygiene factors
Availability and
cleanliness of wash hand 94
basin and consumables
Availability of alcohol rub 100
Availability of PPE 92
Materials and equipment
for cleaning
93
Average Score 95
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
4

Table 7
Hygiene practices
Effective hand hygiene
procedures
100
Safe handling and
disposal of sharps
100
Effective use of PPE 91
Correct use of isolation 87
Effective cleaning of ward 69
Staff uniform and work
wear
96
Average Score 91
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
5

2.0 Background Information to the Inspection Process
RQIA’s infection prevention and hygiene team was established to undertake a
rolling programme of unannounced inspections of acute hospitals. The
Department of Health Social Service and Public Safety (DHSSPS)
commitment to a programme of hygiene inspections was reaffirmed through
the launch in 2010 of the revised and updated version of 'Changing the
Culture' the strategic regional action plan for the prevention and control of
healthcare-associated infections (HCAIs) in Northern Ireland.
The aims of the inspection process are:
to provide public assurance and to promote public trust and confidence
to contribute to the prevention and control of HCAI
to contribute to improvement in hygiene, cleanliness and infection
prevention and control across health and social care in Northern Ireland
In keeping with the aims of the RQIA, the team will adopt an open and
transparent method for inspection, using standardised processes and
documentation.
6

3.0 Inspections
The DHSSPS has devised Regional Healthcare Hygiene and Cleanliness
standards. RQIA has revised its inspection processes to support the
publication of the standards which were compiled by a regional steering group
in consultation with service providers.
RQIA's infection prevention/hygiene team have planned a three year
programme which includes announced and unannounced inspections in acute
and non-acute hospitals in Northern Ireland. This will assess compliance with
the DHSSPS Regional Healthcare Hygiene and Cleanliness standards.
The inspections will be undertaken in accordance with the four core activities
outlined in the RQIA Corporate Strategy, these include:
Improving care: we encourage and promote improvements in the safety
and quality of services through the regulation and review of health and
social care
Informing the population: we publicly report on the safety, quality and
availability of health and social care
Safeguarding rights: we act to protect the rights of all people using
health and social care services
Influencing policy: we influence policy and standards in health and
social care
7

4.0 Unannounced Inspection Process
Trusts receive no advanced notice of the onsite inspection. An email and
telephone call will be made by the Chief Executive of RQIA or nominated
person 30 minutes prior to the team arriving on site. The inspection flow chart
is attached in Section 14.
4.1 Onsite Inspection
The inspection team was made up of two inspectors, from RQIA’s infection
prevention/hygiene team. One inspector led the team and was responsible
for guiding the team and ensuring they were in agreement about the findings
reached. Membership of the inspection team is outlined in Section 12.
The inspection of ward environments is carried out using the Regional
Healthcare Hygiene and Cleanliness audit tool. The inspection process
involves observation, discussion with staff, and review of some ward
documentation.
4.2 Feedback and Report of the Findings
The process concludes with a feedback of key findings to trust
representatives including examples of notable practice identified during the
inspection. The details of trust representatives attending the feedback
session is outlined in Section 12.
The findings, report and follow up action will be in accordance with the
Infection Prevention/ Hygiene Inspection Process (methodology, follow up and
reporting).
The infection prevention/hygiene team escalation process will be followed if
inspectors/reviewers identify any serious concerns during the inspection
(Section 15).
A number of documents have been developed to support and explain the
inspection process. This information is currently available on request and will
be available in due course on the RQIA website.
8

5.0 Audit Tool
The audit tool used for the inspection is based on the Regional Healthcare
Hygiene and Cleanliness standards. The standards incorporate the critical
areas which were identified through a review of existing standards, guidance
and audit tools (Appendix 2 of Regional Healthcare Hygiene and Cleanliness
standards). The audit tool follows the format of the Regional Healthcare
Hygiene and Cleanliness Standards and comprises of the following sections.
1. Organisational Systems and Governance: policies and procedures in
relation to key hygiene and cleanliness issues; communication of policies
and procedures; roles and responsibilities for hygiene and cleanliness
issues; internal monitoring arrangements; arrangements to address issues
identified during internal monitoring; communication of internal monitoring
results to staff
This standard is not audited when carrying out unannounced
inspections however the findings of the organisational system and
governance at annual announced inspection will be, where
applicable, confirmed at ward level.
2. General Environment: cleanliness and state of repair of public areas;
cleanliness and state of repair of ward/department infrastructure;
cleanliness and state of repair of patient bed area; cleanliness and state
of repair of toilets, bathrooms and washrooms; cleanliness and state of
repair of ward/department facilities; availability and cleanliness of isolation
facilities; provision of information for staff, patients and visitors
3. Patient Linen: storage of clean linen; handling and storage of used linen;
ward/department laundry facilities
4. Waste and Sharps: waste handling; availability and storage of sharps
containers
5. Patient Equipment: cleanliness and state of repair of general patient
equipment
6. Hygiene Factors: hand wash facilities; alcohol hand rub; availability of
personal protective equipment (PPE); availability of cleaning equipment
and materials.
7. Hygiene Practices: hand hygiene procedures; handling and disposal of
sharps; use of PPE; use of isolation facilities and implementation of
infection control procedures; cleaning of ward/department; staff uniform
and work wear
9

Level of Compliance
Percentage scores can be allocated a level of compliance using the
compliance categories below. The categories are allocated as follows:
Compliant
85% or above
Partial compliance 76 to 84%
Minimal compliance 75% or below
Each section within the audit tool will receive an individual and an overall
score, to identify areas of partial or minimal compliance to ensure that the
appropriate action is taken.
10

6.0 Environment
STANDARD 2.0
GENERAL ENVIRONMENT
Cleanliness and state of repair of public areas; cleanliness and
state of repair of ward/department infrastructure; cleanliness and
state of repair of patient bed area; cleanliness and state of repair
of toilets, bathrooms and washrooms; cleanliness and state of
repair of ward/department facilities; availability and cleanliness of
isolation facilities; provision of information for staff, patients and
visitors.
General environment
Reception 98
Corridors, stairs lift
N/A
Public toilets
N/A
Ward/department -
general (communal)
95
Patient bed area 93
Bathroom/washroom 84
Toilet 93
Clinical room/treatment
room
93
Clean utility room 87
Dirty utility room 86
Domestic store 82
Kitchen 98
Equipment store 68
Isolation 91
General information 88
Average Score 89
The above table outlines the findings in relation to the general environment of
the facility inspected. Compliance was demonstrated in the majority of areas
within the ward with the regional specifications for cleaning standards. The
findings in respect of the general environment are detailed in the following
sections. This standard achieved an overall compliant score, the only section
within the standard with a minimally compliant score was the equipment store.
6.1 Cleaning
The equipment store was cluttered and had not been cleaned for some time.
There was debris and balls of fluff on the floor, the skirting was stained and
there were cobwebs around the window and the tops of the wall.
In relation to the general environment more detailed cleaning is required when
cleaning the underside of patient bedside tables, toilet brush holders and
some walls, which were stained. There was a build up of dust on the air vent
11

in a bathroom and surfaces in the dirty utility room. It was also noted in the
dirty utility room that the inside of the sluice hopper was stained and the
shower chairs, which were stored in the dirty utility room, had rust damage,
paper labels and adhesive residue on the framework.
A single room where a patient was being nursed under isolation precautions
was inspected. Several cleaning issues were identified. There were splashes
and stains on the wall below the soap and towel dispensers and on the wall
behind the patient’s bed. The patient bedside table was being used as a work
surface and storage area for food supplements; the underside of the bedside
table was stained. There was a build up of debris and dust behind the door
and the waste bins. In the en-suite, the toilet brush holder was dusty, spare
toilet rolls were stored on top of the cistern and the patient’s duvet cover was
draped over the hand washing sink and was trailing on the floor (Picture 3).
6.2 Clutter
Picture 3 Bed clothes stored on hand wash sink
The only section which was minimally compliant
was the equipment store; the room was very
cluttered with IV stands and large patient chairs
making the room inaccessible (Picture 4).
There was also a stale odour present, which
may be coming from a hand washing sink in the
room. The sink was not accessible due to the
clutter, staff confirmed that the water was not
being run regularly. Staff should liaise with the
Estates department regarding the requirements
to running water in line with the trust legionella
policy.
Picture 4 Cluttered equipment store
12

The main patient areas were generally clutter free, however the inspectors did
note that there was little storage space for patients personal belongings. In
one room patients’ clothes and personal items were stored on the floor.
The clean utility room was cluttered, boxes of stock were being stored on work
surfaces. Clutter can be a barrier to effective regular cleaning.
6.3 Maintenance and Repair
This is a new building and has been
maintained in good repair. However
the inspectors did observe the vinyl
flooring behind the washing machine
in the laundry room and under the
sluice sink in the domestic store was
split and lifting and in need of repair
(Picture 5).
Picture 5 Damage to vinyl flooring in domestic store
6.4 Fixtures and fittings
The fixtures and fitting within the unit were in good condition, the only area
which required attention was in relation to sanitary fittings; the caps on hinges
of the toilet seat in room GN030 and the cap on the single tap in the isolation
room were missing.
6.5 Information
Cleaning schedules for both domestic and nursing staff were available,
however the schedules for nursing staff require more detail. When questioned
nursing staff did show they had been piloting a new daily joint nursing and
domestic cleaning sheet for the patient bed area which had to be signed off
daily. The record sheet the inspectors observed in the bedroom had not been
completed by domestic staff and had not been consistently completed by
nursing staff.
Colour coded posters for cleaning equipment were not available for nursing
staff; staff addressed this issue at the time of inspection. The inspectors did
not observe information leaflets on Clostridium difficle.
13

Recommendations
1. The trust should ensure that the systems and processes in place
for environmental cleaning, provide the necessary assurance that
cleaning is carried out effectively, and that all staff are aware of
their responsibilities.
2. The healthcare environment should be repaired and maintained,
and damaged fixtures and fittings replaced to maintain public
confidence and to help reduce the risk of the spread of infection.
3. Staff should review the use of the equipment store and clean utility
room and the level of stock required in the unit with a view to
improving storage and maintaining a clutter free environment.
4. Detailed nursing cleaning schedules should be further developed.
14

7.0 Patient Linen
STANDARD 3.0
PATIENT LINEN
Storage of clean linen; handling and storage of used linen; ward/
department laundry facilities.
7.1 Management of Linen
Linen
Storage of clean linen 83
Storage of used linen 87
Laundry facilities 90
Average Score 87
This standard achieved an overall compliance score, two of the three sections
were compliant. The section on the storage of clean linen was partially
compliant. The ward had a good, well laid out linen store however the
wooden shelving required sealing and paper labels should be removed. The
store had no natural light and the light bulb was not working. In a patient’s
bedroom the inspectors observed clean linen was being stored on the window
sill to encourage and support independence for a patient who makes their
own bed. If linen is to be stored in bedrooms, a suitable cupboard or storage
unit should be supplied.
With regard to the section on handling and storage of used linen, a member of
staff was observed carrying a bag of used linen to the dirty utility room. The
member of staff was not wearing a disposable apron. When handling used
linen staff should ensure they wear personal protective equipment (PPE) and
that the used linen trolley is taken to the bedside for the immediate disposal of
used linen.
A working laundry had been installed in the ward for patient use; staff advised
that this was not used very often. There was debris in the ceiling light fittings,
one of the light bulbs was not working and as stated in the previous standard
the vinyl flooring behind the washing machine was damaged.
Recommendations
5. The trust should ensure the correct storage of clean linen in a
designated area which is fit for purpose
6. Systems should be in place to ensure that staff adhere to regional
guidance and trust policies and that staff knowledge is kept up to
date in respect of handling and storage of linen.
15

8.0 Waste and Sharps
STANDARD 4.0
WASTE AND SHARPS
Waste: Effectiveness of arrangements for handling, segregation,
storage and disposal of waste on ward/ department
Sharps: Availability, use and storage of sharps containers on
ward/ department
Waste and sharps
Handling, segregation,
storage, waste
Availability, use, storage
of sharps
88
79
8.1 Waste
The ward achieved a compliance score in the management of waste. The
inspection evidenced that there were arrangements in place for the handling
and storage of waste in line with local and regional guidance.
Some issues were identified in respect of the correct segregation of waste.
There was no black lidded burn bin for the disposal of pharmaceutical waste
and medicine bottles were disposed off inappropriately into a magpie box.
There was no household waste bin available in the dirty utility room, and the
underside of a lid on the waste bin in a bedroom and at the nurses’ station
was rusty.
8.2 Sharps
A partially compliant score was achieved in this standard. Sharps boxes in
use conformed to BS7320 (1990)/UN9291 standard and were assembled
correctly.
The issues identified were in relation to the temporary closure mechanism on
the sharps boxes which were not in place. Also the integrated sharps trays
which are used when assembling equipment to carry out a clinical procedure
were stained.
16

Recommendations
7. Systems and process should be in place to ensure that staff
comply with the trust policy on the segregation and safe disposal
of waste.
8. The trust should monitor the implementation of its policies and
procedures in respect of the management of waste and sharps to
ensure that safe and appropriate practice is in place.
17

9.0 Patient Equipment
STANDARD 5.0
PATIENT EQUIPMENT
Cleanliness and state of repair of general patient equipment.
Patient equipment
Patient equipment
84
A partial compliance score was achieved in this standard. In general the
equipment at the patient’s bedside was clean and in good repair. Trigger tape
was used extensively to indicate and record when cleaning had taken place.
Care should be taken to ensure that stored equipment which has been
cleaned is checked at regular intervals, as stored equipment was very dusty
and the trigger tape was dated July 2011.
A commode in the dirty utility room also had trigger tape, indicating it had
been cleaned that morning; on inspection the underside was found to be
stained and the vinyl of the cushion was split. Damaged surfaces can not be
effectively cleaned and such items should be reported for replacement.
Validation audits should be carried out to ensure the standard of cleaning
required is being achieved on all equipment
Other pieces of equipment which need more attention to detail when cleaning
include the resuscitation trolley which had adhesive residue on the work
surface. The leads of the ECG machine were grubby and the underside of the
drugs and dressing trolleys was stained and had tape and plastic bag residue
on the underside of the frame. The drinking water dispenser in the reception
had a white limescale deposit; this was cleaned by staff during the inspection.
Inspectors observed that the box of
the Laerdal Pocket Mask on top of
the resuscitation trolley was open
and that the mask was exposed
(Picture 6). In the drawer of the
trolley two laryngoscope handles had
blades attached, sterile single use
items should remain in the original
packaging until ready for use for
traceability purpose.
Picture 6 Exposed Laerdal mask
18

Recommendations
9 The trust and individual staff have a collective responsibility to
ensure that patient equipment is clean, stored correctly and in good
repair.
10 Systems and processes should be in place to assure that staff
knowledge and practice is kept up to date regarding the
decontamination of patient equipment.
19

10.0 Hygiene Factors
STANDARD 6.0
HYGIENE FACTORS
Hand wash facilities; alcohol hand rub; availability of PPE;
availability of cleaning equipment and materials.
Hygiene factors
Availability and
cleanliness of wash hand
94
basin and consumables
Availability of alcohol rub 100
Availability of PPE 92
Materials and equipment
for cleaning
93
Average Score 95
Staff are to be commended for achieving a compliance score in each of the
sections in this standard, with the section on availability of alcohol rub
achieving full compliance.
In the section on availability and cleanliness of hand wash sinks and
consumables the inspectors noted the seal behind the hand wash sink in the
nurses’ work station was dirty and that the soap dispenser in the clean utility
room was missing form the wall. The waste disposal room had been fitted
with a hand washing sink, a good initiative, however access to the sink was
blocked by filled soiled linen bags.
With regard to the availability of PPE, a trolley had been positioned outside
each isolation room to hold boxes of gloves and rolls of disposable aprons.
The trolleys were cluttered and untidy with additional items and paper work.
In the fourth section, material and equipment for cleaning, the door to the
domestic store was unlocked therefore chemicals were not stored in line with
Control of Substances Hazardous to Health (COSHH) regulations. The
inspectors also noted that the chrome extension tubes for the vacuum cleaner
had been repaired with adhesive tape.
20

Recommendations
11 The trust should ensure that hand washing sinks and consumables
are available, clean, and in a good state of repair.
12 The trust should ensure that all cleaning products are stored in a
locked cupboard, in accordance with COSHH regulations.
21

11.0 Hygiene Practices
STANDARD 7.0
HYGIENE PRACTICES
Hand hygiene procedures; handling and disposal of sharps; use
of PPE; use of isolation facilities and implementation of infection
control procedures; cleaning of ward/ department; staff uniform
and work wear.
Hygiene practices
Effective hand hygiene
procedures
100
Safe handling and
disposal of sharps
100
Effective use of PPE 91
Correct use of isolation 87
Effective cleaning of ward 69
Staff uniform and work
wear
96
Average Score 91
Five out of the six sections achieved compliance. Two of those sections,
hand hygiene procedures and safe disposal of sharps, were fully compliant.
In the section on effective cleaning of the ward, it was disappointing to note a
minimally compliant score. The inspectors noted that on questioning nursing
staff in both the practical application on how to make up disinfectants and
correct disinfectant dilution rates, staff needed to update their knowledge.
Information posters on correct dilution rates of disinfectants for staff to
reference were not available, however, copies of dilution rate charts were
obtained and displayed by the end of the inspection.
The inspectors were told by a member of domestic staff that Actichlor Plus, a
disinfectant with detergent, was not used as part of the daily cleaning process
for an isolation room; only detergent was used. Actichlor Plus was only used
when the room was empty and being terminally cleaned. This practice should
be clarified with the domestic services manager and infection prevention and
control staff to ensure that this practice is in accordance with the local policy
and procedure.
In relation to the correct use of isolation a review of patients’ nursing notes
with known infections was carried out. Staff should ensure that care
pathways are fully completed and reviewed within the set timescale. In one of
the patient’s nursing notes, a care plan was also available, this enabled staff
to record daily in the progress notes. In the other notes it was observed that
nursing interventions that had occurred on the day of the inspection, in
relation to the on going care for their infection, had not always been recorded.
22

Recommendations
13 Systems and processes should be in place to assure that staff
knowledge and practice is kept up to date regarding the use of
disinfectants.
14 Staff should ensure that care pathways are fully completed and
reviewed within the set timescale.
23

12.0 Key Personnel and Information
Members of the RQIA inspection team
Mrs E Colgan
Mrs M Keating
- Senior Officer Infection Prevention/Hygiene Team
- Inspector Infection Prevention/Hygiene Team
Trust representatives attending the feedback session
The key findings of the inspection were outlined to the following trust
representatives:
Ms A. Witherow - Assistant Director of Nursing
Mr S Gibson - Head of Operations and Maintenance
Ms M Kelly - Head of Support Services
Mr M Quinn - Head of Service Adult Disability Services/Lead Nurse
Ms E England - Lead Nurse/General Manager Cancer Services
Ms S Gormley - Support Services Manager
Ms S Glenn - Ward Manager, Ward 43 Sperrin Ward
Ms C Brown - Ward Manager, Spruce House
Ms U Cardin - Ward Manager, Sperrin Unit
Ms Y Black - Assistant Manager Support Services
Supporting documentation
A number of documents have been developed to support the inspection
process, these are:
Infection Prevention/Hygiene Inspection Process (methodology, follow
up and reporting)
Infection Prevention/Hygiene Team Inspection Protocol (this document
contains details on how inspections are carried out and the composition
of the teams)
Infection Prevention/Hygiene Team Escalation Policy
RQIA Policy and Procedure for Use and Storage of Digital Images
This information is currently available on request and will be available in due
course on the RQIA website.
24

13.0 Summary of Recommendations
1. The trust should ensure that the systems and processes in place
for environmental cleaning, provide the necessary assurance that
cleaning is carried out effectively, and that all staff are aware of
their responsibilities.
2. The healthcare environment should be repaired and maintained,
and damaged fixtures and fittings replaced to maintain public
confidence and to help reduce the risk of the spread of infection
3. Staff should review the use of the equipment store and clean utility
room and the level of stock required in the unit with a view to
improving storage and maintaining a clutter free environment
4. Detailed nursing cleaning schedules should be further developed.
5. The Trust should ensure the correct storage of clean linen in a
designated area which is fit for purpose
6. Systems should be in place to ensure that staff adhere to regional
guidance and trust policies and that staff knowledge is kept up to
date in respect of handling and storage of linen.
7. Systems and process should be in place to ensure that staff
comply with the trust policy on the segregation and safe disposal
of waste.
8. The trust should monitor the implementation of its policies and
procedures in respect of the management of waste and sharps to
ensure that safe and appropriate practice is in place.
9. The trust and individual staff have a collective responsibility to
ensure that patient equipment is clean, stored correctly and in good
repair.
10. Systems and processes should be in place to assure that staff
knowledge and practice is kept up to date regarding the
decontamination of patient equipment.
11. The trust should ensure that hand washing sinks consumables are
available clean, and in a good state of repair.
12. The trust should ensure that all cleaning products are stored in
locked cupboard, in accordance with COSHH regulations.
13. Systems and processes should be in place to assure that staff
knowledge and practice is kept up to date regarding the use of
disinfectants.
25

Reporting & Re-Audit
Episode of Inspection
Plan Programme
14.0 Unannounced Inspection Flowchart
Environmental Scan:
Stakeholders & External
Information
Plan
Programme
Consider:
Areas of Non-Compliance
Infection Rates
Trust Information
RQIA Hygiene Team
Prioritise Themes & Areas for Core Inspections
Prior to Inspection Year
Balance Programme
January/February
Schedule Inspections
Prior to Inspection
Identify & Prepare Inspection Team
Day of Inspection
Inform Trust
Day of Inspection
Carry out Inspection
A
Is there immediate risk
requiring formal escalation?
NO
YES
Invoke
RQIA
IPHTeam
Escalation
Process
Day of Inspection
Feedback Session with Trust
14 days after
Inspection
28 days after
Inspection
Preliminary Findings
disseminated to Trust
Draft Report
disseminated to Trust
NO
Does assessment of
the findings require
escalation?
YES
Invoke
RQIA
IPHTeam
Escalation
Process
A
14 days later
Signed Action Plan
received from Trust
Within 0-3 months
Is a Follow-Up required?
Based on Risk Assessment/key
indicators or Unsatisfactory Quality
Improvement Plan (QIP)?
YES
Invoke
Follow-Up
Protocol
Process enables
only 1 Follow-Up
NO
Open Report published to Website
YES
Is Follow-Up
satisfactory?
NO
DHSSPS/HSC
Board/PHA
PHA
1

15.0 Escalation Process
RQIA Hygiene Team: Escalation Process
B
RQIA IPH
Team
Escalation
Process
Concern / Allegation / Disclosure
Inform Team Leader / Head of Programme
MINOR/MODERATE
Has the risk been
assessed as Minor,
Moderate or Major?
MAJOR
Inform key contact and keep a record
Inform appropriate RQIA Director and Chief Executive
Record in final report
Inform Trust / Establishment / Agency
and request action plan
Notify Chairperson and
Board Members
Inform other establishments as appropriate:
E.g.: DHSSPS, RRT, HSC Board, PHA,
HSENI
Seek assurance on implementation of actions
Take necessary action:
E.g.: Follow-Up Inspection
2

16.0 Action Plan
Reference
number
Recommendations
1. The trust should ensure that the systems and
processes in place for environmental cleaning, provide
the necessary assurance that cleaning is carried out
effectively, and that all staff are aware of their
responsibilities.
Designated
department
Support
Services
Nursing
Action required
The Trust has cleaning programmes in
place and support staff have all receive
training on BICS. Support Services Team
leaders carry out their own quality control
audits which are based on the EC audits
check list
Cleaning schedules for patient equipment
are in development and will be re-issued
January 2012
Date for
completion/
timescale
January 2012
2. The healthcare environment should be repaired and
maintained, and damaged fixtures and fittings
replaced to maintain public confidence and to help
reduce the risk of the spread of infection.
Estates
Defects to be reported to Estates Help
Desk.
Environmental Cleanliness audits to be
monitored to assess areas needing
attention. Backlog Maintenance Funding
to be secured from General Capital to
address audit issues
Ongoing
3. Staff should review the use of the equipment store and
clean utility room and the level of stock required in the
unit with a view to improving storage and maintaining
a clutter free environment.
Estates
Nursing
The Productive ward series will be
implemented from February onwards
which using lean methodologies will help
to bring focus to the aspect of stock
management
Work is also on-going in relation to the
development of a de-clutter programme
for staff to have access to regular
disposal opportunities etc.
Early 2012
3

Reference
number
Recommendations
4. Detailed nursing cleaning schedules should be further
developed.
Designated
department
Nursing
Action required
Work has commenced to develop a
nursing cleaning template and this will
also be included in the EC audits from
February onwards
Date for
completion/
timescale
January 2012
5. The Trust should ensure the correct storage of clean
linen in a designated area which is fit for purpose.
Nursing
Training work shops are being scheduled
for staff Jan- March and this will be
addressed in the programme.
Ward managers have been asked to
identify where a problem with linen
storage exists and to raise through their
governance and estates meetings.
On going
6. Systems should be in place to ensure that staff adhere
to regional guidance and trust policies and that staff
knowledge is kept up to date in respect of handling
and storage of linen.
Nursing
Support
services
Guidance for staff on the correct
management will be included in the
training scheduled for jan-march 2012.
Jan- March
2012
7. Systems and process should be in place to ensure
that staff comply with the trust policy on the
segregation and safe disposal of waste.
Estates
Annual Sharps Safety Audit Altnagelvin
and Erne recently completed by Daniels
Heathcare, findings due to be circulated
by 20 th December 2011.
December
2011
8 The trust should monitor the implementation of its
policies and procedures in respect of the management
of waste and sharps to ensure that safe and
appropriate practice is in place.
Estates As above As above
4

Reference
number
Recommendations
9 The trust and individual staff have a collective
responsibility to ensure that patient equipment is
clean, stored correctly and in good repair.
Designated
department
Nursing
Estates
services
Action required
The Trust has an equipment /
decontamination policy and all directors
have been written to advising them of the
measures they must take to ensure that
this is followed.
This is part of the equipment controls
assurance standard and will be monitored
again in spring 23012
Date for
completion/
timescale
Ongoing
10 Systems and processes should be in place to assure
that staff knowledge and practice is kept up to date
regarding the decontamination of patient equipment.
Nursing
IPC Mandatory Training Slides updated
All Ward Managers have received a
reminder email with insructions for how to
access disinfectant training DVD.
Actichlor disinfectant representative to
provide training ward to ward within the
next month.
In addition a laminated information card
will be developed for staff reference.
Commenced
and on-going
11 The trust should ensure that hand washing sinks
consumables are available, clean, and in a good state
of repair.
Support
Services
The cleaning schedules includes the
cleaning/replenishing of hand towels,
toilet rolls and hand washing dispensers
On-going
12 The trust should ensure that all cleaning products
are stored in locked cupboard, in accordance with
COSHH regulations.
Support
Services
Support Services staff receive training on
COSHH as part of their induction. Also
BICS training incorporates COSHH
training. Support Services Team Leaders
to monitor as part of their supervisory
duties.
On-going
5

Reference
number
Recommendations
13 Systems and processes should be in place to assure
that staff knowledge and practice is kept up to date
regarding the use of disinfectants.
Designated
department
Nursing and
Support
Services
Action required
As for reference number 10
Support Services induction provides basic
training for all new staff. The BICS
training programme incorporates dilution
rates for all cleaning
products/disinfectants used.
Date for
completion/
timescale
On-going
14 Staff should ensure that care pathways are fully
completed and reviewed within the set timescale.
Nursing
A Trust Nursing Record Keeping Project
is commencing February 2011 which
includes a new nursing document and
audit processes.
The matter of care planning and the
review of care plans will be central to this
project.
A facilitator has been appointed to take
this work forward for the incoming year
February 2012
6