33333333333333333333333333333333 RQIA Infection Prevention/Hygiene Announced inspection Kingsbridge Private Hospital 20 January 2012
Contents 1.0 Inspection Summary 1 2.0 Background Information to the Inspection Process 5 3.0 Inspections 6 4.0 Unannounced Inspection Process 7 4.1 Onsite Inspection 7 4.2 Feedback and Report of the Findings 7 5.0 Audit Tool 8 6.0 Environment 10 6.1 Cleaning 10 6.2 Clutter 11 6.3 Maintenance and Repair 11 6.4 Fixture and Fittings 11 6.5 Information 11 7.0 Patient Linen 13 7.1 Management of Linen 13 8.0 Waste and Sharps 14 8.1 Waste 14 8.2 Sharps 14 9.0 Patient Equipment 16 10.0 Hygiene Factors 17 11.0 Hygiene Practice 19 12.0 Endoscopy Suite 21 12.1 Endoscopy Suite Environment 23 12.2 Specialist Patient Equipment 23 12.3 Policies and Procedures 23 13.0 Key Personnel and Information 24 14.0 Summary of Recommendations 25 15.0 RQIA Hygiene Team Escalation Policy Flowchart 27 16.0 Action Plan 28
1.0 Inspection Summary A joint inspection of endoscopy units in regulated independent healthcare facilities was conducted by members of RQIA infection prevention/hygiene Team (IPHT), estates, and HEIG (Health Estates Investment Group) inspectors from the DHSSPS. The purpose of the announced inspection to Kingsbridge Private Hospital on the 21January 2011 was to provide assurance that facilities and practices specific to endoscopic procedures within the clinic complied with current standards. The clinic was assessed against the Regional Healthcare Hygiene and Cleanliness standards, with an additional section developed specifically for endoscopy suites. Inspectors from HEIG also carried out an inspection using the Flexible Endoscope audit tool produced by DHSSPS Health Estates and Investment Group (HEIG) the following area was inspected: Specialist Area - Endoscopy Suite/Theatre The hospital was originally registered 2006, it was re-registered as the Kings Bridge Private Hospital in November 2011, it is located in South Belfast and offers a range of both inpatient and out patient procedures. The endoscopy unit, which operates on an outpatient basis, is a separate area within the hospital. The endoscopy suite is on the second floor and is accessed via the main reception by lift or stairs. There is a small reception area with a consulting room (under construction), two changing rooms with en-suite, a theatre, clean utility room and two linked dirty utility rooms. Inspection Outcomes The results of the inspection showed an overall compliance level. However the structure and layout of the endoscopy decontamination room do not comply with the required standards as evidenced in the minimally compliant score achieved in this section of the audit tool. Inspectors also noted that improvement was required in some associated endoscopic practices. Observation of staff practice indicated overall compliance with hygiene and infection prevention and control practices. However more work is required to ensure effective hand hygiene is carried out by all staff. The safe management and disposal of waste also requires attention, and the clinic needs to review the use and supply of personal protective equipment (PPE). The inspection resulted in 22 recommendations for Kingsbridge Private Hospital, a full list of recommendations is listed in Section 14. The 1
report and recommendations will be forwarded to the relevant inspector for performance management under the following regulations and standards: The HPSS (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 The Independent Health Care Regulations (Northern Ireland) 2005 The Department of Health, Social Services and Public Safety's (DHSSPS) draft Independent Health Care Minimum Standards for Hospitals and Clinics March 2005 The Department of Health, Social Services and Public Safety's (DHSSPS) Health Estates Investment Group, Flexible Endoscope Decontamination Audit Tool, January 2010 A report from HEIG inspectors on their findings has been provided in the format of key audit findings and points of concern. A copy has been forwarded to the clinic requesting an action plan to address the deficiencies identified. The clinic was also asked to provide RQIA with a position statement regarding their proposal for future service delivery i.e. upgrading of the existing on-site reprocessing facilities or outsourcing of endoscope reprocessing. Notable Practice The inspection identified the following areas of notable practice: Staff displayed a positive attitude to inspection and a willingness to learn and improve practices. The RQIA inspection team would like to thank the staff at the Kingsbridge 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. 2
Table 1 Areas Inspected Environment 84 Patient Linen 91 Waste 86 Sharps 67 General Patient Equipment 87 Hygiene Factors 88 Hygiene Practices 86 Endoscopy Suite 85 Average Score 84 Table 2 General Environment Reception 98 Corridors, stairs lift 83 Public toilets 83 Ward/department - general (communal) 85 Toilet 82 Domestic store 78 General information 77 Average Score 84 Table 3 Patient Linen Storage of clean linen 90 Storage of used linen 91 Laundry facilities N/A Average Score 91 Table 4 Waste and Sharps Handling, segregation, storage, waste Availability, use, storage of sharps 86 67 Compliant: 85% or above Partial Compliance: 76% to 84% Minimal Compliance: 75% or below 3
Table 5 Patient Equipment Patient equipment 87 Table 6 Hygiene Factors Availability and cleanliness of wash hand 96 basin and consumables Availability of alcohol rub 92 Availability of PPE 82 Materials and equipment for cleaning 81 Average Score 88 Table 7 Hygiene Practices Effective hand hygiene procedures 67 Safe handling and disposal of sharps 100 Effective use of PPE 83 Correct use of isolation N/A Effective cleaning of ward 82 Staff uniform and work wear 97 Average Score 86 Table 8 Endoscopy Suite Scrub Room N/A Endoscopy Theatre 97 Endoscopy 60 decontamination room Specialist 90 Equipment/practices Policies and Procedures 93 Average Score 85 Compliant: 85% or above Partial Compliance: 76% to 84% Minimal Compliance: 75% or below 4
2.0 Background Information to the Inspection Process RQIA s infection prevention and hygiene team was established to undertake a rolling programme of unannounced inspections of acute hospitals. The Department of Health Social Service and Public Safety (DHSSPS) commitment to a programme of hygiene inspections was reaffirmed through the launch in 2010 of the revised and updated version of 'Changing the Culture' the strategic regional action plan for the prevention and control of healthcare-associated infections (HCAIs) in Northern Ireland. The aims of the inspection process are: to provide public assurance and to promote public trust and confidence to contribute to the prevention and control of HCAI to contribute to improvement in hygiene, cleanliness and infection prevention and control across health and social care in Northern Ireland In keeping with the aims of the RQIA, the team will adopt an open and transparent method for inspection, using standardised processes and documentation. 5
3.0 Inspections The DHSSPS has devised 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. The inspections will be undertaken in accordance with the four core activities outlined in the RQIA Corporate Strategy, these include: Improving care: we encourage and promote improvements in the safety and quality of services through the regulation and review of health and social care Informing the population: we publicly report on the safety, quality and availability of health and social care Safeguarding rights: we act to protect the rights of all people using health and social care services Influencing policy: we influence policy and standards in health and social care 6
4.0 Announced Inspection Process The hospital received advanced notice of the onsite inspection. 4.1 Onsite Inspection The inspection team was made up of two inspectors, from RQIA s infection prevention/hygiene team, one inspector from RQIA s estates team and two inspectors from the DHSSPS Health Estates Investment Group (HEIG) inspection team. Membership of the inspection team is outlined in Section 13. 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 organisational representatives and includes examples of notable practice identified during the inspection. The details of organisational representatives attending the feedback session is outlined in Section 13. The RQIA team responsible for the facility is forwarded a copy of the draft report. The responsible inspector will review the report and recommendations and devise a Quality Improvement Plan. The draft report containing the Quality Improvement Plan of the inspection is forwarded to the organisation for agreement and factual accuracy checking and returned within two weeks. The Quality Improvement Plan will be subject to performance management by the inspector responsible for the facility. The infection prevention/hygiene team escalation process will be followed if inspectors/reviewers identify any serious concerns during the inspection (Section 15). A number of documents have been developed to support and explain the inspection process. This information is currently available on request and will be available in due course on the RQIA website. 7
5.0 Audit Tool The audit tool used for the inspection is based on the Regional Healthcare Hygiene and Cleanliness standards. The standards incorporate the critical areas which were identified through a review of existing standards, guidance and audit tools (Appendix 2 of Regional Healthcare Hygiene and Cleanliness standards). The audit tool follows the format of the Regional Healthcare Hygiene and Cleanliness Standards and comprises of the following sections. 1. Organisational Systems and Governance: policies and procedures in relation to key hygiene and cleanliness issues; communication of policies and procedures; roles and responsibilities for hygiene and cleanliness issues; internal monitoring arrangements; arrangements to address issues identified during internal monitoring; communication of internal monitoring results to staff 2. General Environment: cleanliness and state of repair of public areas; cleanliness and state of repair of ward/department infrastructure; cleanliness and state of repair of patient bed area; cleanliness and state of repair of toilets, bathrooms and washrooms; cleanliness and state of repair of ward/department facilities; availability and cleanliness of isolation facilities; provision of information for staff, patients and visitors 3. Patient Linen: storage of clean linen; handling and storage of used linen; ward/department laundry facilities 4. Waste and Sharps: waste handling; availability and storage of sharps containers 5. Patient Equipment: cleanliness and state of repair of general patient equipment 6. Hygiene Factors: hand wash facilities; alcohol hand rub; availability of personal protective equipment (PPE); availability of cleaning equipment and materials. 7. Hygiene Practices: hand hygiene procedures; handling and disposal of sharps; use of PPE; use of isolation facilities and implementation of infection control procedures; cleaning of ward/department; staff uniform and work wear 8. Endoscopy Suite: anaesthetic room, scrub room, endoscopy theatre/room, endoscopy decontamination room/area, specialist equipment and policies/procedures. 8
Level of Compliance Percentage scores can be allocated a level of compliance using the compliance categories below. The categories are allocated as follows: Compliant 85% or above Partial compliance 76 to 84% Minimal compliance 75% or below Each section within the audit tool will receive an individual and an overall score, to identify areas of partial or minimal compliance to ensure that the appropriate action is taken. 9
6.0 Environment STANDARD 2.0 GENERAL ENVIRONMENT Cleanliness and state of repair of public areas; cleanliness and state of repair of ward/department infrastructure; cleanliness and state of repair of patient bed area; cleanliness and state of repair of toilets, bathrooms and washrooms; cleanliness and state of repair of ward/department facilities; availability and cleanliness of isolation facilities; provision of information for staff, patients and visitors. General Environment Reception 98 Corridors, stairs lift 83 Public toilets 83 Ward/department - general (communal) 85 Toilet 82 Domestic store 78 General information 77 Average Score 84 The above table outlines the findings in relation to the environment of the facility inspected. The findings indicate that there are some areas for improvement. The findings in respect of the general environment, are detailed in the following sections. At the time of inspection major construction work was under way to create a new shared recovery bay, to service the endoscopy unit and theatres. The area had been screened off prior to taking down a wall however the screens had been removed once this work had finished. As a result the inspectors were concerned about the amount of dust that continued to permeate throughout the areas leading to the endoscopy unit 6.1 Cleaning At the time of the inspection there was some evidence to indicate compliance with regional specifications for cleaning. However inspectors observed that greater attention to detail was required to ensure effective cleaning mechanisms were in place and implemented to prevent the build-up of dust and debris. This in turn prevents the build-up of bacteria and subsequently reduces the potential risk for the transmission of infection. 10
The main hospital reception on the ground floor and the waiting area for the endoscopy unit were clean and in good decorative order. Greater attention to detail was required when cleaning the public toilets on the ground floor to remove splashes and stains from walls, skirting and the air vent. The inside of the toilet was stained and there was limescale on the taps. The toilets in the endoscopy unit also required further cleaning as the inside of both toilets and the vinyl covered back rest on the disabled toilet were stained. The walls in the domestic store were splashed and stained and there was debris on the floor under the low sluice sink. Both the sluice sink and equipment sink were dirty and the taps had limescale present. The hand touch points on the door were grubby and the shelving unit was dusty. 6.2 Clutter The general areas were clutter free, two large x-ray machines were observed in the endoscopy waiting area, these were removed during the inspection. 6.3 Maintenance and Repair This is a relatively new building and in good repair, however the inspectors did note that the vinyl flooring in the endoscopy unit was damaged in places. The flooring outside the endoscopy room has bubbled and some of the welds at the joins were missing or of poor finish and there were cracks to plaster work in the patient changing area. 6.4 Fixtures and Fittings Unlike the rest of the unit the chairs in the patient changing area were old and worn, the vinyl covering was split and torn in places and therefore not impervious to moisture. 6.5 Information Picture 1: Damaged vinyl on chair As the hospital has only been registered to the current owners some policies and guidelines are still being developed. A cleaning policy for 11
nursing staff is in place but detailed cleaning schedules are being formulated. Similarly a support service manager has just been appointed and is currently re-drafting the domestic cleaning schedule which was very basic. Information leaflets on MRSA, Clostridium difficile and common infections were not available. Infection Prevention and Control policies are being developed for the hospital but staff have access to the Regional Infection Prevention and Control manual on line. Recommendations 1. The hospital 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 furniture replaced to maintain public confidence and to help reduce the risk of the spread of infection. 3. The hospital should review current storage arrangements to maintaining a clutter free environment. 4. The hospital should continue on developing policies, guidelines and cleaning schedules. 12
7.0 Patient Linen STANDARD 3.0 PATIENT LINEN Storage of clean linen; handling and storage of used linen; ward/ department laundry facilities. 7.1 Management of Linen Patient Linen Storage of clean linen 90 Storage of used linen 91 Laundry facilities N/A Average Score 91 Staff achieved an overall compliant score in this standard. The bed linen store was clean neat and tidy, however in the store used for staff scrubs the inspectors noted that some scrub suits were lying on the floor. In the clean decontamination room off the theatre, a supply of exposed clean sheets was observed on a trolley, these sheets should be stored covered or in a linen cupboard to prevent exposure to airborne contamination. The used linen baskets in the patient changing areas were made of wicker and therefore could not be effectively cleaned, and the cloth bags used as liners were ripped and damaged. Used linen awaiting collection was stored in a designated area and bags were not over filled. Staff advised inspectors that personal protective equipment (PPE) is used when handling soiled/contaminated linen and that theatre uniforms are reprocessed by a recognised external laundry contractor. Recommendations 5. The hospital should ensure that clean linen is stored in a designated area which is fit for purpose. 6. Equipment used for the storage of used linen should be cleanable and fit for purpose. 13
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 86 67 8.1 Waste Although this standard was compliant, several issues were identified which need to be addressed. Waste was not disposed of appropriately in accordance with the hospitals waste policy, paper waste was observed in the sharps box in the endoscopy theatre and household waste bags were in the large clinical waste euro bins in the outside compound. The inside of the clinical waste euro bins were dirty and had loose waste, one of the clinical waste bins was over filled and the lid could not be locked. In the endoscopy reception area there was no household waste bin only a clinical waste bin, the clinical waste bin in the theatre had a paper label secured with tape and the clinical waste bin in the dirty utility room had a black household waste liner. 8.2 Sharps This standard was minimally compliant and improvement is required in the following areas to ensure safe practice. The temporary closure mechanism on sharps boxes was not in use, the sharps box in the theatre had blood splatters and the sharps box on the dressing trolley was not secured. Not all sharps boxes within the unit were signed and dated and the inspectors noted this was also the same for sharps bins which had been disposed of into the large outside clinical waste euro bin. Recommendations 7. The hospital should monitor the implementation of its policies and procedures in respect of the management of 14
waste and sharps to ensure safe and appropriate practice is in place. 8. The hospital should ensure waste bins and sharps boxes are clean. 9. Systems and processes should be in place to assure that staff practice is correct in respect of the correct disposal of waste. 15
9.0 Patient Equipment STANDARD 5.0 PATIENT EQUIPMENT Cleanliness and state of repair of general patient equipment. Patient Equipment Patient equipment 87 The unit achieved compliance in this standard however with attention to detail and the implementation and monitoring of the nursing cleaning schedule for patient equipment this score could be improved. In the endoscope theatre inspectors observed that ventilator equipment, oxygen pipes on the anaesthetic machine and notes trolley were dusty and stained. Staff dealt with these cleaning issues immediately. Picture 2: Stained framework of ventilator The inside of the doors of the dressing procedure trolley were stained and the top surface was dusty. Tourniquets were made of material and could not be effectively cleaned, and in the dirty utility room a 50ml flushing syringe had been removed from it packaging and left on the side of the double, scope cleaning sink. Recommendations 10. The hospital and individual staff have a collective responsibility to ensure that general and specialist equipment is clean. 11. Staff should ensure sterile equipment is not removed from its packaging prior to use. 16
10.0 Hygiene Factors STANDARD 6.0 HYGIENE FACTORS Hand wash facilities; alcohol hand rub; availability of PPE; availability of cleaning equipment and materials. Hygiene Factors Availability and cleanliness of wash hand 96 basin and consumables Availability of alcohol rub 92 Availability of PPE 82 Materials and equipment for cleaning 81 Average Score 88 In this standard overall compliance was achieved. Alcohol hand rub was generally available, however the portable alcohol dispenser and holder in the endoscope theatre room was dirty, dusty and empty. The section on the availability of personal protective equipment was partially compliant. Gauntlet sleeves were worn by staff when manually cleaning the endoscopes, however these were not effective as they continually slid down exposing the arm. Different colour single used aprons for clean and dirty work were not available and a box of vinyl gloves were observed on the shelf in the endoscope theatre. The Infection Prevention Society advise that these are used during low risk procedures. It is advised that the type of glove used is reviewed to ensure staff are use the correct gloves with the correct protection for all care activities. Face or eye protection was not worn consistently for the manual cleaning procedure, reusable goggles were available but stained. Hats and head gear were not available for use in the endoscope area. The section on cleaning materials and equipment was also partially compliant. On inspection of the domestic store, wooden mop handles and a wooden deck scrubber were noted, the mop buckets were dirty and water buckets were not colour coded. Not all buckets were inverted or dry. Equipment such as wet pickup mops, floor polishers and the domestic trolley were dusty. 17
Recommendations 12. The hospital should ensure hand washing facilities are clean and accessible. 13. The hospital should ensure alcohol rub dispensers and filled and clean. 14. The hospital should ensure PPE is available, fit for purpose and worn by staff. 15. The hospital should ensure equipment for general cleaning is clean and fit for purpose. 18
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 Effective hand hygiene procedures 67 Safe handling and disposal of sharps 100 Effective use of PPE 83 Correct use of isolation N/A Effective cleaning of the facility 82 Staff uniform and work wear 97 Average Score 86 In this standard overall compliance was achieved, the safe handling and disposal of sharps was fully compliant, however a minimally compliant score was achieved in effective hand hygiene procedures. Staff were observed entering the dirty utility room on several occasions but failed to use alcohol hand rub to decontaminate their hands. Staff were also observed not washing their hands before donning disposable gloves. Personal protective equipment, disposable gloves and aprons were worn where appropriate. Staff did not wear the appropriate head protection when in the endoscope unit, staff in the adjoining theatre were observed wearing their head protection continuously instead of as a single use item. Nursing staff when questioned, were not aware of NPSA guidelines for colour coding of cleaning equipment in relation to theatres. The information on dilution rates for cleaning and disinfection chemicals was displayed in the domestic store but was difficult to read, and when domestic staff were questioned they were they were unable to give the correct dilution rates for the cleaning agent or disinfectant in use in the hospital. A dress code policy is in place within the hospital and generally staff were compliant, however inspectors observed that a member of theatre staff was wearing hoop earrings. 19
Recommendations 16. The hospital and individual staff have a responsibility to ensure that hand hygiene is carried out in line with the seven step technique and that all PPE is used appropriately. 17. The hospital and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date with regard to the correct dilution rates for chemicals and colour coded equipment used for cleaning and decontamination of equipment and specialist patient equipment. 18. Staff should comply with the hospitals dress code policy. 20
12.0 Endoscopy Suite STANDARD 8.0 ENDOSCOPY SUITE Endoscopy Suite: anaesthetic room, scrub room, endoscopy theatre/room, endoscopy decontamination room/area, specialist equipment and policies/procedures. 12.1 Endoscopy Suite Environment Endoscopy Suite Scrub Room N/A Endoscopy Theatre 97 Endoscopy 60 decontamination room Specialist 90 Equipment/practices Policies and Procedures 93 Average Score 85 The endoscopy unit is a separate area located at one end of the hospital and accessed by a dedicated stairway or lift which leads to the first floor unit. In the endoscope theatre, inspectors observed a blood stain and paper labels attached to the theatre trolley. The scrub sink is located within the theatre space, the sink was clean and in good state of repair. The clean decontamination room is located off the theatre and can only be accessed through the theatre. In the clean decontamination room the top of the endoscope storage unit was dusty and the shelves were cluttered, stained and dusty. Adhesive tape had been used to secure labels to the drawers of the dressing trolley, adhesive tape cannot be effectively cleaned and alternatives should be sourced. A new drying cabinet had been installed in the clean decontamination room was in the process of being commissioned. Picture 3: New drying cabinet 21
Picture 4: Blocked access to and washing sink The dirty decontamination area, was cluttered and dust was again an issue, there was dust on the top of the endoscope cabinet, air vents, storage units and skirting. Access to the hand wash sink was obstructed by boxes, the sink also required cleaning. There were stains on the front of the drying cabinet, adjoining door and the floor. The low sluice sink was dirty, and was being used as a work surface, inspectors noted that the central wheel from the endoscope washer disinfector stored on top of it. Picture 5: Sluice sink used as storage surface The double deep sink used to manually clean the scopes was stained and had signs of rust, and a dirty measuring jug was sitting on the edge of the sink unit. The double sink in the dirty decontamination room was not set at the correct high to minimise back injury. There was limescale deposits on the taps. The ventilation in the decontamination room did not appear to be working. Both the clean and dirty decontamination areas were cluttered with boxes and plastic bags sitting on the floor. In the dirty decontamination area the scope storage area was cramped and there was insufficient work area. The recovery room was not inspected as it was in constant use throughout the inspection. New guidance CFPP 01-06 is to be issued in the near future, all endoscope decontamination facilities in Northern Ireland will be required to meet "best practice" requirements of this document in relation to layout, quality systems and environmental requirements. 22
12.1 Specialist Patient Equipment In the clean decontamination room the storage trolley for the endoscopes was dusty. In the dirty decontamination room, the second sink used in the double sink manual cleaning process of the scopes did not have a fill line. In relation to effective cleaning, the HEIG inspectors noted that in the manual wash area the unit dispensing detergent was faulty and an incorrect ratio of detergent to water was being used. Detergents should be diluted as per the manufactures guidelines to be effective. 12.2 Policies Procedures and Training This is a new open facility and while some policies, for example the decontamination of endoscopy equipment and stand operational procedures are in place. Others such as, procedures for regular audits and the hospitals own infection prevention and control policy have still to receive approval. Staff currently use the Regional Infection Prevention and Control guidance on line. A training and validation programme has just been put in place. Recommendations 19. The environment of the endoscopy suite should be clean and free of clutter. 20. The decontamination room should be fit for purpose and comply with relevant standards. 21. Improvements required in the decontamination process should be addressed and work commenced to comply with CFPP. 22. All recommendations as outlined by the HEIG inspectors in their key findings report should be addressed. 23
13.0 Key Personnel and Information Members of the RQIA inspection team Mrs S O'Connor Mrs M Keating Mr C Muldoon - Inspector Infection Prevention/Hygiene Team - Inspector Infection Prevention/Hygiene Team - Inspector Estates Team Members of the DHSSPS Health Estates Investment Group (HEIG) inspection team Mr David Pollock - Inspector, Health Estates Investment Group Mr Eddie Clarke - Inspector, Health Estates Investment Group Hospital representatives attending the feedback session The key findings of the inspection were outlined to the following trust representatives: Ms R Wilson - Governance Manager Mr R Mackinnon - Facilities Manager Ms Zana O Neill - GON Cleaning Contractor Mr P Monaghan - GON Cleaning Contractor 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. 24
14.0 Summary of Recommendations 1. The hospital 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 furniture replaced to maintain public confidence and to help reduce the risk of the spread of infection. 3. The hospital should review current storage arrangements to maintaining a clutter free environment. 4. The hospital should continue on developing policies, guidelines and cleaning schedules. 5. The hospital should ensure that clean linen is stored in a designated area which is fit for purpose. 6. Equipment used for the storage of used linen should be cleanable and fit for purpose. 7. The hospital should monitor the implementation of its policies and procedures in respect of the management of waste and sharps to ensure safe and appropriate practice is in place. 8. The hospital should ensure waste bins and sharps boxes are clean. 9. Systems and processes should be in place to assure that staff practice is correct in respect of the correct disposal of waste. 10. The hospital and individual staff have a collective responsibility to ensure that general and specialist equipment is clean. 11. Staff should ensure sterile equipment is not removed from its packaging prior to use. 12. The hospital should ensure hand washing facilities are clean and accessible. 13. The hospital should ensure alcohol rub dispensers and filled and clean. 25
14. The hospital should ensure PPE is available, fit for purpose and worn by staff. 15. The hospital should ensure equipment for general cleaning is clean and fit for purpose. 16. The hospital and individual staff have a responsibility to ensure that hand hygiene is carried out in line with the seven step technique and that all PPE is used appropriately. 17. The hospital and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date with regard to the correct dilution rates for chemicals and colour coded equipment used for cleaning and decontamination of equipment and specialist patient equipment. 18. Staff should comply with the hospitals dress code policy. 19. The environment of the endoscopy suite should be clean and free of clutter. 20. The decontamination room should be fit for purpose and comply with relevant standards. 21. Improvements required in the decontamination process should be addressed and work commenced to comply with CFPP. 22. All recommendations as outlined by the HEIG inspectors in their key findings report should be addressed. 26
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, Seek assurance on implementation of actions Take necessary action: E.g.: Follow-Up Inspection 27
16.0 Action Plan Reference number Recommendations 1. The hospital 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. Designated department Action required Date for completion/ timescale 2. The healthcare environment should be repaired and maintained, and damaged furniture replaced to maintain public confidence and to help reduce the risk of the spread of infection. 3. The hospital should review current storage arrangements to maintaining a clutter free environment. 4. The hospital should continue on developing policies, guidelines and cleaning schedules. 5. The hospital should ensure that clean linen is stored in a designated area which is fit for purpose. 6. Equipment used for the storage of used linen should be cleanable and fit for purpose. 7. The hospital should monitor the implementation of its policies and procedures in respect of the management of waste and sharps to ensure safe and appropriate practice is in place. 28
Reference number Recommendations 8. The hospital should ensure waste bins and sharps boxes are clean. Designated department Action required Date for completion/ timescale 9. Systems and processes should be in place to assure that staff practice is correct in respect of the correct disposal of waste. 10. The hospital and individual staff have a collective responsibility to ensure that general and specialist equipment is clean. 11. Staff should ensure sterile equipment is not removed from its packaging prior to use. 12. The hospital should ensure hand washing facilities are clean and accessible. 13. The hospital should ensure alcohol rub dispensers and filled and clean. 14. The hospital should ensure PPE is available, fit for purpose and worn by staff. 15. The hospital should ensure equipment for general cleaning is clean and fit for purpose. 16. The hospital and individual staff have a responsibility to ensure that hand hygiene is carried out in line with the seven step technique and that all PPE is used appropriately. 29
Reference number Recommendations 17. The hospital and individual staff have a collective responsibility to ensure that staff knowledge is kept up to date with regard to the correct dilution rates for chemicals and colour coded equipment used for cleaning and decontamination of equipment and specialist patient equipment. Designated department Action required Date for completion/ timescale 18. Staff should comply with the hospitals dress code policy. 19. The environment of the endoscopy suite should be clean and free of clutter. 20. The decontamination room should be fit for purpose and comply with relevant standards. 21. Improvements required in the decontamination process should be addressed and work commenced to comply with CFPP. 22. All recommendations as outlined by the HEIG inspectors in their key findings report should be addressed. 30
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