Royal Victoria Hospital, Belfast - 17 July 2012 - Regulation and ...

RQIA
Infection Prevention/Hygiene
Unannounced Inspection
Belfast Health and Social Care Trust
Royal Victoria Hospital
17 July 2012

Contents
1.0 Inspection Summary 1
2.0 Background Information to the Inspection Process 6
3.0 Inspections 6
4.0 Unannounced Inspections 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 12
6.3 Maintenance and Repair 13
6.4 Fixture and Fittings 14
6.5 Information 14
6.6 Additional Issues 15
7.0 Patient Linen 17
7.1 Management of Linen 17
8.0 Waste and Sharps 19
8.1 Waste 19
8.2 Sharps 19
8.3 Additional Issue Ward 7B 20
9.0 Patient Equipment 22
10.0 Hygiene Factors 24
11.0 Hygiene Practice 25
12.0 Key Personnel and Information 29
13.0 Summary of Recommendations 31
14.0 Unannounced Inspection Flowchart 33
15.0 RQIA Hygiene Team Escalation Policy Flowchart 34
16.0 Action Plan 35

1.0 Inspection Summary
An unannounced inspection was undertaken to the Royal Victoria
Hospital, on the 17 July 2012. The hospital was assessed against the
Regional Healthcare Hygiene and Cleanliness Standards and the
following areas were inspected:
• Ward 4C - Orthopaedic
• Ward 5A - Vascular
• Ward 6A - Gastro-intestinal Surgery
• Ward 7B - Medical Respiratory
Inspection Outcomes
Overall the inspection teams found evidence that the Royal Victoria
Hospital was working to comply with the Regional Healthcare Hygiene
and Cleanliness standards. Improvements in the overall levels of
compliance have been noted since the previous inspection, three of the
wards achieved an overall partially compliant score and Ward 6A
achieved an overall compliant score.
Inspectors found that further improvement was required in the following
areas. The environment in all wards required attention to detail where
cleaning; clutter, and at times poor maintenance and repair, notably in
Ward 5A, have impacted negatively on the scoring.
Although all wards scored overall compliance for the standard
regarding hygiene factors, the section on materials and equipment for
cleaning, indicates that more work is required to improve practice. In
the hygiene practices standard, Ward 4C scored a minimal compliance
in the section hand hygiene procedures and none of the wards were
compliant for the section concerning effective cleaning of the ward. In
all wards, all staff groups must implement hygiene and infection
prevention and control practices consistently to minimise the potential
risk of transmission of infection to patients, visitors and staff. As a
result of the findings for Wards 4C and 5A a follow up inspection will be
carried out within three months.
The inspectors noted that good practice by staff resulted in compliance
in the following sections of the audit tool; the management of waste
and used linen and within the Hygiene Factors and Hygiene Practices
standards.
The inspection resulted in 22 recommendations for the BHSCT and the
Royal Victoria 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 within 14 days of the inspection to enable early
action on identified areas which have achieved non complaint scores.
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The draft report which includes the high level recommendations in a
Quality Improvement Plan is forwarded within 28 days of the inspection
for agreement and factual accuracy. The draft report is agreed and a
completed action plan is returned to RQIA within 14 days from the date
of issue. The detailed list of preliminary findings is available from RQIA
on request.
The final report and Quality Improvement Plan will be available on the
RQIA website. Reports and action plans will be subject to performance
management by the Health and Social Care Board and the Public
Health Agency.
Notable Practice
The inspection identified the following areas of notable practice:
• Care bundles are performed for insertion and maintenance of
peripheral IV lines, maintenance of central lines and urinary
catheterization
• Audits are carried out on; hand hygiene, peripheral vascular
catheters, central venous catheters, urinary catheter care
• Ward 5A has implemented a care bundle for the acutely ill
patient
• Vapourised hydrogen peroxide cleans are carried following
discharge of patients with VRE (Vancomycin Resistant
Enterococcus) infection
• Ward 6A has initiated a “Body Chart” for use with each
patient. This is a good visual trigger for staff to quickly
identify catheters, cannulae, wounds, pressure areas
• In Ward 6A and 7B, the use of the electronic handover tool
has shortened handover time to approximately 10 minutes
and can highlight IPC issues for staff
The RQIA inspection team would like to thank the BHSCT and in
particular all staff at the Royal Victoria 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 the organisation to target areas that
require more specific attention.
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Table 1
Ward 4C 5A 6A 7B
Environment 80 70 81 80
Patient Linen 87 88 89 83
Waste 88 86 89 86
Sharps 79 76 94 79
Equipment 81 76 88 86
Hygiene Factors 92 88 91 87
Hygiene Practices 81 89 90 90
Total 84 82 89 84
Table 2
Environment 4C 5A 6A 7B
Reception N/A N/A 70 N/A
Corridors, stairs lift 88 83 81 95
Public toilets 86 N/A 84 N/A
Ward/department –
general (communal)
90 72 79 80
Patient bed area 83 72 84 77
Bathroom/washroom 87 65 79 94
Toilet N/A N/A 87 79
Clinical room/treatment
room
66 50 96 74
Clean utility room 85 59 76 80
Dirty utility room 86 71 75 73
Domestic store 73 64 81 79
Kitchen N/A 57 78 67
Equipment store 67 80 81 81
Isolation 76 86 79 73
General information 60 85 81 85
Total 80 70 81 80
Table 3
Linen 4C 5A 6A 7B
Storage of clean linen 79 81 83 65
Storage of used linen 94 94 94 100
Laundry facilities N/A N/A N/A N/A
Total 87 88 89 83
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
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Table 4
Waste and sharps 4C 5A 6A 7B
Handling, segregation,
storage, waste
88 86 89 86
Availability, use,
storage of sharps
79 76 94 79
Table 5
Patient Equipment 4C 5A 6A 7B
Patient equipment 81 76 88 86
Table 6
Hygiene Factors 4C 5A 6A 7B
Availability and
cleanliness of WHB and 94 91 91 85
consumables
Availability of alcohol
rub
100 100 97 93
Availability of PPE 94 100 93 93
Materials and
equipment for cleaning
79 59 83 77
Total 92 88 91 87
Table 7
Hygiene Practices 4C 5A 6A 7B
Effective hand hygiene
procedures
71 85 94 80
Safe handling and
disposal of sharps
100 100 100 100
Effective use of PPE 86 100 94 100
Correct use of isolation 82 N/A 88 86
Effective cleaning of
ward
76 74 76 80
Staff uniform and work
wear
72 86 90 93
Total 81 89 90 90
Compliant:
85% or above
Partial Compliance: 76% to 84%
Minimal Compliance: 75% or below
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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.
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3.0 Inspections
The DHSSPS has devised draft Regional Healthcare Hygiene and
Cleanliness standards. RQIA has revised its inspection processes to
support the publication of the standards which were compiled by a
regional steering group in consultation with service providers.
RQIA's infection prevention/hygiene team have planned a three year
programme which includes announced and unannounced inspections
in acute and non-acute hospitals in Northern Ireland. This will assess
compliance with the DHSSPS Regional Healthcare Hygiene and
Cleanliness standards.
The inspections will be undertaken in accordance with the four core
activities outlined in the RQIA Corporate Strategy, these include:
• Improving care: we encourage and promote improvements in the
safety and quality of services through the regulation and review of
health and social care
• Informing the population: we publicly report on the safety,
quality and availability of health and social care
• Safeguarding rights: we act to protect the rights of all people
using health and social care services
• Influencing policy: we influence policy and standards in health
and social care
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4.0 Unannounced Inspection Process
Trusts receive no advanced notice of the onsite inspection. An email
and telephone call will be made by the Chief Executive of RQIA or
nominated person 30 minutes prior to the team arriving on site. The
inspection flow chart is attached in Section 14.
4.1 Onsite Inspection
The inspection team was made up of four inspectors from RQIA’s
infection prevention/hygiene team along with four peer reviewers. One
inspector led the team and was responsible for guiding the team and
ensuring they were in agreement about the findings reached.
Membership of the inspection team is outlined in Section 12.
The inspection of ward environments is carried out using the draft
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.
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5.0 Audit Tool
The audit tool used for the inspection is based on the draft 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 draft 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
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Level of Compliance
Percentage scores can be allocated a level of compliance using the
compliance categories below. The categories are allocated as follows:
Compliant
85% or above
Partial compliance 76 to 84%
Minimal compliance 75% or below
Each section within the audit tool will receive an individual and an
overall score, to identify areas of partial or minimal compliance to
ensure that the appropriate action is taken.
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6.0 Environment
STANDARD 2.0
GENERAL ENVIRONMENT
Cleanliness and state of repair of public areas; cleanliness and
state of repair of ward/department infrastructure; cleanliness and
state of repair of patient bed area; cleanliness and state of repair
of toilets, bathrooms and washrooms; cleanliness and state of
repair of ward/department facilities; availability and cleanliness
of isolation facilities; provision of information for staff, patients
and visitors.
Environment 4C 5A 6A 7B
Reception N/A N/A 70 N/A
Corridors, stairs lift 88 83 81 95
Public toilets 86 N/A 84 N/A
Ward/department –
general (communal)
90 72 79 80
Patient bed area 83 72 84 77
Bathroom/washroom 87 65 79 94
Toilet N/A N/A 87 79
Clinical room/treatment
room
66 50 96 74
Clean utility room 85 59 76 80
Dirty utility room 86 71 75 73
Domestic store 73 64 81 79
Kitchen N/A 57 78 67
Equipment store 67 80 81 81
Isolation 76 86 79 73
General information 60 85 81 85
Total 80 70 81 80
The above table outlines the findings in relation to the general
environment of the facilities inspected where none of the wards
achieved compliance in this standard. The findings indicate that there
were areas for improvement in all wards, notably Ward 5A, where
clutter, the poor repair and cleaning of the fabric of the building, fixtures
and fittings have contributed to the minimally compliant areas
highlighted in red. The findings in respect of the general environment
are detailed in the following sections.
6.1 Cleaning
At the time of the inspection there was evidence in some areas to
indicate compliance with regional specifications for cleaning. However,
the inspectors observed that while cleaning mechanisms were in place
to prevent the build up of dust, debris and bacteria and subsequently
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educe the potential risk for the transmission of infection, they were not
always implemented or adhered to.
Ward 5A was minimally compliant for the majority of criteria within this
standard with an overall minimally compliant score. A concentrated
effort is required by staff in all wards to improve cleaning practice.
In the main reception area, walls and flooring were stained, the edges
of the stairs and ceiling air vents had a build up of dust, external
windows were smeared, public telephones were dirty and had paper
labels attached to the wall mounted frame. Dust was also noted on the
plants, the wooden panelling housing the plants and on the window sill
and in the radiator cover of the public toilet. Similar issues were noted
in the public toilet of Ward 4C where the vinyl flooring was grubby, the
air vent was dusty and the door was stained.
In the corridors leading to Wards 4C, 5A and 7B green algae was
present on some window panels and cobwebs were observed in the
lobby outside Wards 6A and 5A. Greater attention to detail when
cleaning window sills, external windows, stained flooring, corners and
edges of flooring was required in the lobby of Ward 6A. Similarly, in
Ward 5A, the lift doors and ceiling tiles were stained, sticky hand marks
were noted on windows and sticky adhesive residue on the public
telephone.
In all wards inspected greater attention to detail was required when
cleaning, to ensure dust, debris and stains are removed from all high
and low horizontal surfaces, such as skirting, radiators, walls and
flooring. The interior and exterior of high density shelving, windows,
lights and vents, all fixtures and fittings, including sanitary, dirty utility
and disposal areas required attention. Inspectors observed that
adhesive tape was used to attach labels or posters to surfaces which in
some instances had left a sticky residue, impeding the cleaning
process.
Lime scale was observed on taps. Particular care is required to ensure
that lime scale is removed from taps and fittings as recent evidence
has shown that lime scale may harbour biofilms and the build-up of
lime scale can interfere with good cleaning and disinfection by masking
and protecting pathogens.
In Wards 6A and 7B shower chairs were stained, in Ward 5A, the
inside and outside of the toilet bowl, the underneath of the toilet seat
and the toilet brush and holder required cleaning.
Wards 4C, 5A and 6A require further work to ensure that the inside/
outside of the drugs’ fridges and door touch points throughout the
wards are clean. In Wards 4C, 5A and 7B temperature recordings
were inconsistent and record sheets did not all provide evidence for
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ecord variations outside recommended temperature ranges or actions
taken.
Cleaning issues such as dust on horizontal surfaces, debris in corners
and edges of flooring, grubby pull cords and hand washing facilities
and excess toilet rolls were identified in rooms designated for isolation
purposes. In Ward 4C a room had been treated with Vaporised
Hydrogen Peroxide (VHP) however, the cleaning process had not been
completed to an acceptable standard. Surfaces were still dusty, the
suction canister, disposable ear phones, soap and hibiscrub dispensers
had not been removed prior to the treatment and there were footprints
on the patient wash chair. In Ward 7B the rim of the toilet bowl and the
shower chair were stained, in Ward 6A the shower drain, shower panel
and toilet seat were dirty.
Catering kitchens were inspected on Levels 5, 6 and 7. Level 6 was
partially compliant; Levels 5 and 7 were minimally compliant. Flooring,
skirting, horizontal surfaces, taps and sinks, some fixtures and fittings
required more in depth cleaning. In Level 5, the hot water geyser, the
exterior of cleaned water jugs and the inside of the dishwasher were
dirty. Opened food was not stored in sealed, airtight containers, work
surfaces were grubby. In Level 7, surfaces were untidy and cluttered,
many kitchen appliances were stained, the Gastnorm tray was on the
floor, fly screens and the dishwasher were dirty and catering staff were
observed not wearing head gear when plating up chicken.
6.2 Clutter
The provision of clutter free wards and effective utilisation of space and
good stock management assists with effective cleaning in the wards
(Picture 1). Inspectors however noted in Ward 4C a cage containing
stores, a mattress and a bed were in the corridor outside the ward and
the equipment store, also used as a staff locker room and domestic
store was disorganised and very cluttered (Picture 2). The on going
refurbishment of Ward 6A contributed to the storage of domestic
equipment cluttering the dirty utility room and unfixed shelving littering
the floor of the equipment store and reducing storage capabilities within
the room.
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Picture 1: Tidy mail box storage
Picture 2: Cluttered locker room
in Ward 4C
The clean utility rooms and domestic stores of Wards 5A and 7B did
not have sufficient space to allow for effective storage of equipment
and patient equipment was stored in both treatment rooms. In Ward
7B, the 6 bedded bays appeared cramped with little space between
beds and the displaying of cards on wall trunking created a cluttered
environment. There was inadequate shelving in the dirty utility room
and patient equipment was stored in the en-suite of a room used for
isolation purposes.
The lobby of Ward 5A was cluttered with a bicycle, chair, transport
cage and pharmacy boxes, the latter two blocking access to the public
telephone. Shelving units in the equipment store were cluttered and
untidy, communal toiletries were present in shower rooms. Excess
toilet rolls were noted in toilet areas of Wards 5A, 6A and 7B.
6.3 Maintenance and Repair
Inspectors observed that in the main reception, the entrance doors
were damaged, there was minor wall damage, and the wooden
panelling, reception desk and internal frame at the glass brick window
were worn, exposing bare wood.
In all wards inspected, inspectors noted wall, door and paintwork
damage. It was evident that staff practice in propping doors open with
waste bins or storing equipment against walls has in some part
contributed to the wall and door damage observed. In Ward 4C
inspectors observed holes in the shower room wall from removed
fixtures and skirting poorly joined in the treatment room. Flooring was
damaged in Wards, 4C, 5A and 6A, water leaks were noted in the
kitchens of Levels 5 and 7 and damaged formica or veneer was
observed on work surfaces and at the nurses’ station in Wards 5A and
6A.
Wall repairs of a poor standard were noted in Ward 7B. Wall trunking
was damaged, electrical flex was hanging from a ceiling light in a toilet
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and some lights did not work. An issue also observed in Ward 5A
treatment room.
Damaged fly screens and radiator covers, displaced or damaged
ceiling tiles, split covers on pull cords and rusted shelving in the
chemical cupboard of the domestic store contributed to the minimally
compliant score achieved in Ward 5A for this standard. The drugs’
fridge was old, worn and damaged, an issue also identified in Ward 6A.
In Ward 6A, wiring was exposed on a hand held call bell, wall trunking
in the bays and the sealant at some hand washing sinks were
damaged. Some caps used to cover mirror screws were missing
resulting in rusted screw heads.
6.4 Fixtures and Fittings
The fixtures, fittings and equipment in all wards were generally fit for
purpose however common issues were identified for action. In Wards
4C, 5A and 6A, shower rail fittings were available but there was no
curtain to protect patient’s privacy and dignity. The lack of bedpan drip
trays and chipped bedrails were noted in Wards 5A, 6A and 7B,
bedpan holders were overstocked in Ward 7B.
Vertical blinds and wooden chairs were damaged in Wards 6A and 7B
and there was no sign on the treatment door alerting the storage of
oxygen cylinders. Pillows in Ward 7B did not have plastic protective
covering, inspectors observed stained pillows.
In Ward 6A the leaflet rack in the waiting area was badly damaged and
the fabric covers on the seating benches were badly stained. At the
feedback trust representatives confirmed these would be replaced.
Also observed were damaged toilet seats and worn plugholes, the blue
storage containers in the treatment room were worn and damaged.
A mattress spot checked in Ward 4C was damaged, the undercarriage
of a bed was broken and privacy curtains were not dated. Privacy
curtains in Ward 5A required changing.
6.5 Information
With the exception of Ward 6A, the trust’s new nursing cleaning
schedules outlining responsibility, equipment and frequency of cleaning
were not in place for staff to reference and document. Due to on-going
refurbishment of the domestic store in Ward 6A, domestic cleaning
schedules had been removed.
Hand washing posters in Ward 4C demonstrated a 6 step procedure
instead of the recommended 7 step, information leaflets on MRSA,
Clostridium difficile, general infections or hand hygiene were not
available, MRSA leaflets were also not available in Ward 7B.
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In Wards 4C and 5A National Patient Safety Agency (NPSA) guidelines
were not clearly displayed for nursing staff to reference and in Ward 6A
there was no poster available on the segregation of linen. In all wards
inspectors observed posters and labels which were not laminated and
posters attached to surfaces with adhesive tape.
6.6 Additional Issues
• User friendly information on hand hygiene and environmental
cleanliness audits and evidence on care bundle performance
(Picture 3) were not displayed in all wards, for example Wards 6A
and 7B. Staff in Ward 6A confirmed that the notice board for
displaying the information had been removed for the ongoing
refurbishment.
Picture 3: Notice board displaying audits,
information and mandatory training dates
• In Ward 6A the original linen store had been spit into a smaller
linen store and a domestic sluice room. The sluice room was still
under construction therefore staff were using the domestic store
in Ward 6B to store equipment, material and supplies and the
nursing sluice to empty buckets.
Recommendations
1. The trust should work to improve, monitor and ensure that
environmental cleaning is carried out effectively, that patient
equipment is fit for purpose and that the environment is in a
good state of repair.
2. The senior management within trust should ensure that all
staff are aware of their roles and responsibilities in
environmental cleaning.
3. The trust should work on the repair and maintenance of ward
and public environments and to replace damaged fixtures
and fittings.
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4. The trust and staff should work to improve storage and
maintain clutter free ward environments.
5. The trust should ensure all relevant information is available
for patients, visitors and staff to reference.
6. The trust should continue to roll out the newly developed
nursing cleaning schedules.
7. The trust should ensure that all staff are aware of the
importance of monitoring fridge temperatures.
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7.0 Patient Linen
STANDARD 3.0
PATIENT LINEN
Storage of clean linen; handling and storage of used linen; ward/
department laundry facilities.
Linen 4C 5A 6A 7B
Storage of clean linen 79 81 83 65
Storage of used linen 94 94 94 100
Laundry facilities N/A N/A N/A N/A
Total 87 88 89 83
7.1 Management of Linen
The poor repair of the linen store affected the levels of compliance in
all wards. Ward 6A was the only linen store which appeared tidy and
organised, non-linen items contributed to the cluttered environment in
Wards 5A and 7B. Shelving was damaged in Ward 5A and 7B, wall
damage was noted in all stores except in Ward 7B, although inspectors
noted a wall mounted wooden plinth which could not be effectively
cleaned and a missing light cover.
The wooden door frame of Ward 4C was damaged preventing full
closure of the door; the door handle in Ward 7B was broken. In Wards
6A and 7B debris was noted on the corners and edges of the flooring,
sticky labels were posted untidily on the door.
Washed in stains were noted on bed sheets of two beds in Ward 6A;
staff confirmed that this was an ongoing issue. In Ward 5A the ward
sister advised that on occasions cleaned ‘wet’ sheets were returned to
the ward from the laundry services. At the feedback trust
representatives advised that the laundry company responsible for
laundering linen would be contacted and that staff on the wards were to
record and inform of any further incidents.
The storage and segregation of used linen was generally good, no
issues were identified in Ward 7B where good practices were
observed. In Ward 4C, had the frames of the linen skips been in good
repair full compliance would also have been achieved for this section of
the audit.
Staff practice affected scores in Wards 5A and 6A. In Ward 5A
although not observed, nursing staff advised inspectors that they did
not wear personal protective equipment when washing and changing a
bed. In Ward 6A inspectors noted used linen which had not been
placed into an alginate bag in a red linen laundry bag designated for
contaminated linen. Staff questioned confirmed the linen was not
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contaminated and had been incorrectly disposed of into the wrong linen
skip.
Recommendations
8. The trust should ensure the correct storage of clean linen in
a designated area which is clean and fit for purpose.
9. The trust should monitor the implementation of its policies
and procedures in respect of the handling and storage of
linen to ensure that safe and appropriate practice is in place.
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8.0 Waste and Sharps
STANDARD 4.0
WASTE AND SHARPS
Waste: Effectiveness of arrangements for handling, segregation,
storage and disposal of waste on ward/department
Sharps: Availability, use and storage of sharps containers on
ward/department
Waste and sharps 4C 5A 6A 7B
Handling, segregation,
storage, waste
88 86 89 86
Availability, use,
storage of sharps
79 76 94 79
8.1 Waste
The inspection evidenced that all wards were compliant for the
handling, segregation and storage of waste standard. Some issues
however were identified that require attention.
With the exception of Ward 4C damage was noted to waste bins and at
least one waste bin in all wards inspected required cleaning.
To encourage good hand hygiene practices in all wards inspected, it is
essential that household waste bins are available at all hand washing
sinks and the placement does not affect patient privacy and dignity.
In Bay B Ward 4C the waste bins were located under privacy curtains.
In all wards waste was not disposed of into the correct waste stream
and in line with trust policy. The magpie box in Ward 7B designated for
aerosols, broken crockery and glass contained a dirty dust pan.
There was pharmacy waste in the magpie boxes of Wards 4C, 5A and
6A, in Ward 5A pharmacy waste had also been disposed into a yellow
lidded burn bin and in Ward 6A into a large sharps box. Ward 4C did
not have a black lidded burn bin.
Incorrect disposal of household waste into the clinical waste stream
was noted in Wards 5A and 6A. A sharps box in Ward 5A also
contained household waste, in Ward 4C a sharps box contained used
dressings. Inspectors observed in Ward 7B a clinical waste bag
incorrectly placed in a black lidded household waste bin.
8.2 Sharps
The inspection evidenced that only Ward 6A achieved compliance on
the safe handling, segregation, storage and disposal of sharps
standard. The ward shares the emergency trolley with Ward 6B.
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Inspectors were disappointed to note that in this ward the sharps box
on the emergency trolley was not labeled, signed or secure and the
temporary closure was open.
Common themes were observed in the other three wards. Temporary
closure mechanisms were not all in place on the sharps boxes when
not in use, sharps boxes on the emergency or drugs trolleys were not
secure or empty and sharps trays were stained in Wards 4C and 5A.
Inspectors in Wards 5A and 7B
observed items such as IV tubing and
syringe plungers, protruding from
sharps boxes (Picture 4). In Ward 7B
the sharps box on the resuscitation
trolley was not dated, or signed and
sharps were not disposed of at the
point of care as there were no
compatible sharps boxes for the IV
trays in use.
Picture 4: Protruding plunger in sharps box
8.3 Additional Issue Ward 7B
On entering the treatment room during the inspection the inspector
observed that IV/IM medication had been drawn up and left sitting in
trays, this is unsafe practice and was addressed immediately by the
nurse and brought to the attention of the ward manager. It is
concerning that this issue was also identified on the re-audit of a
different ward last year; this may be a training issue for the trust.
Recommendations
10. 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.
11. The trust should ensure that waste bins and equipment used
in the management of waste are available, kept clean and
replaced as appropriate.
12. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
the safe and the correct handling and disposal of waste and
sharps is adhered to.
20

13. The trust need to review staff practice in relation to the
administration of medications and provide training if required.
21

9.0 Patient Equipment
STANDARD 5.0
PATIENT EQUIPMENT
Cleanliness and state of repair of general patient equipment.
Patient Equipment 4C 5A 6A 7B
Patient equipment 81 76 88 86
Wards 6A and 7B achieved compliance for this standard; Wards 4C
and 5A were partially compliant, issues were identified in all wards
inspected.
Common themes were noted. Trigger tape to denote equipment had
been cleaned and was ready to use was not in use in Wards 5A and
4C, it was sporadically used in Ward 7B. In Ward 7B disposable
tourniquets were not in use, in Ward 6A used disposable tourniquets
had been left on sharps trays, these were discarded immediately by a
senior staff nurse. With the exception of Ward 7B, staff questioned
were unaware of the symbol for single use equipment.
Greater attention to detail when cleaning patient equipment such as the
underside of commodes, walking aids, IV stands, suction machines,
drugs’ and resuscitation trolleys and re-usable blood pressure cuffs
was required in Wards 4C and 7B. Staff in Ward 4C should ensure
stock is regularly rotated and adhesive tape and plasters removed from
all equipment; in Ward 7B there was no filter on the portable suction
machine. In both wards patient washbowls were not stored inverted to
aid the drying process.
The low partially compliant score in Ward 5A is indicative of patient
equipment which required cleaning, was in poor repair or stored out of
packaging. Items such as Magills forceps, ambu bags and masks out
of packaging did not have traceability labels to denote expiry date and
lot number; some IV bags were also stored out of original packaging.
Detailed cleaning of stored equipment such as IV stands, IV pumps
and observation monitors and in use drugs’, notes’ and dressing
trolleys was required. Some equipment had minor damage such as
chipped framework, the undercarriage of a commode was rusted, the
plastic protective coating on some urinal holders or catheter stands
was missing in places exposing the metal underneath and the casing of
a glucose monitor was held together with adhesive tape (Picture 5).
Inspectors noted two bedpans which had been processed by the
washer disinfector had faecal stains present. Staff should ensure
effective cleaning processes are in place.
22

Picture 5: Glucose monitor casing and
dirty adhesive tape
Patient equipment in Ward 6A was generally visibly clean and in good
condition although some bedpans and IV stands were old and worn.
Blood stains were noted on the glucose monitoring machine and the
interior lid of its container.
Recommendations
14. The trust and individual staff have a collective responsibility
to ensure that equipment is clean, stored correctly and in a
good state of repair.
15. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
equipment cleaning.
23

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 4C 5A 6A 7B
Availability and
cleanliness of WHB and 94 91 91 85
consumables
Availability of alcohol
rub
100 100 97 93
Availability of PPE 94 100 93 93
Materials and
equipment for cleaning
79 59 83 77
Total 92 88 91 87
All wards were compliant for this standard; Wards 4C and 5A were fully
compliant for the sections concerning availability of alcohol rub.
Hand washing sinks and fixtures and fittings in all wards were generally
clean, working and in a good state of repair however, greater attention
to detail could further improve scoring. In Wards 4C and 6A although
clean, some hand washing sinks were old, worn or stained, in Ward 4C
the laminate surround was badly worn. Staff in Ward 6A and 7B were
unsure who had responsibility for running the sink in the shared
disposal area in line with the trust Legionella control measures.
In Ward 7B the hand washing sinks in the clean and dirty utility rooms
were not draining properly, the surface was tarnished and drainage
holes were dirty. The hand washing sink in the treatment room was not
visibly clean, the seal was stained and peeling away from the splash
back. There was no soap dispenser in the dirty utility room and
Chlorhexidine hand wash was supplied at all hand washing sinks, a
similar issue in Ward 6A.
It is imperative that in order to promote effective hand hygiene for staff
and visitors that hand hygiene consumables are available for use.
There was one alcohol rub dispenser in Ward 6A which was empty, the
hand rub container at the entrance to Ward 7B was missing and
Hydrex dispenser plungers were dirty.
None of the wards was compliant in the section materials and
equipment for cleaning, Ward 5A was minimally compliant. With the
exception of Ward 7B, inspectors noted chemicals stored in unlocked
cupboards breaching COSHH regulations, in Ward 6B disinfectant
24

tablets were decanted into an unlabelled foil dish, in Ward 6A out of
date cleaning chemicals were in the unlocked equipment store waiting
collection. Trigger spray bottles of air freshener were hanging in
shower rooms in Wards 5A and 6A.
In Wards 4C, 5A and 6A, some mop buckets were dirty in the crevices,
not all were stored inverted. Mops buckets in Wards 5A and one
bucket in Ward 6A were observed stored in the domestic store filled
with solution. In Ward 5A some contained used mop heads, in both
wards some mop heads were soaking in the solution and therefore not
laundered after use.
Picture 6: Cloths and mops left soaking
in solution
In Ward 5A, a red hand held
bucket filled with solution and
a cloth had been left in the
domestic store and not
discarded after use (Picture
6). Mop handles were stored
propped against the wall as
holders were not available.
Dirty, wooden floor brushes,
which cannot be effectively
cleaned were observed, and
the brushes were not colour
coded in line with NPSA
guidelines.
Dustpans were dirty in Wards 5A, 6A and 7B, brushes in Ward 7B also
required cleaning. Cleaning equipment such as burnishers, high
dusters, vacuums were dirty or had minor damage in Ward 5A, floor
polishing pads were dirty in Ward 4C, and the polisher was dusty. Dirty
or damaged equipment was observed in Ward 7B, the flex of the
burnisher and the vacuum hose was damaged, the castors and base of
the burnisher were dusty.
Recommendations
16. The trust should ensure that hand washing sinks and
consumables are available, clean, working and in a good
state of repair.
17. The trust should ensure that all cleaning products are stored
in a locked cupboard, in line with COSHH regulations.
18. Further attention to detail is required to ensure that
equipment used for the general cleaning purposes of a ward
are clean, used and stored appropriately and are fit for
purpose.
25

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 4C 5A 6A 7B
Effective hand hygiene
procedures
71 85 94 80
Safe handling and
disposal of sharps
100 100 100 100
Effective use of PPE 86 100 94 100
Correct use of isolation 82 N/A 88 86
Effective cleaning of
ward
76 74 76 80
Staff uniform and work
wear
72 86 90 93
Total 81 89 90 90
With the exception of Ward 4C overall compliance was achieved in this
standard. Poor hand hygiene practices were observed in Ward 4C.
Many staff did not carry out all seven steps of the hand wash
technique, staff did not comply with hand hygiene in line with the World
Health Organisation (WHO) five moments of care and patients were
not offered hand hygiene prior to meals. In Ward 7B the majority of
staff observed evidenced effective hand hygiene practice however on
two occasions staff did not undertake the seven step technique
properly and all but one member of staff used antibacterial hand wash
in preference to soap.
Staff in all wards are commended for achieving full compliance for the
section relating to safe handling and disposal of sharps. Wards 5A and
7B were fully compliant with effective use of PPE. In Ward 4C
domestic staff confirmed they did not wear aprons for wet work and a
member of staff was observed not removing gloves after completing an
activity. In Ward 6A a nursing auxiliary was observed leaving an
isolation room having removed PPE and not decontaminating their
hands outside the room.
There were no patients requiring isolation precautions in Ward 5A
therefore this section of the tool kit was not scored. In Wards 4C and
7B inspectors reviewed the notes of a patient with a known infection;
the care pathway was in place however the infection prevention and
control assessment had not been completed. Additionally, in Ward 7B
26

dust in the isolation room would suggest that cleaning was not being
carried out effectively on a daily basis, while in Ward 4C patients and
relatives were not provided with relevant information leaflets. A review
of the notes in Ward 6A identified that both the care pathway and the
infection, prevention and control assessment had not been completed.
To improve practice and knowledge in the effective cleaning at ward
level further effort is required in all wards inspected, and notably Ward
5A which was minimally compliant in this section. In Ward 5A
registered nursing staff did not routinely clean patient equipment
between use however nursing auxiliary staff did. Some nursing staff
questioned were unaware of the dilution rates for the disinfectant in use
for routine cleaning, none knew the dilution rate for cleaning blood and
body spillages and the NPSA (National Patient Safety Agency) colour
coded system for cleaning.
In Ward 4C there was little evidence to demonstrate patient equipment
was cleaned between use as detergent wipes were exposed and dry in
their canisters. Individual bottles of constituted disinfectant bottles
were not dated, NPSA colour coding guidelines were not available for
nursing staff and staff were unaware of the need for a decontamination
certificate for equipment needing repaired, serviced or maintained.
Staff in Wards 6A and 7B were unable to outline the correct procedure
for cleaning blood and body fluid spillage as they did not know the
correct disinfectant dilution rate. Data sheets for the disinfectant in use
were not available in Ward 6A and not all nursing staff were aware of
the NPSA colour coding system.
Inspectors observed that the trust has in general implemented the
concept of ‘bare below the elbow’ for staff delivering care. However, in
Ward 4C two members of staff did not comply with the policy, two
members of medical staff wore wrist watches, two members of staff
wore unsecured clothing. In Ward 5A medical staff were observed with
stethoscopes hanging around their necks, a student nurse in Ward 6A
wore false nails. These were removed before the end of the
inspection.
Designated staff changing facilities were not available for nursing and
domestic staff to change into and out of their uniform at work.
Recommendations
19. The trust and individual staff have a collective responsibility
to ensure that hand hygiene is carried out in line with WHO
guidance and that all PPE is used appropriately.
20. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date with regard
to isolation, cleaning and decontamination of equipment.
27

21. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
the use of disinfectants.
22. The trust should ensure that all members of staff are familiar
with and adhere to the regional dress code policy.
28

12.0 Key Personnel and Information
Members of the RQIA inspection team
Mrs E Colgan
Mrs L Gawley
Mrs S O’Connor
Mrs M Keating
- Senior Officer Infection Prevention/Hygiene Team
- Inspector Infection Prevention/Hygiene Team
- Inspector Infection Prevention/Hygiene Team
- Inspector Infection Prevention/Hygiene Team
Peer Reviewers
Janice Clarke
Colin Clarke
Shirley Baird
Noelle Donnelly
- Senior Manager, Patient Experience, SEHSCT
- Lead Nurse, Infection Prevention & Control,
SHSCT
- Sister, North West Independent Clinic
- Assistant Support Services Manager, WHSCT
Trust representatives attending the feedback session
The key findings of the inspection were outlined to the following trust
representatives:
Ms B Creaney
Mr R Sowney
Ms L Linford
Mr C Thomas
Ms K Ms Clenaghan
Ms E McDonald
Ms L Symington
Ms C Lecky
Ms D Cunningham
Ms J Callaghan
Ms R Gillen
Ms S Douthart
Ms J Ms Keown
Ms K Browne
Ms N Scott
Ms C Kearns
Ms K Thompson
- Executive Director of Nursing
- Co Director A/S
- Senior Manager & ADN A/S
- Service Manager Surgery
- Service Manager Specialist Surgery
- Fracture Services Manager
- Assistant Service Manager Surgery
- Assistant Service Manager Medicine
- Acting Ward Manager Ward 6A
- CCO
- Senior Infection Prevention and Control Nurse
- Deputy Ward Manager Ward 4C
- Ward Sister 5A
- Ward Sister 7B
- Senior Manager PCSS
- PCSS Operational Manager
- Infection Prevention and Control Nurse
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)
29

• Infection Prevention/Hygiene Team Escalation Policy
• RQIA Policy and Procedure for Use and Storage of Digital Images
This information is currently available on request and will be available
in due course on the RQIA website.
30

13.0 Summary of Recommendations
1. The trust should work to improve, monitor and ensure that
environmental cleaning is carried out effectively, that patient
equipment is fit for purpose and that the environment is in a
good state of repair.
2. The senior management within trust should ensure that all
staff are aware of their roles and responsibilities in
environmental cleaning.
3. The trust should work on the repair and maintenance of ward
and public environments and to replace damaged fixtures and
fittings.
4. The trust and staff should work to improve storage and
maintain clutter free ward environments.
5. The trust should ensure all relevant information is available
for patients, visitors and staff to reference.
6. The trust should continue to roll out the newly developed
nursing cleaning schedules.
7. The trust should ensure that all staff are aware of the
importance of monitoring fridge temperatures.
8. The trust should ensure the correct storage of clean linen in a
designated area which is clean and fit for purpose.
9. The trust should monitor the implementation of its policies
and procedures in respect of the handling and storage of linen
to ensure that safe and appropriate practice is in place.
10. 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.
11. The trust should ensure that waste bins and equipment used
in the management of waste are available, kept clean and
replaced as appropriate.
12. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding the
safe and the correct handling and disposal of waste and
sharps is adhered to.
13. The trust need to review staff practice in relation to the
administration of medications and provide training if required.
31

14. The trust and individual staff have a collective responsibility
to ensure that equipment is clean, stored correctly and in a
good state of repair.
15. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding
equipment cleaning.
16. The trust should ensure that hand washing sinks and
consumables are available, clean, working and in a good state
of repair.
17. The trust should ensure that all cleaning products are stored
in a locked cupboard, in line with COSHH regulations.
18. Further attention to detail is required to ensure that equipment
used for the general cleaning purposes of a ward are clean,
used and stored appropriately and are fit for purpose.
19. The trust and individual staff have a collective responsibility
to ensure that hand hygiene is carried out in line with WHO
guidance and that all PPE is used appropriately.
20. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date with regard to
isolation, cleaning and decontamination of equipment.
21. The trust and individual staff have a collective responsibility
to ensure that staff knowledge is kept up to date regarding the
use of disinfectants.
22. The trust should ensure that all members of staff are familiar
with and adhere to the regional dress code policy.
32

14.0 Unannounced Inspection Flowchart
Plan Programme
Environmental Scan:
Stakeholders & External
Information
Prior to Inspection Year
Plan
Programme
Prioritise Themes & Areas for Core Inspections
Balance Programme
Consider:
Areas of Non-Compliance
Infection Rates
Trust Information
January/February
Schedule Inspections
Prior to Inspection
Identify & Prepare Inspection Team
Episode of Inspection
Day of Inspection
Day of Inspection
Inform Trust
Carry out Inspection
Is there immediate risk
requiring formal escalation?
NO
YES
Invoke
RQIA
IPHTeam
Escalation
Process
A
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
Reporting & Re-Audit
14 days later
Within 0-3 months
Signed Action Plan
received from Trust
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
33

15.0 Escalation Process
RQIA Hygiene Team: Escalation Process
B
RQIA IPH
Team
Escalation
Process
Concern / Allegation / Disclosure
Inform Team Leader / Head of Programme
MINOR/MODERATE
Has the risk been
assessed as Minor,
Moderate or Major?
MAJOR
Inform key contact and keep a record
Inform appropriate RQIA Director and Chief Executive
Record in final report
Inform Trust / Establishment / Agency
and request action plan
Notify Chairperson and
Board Members
Inform other establishments as appropriate:
E.g.: DHSSPS, RRT, HSC Board, PHA,
Seek assurance on implementation of actions
Take necessary action:
E.g.: Follow-Up Inspection
34

16.0 Action Plan
Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
1. The trust should work to improve, monitor and ensure
that environmental cleaning is carried out effectively,
that patient equipment is fit for purpose and that the
environment is in a good state of repair.
Nursing
PCSS
IPC
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
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.
2. The senior management within trust should ensure
that all staff are aware of their roles and
responsibilities in environmental cleaning.
Nursing
PCSS
IPC
‘Roles and responsibilities of Staff in
relation to Environmental Cleanliness and
Cleanliness of Equipment’ policy under
review.
Ongoing
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.
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.
35

Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
3. The trust should work on the repair and maintenance
of ward and public environments and to replace
damaged fixtures and fittings.
4. The trust and staff should work to improve storage
and maintain clutter free ward environments.
Estates
IPC
Other
appropriate
staff
All
Directorates
This is ongoing as part of Estate daily
maintenance and refurbishment
programmes.
Planned programme of de-clutter and deep
cleaning in place. Ongoing space utilisation
and de-cluttering is being driven by Service
Managers.
Ongoing
Ongoing
5. The trust should ensure all relevant information is
available for patients, visitors and staff to reference.
6. The trust should continue to roll out the newly
developed nursing cleaning schedules.
IPC
Nursing
Nursing
IPECC
All relevant information is now displayed (or
will be displayed following refurbishment).
The Trust has secured funding from the
PHA to take forward the issue of HCAI
communication.
A sub-group of IPECC (Infection Prevention
& Environment and Cleanliness
Committee) has been set up to review and
standardise cleaning schedules, and will
establish any outstanding issues of audit
standardisation process.
Complete
Complete
Agree a standardised audit which will be
used in all areas. This will include
standardised responsibilities. To be kept
under review.
Commenced
Feb 2012
Systematic roll out of the agreed
standardised audit using the Maximiser
system.
7. The trust should ensure that all staff are aware of the Nursing The Medicines Code outlines procedures Ongoing
36

Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
importance of monitoring fridge temperatures.
for use of medicine fridges. A
pharmaceutical refrigerator temperature log
sheet is maintained for each individual
fridge, with records being maintained and
monitored by Ward Managers.
A dishwasher temperature log sheet is
maintained for each individual dishwasher,
where possible, with records being
maintained and monitored by Ward
Managers. Not all dishwasher
temperatures can be recorded.
8. The trust should ensure the correct storage of clean
linen in a designated area which is clean and fit for
purpose.
Nursing
Guidance regarding storage of linen is in
the Regional Infection Prevention Manual.
Linen storage and segregation guidance
has been circulated to all Directorates.
Complete
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.
9. The trust should monitor the implementation of its
policies and procedures in respect of the handling and
storage of linen to ensure that safe and appropriate
practice is in place.
Nursing
Guidance regarding storage of linen is in
the Regional Infection Prevention Manual.
Linen storage and segregation guidance
has been circulated to all Directorates.
Complete
10. The trust should monitor the implementation of its PCSS The Trust has piloted and rolled out across Complete
37

Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
policies and procedures in respect of the
management of waste and sharps to ensure that safe
and appropriate practice is in place.
Nursing
all facilities the use of an electronic tool to
audit waste management compliance
against policy, procedure and RQIA
requirements. This process supplements
the existing audit tools used by PCSS, IPC
and also existing external audits conducted
by Daniels (sharps box suppliers).
Daniels’ audit completed Oct 2011 and
results disseminated.
11. The trust should ensure that waste bins and
equipment used in the management of waste are
available, kept clean and replaced as appropriate.
PCSS
Nursing
This is monitored as part of the
Environmental Cleanliness Audit
Programme.
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.
Where an issue has been highlighted,
action will be taken in conjunction with the
appropriate department to ensure
rectification.
12. The trust and individual staff have a collective
responsibility to ensure that staff knowledge is kept up
to date regarding the safe and the correct handling
and disposal of waste and sharps is adhered to.
PCSS
The Trust has piloted and rolled out across
all facilities the use of an electronic tool to
audit waste management compliance
against policy, procedure and RQIA
Complete
38

Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
requirements. This process supplements
the existing audit tools used by PCSS, IPC
and also existing external audits conducted
by Daniels (sharps box suppliers).
Daniels’ audit completed Oct 2011 and
results disseminated.
13. The trust need to review staff practice in relation to
the administration of medications and provide training
if required.
Nursing
The administration of medications is a
statutory and mandatory training
requirement for nursing staff.
Ongoing
The administration of medications is in the
annual mandatory training study days and
staff are required to complete pre-course
information prior to attendance. Staff must
adhere to the Trust’s Medicines
Management Code.
14. The trust and individual staff have a collective
responsibility to ensure that equipment is clean,
stored correctly and in a good state of repair.
Nursing
PCSS
IPC
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.
Ongoing
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.
Staff have been reminded of protocols in
relation to sterile items.
39

Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
15. The trust and individual staff have a collective
responsibility to ensure that staff knowledge is kept up
to date regarding equipment cleaning.
Nursing
Role and responsibilities policy in place.
Cleaning statements document for all
wards and departments to be finalised and
disseminated. This forms part of the
cleaning manual.
Complete
Ongoing
16. The trust should ensure that hand washing sinks and
consumables are available, clean, working and in a
good state of repair.
PCSS
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. Training is being updated
following recent guidance.
17. The trust should ensure that all cleaning products are
stored in a locked cupboard, in line with COSHH
regulations.
PCSS
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
Complete and
ongoing
40

Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
18. Further attention to detail is required to ensure that
equipment used for the general cleaning purposes of
a ward are clean, used and stored appropriately and
are fit for purpose.
Nursing
PCSS
Audit Tool (BRAAT).
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.
19. The trust and individual staff have a collective
responsibility to ensure that hand hygiene is carried
out in line with WHO guidance and that all PPE is
used appropriately.
IPCT
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.
Balance scorecards 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.
Complete and
ongoing
The IPCT carried out an independent audit
and results have been fed back.
Independent audits will be carried out 4
times a year (2 of which will be carried out
by Infection Prevention and Control).
The IPCT is currently devising an
41

Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
educational tool to remind staff of the
appropriate use of PPE.
The Trust has produced a colour-coded
guidance document based on the NPSA
system, which is displayed in all clinical
areas.
20. The trust and individual staff have a collective
responsibility to ensure that staff knowledge is kept up
to date with regard to isolation, cleaning and
decontamination of equipment.
IPCT
Mandatory Infection Prevention & Control
training is delivered by IPCN Team.
Staff to be reminded of the link to the
regional Infection Control Manual and the
‘Medical and Nursing Equipment Cleaning
Guide’ has been re-circulated.
Ongoing
All service managers received email copies
of the cleaning guide poster for
dissemination to all wards and
departments. Assurance is gained through
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.
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Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
21. The trust and individual staff have a collective
responsibility to ensure that staff knowledge is kept up
to date regarding the use of disinfectants.
Nursing
All staff have been reminded and made
aware of poster advice.
Mandatory IPC training is provided, poster
advice issued to wards, staff questioned at
audit.
Complete and
ongoing
22. The trust should ensure that all members of staff are
familiar with and adhere to the regional dress code
policy.
All
Directorates
Trust policy available to all staff on Intranet.
Policy is enforced at local level by senior
staff, e.g., Ward Sisters and Senior
Managers.
Complete
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.
Ongoing
43