Inspection Date: 21 August, 5 September and 17 September Improvement Action Plan Declaration It is essential that the NHS board s improvement action plan submission is signed off by the NHS board Chair and NHS board Chief Executive. It is the responsibility of the NHS board Chief Executive and NHS board Chair to ensure the improvement action plan is accurate and complete and that a representative from Patient/Public Involvement within the NHS board has been involved in developing the improvement action plan. By signing this document, the NHS board Chief Executive and NHS board Chair are agreeing to the points above. NHS board Chair NHS board Chief Executive Signature: Signature: Full Name: Full Name: Date: Date: File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 1 of 10 Review Date: 1
Inspection Date: 21 August, 5 September and 17 September Ref: Action Planned Timescale to meet action 1 2 Responsibility for taking action Undertake a review of the current audit tool used in theatre to ensure that it captures best practice Review the HAI audit tool use in theatres and procedure rooms. 31 January 2014 Infection Prevention and Control Progress The current HAI audit will be reviewed in all theatre and procedure room environments across. Date d Review the content of all HAI policies and procedures to ensure that they are compliant with the national infection prevention and control manual. Review the Standard Operating Procedure for the Cleaning of Reusable Patient Equipment, through continued participation in the national expert advisory group, and adopt recommendations made by them. 31 January 2014 Infection Prevention and Control /Nurse Consultant HAI has implemented the national infection prevention and control manual. The document in question (the Standard Operating Procedure for the Cleaning of Reusable Patient Equipment) on Page 10 of the inspection report was developed by Grampian and adopted nationally as part of the manual. The national version has been updated. Our File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 2 of 10 Review Date: 2
Inspection Date: 21 August, 5 September and 17 September 3 version is in the process of being reviewed (as reported to the inspectors at the time) in light of ongoing national work on the document, in which continues to participate. It is currently being tested in a number of areas, including one ward in Aberdeen Maternity Hospital. Review the availability of alcohol-based hand gels in Ashgrove ward. This will ensure that, where hand hygiene is required, it is available to staff as near to the point of care as possible. Review and risk assess the possibility of supplying end of bed/personal/extra wall mounted alcohol gel dispensers in Ashgrove Ward. 3 October Infection Prevention and Control /Senior Charge Midwife The Infection Prevention and Control Team have supported the Senior Charge Midwife in Ashgrove Ward to risk assess the installation of end of bed gel dispensers. These have now been installed. Assess the need for extra gel dispensers throughout AMH. 31 October Head of Midwifery End of bed gel dispensers are being installed throughout AMH. The Neonatal Unit have replaced all non-compliant dispensers. File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 3 of 10 Review Date: 3
4 5 6 Improvement Action Plan Inspection Date: 21 August, 5 September and 17 September Ensure that all staff adhere to HPS National Infection Prevention and Control Manual, Appendix 5 Glove use and selection. Review the use of sterile polythene gloves and advise staff in the Neonatal Unit of correct glove selection and use. / Infection Prevention and Control All polythene gloves were withdrawn from use on 28 August. Clinical teams have been advised that polythene gloves should not be used for any procedures. The team also advised that the practice of double gloving is only recommended for Exposure Prone Procedures (EPP) which does not include suctioning. Ensure that staff implement standard infection control precautions for linen management in the neonatal unit. Install a commercial washing machine that will meet the special needs of the Neonatal Unit. Manger, Estates and Facilities/ Divisional, Women and Children New machine installed to replace a machine which did not consistently maintain the required temperature for infection prevention precautions. Demonstrate that expressed breast milk is stored appropriately and that documentation reflects best practice. 28 August 4 September File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 4 of 10 Review Date: 4
Inspection Date: 21 August, 5 September and 17 September Appropriate storage of breast milk guidance and fridge temperature checklists to be adapted to reflect national guidance. Guidelines reviewed and now state that fridges should be between 2 and 4 degrees Celsius. Fridge checklists amended with this information and implemented for all fridges on the AMH wards and Neonatal Unit. 4 September Check that all fridges where breast milk is stored are fit for purpose and appropriately monitored. Fridges were assessed and as a result two replacement fridges were ordered and installed. Further, new thermometers were installed to all fridges. 3 September Ensure through regular monitoring that appropriate recording of temperatures for all fridges in is undertaken. Ongoing, Acute Management walk rounds are ongoing and where issues are identified with the recording of temperatures they are actioned swiftly. 7 Carry-out a risk assessment to ensure the process for storage of frozen expressed breast milk is safe and effective. 10 October Risk assessment being led by Acting Nurse with support from Infection Prevention and Control Team. Ensure that patient equipment is clean and that the procedure for the cleaning of patient equipment is understood by staff and fully implemented. File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 5 of 10 Review Date: 5
Inspection Date: 21 August, 5 September and 17 September Review cleaning schedules for domestic and nursing staff for patient equipment in the Neonatal Unit /Head of Domestic Services Domestic cleaning schedule reviewed and signed off by the domestic service and the local team at AMH. 4 October Review and clarify roles and responsibilities for the cleaning of patient equipment. 31 October of Estates and Facilities/Head of Nursing A short-life working group to review the roles and responsibilities for cleaning of all patient equipment across has been set up. This will inform future nursing and domestic cleaning schedules. Conduct a review of mattresses in AMH wards. In-patient Services Midwifery All mattress inspected by senior management team. 22 August Review suitability of the labour ward beds and introduce measures to reduce risk of crosscontamination 30 November Nursing Suppliers Coordinator/ Head of Midwifery/ IPCT Review of labour ward beds by IPCT, Nursing Supplies Co-ordinator, senior management and manufacturer was undertaken on 4 September. The ward is currently trialling new beds from the manufacturer. All existing labour ward File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 6 of 10 Review Date: 6
Inspection Date: 21 August, 5 September and 17 September beds have been deep cleaned. Investigate problems with cleaning of the labour ward beds and introduce measures to reduce risk of cross-contamination 30 November Consultant Nurse HAI/Infection Prevention and Control Nurses Established that the mechanical parts of the bed make it difficult to clean thoroughly without damage occurring. Issue to be raised at national procurement meeting. Following risk assessment, sample covers have been sourced and will be trialled. Deep clean all high risk patient equipment and areas of immediate concern in AMH. Head of Midwifery To support the deep cleaning undertaken an ongoing local programme of cleaning is in place while a system wide approach is agreed by the Short Life Working Group. 4 September Training requirements for nursing and midwifery staff to be assessed and delivered. 30 November Senior Charge Midwives/IPCT Initial discussions have identified training needs. Training schedule being developed. Continue to test new national Standard Operating Procedure for Cleaning of Reusable Patient Equipment in and 31 December Nurse Consultant, HAI Testing complete and feedback provided to Health Protection Scotland. Awaiting next update from national group File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 7 of 10 Review Date: 7
Inspection Date: 21 August, 5 September and 17 September implement final version. New system of weekly Senior Nurse Back to the Floor protected sessions throughout all acute areas in to be implemented which will facilitate hot peer audit, education and enhanced visible leadership in support of the quality and safety agenda. Ongoing, Acute System designed and communicated by during September and implemented from 1 October. From 1 October a b Ensure that senior charge nurses and senior charge midwives have accountability for ward cleanliness. Ensure senior charge nurses and senior charge midwives are aware of their accountability for the HEI agenda and its implementation in their area., Acute/ Head of Nursing Acute Ensure that all staff understand and implement the patient placement tool in line with local policy In 2009 a letter was issued to all SCN s working at ARI, outlining their responsibilities for HEI. A further letter has been drafted to reaffirm responsibilities and amplify learning around HEI for Senior Charge Nurses & Midwives. This letter was issued to all Senior Charge Nurses and Senior Charge Midwives on all Acute Sector sites. 11 October File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 8 of 10 Review Date: 8
Inspection Date: 21 August, 5 September and 17 September Patient Placement Tool implemented across all wards in. Head of Midwifery The Infection Prevention and Control Team have advised all AMH ward areas on the implementation of the tool. 16 August The Head of Midwifery has confirmed that this has now been implemented. 2 September c d e Patient placement Tool to be used/trialled for use in NNU Review the storage areas in the neonatal unit. 31 October Patient Placement Tool trial underway. Review storage areas. declutter and disposal of unnecessary items carried out. 3 Sept Contact Health Protection Scotland to discuss and review the use of sterile polythene gloves in clinical areas and its compliance with the national glove selection policy. See uirement 4 response Ensure that all staff understand and implement the checklist for discharge bed space cleaning for nursing staff in line with the local policy. Revised checklist to be implemented. 30 November Head of Midwifery The revised checklist is now in place on all maternity wards in AMH. The Neonatal Unit are developing a specific version of File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 9 of 10 Review Date: 9
Inspection Date: 21 August, 5 September and 17 September the checklist to account for the difference in bed space equipment. f Monitor correct use of bedspace checklist Head of Nursing, Acute Correct use of the bed space checklist and staff understanding is monitored though sprint audits, spot checks of staff knowledge, quarterly environmental audits and the quality measures incorporated into the Back to the Floor inspections now undertaken on a weekly basis across the Acute Sector sites. Continue to review the monitoring framework for cleaning patient care equipment and its application, in partnership with Health Protection Scotland, to provide assurance that this system is effective. See uirement 2 response 10 October File Name: HEI Action Plan Version: 1.4 Date: 24 October Produced by: HEI / Page: Page 10 of 10 Review Date: 10