Bugwatch Infection Prevention Practices Survey 10

Bugwatch

Infection Prevention Practices Survey

10th March 2014

Contents

Executive Summary Page 3

Response from Betsi Cadwaladr University Health Board Page 4

Overview & Background Pages 5 & 6

List of Wards Surveyed Pages 7 & 8

Results & Charts Pages 9 – 30

Findings of Fact & Conclusions Page 31

Recommendations Page 32

Appendix 1 – Summary of Members Comments Pages 33 - 38

Appendix 2 – Survey Questionnaire Pages 39 - 41

Appendix 3 – List of Participating Members Page 42

Appendix 4 – 5 Moments for Hand Hygiene Page 43

Appendix 5 – Handwashing Techniques Page 44

Appendix 6 – Instructions to CHC Members Page 45 - 46

2 Executive Summary

North Wales Community Health Council has undertaken this survey of Infection Prevention Practice as part of its Action Plan following the Duerden Report on the C.difficile outbreak at Glan Clwyd Hospital and the Joint Review by Health Inspectorate Wales and the Wales Audit Office.

 The survey was designed to be undertaken by lay people  The questionnaire was designed by Infection Prevention professionals  The results give an indicator of the quality of Infection Prevention practice – not the presence of MRSA, C.difficile or any other healthcare associated infection

The survey looks at;

 Hand Hygiene/Washing  Clinical Practice  Ward Environment  Waste Disposal  Linen  Disposal of Sharps  Care of Equipment  Visitor & Patient Information

We have also added a section looking at the contribution visitors can make to good infection prevention practice.

The survey was carried out unannounced on a single day in March 2014 on 49 wards across the three Acute Hospitals in North Wales.

The CHC developed the survey from the Bugwatch survey that was carried out by Patients Forums in over 600 English hospitals. The CHC worked closely with Infection Prevention specialists to update Bugwatch and make it relevant to North Wales. The CHC has received assistance, support and co-operation from Betsi Cadwaladr University Health Board at every stage. The Board accepts the findings of the report and will work with the CHC to implement the recommendations.

The survey results show that there are good levels of compliance with infection prevention practice. Standards are being maintained in the three Acute Hospitals – although this varies by ward. Some wards have again produced excellent scores; others remain capable of further improvement.

The survey will continue to be repeated on a regular basis and, as promised in September 2014 we have started to publish ward level performance.

The CHC will extend the Bugwatch programme to include Community Hospitals in the summer and is now looking at the feasibility of using Bugwatch style performance monitoring in primary care settings.

3 Betsi Cadwaladr University Health Board Response to Bugwatch March 2014

We are grateful to the Community Health Council for repeating the Bugwatch Survey across our acute hospitals. The survey provides an extremely helpful independent view of our infection prevention standards.

Following the last Bugwatch Survey in September 2013, we took the following actions:

 Shared the results with staff, to ensure they understood the good practice identified, and the issues which could be improved. We are very pleased that many areas have improved their compliance with the standards following the first survey.

 Celebrated and praised staff for the high standards achieved in a number of areas.

 Focused on improving hand hygiene, and bare below the elbow. Monthly monitoring of hand hygiene practice is in place across all areas, and compliance is reported to public meetings of the Health Board.

 Reviewed the cleaning strategy, cleanliness standards and monitoring arrangements, and put into place a number of improvements. We are delighted to note the changes we made have resulted in noticeable improvements in standards of ward cleaning.

 Initiated a programme to improve the range of infection-related patient information leaflets available. Welsh Government is also in the process of revising and developing some infection-related leaflets and the Health Board has provided input to that work programme. We will ensure all areas have copies of the new leaflets available, once they are finalized.

We acknowledge there is more work to do on a number of issues, especially in relation to hand hygiene. We will increase our focus on this issue, and on waste disposal, taking account of the specific recommendations in this report.

The Health Board values the continuing partnership working with the Community Health Council in North Wales. We remain committed to reducing the number of preventable infections to a minimum, and will take action on all of the findings and recommendations in the Bugwatch report.

Overview

What is North Wales Community Health Council?

The North Wales Community Health Council (NW CHC) is a public body with responsibility to act as the local NHS Watchdog. It is an independent organisation which represents the interests of patients and the public in the National Health Service in North Wales.

The North Wales CHC is made up of 72 volunteer members. Membership is drawn from across North Wales and the counties of; Conwy, Denbighshire, Flintshire, Gwynedd, Wrexham and Ynys Môn. The six counties have a combined population of around 676,000.

What does North Wales CHC do?

The CHC makes sure that when people in North Wales speak about their NHS, those responsible for providing health services listen - and act.

CHCs listen to what individuals and the community have to say about their local health services with regard to quality, availability and access. They then act as the public voice in letting managers of health services know what people want and the improvements they would like to see.

CHCs must be consulted by the providers of local health services about any changes to health services within their area.

CHCs, in turn, consult with the public to make sure they are properly reflecting the views of the public to the local health service providers of the Welsh Assembly Government.

CHCs also help, advise and support people who wish to make a complaint about NHS services. The help and advice is completely free, independent and confidential.

CHCs help people get the health services they need for themselves and those that they care for.

They give information and advice about health services in the local area.

Background to the “Bugwatch” Infection Prevention Survey

One of the functions of the CHC is to listen to the concerns of the public and patients it represents with a view to taking appropriate action. Of all the issues that have been brought to the CHC’s attention, the problem of healthcare acquired infection is widely considered to be one of the most urgent and important.

Following the C.difficile outbreak at Glan Clwyd Hospital in May 2013 the issue of healthcare acquire infection has received unprecedented public attention. The subsequent report by Prof Brian Duerden, a world renowned infection prevention expert, has highlighted the need to improve infection prevention practices.

5 Why was an Infection Prevention Survey undertaken at all Acute Hospitals in North Wales?

The Duerden Report looked at infection prevention across North Wales and the recommendations are for the Betsi Cadwaladr University Health Board as a whole – not just Glan Clwyd Hospital. CHC members are keen to help the Board identify ways in which to improve performance and reduce healthcare acquired infection.

The Betsi Cadwaladr University Health Board has co-operated fully with the Bugwatch project and encouraged its staff to assist CHC members undertaking the survey.

How was the Bugwatch Survey undertaken?

CHC members used a specially designed questionnaire and focused on simple observations and questions associated with good hygiene practice (considered to be a major factor in the control of Hospital Acquired Infection). A poor result in the survey does not show that C.difficile or MRSA is present but it does indicate that infection prevention practice could be improved and levels of risk reduced. The questionnaire is included in the appendices.

The survey is based on observations. If members did not observe a task taking place or a key marker then it was recorded as N/A. This is not a negative finding. In cases where there are a significant number of N/A records then the ratio between positive and negative finding gives the best indication of performance.

Bugwatch is snapshot of infection prevention practice on a single day – it is undertaken by lay people who look at key areas of infection prevention practice. As such, there will be variation in the results from time to time. Some of those variations will not be statistically significant – but Bugwatch will show the general direction of travel and it will highlight issues and draw attention to potential risks.

All of the inspections took place on Monday, 10 March 2014. The Board was not given advance notice of the date of the survey.

It is important to highlight that throughout the survey CHC members found staff to be open, frank and willing to help. The response of the Board to the initial findings has been very positive and improvements are already in hand.

Wards Surveyed – Ysbyty Gwynedd Alaw Unit Haematology/Oncology Aran Ward Endocrine and Diabetics Beuno Ward Emergency Dependency Observations Unit Conwy Ward Trauma and Orthopaedics CCU Coronary Care Unit Dulas Ward General Surgery / Vascular and ENT Enlli Ward Orthopaedics Ffrancon Ward Gynaecology / Breast Surgery Glaslyn Ward Care of the Elderly Glyder Ward Cardiology Gogarth Ward Admissions Hebog Ward Renal Llifon Ward Obstetrics Moelwyn Ward Respiratory Prysor Ward Stroke Care Tegid Ward Urology/Colorectal Tryfan Ward Gastroenterology Tudno Ward Same Day Admissions/Day Ward

Wards Surveyed - Glan Clwyd Hospital Ward 1 Care Of The Elderly Ward 2 Care Of The Elderly Ward 3 Orthopaedics / Trauma Ward 4 ENT / Maxillofacial/ Oral Ward 5 General Surgery Ward 6 Urology Ward 8 Surgery Ward 9 Renal/Diabetes Ward 10 Dermatology Ward 11 Gastroenterology Ward 12 General Medical/ Respiratory Ward 14 Care Of The Elderly / Acute Stroke Ward 19 Gynaecology Ward 22 - Celyn Obstetrics Ward 23 - Brenig Obstetrics AMU Acute Medical Admissions Enfys Inpatient Oncology

Wards Surveyed –Wrexham Maelor Hospital Bonney Ward U10 - Gynae and breast care Cunliffe Ward G1 - Renal and Cardiology Bersham Ward G3 - Stroke ENT Ward G22 - Surgical and Dental Erddig Ward U4a - Care of the Elderly, Gastroenterology, Endocrinology Evington Ward G3 - Respiratory medicine Eye Ward G27 Fleming Ward U1 - Colorectal and vascular Glyndwr Ward U2 – Urology Lister Ward U1 - Upper Gastro-Intestinal, Breast or General Surgery Mason Ward U2 - Haematology, Rheumatology, Dermatology, Diabetes Pantomime / Prince of U9 - Orthopaedic elective Wales Ward Rehabilitation Unit Onnen Ward U4a - Care of the Elderly Rehabilitation Unit - G4a - Care of the Elderly Bedwen Ward

8 Results and Charts

Hand Hygiene

Hand washing is the key to effective infection prevention and the Board has installed alcohol foam sanitiser dispensers on all beds, at key points around the hospitals, as well as dedicated hand washing facilities for staff. The results on the key indicator “Staff are observed to use the correct hand hygiene technique” showed a wide variation in compliance. Members observed members of staff wearing wrist watches and stoned rings – in breach of the Board’s “Bare below the elbow” policy.

Questions Asked

Hand Hygiene

Liquid Soap is available at all sinks

Alcohol foam sanitiser is available at the point of care (at every bed or trolley space, or via staff -carried dispensers).

Where appropriate, dispensers are at suitable height for wheelchair users.

Paper towels are available at all sinks.

Access to hand hygiene basins is unobstructed.

Hand hygiene basins are free of equipment.

Elbow control taps or automatic sensor taps are available at all sinks.

A poster demonstrating good hand hygiene technique is available by at least one sink.

Staff are observed to use the correct hand hygiene technique as per organizational policy.

All staff observed to clean their hands between caring for patients or between different caring tasks for the same patient. N.B. Hands should also be cleaned after removing gloves.

All patient care staff are compliant with the ban on wearing wrist watches and/or rings with stones.

Signs encouraging patients and visitors to clean their hands are prominently displayed.

Signs are displayed asking patients to clean their hands after using the toilet/commode & before meals.

Staff wear aprons & gloves for handling used linen and waste bags.

11 General

Questions Asked

General Clean disposable aprons and gloves are worn for handling all bodily fluids.

Staff questioned have received training on Infection Prevention (Ask “When did you last have an infection prevention training session or complete the electronic-learning module?”). All patient care staff are compliant with the ban on wearing long sleeves (i.e. do they meet the bare below the elbow requirements?). Staff know where to find the Infection Prevention Policies.

Signs and posters are laminated.

The CHC teams noted a considerable improvement in the number of laminated signs and posters. All staff observed handling bodily fluids were using aprons and gloves. There was a significant increase in the number of staff who reported receiving infection prevention training.

Ward Environment

Questions Asked

Ward Environment Chairs/Tables/Lockers are clean.

Chairs/Tables/Lockers are in a good state of repair.

The ward environment is visibly clean and free from dust/grime and soilage. Bathrooms are clean. Bathrooms are free from items of equipment (bed pans etc.).

Bathrooms are free of personal toiletries. Is the general condition/state of repair of the bathroom acceptable? Toilets are clean. Toilets are free from items of equipment.

Commodes have green tape across the seat to confirm that they have been cleaned since last use. Does the ward appear tidy and free from clutter?

Results in this section are broadly comparable to last year but clutter in bathrooms remains a particular problem at Glan Clwyd.

15 Waste Disposal

Questions Asked

Waste Disposal Waste Disposal policy/chart is available to staff.

Waste bags are less than 2/3rds full, securely sealed and labelled.

Foot-operated bins are in working order.

Waste is stored in designated bins that are kept locked.

No significant change in performance.

17 Linen

Questions Asked

Linen Soiled Linen is placed into red bags.

Bags are less than 2/3rds full and capable of being secured.

Public areas are free of bags containing soiled linen. Curtains are visibly clean and in good repair.

There was a significant improvement in performance in this area at both Glan Clwyd and Wrexham Maelor.

19 Sharps

Questions Asked

Sharps Sharps boxes are stored safely away from the public and out of reach of children.

N.B. The key requirement for sharps bin storage is that they are: off the floor, secured to a wall or trolley rather than loose, and have a temporary closure mechanism in place (which stops accidental spillage if it is tipped and also prevents children's hands from accessing the bin).

The CHC teams saw a considerable improvement in this area at Ysbyty Gwynedd but a disappointing fall at Glan Clwyd and Wrexham Maelor.

20 Care of Equipment

Questions Asked

Care of Equipment Bedframes are clean & dust/grime free Bed lamps are clean & dust/grime free Bed tables are clean & dust/grime free Bed curtain rails are clean & dust/grime free Fans are clean & dust/grime free Weighing scales are clean & dust/grime free Notes trolleys are clean & dust/grime free Bedside television sets are dust/grime free Hoists are dust/grime free Other items of medical equipment are dust/grime free. All surfaces are visibly clean and dust/grime free

Broadly similar results – but there have been commendable improvements in surface cleanliness at Ysbyty Gwynedd and Wrexham Maelor.

Information for Patients & Visitors

Questions Asked

Visitor and Patient Information Is information (leaflets and/or posters) available to visitors on appropriate hygiene measures when visiting patients?

Is patient information about Clostridium difficile available?

Is information available for MRSA positive patients on the ward?

These results are very similar to last year and highlight the need to seek further improvements in the provision of good information to patients and visitors.

24 Visitor Role in Infection Prevention

Questions Asked

Visitor Role in Infection Prevention (for completion during visiting hours All visitors are seen sitting on chairs oronly) standing at the bedside (i.e. not sitting on patients’ beds). Are all visitors observed to use alcohol hand gel when entering the ward?

All patients have two or fewer visitors at the bedside. If babies & small children are visiting, are they are sitting quietly with the other visitors (i.e. not running around or crawling on the floor)?

CHCs teams did not visit exclusively at visiting times so, in many instances, visitor behaviour was not observed. The table below represents those surveys completed during visiting hours only.

In the vitally important area of hand hygiene it can be seen that, in all three hospitals, 50% of visitors did not use the alcohol hand gel that is provided at the bedside.

26 27

29 30 Findings of Fact

 All three Acute Hospitals are well-equipped and the infrastructure to support good Infection Prevention practice exists  The appointment of an Assistant Director of Nursing with special responsibility for Infection Prevention continues to have a positive impact  The Infection Prevention Team has been strengthened  Infection Prevention policies and protocols are in place and are subject to regular review  Training is well established and the uptake is increasing  Overall performance is good but there remain disappointing levels of compliance with existing Hand Hygiene policies  There has been a noticeable improvement in the standard of ward cleaning  There is a very disappointing level of compliance with basic hand hygiene by visitors

Conclusions

Good performance is being maintained at all three hospitals. Many wards have outstanding performance and there have been some notable improvements in performance by some wards.

The CHC found many examples of excellent practice being shared across North Wales. There are some areas, however, that need to be improved and the CHC will expect the Board to concentrate on bringing those up to the standard of the best.

The CHC will use the media to highlight the role that visitors and patients have to play in Infection Prevention. Betsi Cadwaladr University Health Board provides the facilities, alcohol hand gel and other hand washing facilities, to allow everyone to comply with good hand hygiene practice. Preventing transfer of infection is everyone’s business and failure to comply with this cornerstone of infection prevention puts patients at risk.

31 Recommendations

Hand Hygiene

Hand hygiene is the key to effective infection prevention.

“Hand-washing is far less glamorous than hi-tech interventions, but it is known to be the single most important thing we can do to reduce the spread of disease. By encouraging good practice among members of the healthcare team - and visitors - you will be helping patients.” (RCN: Good practice in infection prevention and control)

We recommend;

 rigorous enforcement of hand hygiene procedures  rigorous enforcement of policies on the wearing of stoned rings, wrist watches, false nails, earrings and other inappropriate dress practices  usage levels of alcohol foam sanitiser dispensers be monitored to obtain an indicator of hand hygiene compliance of staff and patients/visitors  uniforms should not be regarded as protective clothing. Therefore staff must wear clean aprons and gloves in appropriate situations.  doctors must be reminded that they are not exempt from hand hygiene and dress policies – particularly “Bare Below the Elbow”  the need for visitors to clean their hands on entering and leaving the wards be widely publicised

Ward Environment and Condition of Beds & Equipment

The hospital environment must be visibly clean, free from dust and soilage and acceptable to patients, their visitors and staff.

“High standards of cleanliness will help to reduce the risk of cross-infection and are aesthetically pleasing to patients and the public….. Cleaning removes contaminants, including dust and soil, large numbers of microorganisms, and the organic matter that may shield them – for example, biofilms, faeces, blood and other bodily fluids”. (RCN “Essential Practice for Infection Prevention – 2012)

Waste Disposal

We recommend that the Board monitor and enforce compliance with existing policies on waste bags

Information for Patients & Visitors

We recommend that;

 information leaflets are on display and available in every ward at all times  leaflets are provided to patients and carers on arrival  notices and posters should be laminated.  the Board undertake a public education campaign to inform visitors and patients of their role and responsibilities in relation to infection prevention

32 Appendix 1 - Members Comments Visiting Team Impressions & Observations

Ysbyty Gwynedd CHC Members’ Comments by Ward WARD WHAT IS YOUR OVERALL DO YOU HAVE ANY OTHER NAME IMPRESSION OF THIS OBSERVATIONS? WARD? Tryfan Very good, staff very pleasant A few items of paper on floor beside bed in one bay. Liked the large floor notices outside ward STOP & CLEAN YOUR HANDS Coronary Very calm & generally good Care Unit impression. Staff very pleasant. Conwy Very busy, pleasant staff & Large STOP & CLEAN YOUR general impression very good HANDS notice on floor outside ward. Tegid Very busy, good general Obstruction to sink in treatment impression. Large sign on room. One bathroom had a floor outside ward wash & bedpan. CLEAN YOUR HANDS - bilingual. Tudno Very good, quite quiet when Excellent floor sign outside ward. we were there. Glyder Clean & orderly Update in hard copy, of infection prevention policy could not be located therefore housekeeper has locked it away! Available on line. STOP sign for visitors, but alcohol wash could be more prominent. Hebog All good except dust on curtain An audit of MRSA and C.Diff is rail and one female doctor with carried out regularly by Infection ring. One junior member of Prevention. Results are staff wrote a note on the back prominently displayed. Results are of her hand in biro. There is a currently (for the month) 100%. sign on the floor at the There is an incomprehensible entrance re: hand hygiene. graph showing days since last Sharps box compliant with infection - but neither of us can exception of not secured to make any sense of it (and we are wall or trolley. Never seen this both numerate!) All tables cleaned and don't know how it could be with ‘Actichlor’ every night and after implemented. any 'event'. Brilliant soap / alcohol dispensers - we are told. All renewed in the last month. Dulas Generally very good - but for Excellent instructions / guidance for visitor info - until it was visitors by North West Wales NHS obscured by a big poster. 1 Trust!! The best (only) guidance we staff member had ring with have seen. Large poster explaining stone. Best ward for curtain protected mealtime is placed totally rail cleanliness. We are told obscuring this information and the

33 rota stipulates once a week hand gel dispenser. clean for high surfaces. Cleaner says she does them daily. The evidence supports this Llifon Good well-run ward. Curtain rails attached to ceiling (eliminates dust collection on them). The only one not tight on ceiling was dusty. Visitor observed lying on the bed. Gogarth Good Two clinical waste bins full to top. One commode has green tape across. Ward clean at low levels - but dust on higher levels - especially lamps / TV's / Curtain rails. Beuno Visibly clean but could do with Bathroom used for some storage freshening up. (not used as such very much, anyway). Although many sanitizers - no signs to remind people or draw attention to them. We spoke to Anita Loxton. Some but not all of the following - elbow or sensor taps, signs laminated, foot operated bins in working order, waste in locked bins. Enlli Very clean and welcoming. Observed MRSA chart in notice Patients were complimentary board. Well organised and about care and cleanliness. maintained ward. Met ward sister Karen Thomas. Ffrancon Busy, preparing for lunch, No infection information for cleaning in operation. patients. We met Carol Edwards Glaslyn Charts re: MRSA, C.Diff, Falls, Sister speaks to visitors re: not Pressure sores, Nutrition etc. sitting on beds but to no avail very well displayed on central (spare chairs available). No patient wall chart. Visitor concerned information re: MRSA or C.Diff that there was no hand gel / seen. hand washing facilities between the ward & the lifts or near the lifts. Prysor Clean. Charts on display. Staff members are regularly Friendly staff. Patients were updated. Policy documents very complimentary. MRSA available to staff. information available when patients ask for. Moelwyn Very busy - many patients. Charts monitoring MRSA & C.Diff, Patients & visitors happy with Sepsis etc. prominently displayed. treatment & clean state of No cases for 2 years. ward.

34 Alaw Unit Very busy. Staff nurse 2 or 3 wash basins in corridors explained methods of infection cluttered. prevention. Aran Very busy unit, new sister, Good information displayed on changes being instituted, a notice boards. (MRSA etc.) little cluttered in corridor, some Patients happy. toilets. Sister working to re- organise after new equipment delivered.

Glan Clwyd CHC Members’ Comments by Ward WARD WHAT IS YOUR OVERALL DO YOU HAVE ANY OTHER NAME IMPRESSION OF THIS OBSERVATIONS? WARD? 1 Busy, crowded, poor storage Bathroom used as drying area for laundry planning - disappointed in overall cleanliness 2 Busy and well-ordered ward. One 6-bedded bay closed due to staff shortages. 9 WRVS trolley - needs update Good practice - all equipment labelled re: hygiene policy. Cleaners with green Vernacare tags. Equipment need awareness training. stored in each bay - reduces overall bed numbers. 10 Bowl of ‘Actichlor’ open in Dirty Utility - no lid or cover 11 Toilets / shower areas very Open vomit bowl in sluice area!! Good 'musty' and damp. Basins not bilingual infection prevention poster for very clean. Some commodes patients & visitors - sadly in day room labelled only for use of specific lying on old notes trolley. Broken locker patients!! in one of bays - (has been reported job number 211889) 12 Ward rounds in progress during visiting. Should visitors be asked to leave to preserve confidentiality? 14 Very busy but appeared well Patients seemed well cared for. organised. Very gloomy and dark. Depressing for patients. Clothes drying in bathroom - not good! AMU Very busy ward. Sharps boxes Patients sitting in trolleys waiting on beds. all locked in place. 1 toilet out of order. 3 Very busy Non-uniformed person reading notes at ward station wearing a watch. Fans dust inside. 4 Very busy ward 5 Busy cluttered ward Shower holder black in plastic holder. Fan blades dusty

35 6 Cluttered feel Shower cubicle - chrome peeling off, black mould round shower. 8 Business-like brisk environment Blades of fans are covered with dust, boards above beds coated with dust. Awaiting bilingual signs for clinical waste etc. 19 Calm atmosphere, staff friendly, Staff induction had not included where helpful and honest in response Infection Prevention Policy could be to our questions. Equipment found on intranet. Staff had requested looked clean but corners and patient information on Clostridium Difficile below eye level and above was and MRSA but had not received them. dirty and dusty. Bathroom had used towel on floor. 22 Ward was busy. Staff friendly, Cleaning was superficial. Corners and helpful and honest. wheels of beds, trolley, were dirty and dusty 23 Ward was busy at time of visit - Cleaning appeared superficial - corners, 11:30am. Staff friendly and wheels and bottom of equipment and helpful. Calm atmosphere. bathrooms not cleaned thoroughly. ENFYS Calm busy ward. Staff friendly One bathroom visited cluttered with and helpful. equipment. Rust on floor in one corner by shower.

Wrexham Maelor CHC Members’ Comments by Ward WARD WHAT IS YOUR OVERALL DO YOU HAVE ANY OTHER NAME IMPRESSION OF THIS WARD? OBSERVATIONS? Evington Slightly cluttered, but staff very Sign encouraging visitors to wash helpful. Patients happy but sharp hands needs to be more boxes are not fit for purpose & prominent. 78% staff have badly positioned. No C.Diff or completed training on infection MRSA or Norovirus posters. prevention. Most signs laminated but not all. Needs high dusting. One visitor sitting on bed. No commodes visible. Very few staff with name badges. Bedwen Excellent clean airy fresh, Sharps boxes are not fit for patients happy, rewarding ward purpose. to visit! Fleming This ward is cluttered, children Sharps box is frail & not fit for running around at visiting. purpose. One toilet has a major Toilets are dirty & dusty and a smell problem. urine sample was left in the assisted bathroom whilst we were there (Ward sister not happy with the trialling of micro cloths for cleaning.) Glyndwr General clutter, a lot of dust in The ward needs to look at the way bathrooms & curtain rails. it removes dirty linen from ward Overall entrance has ceiling tiles especially during visiting - no missing & is a little bit sparse. aprons or gloves used.

36 Eye Once we found it (no signage of This is a day ward for the eye corridor & definitely not where it clinic, most patients sit in chair says on signage) a clean and after surgery, and normal ward pleasant environment with practices don't apply. Sharps are friendly staff. still a problem (Staff don't like them). Cunliffe Busy ward (one patient died Shower drains need deep clean. while we were there) Beverage trolley needs cleaning. Hand gel dispenser empty. One toilet in bathroom needs cleaning. One commode left in toilet. One toilet had old fashioned taps. Sharps box on trolley left open. ENT A busy ward in an old building Taps operated by knees. Sink with some damp damage. posters obstructed by curtains. Design of sharps boxes poor - they appear to be open. Toilets - one found loose (male bathroom) and one contained a bedpan (full - female toilet) Erddig Sharps boxes poor design. Drip stands stored in corridor. Limited visitor hygiene signs. Beds / mattresses blocking Dr's reluctant to hand wash when extinguisher. Fabric - floor/ceiling entering ward. No C.Diff alerts. tiles -> estates. Ground floor only washing hands - not thorough. Onnen Exceptionally cluttered ward - Broken chair stored in toilet / communal space, bathrooms. bathroom. Apron on bin, not in it - Doctors non-compliant with hand shower. Linen skips short supply - washing. especially weekends. Good signs on lockers requesting staff to "handwash" Bersham Ward clean - good pleasant staff Bags - skip shortage for dirty linen and attention to hygiene especially over weekend (having observed. to use clean sheet to make parcel) Lister This ward was not as 'bright' as Toothbrush left in 'toilet' room. other wards - very busy. Staff did Light in one toilet not working - this comply with hygiene regulations has been reported. Toilets do not have cleaning charts on wall. One bed did not have hand gel. Mason Busy ward - cleaner busy Leaflets on infection given out at washing floors - some areas litter request. 'Sample' left in toilet. 3 on floor (but cleaner not been beds no gel. Toilets - no cleaning there) chart on wall. Waste disposal policy / chart not available but on internet!

37 Pantomime Ward is busy - clutter free. No leaflets available. Sign for / handwashing not everywhere. Prince of One toilet (assisted) no elbow taps Wales - paper on floor - toilet needed flushing. Man on ward in bed - otherwise ladies. Gel not on every bed - 1 missing gel on another room. Bonney Quiet ward - staff busy with Clothes hanger in bathroom also duties used towel on floor. In another bathroom towels lying around. Equipment left out in treatment room. "Waste is stored in designated bins that are kept locked" cupboard is NOT on ward but in the corridor.

38 Appendix 2 – Survey Questionnaire

Cyngor Iechyd Cymuned Gogledd Cymru / North Wales Community Health Council Infection Prevention Survey

Hospital ……………………………………………… Ward Name ……………………….…. Date ………………………. Team Members …………………………………………………………………………

Hand Hygiene YES NO N/A Liquid Soap is available at all sinks Alcohol foam sanitiser is available at the point of care (at every bed or trolley space, or via staff -carried dispensers). Where appropriate, dispensers are at suitable height for wheelchair users.

Paper towels are available at all sinks. Access to hand hygiene basins is unobstructed. Hand hygiene basins are free of equipment. Elbow control taps or automatic sensor taps are available at all sinks. A poster demonstrating good hand hygiene technique is available by at least one sink. Staff are observed to use the correct hand hygiene technique as per organizational policy. All staff observed to clean their hands between caring for patients or between different caring tasks for the same patient. N.B. Hands should also be cleaned after removing gloves. All patient care staff are compliant with the ban on wearing wrist watches and/or rings with stones (N.B. plain bands are acceptable) Signs encouraging patients and visitors to clean their hands are prominently displayed. Signs are displayed asking patients to clean their hands after using the toilet/commode & before meals. Staff wear aprons & gloves for handling used linen and waste bags. General YES NO N/A Clean disposable aprons and gloves are worn for handling all bodily fluids.

Staff questioned have received training on Infection Prevention (Ask “When did you last have an infection prevention training session or complete the electronic- learning module?”). All patient care staff are compliant with the ban on wearing long sleeves (i.e. do they meet the bare below the elbow requirements?). Staff know where to find the Infection Prevention Policies.

39 Signs and posters are laminated. Ward Environment YES NO N/A Chairs/Tables/Lockers are clean. Chairs/Tables/Lockers are in a good state of repair. The ward environment is visibly clean and free from dust/grime and soilage. Bathrooms are clean. Bathrooms are free from items of equipment (bed pans etc.). Bathrooms are free of personal toiletries. Is the general condition/state of repair of the bathroom acceptable? Toilets are clean. Toilets are free from items of equipment. Commodes have green tape across the seat to confirm that they have been cleaned since last use. Does the ward appear tidy and free from clutter? Waste Disposal YES NO N/A Waste Disposal policy/chart is available to staff.

Waste bags are less than 2/3rds full, securely sealed and labelled. Foot-operated bins are in working order. Waste is stored in designated bins that are kept locked. Linen YES NO N/A Soiled Linen is placed into red bags. Bags are less than 2/3rds full and capable of being secured. Public areas are free of bags containing soiled linen. Curtains are visibly clean and in good repair. Sharps YES NO N/A Sharps boxes are stored safely away from the public and out of reach of children. N.B. The key requirement for sharps bin storage is that they are: off the floor, secured to a wall or trolley rather than loose, and have a temporary closure mechanism in place (which stops accidental spillage if it is tipped and also prevents children's hands from accessing the bin). Care of Equipment YES NO N/A Bedframes are clean & dust/grime free Bed lamps are clean & dust/grime free Bed Tables are clean & dust/grime free Bed curtain rails are clean & dust/grime free Fans are clean & dust/grime free Weighing scales are clean & dust/grime free

40 Notes trolleys are clean & dust/grime free Bedside Television Sets are dust/grime free Hoists are dust/grime free Other items of Medical Equipment are dust/grime free All surfaces are visibly clean and dust/grime free Visitor and Patient Information YES NO N/A Is information (leaflets and/or posters) available to visitors on appropriate hygiene measures when visiting patients? Is patient information about Clostridium difficile available? Is information available for MRSA positive patients on the ward? Visitor Role in Infection Prevention (for completion during visiting hours YES NO N/A Allonly) visitors are seen sitting on chairs or standing at the bedside (i.e. not sitting on patients’ beds). Are all visitors observed to use alcohol hand gel when entering the ward? All patients have two or fewer visitors at the bedside. If babies & small children are visiting, are they are sitting quietly with the other visitors (i.e. not running around or crawling on the floor)?

What is your overall impression of this Ward?

Do you have any other observations?

41 Appendix 3 List of CHC Members Involved

Gordon Donaldson Eva Edwards Llew Evans Sadie Francis Roma Goffett Jenny Harley Garth Higginbotham Rita Jones Russell Jones David Mackie Val Morris Martin O'Donnell Jan Randles Pearl Roberts Sibani Roy Des Williams Roger Williams Delyth Wilson

42 Appendix 4 – 5 Moments for Hand Hygiene

43 Appendix 5 – NPSA Handwashing Instructions

44 Appendix 6 – Instructions to CHC Members

Dear Member,

BUGWATCH – 10TH MARCH 2014

Thank you for volunteering your time and effort to take part in the second North Wales CHC Bugwatch Survey.

I enclose the following supporting papers for your attention;

 A schedule of visiting teams setting out team members contact details, assigned wards and times  A supply of survey forms (only complete and return one form per ward)  The World Health Organisation poster "5 Moments for Hand Hygiene"  The National Patient Safety Agency instructions on hand cleaning techniques  A reply paid envelope to return the forms

If you encounter any problems or difficulties during your visit, you should contact either the CHC office on 01248 679284.

Completing the Survey Form

If you have not done the survey before we will make every effort to team you up with someone who has. On arrival at each ward please wash your hands using a wall mounted gel dispenser on arrival at the ward and on leaving. This is for obvious hygiene reasons and also to help you answer the section on hand hygiene.

The survey form has been agreed with the BCUHB Infection Prevention Specialist and it will provide useful indicators to the quality of infection prevention practice. It is important for this reason, and for consistency, that you complete the questions as they are set out and do not add questions of your own. There is, however, a section at the end for any comments or observations you might have. These comments by CHC members were highly valued by BCUHB managers and staff previously and I encourage you to make your frank comments, good or bad, as you did last time.

The survey is designed to be completed by lay people, no expertise in infection prevention is necessary. You simply have to record what you see on a Yes or No basis. If you do not see something happening during your visit then mark that question N/A. If you do not have the opportunity to speak to staff because they are all engaged in patient care then, again, mark that question N/A.

On questions like "All patient care staff are compliant with the ban on wearing wrist watches and/or stoned rings", if you see only one member of staff who is wearing a stoned ring or wrist watch then you should answer "No". Good Infection Prevention practice needs to be carried out by everyone and one doctor or nurse failing to wash his/her hands has a negative effect on the good work of others.

On this occasion we have included a section that highlights the role of visitors in maintaining good infection prevention practice. If you are on a ward during visiting hours you should complete this section. If you are visiting outside these hours then mark it N/A.

We will be publishing ward level data from this Bugwatch survey and this will be the start of the process of encouraging individual wards to match the standards of the best.

If you have any questions or queries on completing the survey form please contact me before you go on you visit.

Please enjoy your visit. Infection Prevention is a vitally important issue and Patients and the Public will feel reassured that Members of North Wales CHC are working hard on their behalf. Thank you again for giving your time and effort.

Geoff Ryall-Harvey Chief Officer – North Wales CHC