Musgrave Park Hospital, Belfast - Regulation and Quality ...

v
RQIA
Infection Prevention/Hygiene
Unannounced inspection
Belfast Health and Social Care Trust
Musgrave Park Hospital
Regional Acquired Brain Injury Unit
3 April 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 12
6.4 Fixture and Fittings 12
6.5 Information 12
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 15
10.0 Hygiene Factors 17
11.0 Hygiene Practice 19
12.0 Key Personnel and Information 21
13.0 Summary of Recommendations 22
14.0 Unannounced Inspection Flowchart 23
15.0 RQIA Hygiene Team Escalation Policy Flowchart 24
16.0 Action Plan 25

1.0 Inspection Summary
An unannounced inspection was undertaken to the Musgrave Park
Hospital, on the 3 April 2012. The hospital was assessed against the
Regional Healthcare Hygiene and Cleanliness standards and the
following area was inspected:
Regional Acquired Brain Injury Unit
The Regional Acquired Brain Injury Unit (RABIU), is a purpose-built 25
bedded unit, opened in 2006, within the grounds of Musgrave Park
Hospital, Belfast. The unit cares for patients with complex disability
after all forms of acquired brain injury, predominantly in the adult
population (16 – 64 years). Its’ inpatient treatment is complemented by
an active and well-staffed multidisciplinary outpatient service.
Inspection Outcomes
The results of the inspection showed compliance in all but one of the
standards, for which staff are to be commended. In the general
environment standard, the maintenance and repair of the building and
the lack of attention to detail in cleaning practices have impacted
negatively and resulted in some minimally compliant and partially
compliant sections. While it is noted some improvement in the
cleanliness of wash hand basins and consumables is required, overall,
the observation of staff indicated that effective hygiene and infection
prevention and control practices were in place.
The inspection resulted in 13 recommendations for the Musgrave Park
Hospital, a full list of recommendations is listed in Section 13.
A detailed list of preliminary findings is forwarded to Belfast Health and
Social Care Trust /organisation) 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.
1

Notable Practice
The inspection identified the following areas of notable practice:
RABIU has initiated a Ward Cleaning Schedule and Infection
Control Advice Booklet which provides information on
cleaning guidance, relevant telephone numbers, disinfectant
dilution rates, WHO 5 moments and a daily cleaning schedule
for staff. There is a specific daily schedule to be completed
for each sector of the unit
Poster displayed on root cause analysis flowchart for MRSA
for staff to reference
Staff participation in the Productive Ward has benefited both
patients and staff and contributed to the uncluttered
environment
A recently appointed RGN with enthusiasm for infection
control has become the ward link nurse and has attended IPC
training for link nurses
The RQIA inspection team would like to thank the staff at the Musgrave
Park 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.
Table 1
Area Inspected
RABIU
General Environment 83
Patient Linen 96
Waste 89
Sharps 94
Equipment 85
Hygiene Factors 85
Hygiene Practices 94
Average Score 89
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
2

Table 2
General Environment
RABIU
Reception 74
Corridors, stairs lift 77
Public toilets 83
Ward/department -
general (communal)
83
Patient bed area 78
Bathroom/washroom 81
Toilet 95
Clinical room/treatment
room
91
Clean utility room 87
Dirty utility room 87
Domestic store 77
Kitchen 73
Equipment store 92
Isolation 80
General information 89
Average Score 83
Table 3
Patient Linen
RABIU
Storage of clean linen 92
Storage of used linen 100
Laundry facilities
N/A
Average Score 96
Table 4
Waste and Sharps
Handling, segregation,
storage, waste
Availability, use, storage
of sharps
RABIU
89
94
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
3

Table 5
Patient Equipment RABIU
Patient equipment 85
Table 6
Hygiene Factors
RABIU
Availability and
cleanliness of wash hand 82
basin and consumables
Availability of alcohol rub 93
Availability of PPE 80
Materials and equipment
for cleaning
86
Average Score 87
Table 7
Hygiene Practices RABIU
Effective hand hygiene
procedures
87
Safe handling and
disposal of sharps
100
Effective use of PPE 100
Correct use of isolation 90
Effective cleaning of ward 95
Staff uniform and work
wear
93
Average Score 94
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.
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
6

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 two inspectors, from RQIA’s
infection prevention/hygiene team. 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.
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
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
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 74
Corridors, stairs lift 77
Public toilets 83
Ward/department -
general (communal)
83
Patient bed area 78
Bathroom/washroom 81
Toilet 95
Clinical room/treatment
room
91
Clean utility room 87
Dirty utility room 87
Domestic store 77
Kitchen 73
Equipment store 92
Isolation 80
General information 89
Average Score 83
The above table outlines the findings in relation to the general
environment of the facility inspected. Whilst partial compliance was
achieved there were two sections which have been highlighted in red
which were minimally compliant and require prompt attention. Overall
the wards appeared visibly clean, however cleaning issues were
identified and the damage to finishes on shelving, floors, ceiling, doors
and walls has had a negative impact on the compliance scores.
6.1 Cleaning
During the inspection there was some evidence to indicate compliance
with regional specifications for cleaning. However, inspectors
observed, that while cleaning mechanisms were in place these were
not always effectively implemented or adhered to by staff.
10

Greater attention to detail was required when cleaning. Throughout the
unit the inspectors noted dust and debris in the corners and edges of
flooring, dust in air vents, stains or splashes on walls, skirting and
flooring and streak marks on some mirrors. Of particular note was the
main entrance where dust, debris and cobwebs were observed on the
external sliding doors to the unit and the top surface of the wall
mounted photo frames in reception were extremely dusty. Sinks and
the underneath of taps throughout the unit and the sluice bowl in the
dirt utility were dirty; some taps had lime scale.
In the treatment room, the undercarriage of the couch was dusty and in
Bay 3, the undercarriage of the bedframes, the internal fins of the free
standing fan and the supporting arm of the entertainment system were
very dusty. The entertainment screen was smeared.
Similar cleaning issues were identified in the kitchen, also the light
switch was grubby and the fridge interior was dirty, temperature checks
were inconsistently recorded.
Additional cleaning issues identified in the sanitary areas were in
regard to the underneath of the toilet seat in the public toilet and the
outside surface of the toilet bowl in the assisted bathroom W128 were
stained, the underneath of the toilet seat in bathroom W128 was dirty.
Room 9 was spot checked as a room which can be used for isolation
purposes. The room was vacant, cleaned during the inspection and
then inspected. Dust was noted on the external windows and the
undercarriage of the bed, debris was noted in the bedside cabinet
drawer. The underside of the taps, the plughole, soap and paper towel
dispenser all required additional cleaning.
6.2 Clutter
Picture 1 Clutter free treatment room
Staff advised that
participating in the Productive
Ward has benefited both
patients and staff and
contributed to the uncluttered
environment (Pictures 1).
Some minor issues were
identified, excess toilet rolls in
toilet areas, personal clothing
in the domestic store and
some boxes of supplies on
the floor of the equipment
room.
11

6.3 Maintenance and Repair
The unit has a bright, well presented appearance but on closer
inspection minor damage from general wear was noted to doors and
frames and some walls. Ceiling tiles in the main reception were
cracked, some were stained, two were missing, floor tiles were
cracked. Skirting, veneer on work surfaces and protective panelling on
doors and walls were damaged. In bathroom W128 the veneer behind
the toilet bowl was peeling off.
6.4 Fixtures and Fittings
In general the fixtures and fittings were in good repair, a few issues
were highlighted for action. Inspectors observed notice boards made
from felt and chairs upholstered in non-washable fabric, these items
cannot be effectively cleaned. The settees in the main reception were
badly worn and not impermeable to moisture, the top surface of some
bedside tables was worn to the bare wood, bedrails were chipped, and
the wheel bumpers of a bed were badly damaged. In the clean utility
room a cupboard door handle was missing, in the dirty utility room the
macerator lid was cracked at the handle.
6.5 Information
With little effort from staff full compliance could easily be achieved in
this section of the standard. There was some use of adhesive tape to
fix posters and notices, information leaflets on Clostridium difficile were
not easily available and there were inconsistencies in the recording of
the nursing cleaning schedules.
Recommendations
1. The trust should work to ensure all staff are aware of their
roles and responsibilities to improve and ensure that
environmental cleaning is carried out effectively.
2. The trust should continue to work on the repair and
maintenance of the ward and public environments and to
replace damaged or pervious fixtures and fittings.
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 92
Storage of used linen 100
Laundry facilities
N/A
Average Score 96
An overall compliant score was achieved in this standard and staff are
commended for achieving full compliance in the section concerning the
storage of used linen. Issues identified related to cleaning practice and
estates issues in the clean linen store. Dust and debris were noted in
the corner and edges of the flooring and the wooden door and frame
were damaged and worn to the bare wood in places
Recommendations
3. The trust should ensure clean linen is stored in an
environment that is clean and in good repair.
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
89
94
8.1 Waste
Issues identified related to staff practice and the repair of waste bins.
Pharmaceutical waste was disposed of incorrectly into the magpie bin,
a canister of deodorant was disposed of into the black lidded burn bin
and a clinical waste bin contained household waste. In Bay 3 the label
was worn on the household waste bin and the lid and edging of the
clinical waste bin was dirty. The base of the household waste bin in
the clinical room and the domestic store was dirty.
8.2 Sharps
In this section of the standard a high compliant score was achieved
and with minimum effort full compliance could easily be attained. The
temporary closure of the sharps bin on a drugs trolley in the clinical
room was not in place when not in use. As the door to room was open,
the sharps bin with the open closure was therefore accessible to
visitors and patients in the unit.
Recommendations
4. The trust should ensure that waste bins are kept clean, in
good repair and replaced as appropriate.
5. 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.
14

9.0 Patient Equipment
STANDARD 5.0
PATIENT EQUIPMENT
Cleanliness and state of repair of general patient equipment.
Patient Equipment
Patient equipment 85
A compliant score was achieved in this standard; in general the
equipment at the patient’s bedside was clean. Trigger tape was used
to indicate and record when cleaning had taken place. Many of the
issues identified were in relation to the poor repair and state of
equipment. Items such as commode frames and wheels were rusted,
bed rails and hoists had chipped frames and the portable mail box
venepuncture trolleys had damaged rails, the enamel surface top of
one trolley was badly worn.
Some cleaning issues were
identified such as the foot pad of a
standing aid and an oxygen probe were
grubby, tape was wrapped around an IV
stand and sticky residue was noted
underneath the lower shelf of a drugs
trolley. Staff should ensure sterile
equipment such as ambu bags, masks
and laryngoscope blades remain in the
original packaging until
ready for use for traceability
purpose (Picture 2)
Picture 2 Sterile equipment
out of packaging
Inspectors also noted sealed bags containing sterile oxygen masks and
tubing had been speared over the oxygen gauges behind beds,
rendering the contents of the bags not sterile and a nebulizer chamber
(in use) had become detached from the wall and was lying on the floor.
In the gym rehabilitation area a pelvic brace made from sheepskin was
in use; a physiotherapist advised it was unable to be decontaminated
between patients. At the feedback trust representative advised this
was not acceptable practice and would be dealt with immediately.
15

Recommendations
6. The trust and individual staff have a collective responsibility
to ensure that patient equipment is clean, stored correctly
and in good repair.
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
82
basin and consumables
Availability of alcohol rub 93
Availability of PPE 80
Materials and equipment
for cleaning
86
Average Score 85
Overall this standard was compliant however there were issues
identified that need to be addressed. Throughout the unit more
attention to detail when cleaning paper towel dispensers, hand washing
sinks, the underneath of taps (Picture 3), alcohol and soap dispensers
was required. A hand moisturiser dispenser was damaged and the
paper towel dispenser in the domestic store was empty.
Picture 3 Tap of sink in clinical room
17

The availability of PPE
section was affected by
single use plastic aprons
stored in the dirty utility room
and aprons and non-sterile
gloves stored in single/
isolation rooms. There is the
potential for aerosol
contamination in these areas.
Picture 4 Tape wrapped around a mop shaft
Some items of cleaning equipment such as the floor burnisher, dust
pan and brush were dirty; the static mop heads stored in the domestic
store were very dusty and had debris present. Elastoplast tape was
wrapped around a mop shaft (Picture 4). Inspectors noted a blue hand
bucket containing dirty water was on the floor underneath the wash
hand basin in the kitchen. This was removed immediately by catering
staff. Staff should ensure all cleaning products are stored in
accordance with COSHH as a trigger spray bottle containing a cleaning
agent was hanging from the unattended domestic trolley in the ward
corridor.
Additional Issues
There was a clinical hand washing sink in the main reception
area. The sink and taps were dry and dusty which would suggest
the facility was not used by staff or visitors; staff were unsure if
the water was flushed regularly to prevent legionella. At the
feedback trust representatives advised that if the sink was not
used it could be removed and an alcohol dispenser provided
Recommendations
7. The trust should ensure that hand washing sinks and
consumables are clean, in a good state of repair and
adequately stocked.
8. The trust should ensure PPE stations are located away from
potential contamination.
9. Further attention to detail is required to ensure that
equipment used for the general cleaning purposes of a ward
is clean and in good repair.
10. The trust should ensure that all cleaning products are stored
in a locked cupboard, in line with COSHH regulations.
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.
Recommendations
Hygiene Practices
Effective hand hygiene
procedures
87
Safe handling and
disposal of sharps
100
Effective use of PPE 100
Correct use of isolation 90
Effective cleaning of ward 95
Staff uniform and work
wear
93
Average Score 94
The unit achieved overall compliance in this standard and staff are
commended for achieving full compliance in the sections concerning
the safe handling and disposal of sharps and effective use of PPE.
Good hygiene practices were observed however it was disappointing
that not all staff were aware of the 7 step hand washing/alcohol rub
technique and nursing staff were unsure of the NPSA colour coding
system. A review of documentation evidenced that patient centred
care pathways for the identified alert organisms were in place however
inspectors noted that staff were not recording prescribed daily
treatment in the correct section of the document.
Some staff were not adhering to the trust uniform policy as a member
of domestic staff did not tie long hair above the collar and one wore
stoned rings.
Additional Issues
Staff advised they were sometimes sluicing patient laundry as the
washing machine available in the OT therapy room did not have a
sluice programme
19

Recommendations
11. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date on hand
washing practices and NPSA colour coding system
12. The trust should ensure that all members of staff are familiar
with and adhere to the regional dress code policy.
13. Staff should ensure that care pathways are completed
accurately.
20

12.0 Key Personnel and Information
Members of the RQIA inspection team
Mrs L Gawley - Inspector Infection Prevention/Hygiene Team
Mrs S O'Connor - Inspector Infection Prevention/Hygiene Team
Trust representatives attending the feedback session
The key findings of the inspection were outlined to the following trust
representatives:
Ms B Creaney - Executive Director of Nursing, Belfast Health and
Social Care Trust
Mr C Cairns - Co Director Patient and Client Support Services
Ms B Quinn - Service Manager, Recovery and Mental Health
Ms M Kearney - ASM Neurorehabilitation
Mr E Moffitt - Senior Manager, PCSS
Ms J Buchannan - Senior Infection Prevention and Control Nurse
Ms L Bradley - Support Services Manager, PCSS
Ms L Smyth - Support Services Manager, PCSS
Mr T Hughes - Infection Prevention and Control Nurse
Ms C Lockhart - Band 6 Nurse, RABIU, Musgrave Park Hospital
Mr A Shaw - Estates Services Officer
Ms S Higginson - Estates Services Officer
Ms C Herron - Assistant Support Services Manager, PCSS
Ms C Jones - Supervisor, PCSS
Mr S Logan - Supervisor, PCSS
Ms B Wilson - Supervisor, PCSS
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.
21

13.0 Summary of Recommendations
1. The trust should work to ensure all staff are aware of their
roles and responsibilities to improve and ensure that
environmental cleaning is carried out effectively.
2. The trust should continue to work on the repair and
maintenance of the ward and public environments and to
replace damaged or pervious fixtures and fittings.
3. The trust should ensure clean linen is stored in an
environment that is clean and in good repair.
4. The trust should ensure that waste bins are kept clean, in
good repair and replaced as appropriate.
5. 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.
6. The trust and individual staff have a collective responsibility
to ensure that patient equipment is clean, stored correctly
and in good repair.
7. The trust should ensure that hand washing sinks and
consumables are clean, in a good state of repair and
adequately stocked.
8. The trust should ensure PPE stations are located away from
potential contamination.
9. Further attention to detail is required to ensure that
equipment used for the general cleaning purposes of a ward
is clean and in good repair.
10. The trust should ensure that all cleaning products are stored
in a locked cupboard, in line with COSHH regulations.
11. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date on hand
washing practices and NPSA colour coding system.
12. The trust should ensure that all members of staff are familiar
with and adhere to the regional dress code policy.
13. Staff should ensure that care pathways are completed
accurately.
22

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
23

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
24

16.0 Action Plan
Recommendations
Reference
number
Recommendations
1. The trust should work to ensure all staff are aware
of their roles and responsibilities to improve and
ensure that environmental cleaning is carried out
effectively.
Designated
department
Nursing
PCSS
IPC
Action required
‘Roles and responsibilities of Staff in
relation to Environmental Cleanliness
and Cleanliness of Equipment’ policy
under review.
Date for
completion/
timescale
Jun 2012
Work / negotiations in relation to the
cleaning manual are still ongoing. In
particular, there is discussion with
nursing/control of infection with
reference to bed cleaning. Once
agreement is reached the manual will
be finalised.
Ongoing
2. The trust should continue to work on the repair and
maintenance of the ward and public environments
and to replace damaged or pervious fixtures and
fittings.
3. The trust should ensure clean linen is stored in an
environment that is clean and in good repair.
Estates
IPC
Other
appropriate
staff
Nursing
All of these aspects will be monitored
through the programme of
Environmental Cleanliness Audits
based on the Cleanliness Matters
Strategy and results fed back through
Balanced Scorecards.
This is ongoing as part of Estate daily
maintenance and refurbishment
programmes.
Guidance regarding storage of linen is
in the Regional Infection Prevention
Manual. Linen storage and segregation
guidance has been circulated to all
Directorates.
Ongoing
Complete
25

Reference
number
Recommendations
4. The trust should ensure that waste bins are kept
clean, in good repair and replaced as appropriate.
Designated
department
PCSS
Nursing
Action required
This states that all linen must be stored
off the floor in a clean dedicated area
that allows for ease of access and
rotation of stock and that Linen rooms
must have shelving that are easy to
clean, and cleaning frequencies must
be at least quarterly.
This is monitored as part of the
Environmental Cleanliness Audit
Programme.
Date for
completion/
timescale
Ongoing
Regional contract for bins at
adjudication stage.
Environmental cleanliness audit
programmes, which include daily ward
checks, department and managerial
audits, and IPC audits monitor
compliance.
5. 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.
PCSS
Nursing
Where an issue has been highlighted,
action will be taken in conjunction with
the appropriate department to ensure
rectification.
The trust will pilot and roll out across all
facilities the use of an electronic tool to
audit waste management compliance
against policy, procedure and RQIA
requirements. This process will
supplement the existing audit tools
used by PCSS, IPC and also existing
external audits conducted by Daniels
(sharps box suppliers).
Pilot
completed
Roll-out
programme
across Trust
completed Apr
2012
26

Reference
number
Recommendations
Designated
department
Action required
Daniels’ audit completed Oct 2011 and
results disseminated.
Date for
completion/
timescale
Complete
6. The trust and individual staff have a collective
responsibility to ensure that patient equipment is
clean, stored correctly and in good repair.
Nursing
PCSS
Work / negotiations in relation to the
cleaning manual are still ongoing. In
particular, there is discussion with
nursing/control of infection with
reference bed cleaning. Once
agreement is reached the manual will
be finalised.
Jun 2012
7. The trust should ensure that hand washing sinks
and consumables are clean, in a good state of
repair and adequately stocked.
PCSS
The manual includes roles and
responsibilities of trust staff in relation
to patient equipment. A template will be
used to record all cleaning of
equipment.
This is monitored as part of the
Environmental Cleanliness Audit
Programme. Staff are reminded of the
importance of replenishing dispensers.
Ongoing
Environmental cleanliness audit
programmes, which include daily ward
checks, department and managerial
audits, and IPC audits monitor
compliance.
Where an issue has been highlighted,
action will be taken in conjunction with
the appropriate department to ensure
rectification.
Regular training is provided to all
appropriate staff.
27

Reference
number
Recommendations
8. The trust should ensure PPE stations are located
away from potential contamination.
Designated
department
Nursing
Estates
Action required
The trust will review the location of all
existing PPE stations and consider the
location for all new stations.
Date for
completion/
timescale
Complete
9. Further attention to detail is required to ensure that
equipment used for the general cleaning purposes
of a ward is clean and in good repair.
Nursing
PCSS
Environmental cleanliness audit
programmes, which include daily ward
checks, department and managerial
audits, and IPC audits monitor
compliance.
Ongoing
Where an issue has been highlighted,
action will be taken in conjunction with
the appropriate department to ensure
rectification.
Regular training is provided to all
appropriate staff.
10. The trust should ensure that all cleaning products
are stored in a locked cupboard, in line with COSHH
regulations.
PCSS
Work / negotiations in relation to the
cleaning manual are still ongoing. In
particular, there is discussion with
nursing/control of infection with
reference bed cleaning. Once
agreement is reached the manual will
be finalised.
Locked cupboards are provided.
Ward managers and PCSS supervisors
carry out regular checks to ensure all
staff comply with COSHH procedures.
Audited as part of Belfast Risk
Assessment and Audit Tool (BRAAT).
Jun 2012
Complete and
ongoing
28

Reference
number
Recommendations
11. The trust and individual staff have a collective
responsibility to ensure that staff knowledge is kept
up to date on hand washing practices and NPSA
colour coding system.
Designated
department
IPCT
Action required
Balance scorecards, which include
WHO Hand Hygiene audits. All of
these aspects will be monitored through
the programme of Environmental
Cleanliness Audits based on the
Cleanliness Matters Strategy.
Date for
completion/
timescale
Complete and
Ongoing
The IPCT carry out independent audits
and results are fed back. Independent
audits are carried out 4 times a year (2
of which are carried out by Infection
Prevention and Control).
12. The trust should ensure that all members of staff
are familiar with and adhere to the regional dress
code policy.
13. Staff should ensure that care pathways are
completed accurately.
All
Directorates
Nursing
The Trust has produced a colour-coded
guidance document based on the
NPSA system, which is displayed in all
clinical areas.
Trust policy available to all staff on
Intranet. Policy is enforced at local level
by senior staff, e.g., Ward Sisters and
Senior Managers.
The Ward Sister/Charge Nurse Support
Improvement and Accountability
Framework (SIAF) includes an indicator
relating to compliance with the dress
code policy and this is audited on a
quarterly basis.
Care pathways exist for MRSA and
Cdiff.
All patients with these infections are
nursed as per these pathways and this
includes appropriate documentation in
their notes.
Complete
Ongoing
Complete
29