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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

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