Announced Inspection Report. Clackmannanshire Community Healthcare Centre NHS Forth Valley January 2016

Transcription

1 Announced Inspection Report Clackmannanshire Community Healthcare Centre NHS Forth Valley January 2016 The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland

2 The Healthcare Environment Inspectorate was established in April 2009 and is part of Healthcare Improvement Scotland. We inspect acute and community hospitals across NHSScotland. You can contact us to find out more about our inspections or to raise any concerns you have about cleanliness, hygiene or infection prevention and control in an acute or community hospital or NHS board by letter, telephone or . Our contact details are: Healthcare Environment Inspectorate Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone: comments.his@nhs.net Healthcare Improvement Scotland 2016 First published April 2016 The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be reproduced, free of charge in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with the document s date and title specified. Photographic images contained within this report cannot be reproduced without the permission of Healthcare Improvement Scotland. This report was prepared and published by Healthcare Improvement Scotland. 2

3 Contents Ensuring your hospital is safe and clean 1 About this report 4 2 Summary of inspection 5 3 Key findings 7 Appendix 1 Requirements and recommendations 12 Appendix 2 Inspection process flow chart 13 Appendix 3 Details of inspection 14 Appendix 4 Glossary of abbreviations 15 3

4 1 About this report This report sets out the findings from our announced inspection to Clackmannanshire Community Healthcare Centre, NHS Forth Valley, from Wednesday 27 to Thursday 28 January This report summarises our inspection findings on page 5 and detailed findings from our inspection can be found on page 7. The inspection team was made up of two inspectors and a public partner, with support from a project officer and another inspector who observed. One inspector led the team and was responsible for guiding them and ensuring the team members agreed about the findings reached. A key part of the role of the public partner is to talk with patients about their experience of staying in hospital and listen to what is important to them. Membership of the inspection team visiting Clackmannanshire Community Healthcare Centre can be found in Appendix 3. The flow chart in Appendix 2 summarises our inspection process. More information about the Healthcare Environment Inspectorate (HEI), our inspections, methodology and inspection tools can be found at 4

5 2 Summary of inspection About the hospital we inspected Clackmannanshire Community Healthcare Centre, Alloa provides a wide range of outpatient services. The hospital also has two inpatient wards, three GP practices and a day therapy unit. It has a local mental health resource centre providing specialised assessment and support for people with severe or complex mental health issues. The hospital is a base for district nurses, health visitors, community rehabilitation teams, health improvement and a wide range of support services and classes. These include rehabilitation exercise classes for patients with chronic lung conditions, smoking cessation classes, a carers support group, hearing aid repair clinics and cancer support nursing staff. About our inspection We carried out an announced inspection to Clackmannanshire Community Healthcare Centre from Wednesday 27 to Thursday 28 January This was the first inspection of the community healthcare centre, and we inspected it against the new Healthcare Improvement Scotland Healthcare Associated Infection (HAI) Standards (February 2015). Inspection focus Before carrying out this inspection, we reviewed NHS Forth Valley s self-assessment. This informed our decision on which standards to focus on during this inspection. We focused on: Standard 2: Education Standard 4: HAI surveillance Standard 6: Infection prevention and control policies, procedures and guidance, and Standard 8: Decontamination. Our public partner also focused on Standard 3: Communication between organisations and with the patient or their representative. We inspected the following areas: ward 1 (ageing and health) ward 2 (old age and psychiatry) outpatients department, and day therapy unit. Our public partner carried out two staff interviews, six patient interviews and we received nine completed patient and carer questionnaires. What NHS Forth Valley did well High staff compliance rates with completion of infection prevention and control training. A good programme of infection prevention and control audits. 5

6 Staff compliance with standard infection control precautions was good. What action we expect NHS Forth Valley to take after our inspection This inspection resulted in no requirements or recommendations. We would like to thank NHS Forth Valley and in particular all staff and patients at the Clackmannanshire Community Healthcare Centre for their assistance during the inspection. 6

7 3 Key findings Standard 2: Education to support the prevention and control of infection All staff we spoke with demonstrated a clear understanding of their roles and responsibilities in the prevention and control of infection. NHS Forth Valley s mandatory and supplementary training directory states that HAI education and training needs are tailored for specific staff roles in the organisation. NHS Forth Valley staff must complete five core infection prevention and control modules as part of their mandatory training. Senior charge nurses told us that infection control education is covered in staff s e-ksf review. An e-ksf review is where staff meet with their line manager to discuss their personal development plan. We saw evidence in the areas inspected that staff had the opportunity to complete HAI induction and refresher training along with other training modules. We saw good staff compliance with completing these online learnpro modules. Evidence supplied with NHS Forth Valley s self-assessment stated that at least one staff member on each ward had a role as a hand hygiene trainer. During our inspection, we were told that both wards had hand hygiene trainers. These trainers provided practical hand hygiene demonstrations for staff and training in hand washing technique, when required. We found evidence of good attendance levels at these sessions. We were told that staff should complete hand hygiene updates each year. In all areas inspected, all hand hygiene updates had been completed. Domestic/housekeeping staff we spoke with had also completed their mandatory hand hygiene update. Ward staff told us that the infection prevention and control team also provided face-to-face training on the wards. Standard 3: Communication between organisations and with the patient or their representative Throughout the hospital, a range of posters, signs and guidance were available for staff, patients and visitors on infection control and hand hygiene. Patients told us that staff had explained infection control measures verbally, particularly hand hygiene precautions. Infection control leaflets were on patients bedside cabinets. All nine respondents to our patient and carer questionnaire stated they had received infection prevention and control information. Staff demonstrated how they could obtain condition-specific information from the staff intranet to give to patients with a confirmed infection. Staff also showed us how alternative language leaflets could be downloaded from the staff intranet and how they could access the interpreting service. Members of the public were involved in NHS Forth Valley s Patient and Partnership Forum. Forum members represent the community s views on local health issues and discuss the impact of NHS Forth Valley decisions. We saw evidence that this forum discussed infection control issues. However, we were unable to meet with a member of the forum during the inspection. 7

8 Standard 4: HAI surveillance We saw a good display of surveillance information displayed outside wards. This included Clostridium difficile infection (CDI) and Staphylococcus aureus bacteraemia (SAB) rates and the results of hand hygiene compliance audit results. We saw evidence of a monthly report sent to each senior charge nurse from the infection prevention and control team. This report had infection rate information for each area. There had been no CDIs or SABs in the wards since the recording date on the display charts. Standard 6: Infection prevention and control policies, procedures and guidance NHS Forth Valley had adopted the Health Protection Scotland National Infection Prevention and Control Manual (2015). This manual describes standard infection control precautions. These are 10 key precautions staff should take to minimise the spread of infection. They include hand hygiene, the use of personal protective equipment (such as aprons and gloves), and the management of linen, waste and sharps. The manual also describes transmission-based precautions. These are precautions staff should take to help prevent cross-transmission of infections. All staff we asked could demonstrate how they accessed the manual through the staff intranet. Infection prevention and control policy and procedure updates were ed to senior charge nurses who used ward safety briefs to pass this information to ward staff. Senior charge nurses and staff nurses on both wards told us that ward safety briefs were also used to communicate infection control audit results and improvement action plans resulting from audits. Ward staff on wards 1 and 2 and the day therapy unit told us that the infection prevention and control team was visible on the wards at least weekly. They also visited the outpatients department monthly. During these visits, the team gave advice and education, and performed spot audits. We were told that all visits by the infection prevention and control team were recorded on IC Net, an online record management system. We saw a summary report had been produced that included any non-compliances identified. The summary report was included in the HAI Monthly Report distributed to all staff. This report also detailed: education and training HAI improvement work HAI surveillance rates, and links to the monthly infection prevention and control updates produced for each directorate. Staff described a good working relationship with the infection prevention and control team. All staff we asked could explain how to contact the infection prevention and control team for advice or support. During out of hours, staff contacted the on-call consultant microbiologist for advice. NHS boards are required to measure staff compliance with standard infection control precautions and transmission-based precautions. The frequency of this compliance 8

9 monitoring is determined by individual NHS boards. We saw that NHS Forth Valley had a programme of audits carried out by both ward staff and the infection prevention and control team. In wards 1 and 2 and the day therapy unit, we saw senior charge nurses completed a monthly assurance audit and developed improvement action plans from the results. As it was carried out monthly, any non-compliance would have an action plan and would be reaudited to measure improvement the following month. In ward 2, we saw that the last infection prevention and control yearly audit had a score of 99%. The next audit was due in February We saw evidence that the infection prevention and control team responded to data from audits that suggested compliance was not optimal. As part of its self-assessment, NHS Forth Valley gave us a copy of a mock HEI inspection to Forth Valley Royal Hospital. During our inspection, we were told that mock HEI inspections would also be carried out at community hospitals starting from February We were given copies of NHS Forth Valley s internal audit reports with corresponding action plans. These internal audit reports use a red-amber-green (RAG) rating system. We also saw the HAI monthly report that was distributed to all staff and the infection prevention and control update for each directorate. On the wards we saw good staff compliance with standard infection control precautions such as: management of the care environment management of care equipment management of linen management of sharps management of waste, and use of personal protective equipment. We saw appropriate signage on a sideroom door for a patient with an infection. This patient s documentation clearly recorded infection control advice from the infection control team. There was also clear, documented evidence showing nursing staff had communicated information about the infection to the patient s relatives. Staff we spoke with could describe the actions they should take in managing a blood spill, as well as in the event of a needle stick injury. We saw information posters for staff about the various elements of the standard infection control precautions and staff could direct us to these posters. In ward 2, we were shown a cupboard storing equipment and personal protective equipment to be used in the event of an outbreak. Staff also directed us to outbreak-specific guidance available on the intranet for staff to access. Staff told us that they felt supported to challenge colleagues who did not adhere to infection control policies. Alcohol-based hand rub dispensers and wash hand basins were readily available on ward 1. Personal protective equipment (gloves and aprons) were available outside the rooms from 9

10 wall-mounted dispenser units. Although alcohol-based hand rub was not available at the bedsides on ward 2, all staff carried individual dispensers and we saw them use these regularly. All nine respondents to our patient and carer questionnaire stated that ward staff always washed their hands. We also saw that glove and apron dispensers were wall-mounted inside patient rooms and clinical rooms in ward 2. We saw a risk assessment that set out the control measures the ward had put in place for this. We asked about the governance surrounding the risk assessment process. Senior management staff told us that if a senior charge nurse raised a risk assessment, it would be sent to their line manager and clinical nurse manager. If further input or advice was required, it would be escalated to the head of nursing. The Scottish Patient Safety Programme (SPSP) is a national programme that aims to improve the safety and reliability of healthcare and reduce harm, whenever care is delivered. The SPSP details 10 essentials to safety. We saw evidence of audits to ensure compliance with hand hygiene and the use of ward safety briefs two of the essentials to safety. Results of these SPSP audits were displayed at ward entrances. Standard 8: Decontamination Equipment we saw was clean and well maintained. A system that labelled clean equipment was in place. Staff completed cleaning checklists for equipment, such as mattresses and chairs, after cleaning them and kept the checklist inside the mattress or chair cover. With one exception, all mattresses and patient chairs we inspected were clean and ready for use. All nine respondents to our patient and carer questionnaire stated that they felt the equipment used for care was clean and in good repair. We saw copies of completed and up-to-date discharge and weekly cleaning checklists for all areas inspected. The nurse in charge of each shift signed these checklists. Cleaning schedules were kept on patient room doors. We saw that senior charge nurses carried out weekly assurance checks as part of these schedules. The environment was clean and ward staff described a good relationship with domestic services. All nine returned patient and carer questionnaires we received stated that the wards were always clean. Comments from completed patient and carer questionnaires also reflected what we found during the inspection: Lovely ward, very clean. Always found the ward to be very clean. Ward staff also told us that if any cleaning issues were identified, they would contact the domestic supervisor who would deal with them immediately. Domestic/housekeeping staff we spoke with explained the colour-coding system in use at the hospital. Domestic/housekeeping staff told us they felt they would be supported if they had any concerns. They also described how they would seek support for additional cleaning. We were shown a patient questionnaire that NHS Forth Valley was trialling on one ward in another hospital in the NHS board area. The questionnaire asked for feedback from patients or their representatives about cleanliness of the care environment and equipment. It also 10

11 asked for feedback about infection prevention and control measures and the use and maintenance of invasive devices. We will follow this up at future inspections. We saw the estates reporting system and evidence of the actions taken from this. Staff we spoke with described a good relationship with the estates team and could describe the process for reporting faults and repairs. We saw that the built environment was well maintained. 11

12 Appendix 1 Requirements and recommendations The actions the HEI expects the NHS board to take are called requirements and recommendations. Ensuring your hospital is safe and clean Requirement: A requirement sets out what action is required from an NHS board to comply with the standards published by Healthcare Improvement Scotland, or its predecessors. These are the standards which every patient has the right to expect. A requirement means the hospital or service has not met the standards and the HEI is concerned about the impact this has on patients using the hospital or service. The HEI expects that all requirements are addressed and the necessary improvements are made within the stated timescales. Recommendation: A recommendation relates to national guidance and best practice which the HEI considers a hospital or service should follow to improve standards of care. Prioritisation of requirements All requirements are priority rated (see table below). Compliance is expected within the highlighted timescale, unless an extension has been agreed in writing with the lead inspector. Priority Indicative timescale 1 Within 1 week of report publication date 2 Within 1 month of report publication date 3 Within 3 months of report publication date 4 Within 6 months of report publication date This inspection resulted in no requirements and no recommendations. 12

13 Appendix 2 Inspection process flow Ensuring your hospital is safe and clean chart We follow a number of stages in our inspection process. More information about the Healthcare Environment Inspectorate, our inspections, methodology and inspection tools can be found at 13

14 Appendix 3 Details of inspection The inspection to Clackmannanshire Community Healthcare Centre, NHS Forth Valley was carried out from Wednesday 27 to Thursday 28 January The members of the inspection team were: Cheryl Newton Inspector (Lead) Jennifer MacDonald Inspector Ken Barker Public Partner Observed by: Lindsay MacPhee Inspector Supported by: Ross McFarlane Project Officer 14

15 Appendix 4 Glossary of Ensuring your hospital is safe and clean abbreviations Abbreviation CDI HAI HEI RAG SAB SPSP Clostridium difficile infection healthcare associated infection Healthcare Environment Inspectorate red-amber-green rating system Staphylococcus aureus bacteraemia Scottish Patient Safety Programme 15

16 Healthcare Improvement Scotland is committed to equality. We have assessed the inspection function for likely impact on the equality protected characteristics in line with the Equality Act Please contact the Healthcare Improvement Scotland Equality and Diversity Advisor on or to request a copy of: the equality impact assessment report, or this inspection report in other languages or formats. Edinburgh Office Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone Glasgow Office Delta House 50 West Nile Street Glasgow G1 2NP Telephone The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland.