Altnaglevin Hospital, Londonderry - 22 November 2011

RQIA
Infection Prevention/Hygiene
Unannounced inspection
Western Health and Social Care Trust
Altnagelvin Hospital
22 November 2011

Contents
1.0 Inspection Summary 1
2.0 Background Information to the Inspection Process 6
3.0 Inspections 7
4.0 Unannounced Inspections 8
4.1 Onsite Inspection 8
4.2 Feedback and Report of the findings 8
5.0 Audit Tool 9
6.0 Environment 11
6.1 Cleaning 12
6.2 Clutter 14
6.3 Maintenance and Repair 15
6.4 Fixture and Fittings 15
6.5 Information 16
7.0 Patient Linen 18
7.1 Management of Linen 18
8.0 Waste and Sharps 20
8.1 Waste 20
8.2 Sharps 21
9.0 Patient Equipment 23
10.0 Hygiene Factors 25
11.0 Hygiene Practice 28
12.0 Key Personnel and Information 30
13.0 Summary of Recommendations 31
14.0 Unannounced Inspection Flowchart 33
15.0 RQIA Hygiene Team Escalation Policy Flowchart 34
16.0 Action Plan 35

1.0 Inspection Summary
An unannounced inspection was undertaken to Altnagelvin Hospital,
on the 22 November 2011. The hospital was assessed against the
Regional Healthcare Hygiene and Cleanliness standards and the
following areas were inspected:
Ward 3 - Respiratory
Ward 8 - Orthopaedic
Ward 31 - Planned Surgery
Ward 40 - Stroke
Altnagelvin Area Hospital is an acute hospital which offers a range of
services, including a 24-hour Accident and Emergency Department.
The hospital is currently undergoing a major redevelopment
programme consisting of a new build and refurbishment of older wards.
The main hospital building is made up of a tower block with a number
of adjoining new extensions accommodating the outpatients
department, day case unit, medical imaging, theatres, surgical wards,
maternity ward, oncology unit, physiotherapy department. The wards
inspected were a mix of new and old buildings, Ward 3 had just been
refurbished and had only reopened the week before the inspection.
Inspection Outcomes
Overall the inspection teams found evidence that Altnagelvin Area
Hospital is working to comply with the Regional Healthcare Hygiene
and Cleanliness standards. However inspectors found that further
improvement is required in the following areas.
Wards, 3, 31 and 40 achieved an overall compliant score and Ward 8
achieved an overall partially compliant score. Inspectors observed that
the environment in the three wards which were compliant was
generally clean and maintained to a satisfactory standard, however in
Ward 8 more attention to detail was required when cleaning as a
significant number of issues were identified for improvement.
In Ward 8 three standards were minimally compliant, patient linen,
sharps and patient equipment, and three standards were partially
compliant, all require immediate action to reach an acceptable
standard.
In Wards 3, 31 and 40 the standard on patient equipment, and in
Wards 3 and 40 the standard on safe handling and disposal of sharps
were partially compliant which indicates that more work is required to
improve practice.
All wards were compliant in the segregation and storage of waste
standard which is to be commended.
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As a result of the findings for Ward 8 a follow up inspection will be
carried out within three months.
The inspection resulted in 20 recommendations for Altnagelvin
Hospital, a full list of recommendations is listed in Section 13.
A detailed list of preliminary findings is forwarded to Western Health
and Social Care Trust within 14 days of the inspection to enable early
action on identified areas which have achieved non complaint scores.
The draft report which includes the high level recommendations in a
Quality Improvement Plan is forwarded within 28 days of the inspection
for agreement and factual accuracy. The draft report is agreed and a
completed action plan is returned to RQIA within 14 days from the date
of issue. The detailed list of preliminary findings is available from RQIA
on request.
The final report and Quality Improvement Plan will be available on the
RQIA website. Reports and action plans will be subject to performance
management by the Health and Social Care Board and the Public
Health Agency.
Notable Practice
The inspection identified the following areas of notable practice
Domestic staff are trained to the British Institute of Cleaning
Science standards (BICS)
Both a patient on Ward 8 and a relative on Ward 40 spoke to
the inspectors to praise the care given by staff on the ward
The inspectors were informed that the hospital is
commencing the Productive Ward Project in January 2012 1
Waste is being recycled at ward level
The RQIA inspection team would like to thank the staff at the
Altnagelvin 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.
1 Encourages nurses to make small changes to improve the way their ward is run by analysing the way they work
2

Table 1
Areas Inspected Ward 3 Ward 8 Ward 31 Ward 40
General
environment
88 78 87 90
Patient linen 95 68 82 90
Waste 93 96 85 92
Sharps 77 71 87 81
Equipment 84 72 76 84
Hygiene factors 93 84 95 91
Hygiene practices 91 83 87 88
Average Score 89 79 86 88
Table 2
General
Environment Ward 3 Ward 8 Ward 31 Ward 40
Reception N/A N/A 86 92
Corridors, stairs lift 77 76 96 97
Public toilets 94 N/A 88 N/A
Ward/department -
general
88 76 97 93
(communal)
Patient bed area 77 71 81 85
Bathroom/
washroom
96 76 86 94
Toilet 93 86 87 95
Clinical
room/treatment 87 60 88 81
room
Clean utility room 87 75 84 N/A
Dirty utility room 93 77 92 96
Domestic store 98 89 98 91
Kitchen 94 84 N/A 98
Equipment store 96 78 67 77
Isolation 78 86 92 93
General
information
73 77 79 74
Average Score 88 78 87 90
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
3

Table 3
Patient Linen Ward 3 Ward 8 Ward 31 Ward 40
Storage of clean
linen
96 60 87 88
Storage of dirty
linen
94 76 76 91
Laundry facilities N/A N/A N/A N/A
Average Score 95 68 82 90
Table 4
Waste and
Sharps
Handling,
segregation,
storage, waste
Availability, use,
storage of sharps
Ward 3 Ward 8 Ward 31 Ward 40
93 96 85 92
77 71 87 81
Table 5
Patient
Equipment
Ward 3 Ward 8 Ward 31 Ward 40
Patient equipment 84 72 76 84
Table 6
Hygiene Factors Ward 3 Ward 8 Ward 31 Ward 40
Availability and
cleanliness of
wash hand basin
82 91 99 96
and consumables
Availability of
alcohol rub
97 100 100 83
Availability of PPE 100 85 85 100
Materials and
equipment for 93 61 95 83
cleaning
Average Score 93 84 95 91
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
4

Table 7
Hygiene
Practices
Ward 3 Ward 8 Ward 31 Ward 40
Effective hand
hygiene
93 68 95 85
procedures
Safe handling and
disposal of sharps
91 85 91 100
Effective use of
PPE
100 81 81 93
Correct use of
isolation
95 N/A 93 80
Effective cleaning
of ward
76 79 76 76
Staff uniform and
work wear
93 100 90 93
Average Score 91 83 87 88
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
5

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

3.0 Inspections
The DHSSPS has devised draft Regional Healthcare Hygiene and
Cleanliness standards. RQIA has revised its inspection processes to
support the publication of the standards which were compiled by a
regional steering group in consultation with service providers.
RQIA's infection prevention/hygiene team have planned a three year
programme which includes announced and unannounced inspections
in acute and non-acute hospitals in Northern Ireland. This will assess
compliance with the DHSSPS Regional Healthcare Hygiene and
Cleanliness standards.
The inspections will be undertaken in accordance with the four core
activities outlined in the RQIA Corporate Strategy, these include:
Improving care: we encourage and promote improvements in the
safety and quality of services through the regulation and review of
health and social care
Informing the population: we publicly report on the safety,
quality and availability of health and social care
Safeguarding rights: we act to protect the rights of all people
using health and social care services
Influencing policy: we influence policy and standards in health
and social care
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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 and four peer reviewers. One
inspector led the team and was responsible for guiding the team and
ensuring they were in agreement about the findings reached.
Membership of the inspection team is outlined in Section 12.
The inspection of ward environments is carried out using the Regional
Healthcare Hygiene and Cleanliness audit tool. The inspection
process involves observation, discussion with staff, and review of some
ward documentation.
4.2 Feedback and Report of the Findings
The process concludes with a feedback of key findings to trust
representatives including examples of notable practice identified during
the inspection. The details of trust representatives attending the
feedback session is outlined in Section 12.
The findings, report and follow up action will be in accordance with the
Infection Prevention/ Hygiene Inspection Process (methodology, follow
up and reporting).
The infection prevention/hygiene team escalation process will be
followed if inspectors/reviewers identify any serious concerns during
the inspection (Section 15).
A number of documents have been developed to support and explain
the inspection process. This information is currently available on
request and will be available in due course on the RQIA website.
8

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

Level of Compliance
Percentage scores can be allocated a level of compliance using the
compliance categories below. The categories are allocated as follows:
Compliant
85% or above
Partial compliance 76 to 84%
Minimal compliance 75% or below
Each section within the audit tool will receive an individual and an
overall score, to identify areas of partial or minimal compliance to
ensure that the appropriate action is taken.
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6.0 Environment
STANDARD 2.0
GENERAL ENVIRONMENT
Cleanliness and state of repair of public areas; cleanliness and
state of repair of ward/department infrastructure; cleanliness and
state of repair of patient bed area; cleanliness and state of repair
of toilets, bathrooms and washrooms; cleanliness and state of
repair of ward/department facilities; availability and cleanliness of
isolation facilities; provision of information for staff, patients and
visitors.
General
Environment
Ward 3 Ward 8 Ward 31 Ward 40
Reception N/A N/A 86 92
Corridors, stairs
lift
77 76 96 97
Public toilets 94 N/A 88 N/A
Ward/department
- general
88 76 97 93
(communal)
Patient bed area 77 71 81 85
Bathroom/
washroom
96 76 86 94
Toilet 93 86 87 95
Clinical
room/treatment 87 60 88 81
room
Clean utility room 87 75 84 N/A
Dirty utility room 93 77 92 96
Domestic store 98 89 98 91
Kitchen 94 84 N/A 98
Equipment store 96 78 67 77
Isolation 78 86 92 93
General
information
73 77 79 74
Average Score 88 78 87 90
The above table outlines the findings in relation to the general
environment of the facilities inspected. The findings indicate that there
are concerns regarding Ward 8 and in particular the minimally
compliant areas highlighted in red. The findings in respect of the
general environment are detailed in the following sections.
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6.1 Cleaning
During the inspection there was evidence to indicate compliance with
regional specifications for cleaning. However, inspectors observed,
that while cleaning mechanisms were in place to prevent the build up of
dust, debris and bacteria and subsequently minimise the potential risk
for the transmission of infection, these were not always effectively
implemented or adhered to by staff.
The team inspected the two receptions areas, the main reception which
is part of the old hospital and the entrance to the new wing. The main
reception had no cleaning issues except for the fabric finish of the
chairs which were stained. In contrast the outside of the reception of
the new wing was littered with discarded cigarettes butts and grass
was growing up through the paving. The glass entrance doors were
very soiled and the overhead external glass ceiling was partly covered
in green moss (Picture1). The disabled door access button was
marked and required cleaning.
Picture 1: Glass in new reception area
Overall the of cleaning in Ward 3, 31 and 40 was of a good standard.
In Ward 31 more attention was required to cleaning areas such as floor
corners and behind bins, which were dusty. The wall behind the sink in
the clean utility room, the door frame of the dirty utility room and the
frame of a patient bed were stained. In the sanitary areas, the frame of
the shower chair, in the bathroom was stained and in the toilet the
underside of the raised toilet seat was stained and the framework was
rusted. Both the inside of a toilet bowl and the sluice hopper in the
dirty utility room required cleaning.
Ward 3 had only been re-opened for a week after refurbishment and
some surfaces such as the patients’ bedside table and computer key
boards were dusty. In the dirty utility room there was paper debris in
the high density storage units and adhesive residue on the glass panel
of the door. There was a fabric finished chair in the treatment room,
this is not suitable for clinical areas as it cannot be effectively cleaned.
The bathroom was being used to store a hoist and 2 slings, there was
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also evidence of communal products such as toothpaste, talcum
powder, shower gel and E45 cream.
Patients should be discouraged from leaving their soaps and shower
gels in the shower and on the wash hand basins. This will prevent the
use of communal products and help to reduce the risk of contamination
and possible spread of infection.
In Ward 40 some bed frames were dusty, this included one which had
been marked as cleaned on the 21 November 2011. A baby bath
cleansing solution and talcum powder had been left on the hand
washing sink in the bathroom and in the shower room, communal
toiletries and a tube of Tena cream wash were observed. The floor
and shelves in the equipment store were dusty, the room was cluttered
and untidy restricting effective cleaning, an issue also identified in
Ward 31.
In all four wards particular attention was required when cleaning
isolation rooms. In Ward 3, which had just been refurbished, the
flooring in Room H, had ground in stains, the top of the bedside table
was dusty and the laminate finish was damaged. The undercarriage of
the bed was dusty and there was minor damage to the frame. The
fabric of an armchair was torn, therefore the chair could not be
effectively cleaned and there were stains on the newly painted ceiling.
The room was cluttered with patients property, electrical equipment
and respiratory equipment, all of which prevent effective cleaning. In
Wards 8, 31 and 40, the floor required cleaning and in Ward 31 the
underside of the raised toilet seat and the top of the shower chair in the
en-suite were stained.
The inspectors noted three minimally compliant sections in Ward 8; the
bed area, clinical room and clean utility room, (which was a joint
examination and pharmacy room). The inspectors acknowledge that
this ward is in the older part of the hospital and there are estates issues
associated with age which have had a negative impact on some of the
score, however cleaning issues were identified. The floor of bed Bay D
and F, had ground in stains and the floor at the corners and under the
beds was dusty. The top of the bedside tables required cleaning and
bedside chairs were dusty, stained and showing signs of wear. The
undercarriage of some beds and wall shelving were also dusty. In the
treatment room there were stains on the external cupboard doors and
the medical gas alarm.
The ceiling light fitting and air vents were dusty, and there was
adhesive residue on the glass panel of the door. The plug, taps and
overflow on the hand washing sink at the nurses’ station were dirty, the
outside of the drugs fridge was stained, damaged, the door was not
locked. The window blinds in the examination room were broken and
dusty and the high density shelving in the pharmacy was dusty. The
foot stools in the clinical room and clean utility room required cleaning.
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The sanitary areas also had cleaning issues; in the toilets the rim of the
toilet bowl and underneath the raised toilet seat were stained, the
frame of the raised toilet seat was dirty and rusty. The underside of the
taps of the hand washing sink required cleaning. In the bottom shower
room the seal and the edge of the shower door and the shower curtain
were stained; there was mould present in the shower base. The
underside of the toilet seat, the rim of the toilet bowl, and the underside
of the raised seat were all stained.
In both Ward 8 and Ward 31
inspections of bed mattresses
showed that the vinyl covers
and the foam interior were
stained, in Ward 8 a mattress
had a tear and in Ward 31 the
cover had perished (Picture
2).
Picture 2: Ward 31 perished cover on mattress
In all four wards the temperature of the drugs fridge was not recorded
consistently. It is advised that fridge temperature checks are carried
out on a daily basis to ensure medication is kept at the correct
temperature and to identify if a fridge has failed to reach the required
temperature and a cold chain failure has occurred.
Throughout the four wards inspected it was observed that the external
windows were dirty and that there was limescale present on some taps.
6.2 Clutter
The main ward areas of Wards 3, 8 and 40 were cluttered with a mix of
patient equipment, cages, mattresses, mobile vital signs trolleys, linen
trolleys, notes and drugs trolleys. Inspectors noted that with the
exception of Ward 8 the ward areas became less cluttered as the
morning progressed.
The isolation room in Ward 3, as highlighted in the cleaning section
was cluttered, and there was no wardrobe for the patient’s personal
belongings. The linen store of Ward 8 was cluttered in appearance.
Equipment such as wheelchair feet and pressure relieving/support
wedges were stored on shelves. Three mattresses, patient handling
equipment and resuscitation training equipment were either stored on
the floor or were hanging from hooks in the linen store wall.
The equipment stores in Wards 31 and 40 and the treatment room of
Ward 40, were cluttered and untidy with excess equipment, the rooms
had a multi purpose function which needs to be clearly defined.
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Additional Issue
In Ward 8 the lift lobby used to transport patients to theatre was
cluttered and untidy with waste bins and broken equipment. The
inspectors observed a patient going to theatre being wheeled through
this area; this does not promote a good public perception of the ward
environment. From a patient’s perspective going to theatre through a
cluttered service corridor is not conducive to providing a relaxed,
reassuring experience.
6.3 Maintenance and Repair
In all wards there was some damage to walls, doors, flooring, paint and
laminate finishes. In Ward 3, which had just been refurbished, the
walls had been painted but there were still holes in the wall where
fittings had been removed and not been replaced or the holes repaired.
Damaged electrical sockets were noted behind a bed in bed Bay L.
In Ward 40 there was a small gouged hole in the floor of bed Bay B
approximately one inch deep, thus this section of the flooring could not
be effectively cleaned and it was not impervious to moisture. In the
domestic store there was some minor paintwork damage and perished
plaster causing a hole in the wall under the equipment sink; the
damage was previously caused by a leak in the pipework behind the
wall. On inspection of the pipework a dripping sound was heard and
the domestic stated that the leak has recurred. The tiled floor in the
dirty utility room had been repaired, sections of the floor had been replastered,
however this was rough and unsealed, therefore unable to
be effectively cleaned.
The bedpan washers in Ward 8 and Ward 40 were out of order. In
Ward 31 staff said the bedpan washer was not washing effectively and
they were therefore carrying out a manual bedpan pre-wash. The
maintenance and repair of the bedpans washers should be actioned as
a matter of urgency.
6.4 Fixtures and fittings
The chairs in the main entrance were finished in a washable fabric,
however they were showing signs of wear. There were also two large
A&E porter chairs, the arm of one had been repaired with masking tape
and the frame of the other was damaged. Chairs in Wards 3 and 8
were also noted to be worn and in Ward 3, 31 and 40 the bedframes
were chipped or damaged.
In Ward 3 some of the curtains had shrunk and the toilet roll holder in
the public toilet and in a patient ward toilet was broken, the drip tray for
the bedpan rack was missing. In Ward 8 the toilet roll dispenser in the
shower room was also broken, there was no bedpan rack or tray and
the frame of the raised toilet seat was rusty.
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Picture 4: Ward 40 damaged frame
of food service trolley
There was a shortage of bed
screens in Ward 40 and the
ward sister informed the
inspectors that it is difficult to
find sufficient replacement
curtains especially after
patient discharge. Also the
kitchen tray trolley was old,
worn and very damaged; it
should be replaced as it can
not be effectively cleaned
(Picture 4).
In Wards 3, 8 and 40 the notice boards were finished in felt material
which can not be effectively cleaned.
Additional issue
In Ward 40 the inspectors noted that the patient call bell was located at
the opposite side to where the patient chairs were positioned, the cord
of the call bell in use was not long enough to reach to the other side of
the bed.
6.5 Information
Cleaning schedules were available for nursing staff in all four wards,
however they lacked detail in outlining staff roles and responsibilities
for cleaning at ward level. Information posters on waste handling, linen
segregation, NPSA colour coding of cleaning equipment and
management of inoculation injury were not available consistently in all
wards. In Ward 31 some of the posters in the clean utility room were
old and torn. Information leaflets on MRSA and Clostridium-difficile
were not available in Ward 8 or Ward 40, however the ward sister did
say they could be printed from the internet as required.
There were no hand hygiene posters at all of the hand washing sinks in
either Ward 3 or 40 and Ward 40 did not have any advice leaflets on
hand hygiene available. Not all the information posters which were
displayed in Wards 3 and 40 were laminated and in Ward 40 some
were attached to cupboards with adhesive tape. At the entrance to
Ward 40, seven poster type pages had been attached to the door,
some were not laminated, some were duplicated; the need for all these
posters should be reviewed.
Recommendations
1. The trust should ensure that the systems and processes in
place for environmental cleaning, provide the necessary
16

assurance that cleaning is carried out effectively, and that all
staff are aware of their responsibilities.
2. The healthcare environment should be repaired and
maintained, and damaged fixtures and fittings replaced to
maintain public confidence and to help reduce the risk of the
spread of infection.
3. Work should continue on improving storage and maintaining
clutter free environments.
4. Detailed nursing cleaning schedules should be developed.
5. The trust should ensure that all staff are aware of the
importance of monitoring fridge temperatures.
6. An agreed set of core HealthCare Associated Infection (HCAI)
public information leaflets should be available for patients,
visitors, and staff.
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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 Ward 3 Ward 8 Ward 31 Ward 40
Storage of clean
linen
96 60 87 88
Storage of used
linen
94 76 76 91
Laundry facilities N/A N/A N/A N/A
Average Score 95 68 82 90
7.1 Management of Linen
Ward 3 and Ward 40 achieved an overall compliance score in this
standard, which is to be commended. Overall Ward 31 was partially
compliant and Ward 8 was minimally compliant.
Picture 3: Ward 8 Untidy and
cluttered linen store
In Ward 8, the inspectors observed that
the linen store was untidy, cluttered and
over stocked (Picture 3). The ward had
received a linen delivery on the
morning of inspection; the delivery man
had placed the wrapped clean linen
bags on the floor of the linen store.
Ward staff subsequently tidied the linen
store however a bag of sheets
remained on the floor. The store was
also used to store patient equipment
such as mattresses, pressure relieving
supports, resuscitation and patient
handling equipment; the windowsill was
used to store patient pillows. The clutter
made access for cleaning difficult as
skirting, floors and windowsill all
required cleaning.
A similar issue regarding the level of stock was observed in Ward 31.
The store was neat and tidy, but the shelves were not all filled, and it
was noted that the stock was mainly curtains. The ward was storing
linen in small cabinets which were located in one of the main corridors
in public view. The cabinets which also stored incontinence products
did not have doors or protective covers, both the linen and incontinence
pads had been removed from their packaging and were exposed to
18

potential airborne contamination. The room was also being used to
store a bed bumper which was dirty; the floor vinyl was damaged.
Ward 3 linen store also had inappropriate items stored in the room. A
mattress was stored on the floor and the windowsill was cluttered with
a zimmer frame, scourers, green wipes, detergent wipes, cardboard
boxes and bottles of detergent. Ward 4 had patient property bags
stored beside clean linen.
In the section on used linen, Ward 3 and Ward 40 were compliant. The
only issue was in relation to the state of the used linen bags which
were noted to be torn or damaged.
The used linen bags in Ward 31 were overfilled and none of the staff
were wearing gloves and aprons, personal protective equipment (PPE),
when engaged in handling used linen. Staff in Ward 8 had placed used
linen on top of a linen skip and filled linen bags were observed in the
corridor. In relation to practice observed, staff were carrying used linen
to the skips rather than bringing the linen skip to the point of use at the
bedside. A member of staff was observed entering the linen room, mid
patient procedure to retrieve a towel while wearing PPE.
Recommendations
7. A review of the linen stores should be carried out to ensure
clean linen is stored under appropriate conditions.
8. Staff should ensure linen and associated items are fit for
purpose.
9. Staff should wear PPE as per trust guidelines.
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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
Ward 3 Ward 8 Ward 31 Ward 40
93 96 85 92
77 71 87 81
8.1 Waste
In this standard all four wards were compliant in the section which
related to the handling, segregation and storage of waste. Inspectors
noted in all four wards the magpie box was being used for the disposal
of pharmaceutical waste and in Ward 31, the black lidded burn bin
which is used for the disposal of pharmaceutical waste was over
flowing with tubing protruding. The box was replaced during the
inspection.
Paper waste was inappropriately disposed of into clinical waste bins in
both Wards 3 and 8. In Ward 40 there was no household waste bin in
the dirty utility room and the bin in a bed bay was overfilled. Waste
bins in the dirty utility room and staff room in Ward 40 and in a bed bay
and treatment room in Ward 31 were stained and rusty.
In Ward 3 the household waste bin in Room H was not easily
accessible and in some bays clinical waste bins were located beside
the hand washing sinks, which can encourage inappropriate disposal of
non-clinical waste.
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The lift lobby in Ward 8 was
being used to store large euro
waste bins (Picture 4) rather
than the designated disposal
area. In Ward 31 the
disposal room for waste and
the yellow cupboard in the
disposal room for the safe
storage of sharps boxes were
not locked.
8.2 Sharps
Picture 4: Ward 8 Lift lobby area
In the section which related to the safe handling and disposable of
sharps only Ward 31 was compliant, Wards 3 and 40 were partially
compliant and Ward 8 was minimally compliant.
In all of the wards the inspectors noted that not all the temporary
closure mechanisms on the sharps boxes were in place. At Ward 3,
nurses station, Ward 8 clinical room, and Ward 31 clean utility room,
the sharps boxes were not secured by wall brackets and the door to the
rooms were open to the public. With the exception of Ward 31 and
Ward 3, sharps boxes were not signed or dated, however in Ward 3 the
black and yellow lidded burn bins were not signed or dated and the lid
of the black burn bin was not secured.
In Ward 40, the sharps box on the resuscitation trolley was dated
August 2011, it was not secured and had been used.
Compatible sharps trays for the 2.5L sharps boxes were not available
in Ward 3. Staff were using aseptic non touch technique (ANTT) trays
and the 0.5L rectangle sharps boxes to carry clinical equipment. When
questioned staff confirmed the 0.5L boxes were too small to hold
intravenous equipment needed for certain procedures. Sister
confirmed the trays had been lost in transit during the ward decant and
a representative from the sharps box supplier was coming to the ward
this week with replacement sharps trays.
The inspectors in Ward 8 observed a syringe plunger protruding from a
sharps box in the clinical room, the lid of a sharps box was dusty and
the sharps box on the resuscitation trolley was not secured. They also
noted one of the sharps trays was dirty and another was cracked and
dirty.
21

Recommendations
10. Waste bins and equipment used in the management of waste
should be available, clean and free from damage.
11. 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.
22

9.0 Patient Equipment
STANDARD 5.0
PATIENT EQUIPMENT
Cleanliness and state of repair of general patient equipment.
Patient
Equipment
Ward 3 Ward 8 Ward 31 Ward 40
Patient Equipment 84 72 76 84
Improvement is required across all wards with regard to the
cleanliness, state of repair of patient equipment and staff practice.
Ward 3 and Ward 40 were partially compliant, Ward 31 had a low
partial compliance score and Ward 8 was minimally compliant.
Trust staff use a system of green trigger tape to indicate that equipment
has been cleaned. The inspectors found in Wards 3 and 31 that while
tape was in place equipment was not clean. In Ward 3 the portable
nebuliser in room L was very dirty, especially in the crevices of the
handle. This piece of equipment had tape attached indicating it had
been cleaned on the 19 November 2011.
A commode with tape in Ward 31 was heavily stained and a BP
monitor stand in use was dusty and had trigger tape attached dated
July 2011. The use of trigger tape was not consistent in Ward 8, two
commodes checked had no trigger tape and not all stored IV stands
had tape insitu. In all four wards, dust and sticky tape was noted on
portable equipment such as IV stands, ECG, suction machines,
resuscitation trolleys and dressing trolleys.
In both Ward 3 and Ward 31 there was no tracking system for reusable
hoist slings to indicate which patient was using the sling. The slings
were stored over the hoist in the shower room in Ward 3 and over the
hoist stored in the corridor of Ward 31.
In Ward 40, Ward 31, and Ward 3 the ambu bag had been removed
from the original packaging, and in Ward 8 the laryngoscope blade had
also been removed from its’ packaging. In Ward 3, three nasal tubes
with a pin attached were stored out of packaging in a drawer of the
resuscitation trolley. The Association of Anaesthetist of Great Britain
and Ireland guidelines "Infection Control in Anaesthesia "states that
single use resuscitation equipment should be kept in a sealed package
or should be re-sterilised between patients according to manufacturer's
instructions. It also states that packaging should not be removed until
the point of use for infection control, identification, traceability in the
case of a manufacturer's recall and safety.
23

Damaged equipment was noted in all wards. In Ward 3 bedpans in the
dirty utility room and IV stands in the store were old and worn. The
frames of some commodes were rusted, the frame of the notes trolley
was chipped and the legs of the trolley holding the ECG machine were
damaged. The top of the resuscitation trolley in Ward 40 was damaged
and in Ward 31 the catheter stands in the dirty utility room had been
bound in fabric bandage and the plastic coating was split in places.
There were several issues identified by the inspectors in Ward 8
regarding staff practice. The inspectors were advised by staff in Ward
8 that patients anti – embolism stockings (TEDS) were communally
soaked in Daz washing powder and dried in the ward tumble dryer.
Both a nasal cannulae and a detached IV line were observed hanging
loosely from an oxygen point at the patients bedside and IV stand
respectively. The tip of the IV line was uncovered. When questioned
staff gave varying answers on when to change oxygen/nebulizer tubing
and equipment.
In Ward 8, the inspectors observed one patient being assisted with
personal care, the bedside locker was open and clothing/underwear
had spilled on to the floor. Both a bedpan and urinal had not been
emptied after use and were left underneath the bed on the floor for
some time. A doctor was also observed handling the tip of a syringe
prior to use as part of an aseptic non touch (ANTT) procedure.
With the exception of the staff on Ward 3, staff were not aware of the
symbol for single use items.
Recommendations
12. The trust has and individual staff and a collective
responsibility to ensure that patient equipment is clean and
in good repair.
24

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 Ward 3 Ward 8 Ward 31 Ward 40
Availability and
cleanliness of
WHB and
82 91 99 96
consumables
Availability of
alcohol rub
97 100 100 83
Availability of PPE 100 85 85 100
Materials and
equipment for 93 61 95 83
cleaning
Average Score 93 84 95 91
Three wards achieved an overall compliance score, with Ward 31
achieving compliance in all four sections, staff should be commended.
The only section that was minimally compliant was in Ward 8, materials
and equipment for cleaning.
In the first section, the only issue identified in Ward 31 was in relation
to the overflow in the dirty utility room which was dirty. Common areas
for attention in Wards 3, 8 and 40 were some soap and towel
dispensers required cleaning and some required repair. In Ward 8 dirty
utility room the hand washing consumables were situated at the
equipment sink rather than at the hand washing sink for staff to access.
In Ward 8 dirty utility room the hand washing sink had a plug and
overflow and the taps were wrist operated rather than sensor or elbow
operated. There were similar issues in Bays L, K and the dirty utility
room in Ward 3 regarding taps, overflows and plugs. In addition in
Ward 3 the sink in the treatment room was not accessible and was
cluttered with packages containing sterile supplies.
With regard to availability of alcohol rub, Wards 8 and 31 were fully
compliant. In Ward 3 a portable alcohol rub was attached to the bed in
the isolation room where a patient had Clostridium-difficile. Alcohol
based products are not effective in cases of Clostridium difficile.
25

In Ward 40 at the entrance to the ward
the bracket holding the alcohol
dispenser was broken, not visible and
was nearly empty. Also the brackets
for holding the alcohol dispenser on
the drugs trolleys were all broken. The
inspectors were impressed with the
new Infection Control stations located
throughout the ward, however two of
the alcohol dispensers were broken
(Picture 5). Alcohol dispensers were
not always available at the patients
beds, at the point of care.
Picture 5: Ward 40 Hand hygiene station
Ward 3 and Ward 40 were fully compliant with regard to the availability
of personal protective equipment (PPE). In Ward 31, disposable
gloves and aprons and in Ward 8 disposable gloves, were available
from a dispenser in the dirty utility room. The infection prevention and
control staff confirmed at the feed back session that due to a risk of
contamination, PPE should not be stored in this room.
In all four wards inspectors founds instances of cleaning chemicals or
disinfectants not being held under locked conditions in line with Control
of Substances Hazardous to Health (COSHH) regulations. In Wards 3
and 40 nursing staff were not sure of the correct dilution rates for
Actichlor Plus, and in Ward 31 detergent wipes were not available on
patient testing equipment trolleys.
In Ward 8 the bedpan washer was out of order, when questioned
nursing staff gave varying answers on how to manually clean bed
pans. Staff were also unsure of the correction solutions in use for
general cleaning.
The cleaning trolley in Ward 8 was old, worn and required cleaning. A
red mop and bucket with dirty water was observed in the domestic
store and an un-bagged dirty mop head was on the floor. The static
mop in both Wards 8 and Ward 40 was dirty and clogged with dust.
In Ward 40 there were no yellow mops or mop buckets available for
cleaning in isolation areas.
26

Recommendations
13. The trust should ensure that consumables are clean and in a
good state of repair.
14. Hand washing sinks in clinical areas should be accessible
and comply with current guidelines.
15. The trust should ensure that all chemicals are stored under
locked conditions in accordance with COSHH regulations.
16. Equipment used for the general cleaning of a ward should be
available, clean, fit for purpose and stored appropriately.
17. Systems and processes should be in place to assure that
staff knowledge and practice is kept up to date regarding the
cleaning and disinfectant process.
27

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
Ward 3 Ward 8 Ward 31 Ward 40
Effective hand
hygiene
93 68 95 85
procedures
Safe handling and
disposal of sharps
91 85 91 100
Effective use of
PPE
100 81 81 93
Correct use of
isolation
95 N/A 93 80
Effective cleaning
of ward
76 79 76 76
Staff uniform and
work wear
93 100 90 93
Average Score 91 83 87 88
In most cases good hand hygiene practices were observed, however in
each ward instances of staff failing to follow the correct hand hygiene
procedure were observed. In Ward 3 one registered nurse was
observed not completing the seven step hand hygiene procedure. This
was also the case in Ward 40, as two staff had long sleeves and a care
assistant did not wash their hands prior to serving food. In Ward 31 a
member of medical staff did not wash their hands before gathering
equipment to carry out a clinical procedure or before commencing the
procedure.
Ward 8 was minimally compliant in the hand hygiene section. Nursing
and medical staff did not carry out the seven step technique used for
hand hygiene and alcohol gel; some staff when questioned quoted five
steps. Staff were also observed not washing their hands after
removing PPE or before commencing an ANTT procedure. Staff did
not perform hand hygiene prior to meal service nor were patients
offered the opportunity to clean their hands prior to meals.
When questioned staff in Ward 3, 8 and 31 were unsure of the correct
procedure to follow in the event of a needle stick injury. In Ward 8 a resheathed
butterfly needle was observed in a sharps box.
28

Good practice was observed in effective use of PPE in Ward 3
resulting in a full compliance score. In Ward 40 a nursing assistant
was observed serving meals but was not wearing an apron. Staff in
Ward 31 did not wear an apron when engaged in activities where their
uniform could become contaminated, for example cleaning a used
commode or empting urinals and jugs which had been used to
measure urine. A similar issue of staff not wearing an apron when
empting a urinal was noted in Ward 8. In addition a doctor in Ward 8
was observed carrying out ANTT while wear a glove with a missing
finger and a member of staff in green scrubs transporting a patient to
theatre was wearing gloves unnecessarily.
There were no patients in isolation in Ward 8 so this section was
marked as not applicable. As previously mentioned in Standard 6, in
Ward 3 alcohol wipes were supplied in a room where a patient with
Clostridium difficile was being nursed. Staff confirmed that the alcohol
wipes were used to clean equipment in the room. In Ward 31 there
was no care pathway in place for a patient in isolation.
All four wards were partially compliant in effective cleaning of the ward.
The same issues were identified in each ward such as, staff were
unsure of the correct dilution rates for cleaning, disinfecting or dealing
with a blood spill. In Ward 3 a nursing auxiliary made up Actichlor Plus
by adding 4 tablets to a bowl of water and nursing staff were
inconsistent in their practice in cleaning in an isolation room. Nursing
staff were not aware of the colour coding guidelines for cleaning
equipment, nor were there posters with this information displayed.
Recommendations
18. All staff have a responsibility to ensure that hand hygiene is
carried out in line with WHO guidelines and that all PPE is
used appropriately.
19. Systems and processes should be in place to assure that
staff knowledge and practice is kept up to date regarding
isolation, cleaning and decontamination of equipment.
20. Systems and processes should be in place to assure that
staff knowledge and practice is kept up to date regarding the
use of disinfectants.
29

12.0 Key Personnel and Information
Members of the RQIA inspection team
Mrs E Colgan - Senior Officer Infection Prevention/Hygiene Team
Mrs L Gawley - Inspector Infection Prevention/Hygiene Team
Mrs S O'Connor - Inspector Infection Prevention/Hygiene Team
Mrs M Keating - Inspector Infection Prevention/Hygiene Team
Ms J Buchanan - Belfast Health and Social Care Trust
Ms J Norrie - South Eastern Health and Social Care Trust
Ms M Armstrong - Belfast Health and Social Care Trust
Ms G Smyth - South Eastern Health and Social Care Trust
Trust representatives attending the feedback session
The key findings of the inspection were outlined to the following trust
representatives:
Ms A Witherow - Assistant Director of Nursing
Ms G Brown - AD Secondary Care PCOP
Ms W Cross - Lead Nurse Governance and Performance
Ms M Browne - Divisional Nurse EC&M
Ms J Houlahan - Head of Social Care/Lead Nurse
Ms S Gormley - Support Services Manager
Mr T Mc Carter - Head of Estates
Mr T Doherty - Estates Manager
Ms L Fadden - Ward 31 Manager
Ms K Logan - Ward 31 Sister
Ms M Armstrong - Ward Manager
Ms E Buchannan - Ward 3 Sister
Ms E Squires - Ward 8 Sister
Ms N McKenny - Infection Prevention and Control Nurse
Mr E Ming - Infection Prevention and Control Nurse
Ms Y Black - Assistant Support Services Manager
Supporting documentation
A number of documents have been developed to support the inspection
process, these are:
Infection Prevention/Hygiene Inspection Process (methodology,
follow up and reporting)
Infection Prevention/Hygiene Team Inspection Protocol (this
document contains details on how inspections are carried out and
the composition of the teams)
Infection Prevention/Hygiene Team Escalation Policy
RQIA Policy and Procedure for Use and Storage of Digital Images
This information is currently available on request and will be available
in due course on the RQIA website.
30

13.0 Summary of Recommendations
1. The trust should ensure that the systems and processes in
place for environmental cleaning, provide the necessary
assurance that cleaning is carried out effectively, and that all
staff are aware of their responsibilities.
2. The healthcare environment should be repaired and
maintained, and damaged fixtures and fittings replaced to
maintain public confidence and to help reduce the risk of the
spread of infection.
3. Work should continue on improving storage and maintaining
clutter free environments.
4. Detailed nursing cleaning schedules should be developed.
5. The trust should ensure that all staff are aware of the
importance of monitoring fridge temperatures.
6. An agreed set of core HealthCare Associated Infection (HCAI)
public information leaflets should be available for patients,
visitors, and staff.
7. A review of the linen stores should be carried out to ensure
clean linen is stored under appropriate conditions.
8. Staff should ensure linen and associated items are fit for
purpose.
9. Staff should wear PPE as per trust guidelines.
10. Waste bins and equipment used in the management of waste
should be available, clean and free from damage.
11. 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.
12. The trust has and individual staff and a collective
responsibility to ensure that patient equipment is clean and
in good repair.
13. The trust should ensure that consumables are clean and in a
good state of repair.
14. Hand washing sinks in clinical areas should be accessible
and comply with current guidelines.
31

15. The trust should ensure that all chemicals are stored under
locked conditions in accordance with COSHH regulations.
16. Equipment used for the general cleaning of a ward should be
available, clean, fit for purpose and stored appropriately.
17. Systems and processes should be in place to assure that
staff knowledge and practice is kept up to date regarding the
cleaning and disinfectant process.
18. All staff have a responsibility to ensure that hand hygiene is
carried out in line with WHO guidelines and that all PPE is
used appropriately.
19. Systems and processes should be in place to assure that
staff knowledge and practice is kept up to date regarding
isolation, cleaning and decontamination of equipment.
20. Systems and processes should be in place to assure that
staff knowledge and practice is kept up to date regarding the
use of disinfectants.
32

Reporting & Re-Audit
Episode of Inspection
Plan Programme
14.0 Unannounced Inspection Flowchart
Environmental Scan:
Stakeholders & External
Information
Plan
Programme
Consider:
Areas of Non-Compliance
Infection Rates
Trust Information
RQIA Hygiene Team
Prioritise Themes & Areas for Core Inspections
Prior to Inspection Year
Balance Programme
January/February
Schedule Inspections
Prior to Inspection
Identify & Prepare Inspection Team
Day of Inspection
Inform Trust
Day of Inspection
Carry out Inspection
A
Is there immediate risk
requiring formal escalation?
NO
YES
Invoke
RQIA
IPHTeam
Escalation
Process
Day of Inspection
Feedback Session with Trust
14 days after
Inspection
28 days after
Inspection
Preliminary Findings
disseminated to Trust
Draft Report
disseminated to Trust
NO
Does assessment of
the findings require
escalation?
YES
Invoke
RQIA
IPHTeam
Escalation
Process
A
14 days later
Signed Action Plan
received from Trust
Within 0-3 months
Is a Follow-Up required?
Based on Risk Assessment/key
indicators or Unsatisfactory Quality
Improvement Plan (QIP)?
YES
Invoke
Follow-Up
Protocol
Process enables
only 1 Follow-Up
NO
Open Report published to Website
YES
Is Follow-Up
satisfactory?
NO
DHSSPS/HSC
Board/PHA
PHA
33

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
34

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
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
Designated
department
Support
Services
Estates
Action required
Cleaning schedules are developed for each
location. Support Services staff receives
induction training also BICS training is
provided for all Support Services staff. The
Trust is an accredited training centre for
BICS. In addition to the EC Audits, Support
Services team leaders carry out quality
control audits.
Defects to be reported to Estates Help Desk.
Environmental Cleanliness audits to be
monitored to assess areas needing attention.
Backlog Maintenance Funding to be secured
from General Capital to address audit issues.
Date for
completion/
timescale
Commenced
and on-going
On-going
3. Work should continue on improving storage and
maintaining clutter free environments
Nursing and
estates
Work is on-going in relation to a scheduled
de- clutter programme.
February 2012
4. Detailed nursing cleaning schedules should be
developed
5. The trust should ensure that all staff are aware of the
importance of monitoring fridge temperatures
6. An agreed set of core HealthCare Associated Infection
(HCAI) public information leaflets should be available
for patients, visitors, and staff
nursing
Support
Services
Nursing staff
IP&C
Corporate cleaning schedules are being
devised and wil be shared across all the
wards
Support Services ward catering staff monitor
fridge temperatures in accordance with
HACCP plan.
Pharmacy fridges are monitored daily and
staff have been reminded to do this.
The PHA are in the process of producing
standardised patient information leaflets and
have not yet completed that process. All
leaflets are available on the Trust Intranet
site, the appropriateness of leaflets for a
particular area need to be decided by the
Ward/Department manager.
End January
2012
On-going
Not clear
35

Reference
number
Recommendations
7. A review of the linen stores should be carried out to
ensure clean linen is stored under appropriate
conditions
8 Staff should ensure linen and associated items are fit
for purpose
Designated
department
Nursing
Estates
Support
services and
nursing
9 Staff should wear PPE as per trust guidelines Support
Services
Nursing
Action required
Training workshops are being scheduled for
staff Jan- March and this will be addressed in
the programme.
Ward managers have been asked to identify
where a problem with linen storage exists
and to raise through their relevant nursing
governance and estates meetings.
Bed linen is currently being changed to the
provision of slip knit material and staff will be
advised to ensure the linen is clean and fit for
purpose.
Support Services induction and BICS training
programmes include PPE requirements.
This is included in mandatory training and in
IPC guidelines. Additional training on the
revised environmental audit tool for support
services and nursing staff will include specific
scenario training to enhance staff
understanding of the underlying principles of
the correct use of PPE.
Date for
completion/
timescale
March 2012
On-going
Commenced
and on-going
10 Waste bins and equipment used in the management
of waste should be available, clean and free from
Support
Services
The trust is producing a hand held laminated
cards outlining a range of issues such as
correct hand hygiene and the correct use of
PPE.
It is envisaged these will be provided to all
staff during January and February.
Staff in the wards concerned have been
spoken to in respect of this matter
The correct use of PPE has been raised at
the trust accountability meeting with all Lead
nurses for cascade to ward managers etc.
Support Services cleaning schedules include
the cleaning of waste bins.
Jan and
February 2012
Commenced
and on-going
36

Reference
number
damage
Recommendations
Designated
department
Action required
Date for
completion/
timescale
11 The trust should monitor the implementation of its
policies and procedures in respect of the management
of waste and sharps to ensure that safe and
appropriate practice is in place
Estates
Nursing
Trust Waste Manual detailing segregation
and safe disposal of waste to be approved in
early 2012 - to be circulated by Trust
communication.
Waste audit programme to monitor
compliance to commence in January 2012 by
Estates.
Annual Sharps Safety Audit Altnagelvin and
Erne recently completed by Daniels
Heathcare, findings will be circulated by
February 2012.
Sharps safety training including safe handling
and disposal of sharps including temporary
closure of sharps boxes is covered in IPC
induction and mandatory training or nursing
staff.
April 2012
On-going
12 The trust has and individual staff and a collective
responsibility to ensure that patient equipment is clean
and in good repair.
All staff
Cleaning schedules for patient equioment
and training on cleaning I on going in the
Trust.
Commenced
and on-going
Defective equipment to be reported to
Estates Help Desk for repair or for
condemnation.
13 The trust should ensure that consumables are clean
and in a good state of repair.
Support
Services
Support Services cleaning schedules include
the cleaning and replenishing of hand towels,
toilet rolls and hand soap dispensers.
On -going
37

Reference
number
Recommendations
14 Hand washing sinks in clinical areas should be
accessible and comply with current guidelines.
Designated
department
Estates
Action required
Hand washing sinks comply with
requirements with the exception of all taps
having elbow operated taps – cost implication
but we will review if clinical sinks only can be
fitted with these.
Date for
completion/
timescale
March 2012
15 The trust should ensure that all chemicals are stored
under locked conditions in accordance with COSHH
regulations
16 Equipment used for the general cleaning of a ward
should be available, clean, fit for purpose and stored
appropriately
17 Systems and processes should be in place to assure
that staff knowledge and practice is kept up to date
regarding the cleaning and disinfectant process
Support
Services
Support
Services
Support
Services
Nursing
Staff have been reminded to ensure areas
around sinks are kept free from clutter
Support Services staff receive induction
training which includes COSSH training. The
BICS training programme incorporates
dilution rates for all cleaning
products/disinfectants used.
Adherence with the regulation will be
monitored through environmental cleanliness
Support services cleaning schedules
incorporates cleaning equipment and team
leader quality control audits includes audit of
cleaning equipment.
Support Services staff receive induction
training which includes COSSH training. The
BICS training programme incorporates
cleaning procedures and dilution rates for all
cleaning products/disinfectants used.
There are IPC decontamination guidelines
available on the Trust intranet.
Decontamination and dilution rates are
included in IPC induction and mandatory
training for all staff including Nursing Staff
training.
Commenced
and on-going
commenced and
on-going
commenced and
on-going
Staff knowledge of the correct dilution rates is
being addressed through the issue of hand
38

Reference
number
Recommendations
18 All staff have a responsibility to ensure that hand
hygiene is carried out in line with WHO guidelines and
that all PPE is used appropriately
Designated
department
Support
Services
Nursing
Action required
held laminated cards which states the correct
dilution rates as an aid to correct practice.
Staff knowledge and processes will be
checked monthly on the introduction of the
new revised audit tool.
Support Services staff induction training/
BICS training programme incorporates hand
hygiene and PPE requirements.
Hand hygiene is taught at induction and
mandatory training and the practice of
Nursing and Medical staff is monitored every
2 weeks by their peers, exceptions are
reported through robust accountability
systems.
Date for
completion/
timescale
Commenced
and on-going
19 Systems and processes should be in place to assure
that staff knowledge and practice is kept up to date
regarding isolation, cleaning and decontamination of
equipment
Support
Services
Nursing
Hand hygiene scores are reviewed at the
monthly accountability meeting and nursing
matters are dealt with at that meeting with
corrective action taken in terms of repeat
hand hygiene until 5 consecutive days
scoring 95% is achieved.
Staff are advised that where a member of the
medical staff fail the hand hygiene this is to
escalated to the clinical lead for that area
The medical director is to be advised on the
occasion that an individual doctor fails three
times.
Support Services BICS training programme
incorporate cleaning procedures for isolation
and decontamination of equipment.
Attendance at IPC induction and mandatory
training on a 2 yearly basis is mandatory for
all clinical staff in the Trust.
Ad hoc audits of practice related to
commodes and other high risk equipment do
Commenced
and on-going
39

Reference
number
Recommendations
Designated
department
Action required
take place, future audits will include
questioning of staff in relation to chlorine
releasing agent dilution rates.
Date for
completion/
timescale
20 Systems and processes should be in place to assure
that staff knowledge and practice is kept up to date
regarding the use of disinfectants
Support
Services
Nursing
Support Services staff receive induction
training which includes COSSH training. The
BICS training programme incorporates
dilution rates for all cleaning
products/disinfectants used. See point 17.
Commenced
and on-going
The Trust will commence use of the RQIA
tool for environmental cleanliness regular and
managerial audits. This will include staff
questioning of nurses and support services
staff which does not currently take place.
40