Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...
Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...
Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...
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RQIA<br />
Infection Prevention/Hygiene<br />
Unannounced Follow up Inspection<br />
<strong>Belfast</strong> Health <strong>and</strong> Social Care Trust<br />
<strong>Belfast</strong> <strong>City</strong> <strong>Hospital</strong><br />
<strong>12</strong> <strong>December</strong> <strong>2011</strong>
Contents<br />
1.0 Inspection Summary 1<br />
2.0 Background Information to The Inspection Process 5<br />
3.0 Inspections 6<br />
4.0 Unannounced Inspection Process 7<br />
4.1 Onsite Inspection 7<br />
4.2 Feedback <strong>and</strong> Report of the findings 7<br />
5.0 Audit Tool 8<br />
6.0 Environment 10<br />
6.1 Cleaning 10<br />
6.2 Clutter 11<br />
6.3 Maintenance <strong>and</strong> Repair 11<br />
6.4 Fixture <strong>and</strong> Fittings <strong>12</strong><br />
6.5 Information 13<br />
7.0 Patient Linen 15<br />
7.1 Management of Linen 15<br />
8.0 Waste <strong>and</strong> Sharps 17<br />
8.1 Waste 17<br />
8.2 Sharps 18<br />
9.0 Patient Equipment 19<br />
10.0 Hygiene Factors 21<br />
11.0 Hygiene Practice 23<br />
<strong>12</strong>.0 Key Personnel <strong>and</strong> Information 26<br />
13.0 Summary of Recommendations 28<br />
14.0 Unannounced Inspection Flowchart 30<br />
15.0 RQIA Hygiene Team Escalation Policy Flowchart 31<br />
16.0 Action Plan 32
1.0 Inspection Summary<br />
The unannounced inspection of <strong>Belfast</strong> <strong>City</strong> <strong>Hospital</strong> on the 20 October<br />
<strong>2011</strong> identified two of the four wards, Ward 6 North <strong>and</strong> Ward 10 North,<br />
had areas of minimal compliance within st<strong>and</strong>ards 2-7 of the Regional<br />
Healthcare Hygiene <strong>and</strong> Cleanliness St<strong>and</strong>ards. In line with the follow<br />
up process a further unannounced inspection was undertaken to these<br />
wards on the <strong>12</strong> <strong>December</strong> <strong>2011</strong>.<br />
Inspection Outcomes<br />
On the inspection of 20 October <strong>2011</strong>, 22 recommendations were<br />
made in relation to St<strong>and</strong>ards 2-7. Six have been addressed, 16 have<br />
been repeated <strong>and</strong> there are two new recommendations.<br />
Improvements <strong>and</strong> Developments since the previous Inspection<br />
On the<strong>12</strong> <strong>December</strong> <strong>2011</strong> the follow up inspection found that good<br />
progress had been made to address areas identified at the inspection<br />
in October as outlined below:<br />
Ward 6N – 73 per cent of the preliminary findings identified at the<br />
previous inspection have been addressed.<br />
Ward 10N – 70 per cent of the preliminary findings identified at the<br />
previous inspection have been addressed.<br />
In both wards there has been significant improvement as all seven<br />
st<strong>and</strong>ards have now achieved compliance. Improved staff practices<br />
were noted in cleaning of the environment <strong>and</strong> equipment,<br />
management of linen, waste, sharps, hygiene factors <strong>and</strong> hygiene<br />
practices<br />
In both wards inspected the majority of outst<strong>and</strong>ing issues requiring<br />
action are in relation to attention to detail when cleaning,<br />
refurbishment, maintenance <strong>and</strong> repair.<br />
Key Areas for Improvement<br />
In both wards inspected the majority of outst<strong>and</strong>ing issues requiring<br />
action are in relation to attention to detail when cleaning,<br />
refurbishment, maintenance <strong>and</strong> repair. All st<strong>and</strong>ards have achieved<br />
compliance in both wards, staff are encouraged to maintain this result<br />
<strong>and</strong> improve on existing practice especially in hygiene factors;<br />
materials <strong>and</strong> equipment for cleaning.<br />
A summary of the recommendations following the re-audit is listed in<br />
Section 13.<br />
1
A detailed list of the findings from the re-audit is forwarded to <strong>Belfast</strong><br />
Health <strong>and</strong> Social Care Trust within 14 days of the inspection to enable<br />
action on recurring or new areas which have achieved non compliant<br />
scores. The draft report which includes the high level<br />
recommendations in a Quality 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> Quality 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 />
The RQIA inspection team would like to thank the staff at <strong>Belfast</strong> <strong>City</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 />
General Environment<br />
6N 6N 10N 10N<br />
Oct <strong>2011</strong> Dec <strong>2011</strong> Oct <strong>2011</strong> Dec <strong>2011</strong><br />
Environment 87 90 79 90<br />
Patient Linen 83 93 84 91<br />
Waste 76 90 84 92<br />
Sharps 76 89 84 92<br />
Patient Equipment 80 89 75 87<br />
Hygiene Factors 82 95 83 90<br />
Hygiene Practices 77 94 81 90<br />
Total 80 91 81 90<br />
Compliant:<br />
85% or above<br />
Partial Compliance: 76% to 84%<br />
Minimal Compliance: 75% or below<br />
2
Table 2<br />
Environment<br />
6N 6N 10N 10N<br />
Oct <strong>2011</strong> Dec <strong>2011</strong> Oct <strong>2011</strong> Dec <strong>2011</strong><br />
Reception 90 89 N/A N/A<br />
Corridors, stairs lift 87 88 83 92<br />
Public toilets 100 91 93 N/A<br />
Ward/department–<br />
general (communal)<br />
82 93 76 95<br />
Patient bed area 89 87 83 86<br />
Bathroom/washroom 82 N/A 67 75<br />
Toilet 89 95 86 90<br />
Clinical room/<br />
Treatment room<br />
80 86 81 98<br />
Clean utility room N/A N/A 72 94<br />
Dirty utility room 84 86 65 89<br />
Domestic store 85 90 79 82<br />
Kitchen 95 94 84 91<br />
Equipment store 77 96 N/A N/A<br />
Isolation 94 86 89 97<br />
General information 81 86 70 96<br />
Average Score 87 90 79 90<br />
Table 3<br />
Linen<br />
6N 6N 10N 10N<br />
Oct <strong>2011</strong> Dec <strong>2011</strong> Oct <strong>2011</strong> Dec <strong>2011</strong><br />
Storage of clean linen 88 92 88 88<br />
Storage of used linen 78 94 79 93<br />
Laundry facilities N/A N/A N/A N/A<br />
Average Score 83 93 84 91<br />
Table 4<br />
Waste <strong>and</strong> Sharps<br />
H<strong>and</strong>ling,segregation,<br />
storage, waste<br />
Availability, use, storage<br />
of sharps<br />
6N<br />
Oct <strong>2011</strong><br />
6N<br />
Dec <strong>2011</strong><br />
10N<br />
Oct <strong>2011</strong><br />
10N<br />
Dec <strong>2011</strong><br />
76 90 84 92<br />
76 89 84 92<br />
Compliant:<br />
85% or above<br />
Partial Compliance: 76% to 84%<br />
Minimal Compliance: 75% or below<br />
3
Table 5<br />
6N 6N 10N 10N<br />
Patient Equipment<br />
Oct <strong>2011</strong> Dec <strong>2011</strong> Oct <strong>2011</strong> Oct <strong>2011</strong><br />
Patient equipment 80 89 75 87<br />
Table 6<br />
Hygiene Factors<br />
Availability <strong>and</strong><br />
cleanliness of wash<br />
h<strong>and</strong> basin <strong>and</strong><br />
consumables<br />
Availability of alcohol<br />
rub<br />
6N<br />
Oct <strong>2011</strong><br />
6N<br />
Dec <strong>2011</strong><br />
10N<br />
Oct <strong>2011</strong><br />
10N<br />
Dec <strong>2011</strong><br />
92 96 94 97<br />
97 100 100 100<br />
Availability of PPE 73 93 87 87<br />
Materials <strong>and</strong><br />
equipment for cleaning<br />
65 90 51 76<br />
Average Score 82 95 83 90<br />
Table 7<br />
Hygiene Practices<br />
6N<br />
Oct <strong>2011</strong><br />
6N<br />
Dec <strong>2011</strong><br />
10N<br />
Oct <strong>2011</strong><br />
10N<br />
Dec <strong>2011</strong><br />
Effective h<strong>and</strong> hygiene<br />
procedures<br />
64 92 75 90<br />
Safe h<strong>and</strong>ling <strong>and</strong><br />
disposal of sharps<br />
77 100 92 85<br />
Effective use of PPE 81 100 90 88<br />
Correct use of isolation 82 89 61 89<br />
Effective cleaning of<br />
ward<br />
73 95 74 91<br />
Staff uniform <strong>and</strong> work<br />
wear<br />
83 86 93 96<br />
Average Score 77 94 81 90<br />
Compliant:<br />
85% or above<br />
Partial Compliance: 76% to 84%<br />
Minimal Compliance: 75% or below<br />
4
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 />
5
3.0 Inspections<br />
The DHSSPS have devised Regional Healthcare Hygiene <strong>and</strong><br />
Cleanliness st<strong>and</strong>ards. RQIA has revised their 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. One of<br />
the st<strong>and</strong>ards relates to organisational systems <strong>and</strong> governance. To<br />
ensure compliance with this, a new inspection process <strong>and</strong><br />
methodology process has been developed in consultation with the<br />
regional steering group.<br />
RQIA's infection prevention/hygiene team have planned a three year<br />
programme of announced <strong>and</strong> unannounced inspections in acute <strong>and</strong><br />
non-acute hospitals in Northern Irel<strong>and</strong> in a rolling three year<br />
programme to assess compliance with the DHSSPS Regional<br />
Healthcare Hygiene <strong>and</strong> 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 />
6
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. One inspector led the team <strong>and</strong><br />
was responsible for guiding the team <strong>and</strong> ensuring they were in<br />
agreement about the findings reached. Membership of the inspection<br />
team is outlined in Section <strong>12</strong>.<br />
The inspection of ward environments is carried out using the Regional<br />
Healthcare Hygiene <strong>and</strong> Cleanliness audit tool. The inspection process<br />
involves observation, discussion with staff, <strong>and</strong> review of some ward<br />
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 <strong>12</strong>.<br />
Organisations are forwarded a detailed action plan of preliminary<br />
findings within 14 days of the inspection; this does not include the<br />
findings of the overall organisational systems <strong>and</strong> governance. The<br />
action plan is returned with the agreed draft report. The draft report<br />
contains the high level recommendations of the inspection <strong>and</strong> is<br />
forwarded to each organisation within 28 days of the inspection for<br />
agreement <strong>and</strong> factual accuracy checking <strong>and</strong> returned within two<br />
weeks. The detailed action plan is available on request from RQIA.<br />
The findings of the inspection will be followed up in line with infection<br />
prevention/hygiene inspection process (methodology, follow up <strong>and</strong><br />
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 15).<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 />
7
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 />
8
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 />
9
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 of<br />
toilets, bathrooms <strong>and</strong> washrooms; cleanliness <strong>and</strong> state of repair<br />
of ward/department facilities; availability <strong>and</strong> cleanliness of<br />
isolation facilities; provision of information for staff, patients <strong>and</strong><br />
visitors.<br />
Environment<br />
6N 6N 10N 10N<br />
Oct <strong>2011</strong> Dec <strong>2011</strong> Oct <strong>2011</strong> Dec <strong>2011</strong><br />
Reception 90 89 N/A N/A<br />
Corridors, stairs lift 87 88 83 92<br />
Public toilets 100 91 93 N/A<br />
Ward/department<br />
general (communal)<br />
82 93 76 95<br />
Patient bed area 89 87 83 86<br />
Bathroom/washroom 82 N/A 67 75<br />
Toilet 89 95 86 90<br />
Clinical room/treatment<br />
room<br />
80 86 81 98<br />
Clean utility room N/A N/A 72 94<br />
Dirty utility room 84 86 65 89<br />
Domestic store 85 90 79 82<br />
Kitchen 95 94 84 91<br />
Equipment store 77 96 N/A N/A<br />
Isolation 94 86 89 97<br />
General information 81 86 70 96<br />
Average Score 87 90 79 90<br />
The above tables outline the findings in relation to the general<br />
environment of the wards inspected during both inspections. The<br />
findings indicate improvement in both wards <strong>and</strong> in particular Ward 10<br />
North where minimally compliant areas highlighted in red identified in<br />
the first inspection <strong>and</strong> now mainly compliant. The findings in respect<br />
of the general environment are detailed in the following sections.<br />
6.1 Cleaning<br />
The inspection evidenced that there was improvement in both wards to<br />
indicate greater compliance with regional specifications for cleaning.<br />
Inspectors observed that cleaning mechanisms were implemented to<br />
prevent the build up of dust, debris <strong>and</strong> bacteria <strong>and</strong> subsequently<br />
reduce the potential risk for the transmission of infection.<br />
10
Staff in both wards are commended for achieving overall compliant<br />
scores <strong>and</strong> improving the level of compliance in the majority of sections<br />
within this st<strong>and</strong>ard. Inspectors observed in the main reception,<br />
corridors, stairs <strong>and</strong> in both wards a large number of cleaning issues<br />
previously identified had been addressed.<br />
Recurring environmental cleaning issues related to cleaning the carpet<br />
in the main reception <strong>and</strong> in both wards greater attention to detail when<br />
cleaning cupboards <strong>and</strong> the corners <strong>and</strong> edges of floors. In Ward 6<br />
North blu tac <strong>and</strong> tape remained on the walls in the treatment room <strong>and</strong><br />
the equipment sink in the dirty utility room required cleaning. In Ward<br />
10 North the bathroom, domestic sluice <strong>and</strong> an air vent in the east side<br />
toilet required more in-depth cleaning.<br />
New issues identified in Ward 6 North related to removing limescale<br />
from some taps <strong>and</strong> labels or tape residue from fixtures <strong>and</strong> fittings.<br />
The cleaning of radiator grills, a bedside entertainment system,<br />
windows <strong>and</strong> isolation Room J more effectively.<br />
In Ward 10 North new issues identified related to stains on the wall at<br />
the lift buttons, dusty ceiling lights in the clean utility room. In the<br />
kitchen the taped labels on cupboards need to be removed <strong>and</strong> the<br />
freezer <strong>and</strong> freezer door required more in depth cleaning.<br />
6.2 Clutter<br />
In both wards inspected staff have worked hard to address issues<br />
raised in the previous inspection. Inspectors observed good use of<br />
high density storage units <strong>and</strong> stores had been tidied to provide clutter<br />
free ward environments, which promotes effective cleaning <strong>and</strong> good<br />
hygiene practices.<br />
In Ward 10 North one new observation to be addressed was a cluttered<br />
<strong>and</strong> overstocked domestic store, while in Ward 6 North patient property<br />
stored untidily on the windowsill in isolation Room J, impeded effective<br />
cleaning.<br />
6.3 Maintenance <strong>and</strong> Repair<br />
At the time of inspection, inspectors observed maintenance staff, in<br />
both wards, carrying out repairs in relation to issues identified at the<br />
previous inspection. Inspectors were advised that a number of issues<br />
had been addressed however work was on-going to implement the full<br />
maintenance programme. In Ward 6 North work on a new shower<br />
room <strong>and</strong> equipment store was on going at the time of the inspection.<br />
Inspectors observed in Ward 10 North newly installed sluice sinks<br />
(Picture 1) <strong>and</strong> h<strong>and</strong> washing sinks with sensor operated taps.<br />
11
Picture 1: New sluice sink<br />
Recurring maintenance issues in both wards related to the repair of<br />
floors, walls, doors <strong>and</strong> frames, ceiling tiles <strong>and</strong> paintwork damage. A<br />
new issue identified in both wards was some worn, damaged skirting<br />
<strong>and</strong> in the main reception the h<strong>and</strong> washing sink overflow in the female<br />
toilet was blocked.<br />
In Ward 6 North new issues identified related to a leak from the slop<br />
hopper soil pipe which had been repaired with plaster of paris <strong>and</strong><br />
an out of order dishwasher.<br />
6.4 Fixtures <strong>and</strong> Fittings<br />
The fixtures, fittings <strong>and</strong> equipment in both wards were generally fit for<br />
purpose.<br />
Examples of outst<strong>and</strong>ing issues which were common to both wards,<br />
related to the finish on some bedside lockers, wooden furniture,<br />
cupboards <strong>and</strong> shelving was still worn, damaged or missing <strong>and</strong> some<br />
bedrails were chipped. A new issue identified in the main reception<br />
was old <strong>and</strong> worn chairs. Damaged fixtures <strong>and</strong> fittings are not<br />
impervious to moisture <strong>and</strong> impede the cleaning process.<br />
In both wards a recurring issue related to the lack of h<strong>and</strong> washing sink<br />
in the domestic store however inspectors were advised that combined<br />
domestic sluice <strong>and</strong> h<strong>and</strong> washing sinks are to be installed as part of<br />
the maintenance programme.<br />
In Ward 10 North a bedpan drip tray <strong>and</strong> replacement window blind in<br />
side Room A were on order.<br />
<strong>12</strong>
6.5 Information<br />
Staff in both wards are commended for achieving a compliance score<br />
in this section of the st<strong>and</strong>ard.<br />
H<strong>and</strong> hygiene, MRSA, Clostridium difficile <strong>and</strong> general infection<br />
prevention <strong>and</strong> control information leaflets were available for patients<br />
<strong>and</strong> visitors.<br />
A range of posters was in place for staff to reference, such as waste<br />
management, colour coding <strong>and</strong> segregation of linen. In Ward 6 North<br />
the sharps injury poster was available but had been removed from the<br />
wall to facilitate painting. However posters were again observed taped<br />
to surfaces with tape.<br />
In both wards nursing cleaning schedules while available continue to<br />
need further review to ensure all equipment to be cleaned is detailed<br />
<strong>and</strong> to ensure any variances in signing off schedules are recorded.<br />
Recurring issues in Ward 6 North related to temperatures of the drugs<br />
fridge not being consistently recorded <strong>and</strong> no signage on the door of<br />
the treatment room to indicate storage of oxygen. Signage was only<br />
available within the room. A new issue observed relates to wall<br />
mounted felt notice boards which cannot be effectively cleaned.<br />
Additional Issues<br />
Ward 6 North<br />
In a dirty utility room ceiling tiles were missing or damaged<br />
(ongoing refurbishment of the ward was in progress).<br />
Ward 10 North<br />
The deputy ward manager advised that the ward has a deficit in<br />
B<strong>and</strong> 2 staff <strong>and</strong> a ward housekeeper which has an impact on the<br />
cleaning of ward (Repeated).<br />
There were no temperature ranges for staff to reference on the<br />
trust fridge temperature recording sheet.<br />
Side Room F was spot checked by inspectors after being cleaned<br />
with vapourised hydrogen peroxide gas (VHP). VHP is used to<br />
clean areas were patients with infection have been nursed.<br />
Inspectors are aware that prior to VHP, a room should be stripped<br />
of all disposable equipment <strong>and</strong> thoroughly cleaned with a<br />
disinfectant, however inspectors observed that nursing <strong>and</strong><br />
domestic staff preparation of the room had not been carried out<br />
effectively. It was noted that disposable equipment; suction<br />
canister, oxygen mask <strong>and</strong> tubing, soap <strong>and</strong> paper towels were<br />
13
insitu. Inspectors also observed that the bed base was dusty, the<br />
bed frame had blood stains, the underside of the wardrobe shelf<br />
was dirty <strong>and</strong> the inside of an IV pump required cleaning. As<br />
inspectors were very concerned regarding this issue it was<br />
immediately reported to the deputy ward manager <strong>and</strong> domestic<br />
manager for action.<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 (Repeated).<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 (Repeated).<br />
3. Detailed nursing cleaning schedules should be developed<br />
(Repeated).<br />
4. The trust should ensure that all staff are aware of the<br />
importance of monitoring fridge temperatures (Repeated).<br />
5. The trust should ensure that all staff are aware <strong>and</strong> carry out<br />
the correct cleaning procedures prior to commencing VHP<br />
<strong>and</strong> systems are in place to check the effectiveness of the<br />
cleaning.<br />
14
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<br />
6N 6N 10N 10N<br />
Oct <strong>2011</strong> Dec <strong>2011</strong> Oct <strong>2011</strong> Dec <strong>2011</strong><br />
Storage of clean linen 88 92 88 88<br />
Storage of dirty linen 78 94 79 93<br />
Laundry facilities N/A N/A N/A N/A<br />
Average Score 83 93 84 91<br />
7.1 Management of Linen<br />
Staff in both wards are commended for improving the scoring in the<br />
storage of used linen <strong>and</strong> achieving overall compliant scores in this<br />
st<strong>and</strong>ard.<br />
In both inspections effective arrangements were in place for the<br />
storage of clean linen. Clean bed linen was stored in a separate store<br />
from used linen <strong>and</strong> was found to be clean, tidy <strong>and</strong> free from rips <strong>and</strong><br />
tears (Picture 2). In Ward 6 North the issue of clean linen being stored<br />
in an open trolley beside isolation side rooms has been addressed,<br />
however reusable torn linen bags were again observed.<br />
Picture 2: Clean, neat <strong>and</strong> tidy linen store<br />
In Ward 10 North, linen skips remained chipped however inspectors<br />
were advised that new linen skips were on order. There were still<br />
outst<strong>and</strong>ing maintenance <strong>and</strong> repair issues in the clean linen store <strong>and</strong><br />
the floor corners <strong>and</strong> edges again required cleaning.<br />
In Ward 6 North clean linen store issues identified related to damaged<br />
walls, doors <strong>and</strong> door frame.<br />
15
Issues relating to the h<strong>and</strong>ling <strong>and</strong> storage of used linen have been<br />
addressed <strong>and</strong> good practice was observed in both wards. Used linen<br />
was placed immediately into the appropriate colour coded bags at the<br />
point of use <strong>and</strong> staff were observed to be wearing the appropriate<br />
personal protective equipment (PPE) when h<strong>and</strong>ling soiled/<br />
contaminated linen.<br />
Recommendations<br />
6. 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 />
(Repeated).<br />
16
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 />
Waste <strong>and</strong> Sharps<br />
H<strong>and</strong>ling, segregation,<br />
storage, waste<br />
Availability, use, storage<br />
of sharps<br />
6N<br />
Oct <strong>2011</strong><br />
6N<br />
Dec <strong>2011</strong><br />
10N<br />
Oct <strong>2011</strong><br />
10N<br />
Dec <strong>2011</strong><br />
76 90 84 92<br />
76 89 84 92<br />
8.1 Waste<br />
Staff in both wards are commended for improving practice <strong>and</strong><br />
achieving compliance scores in this st<strong>and</strong>ard.<br />
In Ward 6 North issues identified in relation to the inappropriate<br />
disposal of waste have been addressed. However, in Ward 10 North;<br />
household waste was again inappropriately disposed of into the clinical<br />
waste stream <strong>and</strong> sharps boxes. Pharmaceutical waste was disposed<br />
of into a yellow lidded burn bin, used for free fluid; the bin was also<br />
overfilled.<br />
In both wards, magpie boxes, used for the disposal of household tins,<br />
glass <strong>and</strong> crockery, <strong>and</strong> clinical <strong>and</strong> household waste bins were now<br />
available for the appropriate disposal of waste. Waste bins were<br />
generally clean <strong>and</strong> in a good state of repair. However inspectors<br />
again observed in Ward 6 North that some clinical waste bins were<br />
stained under the lid. In the dirty utility room clinical waste bin was<br />
stained <strong>and</strong> starting to rust under the lid <strong>and</strong> a new issue relating to<br />
rust underneath the lid of the household waste bin in the end bay, dirty<br />
utility room <strong>and</strong> treatment room was identified. Waste bags were again<br />
observed tied onto monitor trolleys.<br />
In both wards the shared waste hold area was still easily accessible<br />
<strong>and</strong> not secure, large clinical waste euro bins remained open <strong>and</strong> in<br />
Ward 10 North the hold area was untidy.<br />
17
8.2 Sharps<br />
Staff are commended for achieving compliance. The inspection<br />
evidenced that in both wards inspected, effort had been made to<br />
ensure safe h<strong>and</strong>ling, segregation, storage <strong>and</strong> disposal of sharps.<br />
Sharps boxes in use conformed to BS7320 (1990)/UN9291 st<strong>and</strong>ard<br />
<strong>and</strong> were assembled correctly. However in Ward 6 North sharps boxes<br />
found in the large euro bins were not signed with the date of assembly,<br />
locality <strong>and</strong> staff signature.<br />
Recurring issues in Ward 6 North were, one temporary closure<br />
mechanism, to prevent spillage <strong>and</strong> impede access, was not in place<br />
when the sharps box was not in use <strong>and</strong> in Ward 10 North the sharps<br />
box on the resuscitation trolley although secure was open <strong>and</strong> had<br />
contents insitu.<br />
In Ward 6 North the underneath of sharps trays in use again required<br />
more detailed cleaning <strong>and</strong> on this inspection a paper mache receiver<br />
was observed inside a sharps tray. In Ward 10 North new issues<br />
identified during this inspection related to an unsecure 22 litre sharps<br />
box on the central isl<strong>and</strong> in the clinical room <strong>and</strong> the lid of one sharps<br />
box splashed with blood.<br />
Recommendations<br />
7. Waste bins <strong>and</strong> equipment used in the management of waste<br />
should be available, clean <strong>and</strong> replaced as appropriate<br />
(Repeated).<br />
8. 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 (Repeated).<br />
18
9.0 Patient Equipment<br />
STANDARD 5.0<br />
PATIENT EQUIPMENT<br />
Cleanliness <strong>and</strong> state of repair of general patient equipment.<br />
6N 6N 10N 10N<br />
Patient Equipment<br />
Oct <strong>2011</strong> Dec <strong>2011</strong> Oct <strong>2011</strong> Oct <strong>2011</strong><br />
Patient Equipment 80 89 75 87<br />
In both wards a concentrated effort by all ward staff has improved the<br />
cleaning of patient equipment <strong>and</strong> achieved compliant scores.<br />
Inspectors observed in both wards a large number of cleaning issues<br />
had been addressed, trigger tape to identify equipment has been<br />
cleaned was generally insitu <strong>and</strong> staff knowledge on cleaning practice<br />
had improved.<br />
Recurring issues in Ward 6 North include, a used suction tube on the<br />
shared resuscitation trolley had not been replaced or was again used<br />
<strong>and</strong> not disposed off immediately, one commode was soiled, patient<br />
wash bowls were not stored inverted, one of the drugs trolleys had<br />
missing laminate <strong>and</strong> IV trays required cleaning. It was also noted that<br />
while new commodes <strong>and</strong> IV st<strong>and</strong>s to replace rusty equipment was on<br />
order, they had yet to arrive. In Ward 10 North the underside of one<br />
commode was stained, there was no trigger tape insitu on another <strong>and</strong><br />
the drugs (Picture 3), notes trolley <strong>and</strong> wheelchair required cleaning.<br />
Picture 3: Dirty underside of drugs trolley<br />
In Ward 6 North additional issues for improvement related to tape<br />
residue on the drawers of the resuscitation trolley, single use<br />
tourniquets were not available, soiled suction tubing in a side room<br />
<strong>and</strong> dried out wipes on a monitor trolleys. The latter would suggest that<br />
the wipes were not being used to clean equipment between patients.<br />
In Ward 10 North new issues related to bedpans not stored inverted,<br />
re-used single use jugs, the resuscitation trolley <strong>and</strong> the stethoscope<br />
19
on the resuscitation trolley requiring cleaning. As already mentioned in<br />
the environmental cleaning section in Room F, a suction canister,<br />
oxygen mask <strong>and</strong> tubing were not changed as per trust policy prior to a<br />
room being cleaned <strong>and</strong> an IV pump required cleaning.<br />
Additional Issues<br />
Ward 10 North<br />
Staff advised that the adhesive strip on the trigger tape was<br />
insufficient <strong>and</strong> the tape continually fell off equipment. The use of<br />
an alternative tape should be reviewed.<br />
Recommendations<br />
9. 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 />
(Repeated).<br />
20
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<br />
Availability <strong>and</strong><br />
cleanliness of wash<br />
h<strong>and</strong> basin <strong>and</strong><br />
consumables<br />
Availability of alcohol<br />
rub<br />
6N<br />
Oct <strong>2011</strong><br />
6N<br />
Dec <strong>2011</strong><br />
10N<br />
Oct <strong>2011</strong><br />
10N<br />
Dec <strong>2011</strong><br />
92 96 94 97<br />
97 100 100 100<br />
Availability of PPE 73 93 87 87<br />
Materials <strong>and</strong><br />
equipment for cleaning<br />
65 90 51 76<br />
Average Score 82 95 83 90<br />
Recommendations<br />
Both wards are commended for improving <strong>and</strong> achieving a compliant or<br />
fully compliant score in all sections of this st<strong>and</strong>ard.<br />
H<strong>and</strong> washing sinks <strong>and</strong> fixtures <strong>and</strong> fittings in both wards were<br />
generally clean, working <strong>and</strong> in a good state of repair. Sensor operated<br />
taps were available in clinical areas. However, in Ward 6 North greater<br />
attention to detail when cleaning the taps of the h<strong>and</strong> washing sink in<br />
the treatment room could further improve scoring. In Ward 10 North,<br />
on the day of inspection, the sensor tap on the h<strong>and</strong> washing sink in<br />
the west side dirty utility room was not consistently working; staff<br />
advised that this had been reported for repair.<br />
Liquid soap <strong>and</strong> paper h<strong>and</strong> towels were available in all areas however<br />
an additional issue in Ward 10 North was the paper towel <strong>and</strong> soap<br />
dispensers in the west side dirty utility room were not positioned<br />
bedside the h<strong>and</strong> washing sink for staff to easily use. In Ward 6 North<br />
a recurring <strong>and</strong> additional issue related to cleaning the underside of<br />
some of the paper h<strong>and</strong> towel <strong>and</strong> soap dispensers. There were no<br />
issues identified in the provision of alcohol h<strong>and</strong> rub.<br />
In Ward 10 North, inspectors observed that a range of personal<br />
protective equipment (PPE) was available in the wall mounted<br />
dispensers however wall mounted aprons were again observed in the<br />
dirty utility rooms. This is not advised by the trust infection prevention<br />
<strong>and</strong> control team due to the potential risk of aerosol contamination. In<br />
Ward 6 North inspectors again noted the lack of PPE stations in the<br />
shared corridor <strong>and</strong> at the side room/isolation area of the ward,<br />
however these have been ordered.<br />
21
While improvement was noted, recurring <strong>and</strong> additional issues were<br />
identified in both wards relating to the availability, storage <strong>and</strong> use of<br />
materials <strong>and</strong> equipment for general cleaning of the ward.<br />
In Ward 6 North, the daily changes of Actichlor plus disinfectant were<br />
again inconsistently recorded <strong>and</strong> a yellow mop bucket was soiled with<br />
what appeared to be dried blood. A mop was not stored inverted when<br />
not in use <strong>and</strong> the vacuum <strong>and</strong> floor burnisher were old <strong>and</strong> worn; staff<br />
advised that new equipment was on order.<br />
In Ward 10 North cleaning solutions were again not stored in<br />
accordance with Control of Substances Hazardous to Health (COSHH)<br />
regulations <strong>and</strong> Actichlor plus disinfectant was diluted with hot water<br />
rather than luke warm/cold water; this was immediately addressed by<br />
ward staff. Some mop <strong>and</strong> h<strong>and</strong> held buckets required cleaning <strong>and</strong><br />
some equipment was old, worn <strong>and</strong> in the process of being replaced.<br />
New issues related to a domestic not accurately measuring water when<br />
diluting Actichlor plus <strong>and</strong> an insufficient supply of yellow coloured<br />
cloths for cleaning infected areas; these issues were addressed during<br />
the inspection.<br />
Recommendations<br />
10. 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 (Repeated).<br />
11. Equipment used for the general cleaning of a ward are clean,<br />
fit for purpose, <strong>and</strong> stored appropriately <strong>and</strong> are fit for<br />
purpose (Repeated).<br />
<strong>12</strong>. 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 (Repeated).<br />
13. The trust should ensure that all cleaning products are stored<br />
in a locked cupboard, in accordance with COSHH regulations<br />
(Repeated).<br />
22
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 of<br />
PPE; use of isolation facilities <strong>and</strong> implementation of infection<br />
control procedures; cleaning of ward/department; staff uniform <strong>and</strong><br />
work wear.<br />
Hygiene Practices<br />
6N<br />
Oct <strong>2011</strong><br />
6N<br />
Dec <strong>2011</strong><br />
10N<br />
Oct <strong>2011</strong><br />
10N<br />
Dec <strong>2011</strong><br />
Effective h<strong>and</strong> hygiene<br />
procedures<br />
64 92 75 90<br />
Safe h<strong>and</strong>ling <strong>and</strong><br />
disposal of sharps<br />
77 100 92 85<br />
Effective use of PPE 81 100 90 88<br />
Correct use of isolation 82 89 61 89<br />
Effective cleaning of<br />
ward<br />
73 95 74 91<br />
Staff uniform <strong>and</strong> work<br />
wear<br />
83 86 93 96<br />
Average Score 77 94 81 90<br />
Recommendations<br />
Both wards are commended for improving <strong>and</strong> achieving a compliant or<br />
fully compliant score in all sections of this st<strong>and</strong>ard.<br />
Inspectors observed that effective h<strong>and</strong> hygiene procedures were<br />
generally undertaken by staff <strong>and</strong> staff performed h<strong>and</strong> hygiene in<br />
accordance with WHO guidance at the appropriate moments of care.<br />
However, in Ward 6 North a registered nurse did not carry out the<br />
recommended seven step technique when using alcohol rub <strong>and</strong> in<br />
Ward 10 North, catering <strong>and</strong> domestic staff were observed not washing<br />
their h<strong>and</strong>s after leaving a lobbied isolation room.<br />
Ward 6 North has worked hard <strong>and</strong> achieved full compliance in the<br />
safe h<strong>and</strong>ling <strong>and</strong> disposal of sharps however Ward 10 North’s<br />
compliant score has dropped in this section. Inspectors observed new<br />
issues relating to used white coloured needles re-sheathed (Picture 4)<br />
<strong>and</strong> discarded separately from the syringe rather than discarded as a<br />
complete single unit; this was shown to the nurse in charge during the<br />
inspection.<br />
23
Pictures 4: Re-sheathed needles<br />
Ward 6 North achieved full compliance in the effective use of PPE<br />
however in Ward 10 North the compliance score has again dropped.<br />
Inspectors observed new issues relating to domestic <strong>and</strong> catering staff<br />
leaving a lobbied isolation room without removing their aprons <strong>and</strong><br />
gloves <strong>and</strong> catering staff wearing a white apron rather than a green<br />
apron for serving food.<br />
In both wards compliance has been achieved in the correct use of<br />
isolation with a large number of issues previously identified addressed.<br />
A recurring issue in Ward 10 North was domestic staff using sani wipes<br />
rather than disinfectant to clean isolation rooms. New issues related to<br />
MRSA care pathways not fully completed for two patients in Ward 6<br />
North <strong>and</strong> in Ward 10 North the Vancomycin - Resistant Enterococci<br />
(VRE) isolation care plan did not detail all infection prevention <strong>and</strong><br />
control precautions required for isolation.<br />
Inspectors noted an overall improvement in staff knowledge on the<br />
disinfectant in use <strong>and</strong> the colour coded system for cleaning equipment<br />
used at ward level. However it was noted in Ward 10 North that the<br />
previously mentioned domestic staff shortages has impacted negatively<br />
on the cleaning; inspectors were advised the back corridor outside the<br />
domestic store had not been cleaned for one week.<br />
In both wards, compliance with regional dress code was good, however<br />
for Ward 6 North further work is required to ensure adherence to the<br />
policy from medical staff. Nursing staff informed the inspectors that<br />
changing facilities were not available.<br />
Recommendations<br />
14. 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 (Repeated).<br />
15. The trust <strong>and</strong> all staff have a collective responsibility to<br />
ensure the safe h<strong>and</strong>ling <strong>and</strong> disposal of sharps.<br />
24
16. 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 (Repeated).<br />
17. The trust <strong>and</strong> all staff have a collective responsibility to<br />
ensure that documentation used in relation to patients with<br />
infection fully reflects the care given <strong>and</strong> are completed<br />
appropriately.<br />
18. The trust should ensure that all members of staff are familiar<br />
with <strong>and</strong> adhere to the regional dress code policy (Repeated).<br />
25
<strong>12</strong>.0 Key Personnel <strong>and</strong> Information<br />
Members of the RQIA inspection team<br />
Mrs E Colgan - Senior Inspector Infection Prevention/Hygiene Team<br />
Mrs L Gawley - Inspector Infection Prevention/Hygiene Team<br />
Mrs M Keating - Inspector Infection Prevention/Hygiene Team<br />
Mrs S O’Connor - Inspector Infection Prevention/Hygiene Team<br />
Trust representatives attending the feedback session<br />
The key findings of the inspection were outlined to the following trust<br />
representatives:<br />
Ms Jennifer Welsh - Director, Cancer & Specialist Services<br />
Ms Moira Mannion - Co- Director Nursing (representing Director<br />
of Nursing)<br />
Ms Caroline Leonard - Cancer & Specialist Services Co- Director<br />
Ms Gillian Traub - Service Manager, Oncology/Haematology<br />
Mr Seamus Trainor - PCSS Manager, BCH<br />
Mrs M<strong>and</strong>y Armstrong - <strong>Regulation</strong> & Improvement, Manager<br />
Ms Sarah Williamson - Acting Clinical Co-ordinator, Haematology<br />
Mr Tony O’Hara - SS Catering Manager<br />
Mr Stephen Lawson - Estates<br />
Mrs Caroline Smyth - Senior Infection Prevention & Control Nurse<br />
Ms Rosie Gray - Ward 6 North, Manager<br />
Ms Ruth Finn - Infection Prevention & Control Nurse<br />
Ms Joanne Stewart - Ward 10 North, Deputy Ward Manager<br />
Ms Patricia Berkery - Domestic Services<br />
Apologies<br />
Mr Colm Donaghy<br />
Ms Brenda Creaney<br />
Mr Colin Cairns<br />
- Chief Executive<br />
- Executive Director of Nursing<br />
- Co-Director, PCSS<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 />
26
This information is currently available on request <strong>and</strong> will be available<br />
in due course on the RQIA website.<br />
27
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 (Repeated).<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 (Repeated).<br />
3. Detailed nursing cleaning schedules should be developed<br />
(Repeated).<br />
4. The trust should ensure that all staff are aware of the<br />
importance of monitoring fridge temperatures (Repeated).<br />
5. The trust should ensure that all staff are aware <strong>and</strong> carry out<br />
the correct cleaning procedures prior to commencing VHP<br />
<strong>and</strong> systems are in place to check the effectiveness of the<br />
cleaning.<br />
6. 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 />
(Repeated).<br />
7. Waste bins <strong>and</strong> equipment used in the management of waste<br />
should be available, clean <strong>and</strong> replaced as appropriate<br />
(Repeated).<br />
8. 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 (Repeated).<br />
9. 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 />
(Repeated).<br />
10. 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 (Repeated).<br />
11. Equipment used for the general cleaning of a ward are clean,<br />
fit for purpose, <strong>and</strong> stored appropriately <strong>and</strong> are fit for<br />
purpose (Repeated).<br />
28
<strong>12</strong>. 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 (Repeated).<br />
13. The trust should ensure that all cleaning products are stored<br />
in a locked cupboard, in accordance with COSHH regulations<br />
(Repeated).<br />
14. 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 (Repeated).<br />
15. The trust <strong>and</strong> all staff have a collective responsibility to<br />
ensure the safe h<strong>and</strong>ling <strong>and</strong> disposal of sharps.<br />
16. 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 (Repeated).<br />
17. The trust <strong>and</strong> all staff have a collective responsibility to<br />
ensure that documentation used in relation to patients with<br />
infection fully reflects the care given <strong>and</strong> are completed<br />
appropriately.<br />
18. The trust should ensure that all members of staff are familiar<br />
with <strong>and</strong> adhere to the regional dress code policy (Repeated).<br />
29
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 />
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 Quality<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 />
30
15.0 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 />
31
16.0 Action Plan<br />
Reference<br />
number<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<br />
all staff are aware of their responsibilities (Repeated).<br />
Designated<br />
department<br />
Nursing<br />
PCSS<br />
IPC<br />
Action required<br />
‘Roles <strong>and</strong> responsibilities of Staff in relation<br />
to Environmental Cleanliness <strong>and</strong><br />
Cleanliness of Equipment’ policy under<br />
review.<br />
Date for<br />
completion/<br />
timescale<br />
Mar 20<strong>12</strong><br />
The consultation process in relation to the<br />
cleaning manual has resulted in requests for<br />
significant changes to the content <strong>and</strong> format.<br />
Work is ongoing to have a revised final<br />
consultation document by February 20<strong>12</strong>.<br />
Feb 20<strong>12</strong><br />
All of these aspects will be monitored through<br />
the programme of Environmental Cleanliness<br />
Audits based on the Cleanliness Matters<br />
Strategy <strong>and</strong> results fed back through<br />
Balanced Scorecards.<br />
Ongoing<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<br />
the spread of infection (Repeated).<br />
3. Detailed nursing cleaning schedules should be developed<br />
(Repeated).<br />
Estates<br />
IPC<br />
Other<br />
appropriate<br />
staff<br />
Nursing<br />
IPECC<br />
This is ongoing as part of Estate daily<br />
maintenance <strong>and</strong> refurbishment programmes.<br />
A sub-group of IPECC (Infection Prevention<br />
& Environment <strong>and</strong> Cleanliness Committee)<br />
will be set up to review <strong>and</strong> st<strong>and</strong>ardise<br />
cleaning schedules, <strong>and</strong> will establish any<br />
outst<strong>and</strong>ing issues of audit st<strong>and</strong>ardisation<br />
process.<br />
Agree a st<strong>and</strong>ardised audit which will be<br />
used in all areas. This will include<br />
st<strong>and</strong>ardised responsibilities. To be kept<br />
under review.<br />
Systematic roll out of the agreed<br />
Ongoing<br />
Feb 20<strong>12</strong><br />
Commencing<br />
Feb 20<strong>12</strong><br />
* indicates stated for a second time 32
Reference<br />
number<br />
Recommendations<br />
4. The trust should ensure that all staff are aware of the<br />
importance of monitoring fridge temperatures (Repeated).<br />
Designated<br />
department<br />
Nursing<br />
Action required<br />
st<strong>and</strong>ardised audit using the Maximiser<br />
system.<br />
The Medicines Code outlines procedures for<br />
use of medicine fridges. A pharmaceutical<br />
refrigerator temperature log sheet is<br />
maintained for each individual fridge, with<br />
records being maintained <strong>and</strong> monitored by<br />
Ward Managers.<br />
Date for<br />
completion/<br />
timescale<br />
Ongoing<br />
5. The trust should ensure that all staff are aware <strong>and</strong> carry<br />
out the correct cleaning procedures prior to commencing<br />
VHP <strong>and</strong> systems are in place to check the effectiveness<br />
of the cleaning.<br />
6. The trust should ensure the correct storage of clean linen<br />
in a designated area which is clean <strong>and</strong> fit for purpose<br />
(Repeated).<br />
Nursing<br />
A pre-VHP checklist has been developed <strong>and</strong><br />
currently being consulted on It is due for<br />
implementation in February. There is a<br />
protocol agreed by IPC <strong>and</strong> Estates where<br />
IPC is contacted before VHP is carried out so<br />
that cleaning can be implemented before<br />
VHP.<br />
When possible an IPCN will check the<br />
cleaning before VHP.<br />
Guidance regarding storage of linen is in the<br />
Regional Infection Prevention Manual. Linen<br />
storage <strong>and</strong> segregation guidance has been<br />
circulated to all Directorates.<br />
Feb 20<strong>12</strong><br />
Complete<br />
This states that all linen must be stored off<br />
the floor in a clean dedicated area that allows<br />
for ease of access <strong>and</strong> rotation of stock <strong>and</strong><br />
that Linen rooms must have shelving that are<br />
easy to clean, <strong>and</strong> cleaning frequencies must<br />
be at least quarterly.<br />
7. Waste bins <strong>and</strong> equipment used in the management of<br />
waste should be available, clean <strong>and</strong> replaced as<br />
appropriate (Repeated).<br />
PCSS<br />
Nursing<br />
This is monitored as part of the<br />
Environmental Cleanliness Audit Programme.<br />
Regional contract for bins at adjudication<br />
stage.<br />
Ongoing<br />
* indicates stated for a second time 33
Reference<br />
number<br />
Recommendations<br />
Designated<br />
department<br />
Action required<br />
Environmental cleanliness audit programmes,<br />
which include daily ward checks, department<br />
<strong>and</strong> managerial audits, <strong>and</strong> IPC audits<br />
monitor compliance.<br />
Date for<br />
completion/<br />
timescale<br />
Where an issue has been highlighted, action<br />
will be taken in conjunction with the<br />
appropriate department to ensure<br />
rectification.<br />
8. The trust should monitor the implementation of its policies<br />
<strong>and</strong> procedures in respect of the management of waste<br />
<strong>and</strong> sharps to ensure that safe <strong>and</strong> appropriate practice is<br />
in place (Repeated).<br />
PCSS<br />
Nursing<br />
The Trust will pilot <strong>and</strong> roll out across all<br />
facilities the use of an electronic tool to audit<br />
waste management compliance against<br />
policy, procedure <strong>and</strong> RQIA requirements.<br />
This process will supplement the existing<br />
audit tools used by PCSS, IPC <strong>and</strong> also<br />
existing external audits conducted by Daniels<br />
(sharps box suppliers).<br />
Pilot completed<br />
Roll-out<br />
programme<br />
across Trust to<br />
be completed by<br />
Apr 20<strong>12</strong><br />
9. 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 (Repeated).<br />
Nursing<br />
PCSS<br />
Daniels’ audit completed Oct <strong>2011</strong> <strong>and</strong><br />
results disseminated.<br />
The consultation process in relation to the<br />
cleaning manual has resulted in requests for<br />
significant changes to the content <strong>and</strong> format.<br />
Work is ongoing to have a revised final<br />
consultation document by February 20<strong>12</strong>.<br />
Complete<br />
Feb 20<strong>12</strong><br />
The manual includes roles <strong>and</strong><br />
responsibilities of trust staff in relation to<br />
patient equipment. A template will be used to<br />
record all cleaning of equipment.<br />
10. 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 (Repeated).<br />
PCSS<br />
This is monitored as part of the<br />
Environmental Cleanliness Audit Programme.<br />
Staff are reminded of the importance of<br />
replenishing dispensers.<br />
Ongoing<br />
* indicates stated for a second time 34
Reference<br />
number<br />
Recommendations<br />
Designated<br />
department<br />
Action required<br />
Date for<br />
completion/<br />
timescale<br />
Environmental cleanliness audit programmes,<br />
which include daily ward checks, department<br />
<strong>and</strong> managerial audits, <strong>and</strong> IPC audits<br />
monitor compliance.<br />
Where an issue has been highlighted, action<br />
will be taken in conjunction with the<br />
appropriate department to ensure<br />
rectification.<br />
Regular training is provided to all appropriate<br />
staff.<br />
11. Equipment used for the general cleaning of a ward are<br />
clean, fit for purpose, <strong>and</strong> stored appropriately <strong>and</strong> are fit<br />
for purpose (Repeated).<br />
Nursing<br />
PCSS<br />
The consultation process in relation to the<br />
cleaning manual has resulted in requests for<br />
significant changes to the content <strong>and</strong> format.<br />
Work is ongoing to have a revised final<br />
consultation document by February 20<strong>12</strong>.<br />
Feb 20<strong>12</strong><br />
Environmental cleanliness audit programmes,<br />
which include daily ward checks, department<br />
<strong>and</strong> managerial audits, <strong>and</strong> IPC audits<br />
monitor compliance.<br />
Where an issue has been highlighted, action<br />
will be taken in conjunction with the<br />
appropriate department to ensure<br />
rectification.<br />
Regular training is provided to all appropriate<br />
staff.<br />
<strong>12</strong>. 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 />
the use of disinfectants (Repeated).<br />
Nursing<br />
All staff have been reminded <strong>and</strong> made<br />
aware of poster advice.<br />
Completed <strong>and</strong><br />
ongoing<br />
* indicates stated for a second time 35
Reference<br />
number<br />
Recommendations<br />
Designated<br />
department<br />
Action required<br />
M<strong>and</strong>atory IPC training is provided, poster<br />
advice issued to wards, staff questioned at<br />
audit.<br />
Date for<br />
completion/<br />
timescale<br />
13. The trust should ensure that all cleaning products are<br />
stored in a locked cupboard, in accordance with COSHH<br />
regulations (Repeated).<br />
PCSS<br />
Locked cupboards are provided.<br />
Ward managers <strong>and</strong> PCSS supervisors carry<br />
out regular checks to ensure all staff comply<br />
with COSHH procedures. Audited as part of<br />
<strong>Belfast</strong> Risk Assessment <strong>and</strong> Audit Tool<br />
(BRAAT).<br />
Complete<br />
14. All staff have a responsibility to ensure that h<strong>and</strong> hygiene<br />
is carried out in line with WHO guidance <strong>and</strong> that all PPE<br />
is used appropriately (Repeated).<br />
IPCT<br />
Balance scorecards, which include WHO<br />
H<strong>and</strong> Hygiene audits. All of these aspects will<br />
be monitored through the programme of<br />
Environmental Cleanliness Audits based on<br />
the Cleanliness Matters Strategy.<br />
Complete <strong>and</strong><br />
Ongoing<br />
The IPCT carried out an independent audit<br />
<strong>and</strong> results have been fed back.<br />
Independent audits will be carried out 4 times<br />
a year (2 of which will be carried out by<br />
Infection Prevention <strong>and</strong> Control).<br />
The IPCT is currently devising an educational<br />
tool to remind staff of the appropriate use of<br />
PPE.<br />
15. The trust <strong>and</strong> all staff have a collective responsibility to<br />
ensure the safe h<strong>and</strong>ling <strong>and</strong> disposal of sharps.<br />
PCSS<br />
There is a training programme available to all<br />
staff.<br />
Complete<br />
Update <strong>and</strong> refresher training will continue to<br />
be provided.<br />
The Trust will pilot <strong>and</strong> roll out across all<br />
facilities the use of an electronic tool to audit<br />
Pilot completed<br />
* indicates stated for a second time 36
Reference<br />
number<br />
Recommendations<br />
Designated<br />
department<br />
Action required<br />
waste management compliance against<br />
policy, procedure <strong>and</strong> RQIA requirements.<br />
This process will supplement the existing<br />
audit tools used by PCSS, IPC <strong>and</strong> also<br />
existing external audits conducted by Daniels<br />
(sharps box suppliers).<br />
Date for<br />
completion/<br />
timescale<br />
Roll-out<br />
programme<br />
across Trust to<br />
be completed by<br />
Apr 20<strong>12</strong><br />
‘Daniels’ audit completed in October <strong>2011</strong><br />
<strong>and</strong> results have been disseminated<br />
Safer Needle Device Group met again in Dec<br />
<strong>2011</strong>.<br />
16. 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 (Repeated)<br />
IPCT<br />
M<strong>and</strong>atory Infection Prevention & Control<br />
training is delivered by IPCN Team.<br />
Staff to be reminded of the link to the regional<br />
Infection Control Manual <strong>and</strong> the ‘Medical<br />
<strong>and</strong> Nursing Equipment Cleaning Guide’ has<br />
been re-circulated.<br />
Ongoing<br />
All service managers received email copies<br />
of the cleaning guide poster for dissemination<br />
to all wards <strong>and</strong> departments. Assurance is<br />
gained through environmental cleanliness<br />
audit programmes, which include daily ward<br />
checks, department <strong>and</strong> managerial audits,<br />
<strong>and</strong> IPC audits monitor compliance.<br />
Where an issue has been highlighted, action<br />
will be taken in conjunction with the<br />
appropriate department to ensure<br />
rectification.<br />
17. The trust <strong>and</strong> all staff have a collective responsibility to<br />
ensure that documentation used in relation to patients with<br />
Care pathways exist for MRSA <strong>and</strong> C.Diff.<br />
All patients with these infections are nursed<br />
Complete<br />
* indicates stated for a second time 37
Reference<br />
number<br />
Recommendations<br />
infection fully reflects the care given <strong>and</strong> are completed<br />
appropriately.<br />
Designated<br />
department<br />
Action required<br />
as per these pathways <strong>and</strong> this includes<br />
appropriate documentation in their notes<br />
Date for<br />
completion/<br />
timescale<br />
18. The trust should ensure that all members of staff are<br />
familiar with <strong>and</strong> adhere to the regional dress code policy<br />
(Repeated).<br />
Advice on patients with VRE/GRE or any<br />
other multi-resistant microorganism is given<br />
directly to staff <strong>and</strong> transmission based<br />
precautions implemented.<br />
This guidance is available in the regional<br />
Infection Control Manual. Policy is enforced<br />
at local level by senior staff, e.g., Ward<br />
Sisters <strong>and</strong> Senior Managers.<br />
Assurance is gained through environmental<br />
cleanliness audit programmes, which include<br />
daily ward checks, department <strong>and</strong><br />
managerial audits, <strong>and</strong> IPC audits monitor<br />
compliance.<br />
Where an issue has been highlighted, action<br />
will be taken in conjunction with the<br />
appropriate department to ensure<br />
rectification.<br />
Complete<br />
* indicates stated for a second time 38
* indicates stated for a second time 39