Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...

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Belfast City Hospital, Belfast - 12 December 2011 - Regulation and ...

RQIA

Infection Prevention/Hygiene

Unannounced Follow up Inspection

Belfast Health and Social Care Trust

Belfast City Hospital

12 December 2011


Contents

1.0 Inspection Summary 1

2.0 Background Information to The Inspection Process 5

3.0 Inspections 6

4.0 Unannounced Inspection Process 7

4.1 Onsite Inspection 7

4.2 Feedback and Report of the findings 7

5.0 Audit Tool 8

6.0 Environment 10

6.1 Cleaning 10

6.2 Clutter 11

6.3 Maintenance and Repair 11

6.4 Fixture and Fittings 12

6.5 Information 13

7.0 Patient Linen 15

7.1 Management of Linen 15

8.0 Waste and Sharps 17

8.1 Waste 17

8.2 Sharps 18

9.0 Patient Equipment 19

10.0 Hygiene Factors 21

11.0 Hygiene Practice 23

12.0 Key Personnel and Information 26

13.0 Summary of Recommendations 28

14.0 Unannounced Inspection Flowchart 30

15.0 RQIA Hygiene Team Escalation Policy Flowchart 31

16.0 Action Plan 32


1.0 Inspection Summary

The unannounced inspection of Belfast City Hospital on the 20 October

2011 identified two of the four wards, Ward 6 North and Ward 10 North,

had areas of minimal compliance within standards 2-7 of the Regional

Healthcare Hygiene and Cleanliness Standards. In line with the follow

up process a further unannounced inspection was undertaken to these

wards on the 12 December 2011.

Inspection Outcomes

On the inspection of 20 October 2011, 22 recommendations were

made in relation to Standards 2-7. Six have been addressed, 16 have

been repeated and there are two new recommendations.

Improvements and Developments since the previous Inspection

On the12 December 2011 the follow up inspection found that good

progress had been made to address areas identified at the inspection

in October as outlined below:

Ward 6N – 73 per cent of the preliminary findings identified at the

previous inspection have been addressed.

Ward 10N – 70 per cent of the preliminary findings identified at the

previous inspection have been addressed.

In both wards there has been significant improvement as all seven

standards have now achieved compliance. Improved staff practices

were noted in cleaning of the environment and equipment,

management of linen, waste, sharps, hygiene factors and hygiene

practices

In both wards inspected the majority of outstanding issues requiring

action are in relation to attention to detail when cleaning,

refurbishment, maintenance and repair.

Key Areas for Improvement

In both wards inspected the majority of outstanding issues requiring

action are in relation to attention to detail when cleaning,

refurbishment, maintenance and repair. All standards have achieved

compliance in both wards, staff are encouraged to maintain this result

and improve on existing practice especially in hygiene factors;

materials and equipment for cleaning.

A summary of the recommendations following the re-audit is listed in

Section 13.

1


A detailed list of the findings from the re-audit is forwarded to Belfast

Health and Social Care Trust within 14 days of the inspection to enable

action on recurring or new areas which have achieved non compliant

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.

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

Hospital for their assistance during the inspection.

The following tables give an overview of compliance scores noted in

areas inspected by RQIA:

Table 1 summarises the overall compliance levels achieved.

Tables 2-7 summarise the individual tables for sections two to seven of

the audit tool as this assists organisation to target areas that require

more specific attention.

Table 1

General Environment

6N 6N 10N 10N

Oct 2011 Dec 2011 Oct 2011 Dec 2011

Environment 87 90 79 90

Patient Linen 83 93 84 91

Waste 76 90 84 92

Sharps 76 89 84 92

Patient Equipment 80 89 75 87

Hygiene Factors 82 95 83 90

Hygiene Practices 77 94 81 90

Total 80 91 81 90

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

2


Table 2

Environment

6N 6N 10N 10N

Oct 2011 Dec 2011 Oct 2011 Dec 2011

Reception 90 89 N/A N/A

Corridors, stairs lift 87 88 83 92

Public toilets 100 91 93 N/A

Ward/department–

general (communal)

82 93 76 95

Patient bed area 89 87 83 86

Bathroom/washroom 82 N/A 67 75

Toilet 89 95 86 90

Clinical room/

Treatment room

80 86 81 98

Clean utility room N/A N/A 72 94

Dirty utility room 84 86 65 89

Domestic store 85 90 79 82

Kitchen 95 94 84 91

Equipment store 77 96 N/A N/A

Isolation 94 86 89 97

General information 81 86 70 96

Average Score 87 90 79 90

Table 3

Linen

6N 6N 10N 10N

Oct 2011 Dec 2011 Oct 2011 Dec 2011

Storage of clean linen 88 92 88 88

Storage of used linen 78 94 79 93

Laundry facilities N/A N/A N/A N/A

Average Score 83 93 84 91

Table 4

Waste and Sharps

Handling,segregation,

storage, waste

Availability, use, storage

of sharps

6N

Oct 2011

6N

Dec 2011

10N

Oct 2011

10N

Dec 2011

76 90 84 92

76 89 84 92

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

3


Table 5

6N 6N 10N 10N

Patient Equipment

Oct 2011 Dec 2011 Oct 2011 Oct 2011

Patient equipment 80 89 75 87

Table 6

Hygiene Factors

Availability and

cleanliness of wash

hand basin and

consumables

Availability of alcohol

rub

6N

Oct 2011

6N

Dec 2011

10N

Oct 2011

10N

Dec 2011

92 96 94 97

97 100 100 100

Availability of PPE 73 93 87 87

Materials and

equipment for cleaning

65 90 51 76

Average Score 82 95 83 90

Table 7

Hygiene Practices

6N

Oct 2011

6N

Dec 2011

10N

Oct 2011

10N

Dec 2011

Effective hand hygiene

procedures

64 92 75 90

Safe handling and

disposal of sharps

77 100 92 85

Effective use of PPE 81 100 90 88

Correct use of isolation 82 89 61 89

Effective cleaning of

ward

73 95 74 91

Staff uniform and work

wear

83 86 93 96

Average Score 77 94 81 90

Compliant:

85% or above

Partial Compliance: 76% to 84%

Minimal Compliance: 75% or below

4


2.0 Background Information to the Inspection Process

RQIA’s infection prevention and hygiene team was established to

undertake a rolling programme of unannounced inspections of acute

hospitals. The Department of Health Social Service and Public Safety

(DHSSPS) commitment to a programme of hygiene inspections was

reaffirmed through the launch in 2010 of the revised and updated

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

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

in Northern Ireland.

The aims of the inspection process are:

to provide public assurance and to promote public trust and

confidence

to contribute to the prevention and control of HCAI

to contribute to improvement in hygiene, cleanliness and infection

prevention and control across health and social care in Northern

Ireland

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

transparent method for inspection, using standardised processes and

documentation.

5


3.0 Inspections

The DHSSPS have devised Regional Healthcare Hygiene and

Cleanliness standards. RQIA has revised their inspection processes to

support the publication of the standards which were compiled by a

regional steering group in consultation with service providers. One of

the standards relates to organisational systems and governance. To

ensure compliance with this, a new inspection process and

methodology process has been developed in consultation with the

regional steering group.

RQIA's infection prevention/hygiene team have planned a three year

programme of announced and unannounced inspections in acute and

non-acute hospitals in Northern Ireland in a rolling three year

programme to 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

6


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 four 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.

Organisations are forwarded a detailed action plan of preliminary

findings within 14 days of the inspection; this does not include the

findings of the overall organisational systems and governance. The

action plan is returned with the agreed draft report. The draft report

contains the high level recommendations of the inspection and is

forwarded to each organisation within 28 days of the inspection for

agreement and factual accuracy checking and returned within two

weeks. The detailed action plan is available on request from RQIA.

The findings of the inspection will be followed up in line with infection

prevention/hygiene inspection process (methodology, follow up and

reporting).

The infection prevention/hygiene team escalation process will be

followed if inspectors/reviewers identify any serious concerns during

the inspection (Section 15).

A number of documents have been developed to support and explain

the inspection process. This information is currently available on

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

7


5.0 Audit Tool

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

Healthcare Hygiene and Cleanliness standards. The standards

incorporate the critical areas which were identified through a review of

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

Healthcare Hygiene and Cleanliness standards). The audit tool follows

the format of the Regional Healthcare Hygiene and Cleanliness

standards and comprises of the following sections.

1. Organisational Systems and Governance: policies and

procedures in relation to key hygiene and cleanliness issues;

communication of policies and procedures; roles and

responsibilities for hygiene and cleanliness issues; internal

monitoring arrangements; arrangements to address issues

identified during internal monitoring; communication of internal

monitoring results to staff

This standard is not audited when carrying out unannounced

inspections however the findings of the organisational

system and governance at annual announced inspection will

be, where applicable, confirmed at ward level.

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

areas; cleanliness and state of repair of ward/department

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

cleanliness and state of repair of toilets, bathrooms and

washrooms; cleanliness and state of repair of ward/department

facilities; availability and cleanliness of isolation facilities;

provision of information for staff, patients and visitors

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

used linen; ward/department laundry facilities

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

sharps containers

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

patient equipment

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

availability of personal protective equipment (PPE); availability of

cleaning equipment and materials

7. Hygiene Practices: hand hygiene procedures; handling and

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

implementation of infection control procedures; cleaning of

ward/department; staff uniform and work wear

8


Level of Compliance

Percentage scores can be allocated a level of compliance using the

compliance categories below. The categories are allocated as follows:

Compliant

85% or above

Partial compliance 76 to 84%

Minimal compliance 75% or below

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

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

ensure that the appropriate action is taken.

9


6.0 Environment

STANDARD 2.0

GENERAL ENVIRONMENT

Cleanliness and state of repair of public areas; cleanliness and

state of repair of ward/department infrastructure; cleanliness and

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

toilets, bathrooms and washrooms; cleanliness and state of repair

of ward/department facilities; availability and cleanliness of

isolation facilities; provision of information for staff, patients and

visitors.

Environment

6N 6N 10N 10N

Oct 2011 Dec 2011 Oct 2011 Dec 2011

Reception 90 89 N/A N/A

Corridors, stairs lift 87 88 83 92

Public toilets 100 91 93 N/A

Ward/department

general (communal)

82 93 76 95

Patient bed area 89 87 83 86

Bathroom/washroom 82 N/A 67 75

Toilet 89 95 86 90

Clinical room/treatment

room

80 86 81 98

Clean utility room N/A N/A 72 94

Dirty utility room 84 86 65 89

Domestic store 85 90 79 82

Kitchen 95 94 84 91

Equipment store 77 96 N/A N/A

Isolation 94 86 89 97

General information 81 86 70 96

Average Score 87 90 79 90

The above tables outline the findings in relation to the general

environment of the wards inspected during both inspections. The

findings indicate improvement in both wards and in particular Ward 10

North where minimally compliant areas highlighted in red identified in

the first inspection and now mainly compliant. The findings in respect

of the general environment are detailed in the following sections.

6.1 Cleaning

The inspection evidenced that there was improvement in both wards to

indicate greater compliance with regional specifications for cleaning.

Inspectors observed that cleaning mechanisms were implemented to

prevent the build up of dust, debris and bacteria and subsequently

reduce the potential risk for the transmission of infection.

10


Staff in both wards are commended for achieving overall compliant

scores and improving the level of compliance in the majority of sections

within this standard. Inspectors observed in the main reception,

corridors, stairs and in both wards a large number of cleaning issues

previously identified had been addressed.

Recurring environmental cleaning issues related to cleaning the carpet

in the main reception and in both wards greater attention to detail when

cleaning cupboards and the corners and edges of floors. In Ward 6

North blu tac and tape remained on the walls in the treatment room and

the equipment sink in the dirty utility room required cleaning. In Ward

10 North the bathroom, domestic sluice and an air vent in the east side

toilet required more in-depth cleaning.

New issues identified in Ward 6 North related to removing limescale

from some taps and labels or tape residue from fixtures and fittings.

The cleaning of radiator grills, a bedside entertainment system,

windows and isolation Room J more effectively.

In Ward 10 North new issues identified related to stains on the wall at

the lift buttons, dusty ceiling lights in the clean utility room. In the

kitchen the taped labels on cupboards need to be removed and the

freezer and freezer door required more in depth cleaning.

6.2 Clutter

In both wards inspected staff have worked hard to address issues

raised in the previous inspection. Inspectors observed good use of

high density storage units and stores had been tidied to provide clutter

free ward environments, which promotes effective cleaning and good

hygiene practices.

In Ward 10 North one new observation to be addressed was a cluttered

and overstocked domestic store, while in Ward 6 North patient property

stored untidily on the windowsill in isolation Room J, impeded effective

cleaning.

6.3 Maintenance and Repair

At the time of inspection, inspectors observed maintenance staff, in

both wards, carrying out repairs in relation to issues identified at the

previous inspection. Inspectors were advised that a number of issues

had been addressed however work was on-going to implement the full

maintenance programme. In Ward 6 North work on a new shower

room and equipment store was on going at the time of the inspection.

Inspectors observed in Ward 10 North newly installed sluice sinks

(Picture 1) and hand washing sinks with sensor operated taps.

11


Picture 1: New sluice sink

Recurring maintenance issues in both wards related to the repair of

floors, walls, doors and frames, ceiling tiles and paintwork damage. A

new issue identified in both wards was some worn, damaged skirting

and in the main reception the hand washing sink overflow in the female

toilet was blocked.

In Ward 6 North new issues identified related to a leak from the slop

hopper soil pipe which had been repaired with plaster of paris and

an out of order dishwasher.

6.4 Fixtures and Fittings

The fixtures, fittings and equipment in both wards were generally fit for

purpose.

Examples of outstanding issues which were common to both wards,

related to the finish on some bedside lockers, wooden furniture,

cupboards and shelving was still worn, damaged or missing and some

bedrails were chipped. A new issue identified in the main reception

was old and worn chairs. Damaged fixtures and fittings are not

impervious to moisture and impede the cleaning process.

In both wards a recurring issue related to the lack of hand washing sink

in the domestic store however inspectors were advised that combined

domestic sluice and hand washing sinks are to be installed as part of

the maintenance programme.

In Ward 10 North a bedpan drip tray and replacement window blind in

side Room A were on order.

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6.5 Information

Staff in both wards are commended for achieving a compliance score

in this section of the standard.

Hand hygiene, MRSA, Clostridium difficile and general infection

prevention and control information leaflets were available for patients

and visitors.

A range of posters was in place for staff to reference, such as waste

management, colour coding and segregation of linen. In Ward 6 North

the sharps injury poster was available but had been removed from the

wall to facilitate painting. However posters were again observed taped

to surfaces with tape.

In both wards nursing cleaning schedules while available continue to

need further review to ensure all equipment to be cleaned is detailed

and to ensure any variances in signing off schedules are recorded.

Recurring issues in Ward 6 North related to temperatures of the drugs

fridge not being consistently recorded and no signage on the door of

the treatment room to indicate storage of oxygen. Signage was only

available within the room. A new issue observed relates to wall

mounted felt notice boards which cannot be effectively cleaned.

Additional Issues

Ward 6 North

In a dirty utility room ceiling tiles were missing or damaged

(ongoing refurbishment of the ward was in progress).

Ward 10 North

The deputy ward manager advised that the ward has a deficit in

Band 2 staff and a ward housekeeper which has an impact on the

cleaning of ward (Repeated).

There were no temperature ranges for staff to reference on the

trust fridge temperature recording sheet.

Side Room F was spot checked by inspectors after being cleaned

with vapourised hydrogen peroxide gas (VHP). VHP is used to

clean areas were patients with infection have been nursed.

Inspectors are aware that prior to VHP, a room should be stripped

of all disposable equipment and thoroughly cleaned with a

disinfectant, however inspectors observed that nursing and

domestic staff preparation of the room had not been carried out

effectively. It was noted that disposable equipment; suction

canister, oxygen mask and tubing, soap and paper towels were

13


insitu. Inspectors also observed that the bed base was dusty, the

bed frame had blood stains, the underside of the wardrobe shelf

was dirty and the inside of an IV pump required cleaning. As

inspectors were very concerned regarding this issue it was

immediately reported to the deputy ward manager and domestic

manager for action.

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 (Repeated).

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 (Repeated).

3. Detailed nursing cleaning schedules should be developed

(Repeated).

4. The trust should ensure that all staff are aware of the

importance of monitoring fridge temperatures (Repeated).

5. The trust should ensure that all staff are aware and carry out

the correct cleaning procedures prior to commencing VHP

and systems are in place to check the effectiveness of the

cleaning.

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7.0 Patient Linen

STANDARD 3.0

PATIENT LINEN

Storage of clean linen; handling and storage of used linen; ward/

department laundry facilities.

Patient Linen

6N 6N 10N 10N

Oct 2011 Dec 2011 Oct 2011 Dec 2011

Storage of clean linen 88 92 88 88

Storage of dirty linen 78 94 79 93

Laundry facilities N/A N/A N/A N/A

Average Score 83 93 84 91

7.1 Management of Linen

Staff in both wards are commended for improving the scoring in the

storage of used linen and achieving overall compliant scores in this

standard.

In both inspections effective arrangements were in place for the

storage of clean linen. Clean bed linen was stored in a separate store

from used linen and was found to be clean, tidy and free from rips and

tears (Picture 2). In Ward 6 North the issue of clean linen being stored

in an open trolley beside isolation side rooms has been addressed,

however reusable torn linen bags were again observed.

Picture 2: Clean, neat and tidy linen store

In Ward 10 North, linen skips remained chipped however inspectors

were advised that new linen skips were on order. There were still

outstanding maintenance and repair issues in the clean linen store and

the floor corners and edges again required cleaning.

In Ward 6 North clean linen store issues identified related to damaged

walls, doors and door frame.

15


Issues relating to the handling and storage of used linen have been

addressed and good practice was observed in both wards. Used linen

was placed immediately into the appropriate colour coded bags at the

point of use and staff were observed to be wearing the appropriate

personal protective equipment (PPE) when handling soiled/

contaminated linen.

Recommendations

6. The trust should ensure the correct storage of clean linen in

a designated area which is clean and fit for purpose

(Repeated).

16


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

6N

Oct 2011

6N

Dec 2011

10N

Oct 2011

10N

Dec 2011

76 90 84 92

76 89 84 92

8.1 Waste

Staff in both wards are commended for improving practice and

achieving compliance scores in this standard.

In Ward 6 North issues identified in relation to the inappropriate

disposal of waste have been addressed. However, in Ward 10 North;

household waste was again inappropriately disposed of into the clinical

waste stream and sharps boxes. Pharmaceutical waste was disposed

of into a yellow lidded burn bin, used for free fluid; the bin was also

overfilled.

In both wards, magpie boxes, used for the disposal of household tins,

glass and crockery, and clinical and household waste bins were now

available for the appropriate disposal of waste. Waste bins were

generally clean and in a good state of repair. However inspectors

again observed in Ward 6 North that some clinical waste bins were

stained under the lid. In the dirty utility room clinical waste bin was

stained and starting to rust under the lid and a new issue relating to

rust underneath the lid of the household waste bin in the end bay, dirty

utility room and treatment room was identified. Waste bags were again

observed tied onto monitor trolleys.

In both wards the shared waste hold area was still easily accessible

and not secure, large clinical waste euro bins remained open and in

Ward 10 North the hold area was untidy.

17


8.2 Sharps

Staff are commended for achieving compliance. The inspection

evidenced that in both wards inspected, effort had been made to

ensure safe handling, segregation, storage and disposal of sharps.

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

and were assembled correctly. However in Ward 6 North sharps boxes

found in the large euro bins were not signed with the date of assembly,

locality and staff signature.

Recurring issues in Ward 6 North were, one temporary closure

mechanism, to prevent spillage and impede access, was not in place

when the sharps box was not in use and in Ward 10 North the sharps

box on the resuscitation trolley although secure was open and had

contents insitu.

In Ward 6 North the underneath of sharps trays in use again required

more detailed cleaning and on this inspection a paper mache receiver

was observed inside a sharps tray. In Ward 10 North new issues

identified during this inspection related to an unsecure 22 litre sharps

box on the central island in the clinical room and the lid of one sharps

box splashed with blood.

Recommendations

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

should be available, clean and replaced as appropriate

(Repeated).

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 (Repeated).

18


9.0 Patient Equipment

STANDARD 5.0

PATIENT EQUIPMENT

Cleanliness and state of repair of general patient equipment.

6N 6N 10N 10N

Patient Equipment

Oct 2011 Dec 2011 Oct 2011 Oct 2011

Patient Equipment 80 89 75 87

In both wards a concentrated effort by all ward staff has improved the

cleaning of patient equipment and achieved compliant scores.

Inspectors observed in both wards a large number of cleaning issues

had been addressed, trigger tape to identify equipment has been

cleaned was generally insitu and staff knowledge on cleaning practice

had improved.

Recurring issues in Ward 6 North include, a used suction tube on the

shared resuscitation trolley had not been replaced or was again used

and not disposed off immediately, one commode was soiled, patient

wash bowls were not stored inverted, one of the drugs trolleys had

missing laminate and IV trays required cleaning. It was also noted that

while new commodes and IV stands to replace rusty equipment was on

order, they had yet to arrive. In Ward 10 North the underside of one

commode was stained, there was no trigger tape insitu on another and

the drugs (Picture 3), notes trolley and wheelchair required cleaning.

Picture 3: Dirty underside of drugs trolley

In Ward 6 North additional issues for improvement related to tape

residue on the drawers of the resuscitation trolley, single use

tourniquets were not available, soiled suction tubing in a side room

and dried out wipes on a monitor trolleys. The latter would suggest that

the wipes were not being used to clean equipment between patients.

In Ward 10 North new issues related to bedpans not stored inverted,

re-used single use jugs, the resuscitation trolley and the stethoscope

19


on the resuscitation trolley requiring cleaning. As already mentioned in

the environmental cleaning section in Room F, a suction canister,

oxygen mask and tubing were not changed as per trust policy prior to a

room being cleaned and an IV pump required cleaning.

Additional Issues

Ward 10 North

Staff advised that the adhesive strip on the trigger tape was

insufficient and the tape continually fell off equipment. The use of

an alternative tape should be reviewed.

Recommendations

9. The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean and in good repair

(Repeated).

20


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 basin and

consumables

Availability of alcohol

rub

6N

Oct 2011

6N

Dec 2011

10N

Oct 2011

10N

Dec 2011

92 96 94 97

97 100 100 100

Availability of PPE 73 93 87 87

Materials and

equipment for cleaning

65 90 51 76

Average Score 82 95 83 90

Recommendations

Both wards are commended for improving and achieving a compliant or

fully compliant score in all sections of this standard.

Hand washing sinks and fixtures and fittings in both wards were

generally clean, working and in a good state of repair. Sensor operated

taps were available in clinical areas. However, in Ward 6 North greater

attention to detail when cleaning the taps of the hand washing sink in

the treatment room could further improve scoring. In Ward 10 North,

on the day of inspection, the sensor tap on the hand washing sink in

the west side dirty utility room was not consistently working; staff

advised that this had been reported for repair.

Liquid soap and paper hand towels were available in all areas however

an additional issue in Ward 10 North was the paper towel and soap

dispensers in the west side dirty utility room were not positioned

bedside the hand washing sink for staff to easily use. In Ward 6 North

a recurring and additional issue related to cleaning the underside of

some of the paper hand towel and soap dispensers. There were no

issues identified in the provision of alcohol hand rub.

In Ward 10 North, inspectors observed that a range of personal

protective equipment (PPE) was available in the wall mounted

dispensers however wall mounted aprons were again observed in the

dirty utility rooms. This is not advised by the trust infection prevention

and control team due to the potential risk of aerosol contamination. In

Ward 6 North inspectors again noted the lack of PPE stations in the

shared corridor and at the side room/isolation area of the ward,

however these have been ordered.

21


While improvement was noted, recurring and additional issues were

identified in both wards relating to the availability, storage and use of

materials and equipment for general cleaning of the ward.

In Ward 6 North, the daily changes of Actichlor plus disinfectant were

again inconsistently recorded and a yellow mop bucket was soiled with

what appeared to be dried blood. A mop was not stored inverted when

not in use and the vacuum and floor burnisher were old and worn; staff

advised that new equipment was on order.

In Ward 10 North cleaning solutions were again not stored in

accordance with Control of Substances Hazardous to Health (COSHH)

regulations and Actichlor plus disinfectant was diluted with hot water

rather than luke warm/cold water; this was immediately addressed by

ward staff. Some mop and hand held buckets required cleaning and

some equipment was old, worn and in the process of being replaced.

New issues related to a domestic not accurately measuring water when

diluting Actichlor plus and an insufficient supply of yellow coloured

cloths for cleaning infected areas; these issues were addressed during

the inspection.

Recommendations

10. The trust should ensure that hand washing sinks and

consumables are available, clean, and in a good state of

repair (Repeated).

11. Equipment used for the general cleaning of a ward are clean,

fit for purpose, and stored appropriately and are fit for

purpose (Repeated).

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

staff knowledge and practice is kept up to date regarding the

use of disinfectants (Repeated).

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

in a locked cupboard, in accordance with COSHH regulations

(Repeated).

22


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

6N

Oct 2011

6N

Dec 2011

10N

Oct 2011

10N

Dec 2011

Effective hand hygiene

procedures

64 92 75 90

Safe handling and

disposal of sharps

77 100 92 85

Effective use of PPE 81 100 90 88

Correct use of isolation 82 89 61 89

Effective cleaning of

ward

73 95 74 91

Staff uniform and work

wear

83 86 93 96

Average Score 77 94 81 90

Recommendations

Both wards are commended for improving and achieving a compliant or

fully compliant score in all sections of this standard.

Inspectors observed that effective hand hygiene procedures were

generally undertaken by staff and staff performed hand hygiene in

accordance with WHO guidance at the appropriate moments of care.

However, in Ward 6 North a registered nurse did not carry out the

recommended seven step technique when using alcohol rub and in

Ward 10 North, catering and domestic staff were observed not washing

their hands after leaving a lobbied isolation room.

Ward 6 North has worked hard and achieved full compliance in the

safe handling and disposal of sharps however Ward 10 North’s

compliant score has dropped in this section. Inspectors observed new

issues relating to used white coloured needles re-sheathed (Picture 4)

and discarded separately from the syringe rather than discarded as a

complete single unit; this was shown to the nurse in charge during the

inspection.

23


Pictures 4: Re-sheathed needles

Ward 6 North achieved full compliance in the effective use of PPE

however in Ward 10 North the compliance score has again dropped.

Inspectors observed new issues relating to domestic and catering staff

leaving a lobbied isolation room without removing their aprons and

gloves and catering staff wearing a white apron rather than a green

apron for serving food.

In both wards compliance has been achieved in the correct use of

isolation with a large number of issues previously identified addressed.

A recurring issue in Ward 10 North was domestic staff using sani wipes

rather than disinfectant to clean isolation rooms. New issues related to

MRSA care pathways not fully completed for two patients in Ward 6

North and in Ward 10 North the Vancomycin - Resistant Enterococci

(VRE) isolation care plan did not detail all infection prevention and

control precautions required for isolation.

Inspectors noted an overall improvement in staff knowledge on the

disinfectant in use and the colour coded system for cleaning equipment

used at ward level. However it was noted in Ward 10 North that the

previously mentioned domestic staff shortages has impacted negatively

on the cleaning; inspectors were advised the back corridor outside the

domestic store had not been cleaned for one week.

In both wards, compliance with regional dress code was good, however

for Ward 6 North further work is required to ensure adherence to the

policy from medical staff. Nursing staff informed the inspectors that

changing facilities were not available.

Recommendations

14. All staff have a responsibility to ensure that hand hygiene is

carried out in line with WHO guidance and that all PPE is

used appropriately (Repeated).

15. The trust and all staff have a collective responsibility to

ensure the safe handling and disposal of sharps.

24


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

staff knowledge and practice is kept up to date regarding

isolation cleaning (Repeated).

17. The trust and all staff have a collective responsibility to

ensure that documentation used in relation to patients with

infection fully reflects the care given and are completed

appropriately.

18. The trust should ensure that all members of staff are familiar

with and adhere to the regional dress code policy (Repeated).

25


12.0 Key Personnel and Information

Members of the RQIA inspection team

Mrs E Colgan - Senior Inspector Infection Prevention/Hygiene Team

Mrs L Gawley - Inspector Infection Prevention/Hygiene Team

Mrs M Keating - Inspector Infection Prevention/Hygiene Team

Mrs S O’Connor - Inspector Infection Prevention/Hygiene Team

Trust representatives attending the feedback session

The key findings of the inspection were outlined to the following trust

representatives:

Ms Jennifer Welsh - Director, Cancer & Specialist Services

Ms Moira Mannion - Co- Director Nursing (representing Director

of Nursing)

Ms Caroline Leonard - Cancer & Specialist Services Co- Director

Ms Gillian Traub - Service Manager, Oncology/Haematology

Mr Seamus Trainor - PCSS Manager, BCH

Mrs Mandy Armstrong - Regulation & Improvement, Manager

Ms Sarah Williamson - Acting Clinical Co-ordinator, Haematology

Mr Tony O’Hara - SS Catering Manager

Mr Stephen Lawson - Estates

Mrs Caroline Smyth - Senior Infection Prevention & Control Nurse

Ms Rosie Gray - Ward 6 North, Manager

Ms Ruth Finn - Infection Prevention & Control Nurse

Ms Joanne Stewart - Ward 10 North, Deputy Ward Manager

Ms Patricia Berkery - Domestic Services

Apologies

Mr Colm Donaghy

Ms Brenda Creaney

Mr Colin Cairns

- Chief Executive

- Executive Director of Nursing

- Co-Director, PCSS

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

26


This information is currently available on request and will be available

in due course on the RQIA website.

27


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 (Repeated).

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 (Repeated).

3. Detailed nursing cleaning schedules should be developed

(Repeated).

4. The trust should ensure that all staff are aware of the

importance of monitoring fridge temperatures (Repeated).

5. The trust should ensure that all staff are aware and carry out

the correct cleaning procedures prior to commencing VHP

and systems are in place to check the effectiveness of the

cleaning.

6. The trust should ensure the correct storage of clean linen in

a designated area which is clean and fit for purpose

(Repeated).

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

should be available, clean and replaced as appropriate

(Repeated).

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 (Repeated).

9. The trust and individual staff have a collective responsibility

to ensure that patient equipment is clean and in good repair

(Repeated).

10. The trust should ensure that hand washing sinks and

consumables are available, clean, and in a good state of

repair (Repeated).

11. Equipment used for the general cleaning of a ward are clean,

fit for purpose, and stored appropriately and are fit for

purpose (Repeated).

28


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

staff knowledge and practice is kept up to date regarding the

use of disinfectants (Repeated).

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

in a locked cupboard, in accordance with COSHH regulations

(Repeated).

14. All staff have a responsibility to ensure that hand hygiene is

carried out in line with WHO guidance and that all PPE is

used appropriately (Repeated).

15. The trust and all staff have a collective responsibility to

ensure the safe handling and disposal of sharps.

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

staff knowledge and practice is kept up to date regarding

isolation cleaning (Repeated).

17. The trust and all staff have a collective responsibility to

ensure that documentation used in relation to patients with

infection fully reflects the care given and are completed

appropriately.

18. The trust should ensure that all members of staff are familiar

with and adhere to the regional dress code policy (Repeated).

29


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

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

30


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

31


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 (Repeated).

Designated

department

Nursing

PCSS

IPC

Action required

‘Roles and responsibilities of Staff in relation

to Environmental Cleanliness and

Cleanliness of Equipment’ policy under

review.

Date for

completion/

timescale

Mar 2012

The consultation process in relation to the

cleaning manual has resulted in requests for

significant changes to the content and format.

Work is ongoing to have a revised final

consultation document by February 2012.

Feb 2012

All of these aspects will be monitored through

the programme of Environmental Cleanliness

Audits based on the Cleanliness Matters

Strategy and results fed back through

Balanced Scorecards.

Ongoing

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 (Repeated).

3. Detailed nursing cleaning schedules should be developed

(Repeated).

Estates

IPC

Other

appropriate

staff

Nursing

IPECC

This is ongoing as part of Estate daily

maintenance and refurbishment programmes.

A sub-group of IPECC (Infection Prevention

& Environment and Cleanliness Committee)

will be set up to review and standardise

cleaning schedules, and will establish any

outstanding issues of audit standardisation

process.

Agree a standardised audit which will be

used in all areas. This will include

standardised responsibilities. To be kept

under review.

Systematic roll out of the agreed

Ongoing

Feb 2012

Commencing

Feb 2012

* indicates stated for a second time 32


Reference

number

Recommendations

4. The trust should ensure that all staff are aware of the

importance of monitoring fridge temperatures (Repeated).

Designated

department

Nursing

Action required

standardised audit using the Maximiser

system.

The Medicines Code outlines procedures for

use of medicine fridges. A pharmaceutical

refrigerator temperature log sheet is

maintained for each individual fridge, with

records being maintained and monitored by

Ward Managers.

Date for

completion/

timescale

Ongoing

5. The trust should ensure that all staff are aware and carry

out the correct cleaning procedures prior to commencing

VHP and systems are in place to check the effectiveness

of the cleaning.

6. The trust should ensure the correct storage of clean linen

in a designated area which is clean and fit for purpose

(Repeated).

Nursing

A pre-VHP checklist has been developed and

currently being consulted on It is due for

implementation in February. There is a

protocol agreed by IPC and Estates where

IPC is contacted before VHP is carried out so

that cleaning can be implemented before

VHP.

When possible an IPCN will check the

cleaning before VHP.

Guidance regarding storage of linen is in the

Regional Infection Prevention Manual. Linen

storage and segregation guidance has been

circulated to all Directorates.

Feb 2012

Complete

This states that all linen must be stored off

the floor in a clean dedicated area that allows

for ease of access and rotation of stock and

that Linen rooms must have shelving that are

easy to clean, and cleaning frequencies must

be at least quarterly.

7. Waste bins and equipment used in the management of

waste should be available, clean and replaced as

appropriate (Repeated).

PCSS

Nursing

This is monitored as part of the

Environmental Cleanliness Audit Programme.

Regional contract for bins at adjudication

stage.

Ongoing

* indicates stated for a second time 33


Reference

number

Recommendations

Designated

department

Action required

Environmental cleanliness audit programmes,

which include daily ward checks, department

and managerial audits, and IPC audits

monitor compliance.

Date for

completion/

timescale

Where an issue has been highlighted, action

will be taken in conjunction with the

appropriate department to ensure

rectification.

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 (Repeated).

PCSS

Nursing

The Trust will pilot and roll out across all

facilities the use of an electronic tool to audit

waste management compliance against

policy, procedure and RQIA requirements.

This process will supplement the existing

audit tools used by PCSS, IPC and also

existing external audits conducted by Daniels

(sharps box suppliers).

Pilot completed

Roll-out

programme

across Trust to

be completed by

Apr 2012

9. The trust and individual staff have a collective

responsibility to ensure that patient equipment is clean

and in good repair (Repeated).

Nursing

PCSS

Daniels’ audit completed Oct 2011 and

results disseminated.

The consultation process in relation to the

cleaning manual has resulted in requests for

significant changes to the content and format.

Work is ongoing to have a revised final

consultation document by February 2012.

Complete

Feb 2012

The manual includes roles and

responsibilities of trust staff in relation to

patient equipment. A template will be used to

record all cleaning of equipment.

10. The trust should ensure that hand washing sinks and

consumables are available, clean, and in a good state of

repair (Repeated).

PCSS

This is monitored as part of the

Environmental Cleanliness Audit Programme.

Staff are reminded of the importance of

replenishing dispensers.

Ongoing

* indicates stated for a second time 34


Reference

number

Recommendations

Designated

department

Action required

Date for

completion/

timescale

Environmental cleanliness audit programmes,

which include daily ward checks, department

and managerial audits, and IPC audits

monitor compliance.

Where an issue has been highlighted, action

will be taken in conjunction with the

appropriate department to ensure

rectification.

Regular training is provided to all appropriate

staff.

11. Equipment used for the general cleaning of a ward are

clean, fit for purpose, and stored appropriately and are fit

for purpose (Repeated).

Nursing

PCSS

The consultation process in relation to the

cleaning manual has resulted in requests for

significant changes to the content and format.

Work is ongoing to have a revised final

consultation document by February 2012.

Feb 2012

Environmental cleanliness audit programmes,

which include daily ward checks, department

and managerial audits, and IPC audits

monitor compliance.

Where an issue has been highlighted, action

will be taken in conjunction with the

appropriate department to ensure

rectification.

Regular training is provided to all appropriate

staff.

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

staff knowledge and practice is kept up to date regarding

the use of disinfectants (Repeated).

Nursing

All staff have been reminded and made

aware of poster advice.

Completed and

ongoing

* indicates stated for a second time 35


Reference

number

Recommendations

Designated

department

Action required

Mandatory IPC training is provided, poster

advice issued to wards, staff questioned at

audit.

Date for

completion/

timescale

13. The trust should ensure that all cleaning products are

stored in a locked cupboard, in accordance with COSHH

regulations (Repeated).

PCSS

Locked cupboards are provided.

Ward managers and PCSS supervisors carry

out regular checks to ensure all staff comply

with COSHH procedures. Audited as part of

Belfast Risk Assessment and Audit Tool

(BRAAT).

Complete

14. All staff have a responsibility to ensure that hand hygiene

is carried out in line with WHO guidance and that all PPE

is used appropriately (Repeated).

IPCT

Balance scorecards, which include WHO

Hand Hygiene audits. All of these aspects will

be monitored through the programme of

Environmental Cleanliness Audits based on

the Cleanliness Matters Strategy.

Complete and

Ongoing

The IPCT carried out an independent audit

and results have been fed back.

Independent audits will be carried out 4 times

a year (2 of which will be carried out by

Infection Prevention and Control).

The IPCT is currently devising an educational

tool to remind staff of the appropriate use of

PPE.

15. The trust and all staff have a collective responsibility to

ensure the safe handling and disposal of sharps.

PCSS

There is a training programme available to all

staff.

Complete

Update and refresher training will continue to

be provided.

The Trust will pilot and roll out across all

facilities the use of an electronic tool to audit

Pilot completed

* indicates stated for a second time 36


Reference

number

Recommendations

Designated

department

Action required

waste management compliance against

policy, procedure and RQIA requirements.

This process will supplement the existing

audit tools used by PCSS, IPC and also

existing external audits conducted by Daniels

(sharps box suppliers).

Date for

completion/

timescale

Roll-out

programme

across Trust to

be completed by

Apr 2012

‘Daniels’ audit completed in October 2011

and results have been disseminated

Safer Needle Device Group met again in Dec

2011.

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

staff knowledge and practice is kept up to date regarding

isolation cleaning (Repeated)

IPCT

Mandatory Infection Prevention & Control

training is delivered by IPCN Team.

Staff to be reminded of the link to the regional

Infection Control Manual and the ‘Medical

and Nursing Equipment Cleaning Guide’ has

been re-circulated.

Ongoing

All service managers received email copies

of the cleaning guide poster for dissemination

to all wards and departments. Assurance is

gained through environmental cleanliness

audit programmes, which include daily ward

checks, department and managerial audits,

and IPC audits monitor compliance.

Where an issue has been highlighted, action

will be taken in conjunction with the

appropriate department to ensure

rectification.

17. The trust and all staff have a collective responsibility to

ensure that documentation used in relation to patients with

Care pathways exist for MRSA and C.Diff.

All patients with these infections are nursed

Complete

* indicates stated for a second time 37


Reference

number

Recommendations

infection fully reflects the care given and are completed

appropriately.

Designated

department

Action required

as per these pathways and this includes

appropriate documentation in their notes

Date for

completion/

timescale

18. The trust should ensure that all members of staff are

familiar with and adhere to the regional dress code policy

(Repeated).

Advice on patients with VRE/GRE or any

other multi-resistant microorganism is given

directly to staff and transmission based

precautions implemented.

This guidance is available in the regional

Infection Control Manual. Policy is enforced

at local level by senior staff, e.g., Ward

Sisters and Senior Managers.

Assurance is gained through environmental

cleanliness audit programmes, which include

daily ward checks, department and

managerial audits, and IPC audits monitor

compliance.

Where an issue has been highlighted, action

will be taken in conjunction with the

appropriate department to ensure

rectification.

Complete

* indicates stated for a second time 38


* indicates stated for a second time 39

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