North Wales NHS Trust
Unannounced Hospital Cleanliness Spot Check
Date of visit: 9th and 10th July 2008
Contents
Page Number
1. Introduction...... 1
2. Findings: Areas of strength, areas for further improvement ...
2.1 Environment of Care...... 3
2.2 Handling and Disposal of Linen...... 12
2.3 Departmental Waste Handling and Disposal ...... 12
2.4 Safe Handling and Disposal of Sharps ...... 13
2.5 Equipment ...... 13
2.6 Hand Hygiene...... 13
2.7 Ward/Departmental Kitchens...... 16
i ii 1. Introduction
1.1 In May 2006, in response to concerns raised by public and patients across Wales, Healthcare Inspectorate Wales (HIW) announced its intention to undertake unannounced cleanliness spot checks of healthcare organisations across Wales.
1.2 Many different sources of information relevant to this agenda are considered and used to shape the direction of the spot check programme, which is kept under review in light of any new information that comes to our attention.
1.3 As part of our Hospital Cleanliness Spot Check Visit discussions are held with clinical staff, key documents are reviewed and direct observations of clinical areas are undertaken. The check list used to guide the spot checks is based on the Infection Control audit tool developed by the Infection Control Nurses Association (ICNA).
1.4 Further information about HIW, its spot check visits and the audit tool used can be found at www.hiw.org.uk
Visit to North Wales NHS Trust
1.5 On the 9th and 10th July 2008 HIW visited North Wales NHS Trust and undertook cleanliness spot checks of the following areas:
Elective Orthopaedics, Ward 6 at Abergele Hospital. Colorectal Surgery, Ward 5 at Ysbyty Glan Clwyd. Acute Medical Unit, Ysbyty Glan Clwyd. Respiratory, Ward 12, at Ysbyty Glan Clwyd. Elderly Care, Llweni Ward, Denbigh Community Hospital. Special Medical, Mason Ward, Wrexham Maelor Hospital. Trauma/Orthopaedic, Pantomime Ward, Wrexham Maelor Hospital.
1 Urology/General Surgery, Glyndwr Ward, Wrexham Maelor Hospital.
1.6 Our findings are set out in the following sections of this report. Areas of strengths as well as areas for further improvement, including recommendations for actions are highlighted. The Trust is required to complete an improvement plan to address the key areas of concern and to submit it to HIW within two weeks of the report being published.
2 2. Findings: Areas of strength, areas for further improvement and actions that need to be taken
2.1 Environment of Care
General observations common to all areas visited
2.1.1 HIW asked staff about the arrangements for cleaning on the wards we visited and while the majority of staff knew generally when domestic staff should be on the ward, most staff were unaware of where documented cleaning schedules were located should they need to refer to them. Housekeepers have been introduced at the former Conwy and Denbighshire Trust to co-ordinate cleaning and ensure that wards are kept in an orderly fashion. The hours vary from ward to ward and appears to be working well on some wards, for others it does not appear to be fully embedded and therefore not working so well. The former North East Wales Trust piloted housekeepers on a few wards, but has not taken this approach forward and on some of the wards visited there was a lack of co-ordination in relation to cleaning and keeping the wards in order, which should be addressed.
Actions to be taken:
• Cleaning schedules should be documented and available for all staff to refer to. • The Trust should review the arrangements for co-ordination of ward cleaning and the provision of housekeeping services to ensure clear lines of accountability and co-ordination of cleaning activities to make sure that standards remain high.
3 Elective Orthopaedics, Ward 6. Abergele Hospital
2.1.2 We found the ward to have a high standard of cleanliness, it was well organised throughout, even though there are some challenges given the age of the hospital.
• The Sluice was spotlessly clean and well organised.
Specific issues and actions to be taken:
• There are a number of maintenance and estates issues that need to be addressed, such as the poor state of the skirting and walls in the ward area.
• The only isolation cubicle on the ward is currently out of use as a result of damage to the ceiling due to a leak, this should be addressed as a matter of urgency as it is not acceptable to have such an essential room out of action.
4 • The wards large storage room was not being utilised appropriately. Supplies were stored on the floor making the area difficult to clean. Suitable flooring and shelving should be installed to ensure this space is utilised effectively.
Colorectal Surgery, Ward 5. Ysbyty Glan Clwyd
2.1.3 The cleanliness of the ward was generally sub optimal from a nursing and domestic responsibility. There were no significant infection control issues but given the nature of the patients on the ward, the levels of cleanliness should be maintained at a higher standard. There were some dusty and dirty surfaces including windowsills and lockers and the ward seemed to be somewhat cluttered and lacked storage space. However it was evident that stock levels and ordering are kept under control.
Specific issues and actions to be taken:
• The clutter within and around the ward does not provide easy access to personal protective equipment and can make the area difficult to clean. This included the corridor and sluice.
5 • Facilities within the ward such as bathrooms were generally clean, however, on examination a toilet and a commode not been cleaned to an acceptable standard. Both nursing and domestic staff should ensure that cleaning is carried out to an acceptable standard.
Acute Medical Unit, Ysbyty Glan Clwyd
2.1.4 The ward is a relatively new build and infection control staff inputted into its design. This was noticeable from the layout of the ward and the way in which bays and rooms were laid out. There were some minor maintenance issues which should be addressed as deterioration will occur quickly if timely action is not taken.
2.1.5 The ward environment was generally clean and tidy although there was a little dust on two of the bed frames and the nurses workstation. All other areas were of an acceptable standard.
2.1.6 There were a number of areas of good practice noted:
• The Trust has invested in a tape to wrap around commodes when cleaned, this enables all staff to see that cleaning has taken place and that the commodes are suitable to use. This practice should be rolled out throughout the organisation.
6 • The Trust has also worked with the Clwyd Community Health Council (CHC) and they have funded a toiletry bag that is available for new admissions who have been brought in as an emergency. The bag includes single use items, such as a comb and a toothbrush. The Trust/CHC should be commended for implementing this project.
Specific issues and actions to be taken:
• There were some boxes stored on the floor within the examination room, this is not appropriate and makes cleaning difficult. Suitable shelving should be put in place.
• There was also a mop and bucket observed in the sluice these should be stored in a domestic’s room and nurses should have access to the room.
Ward 12, Respiratory. Ysbyty Glan Clwyd
2.1.8 The ward had a generally good standard of cleanliness, there was a small amount of dust on high level surfaces and around the electrical sockets. The main rooms were free from clutter and items were stored appropriately.
7 Specific issues and actions to be taken:
• However, the treatment room did have inappropriate equipment stored in it, this makes it difficult for both the equipment and room to be cleaned properly. All equipment should be stored in an appropriate area.
Llweni Ward, Denbigh Community Hospital
2.1.9 The ward and surrounding areas were cleaned to a high standard and well maintained. The storage facilities were utilised excellently and high risk rooms such as the drug preparation area and sluice were uncluttered and easy to clean. This was an excellent example of how older buildings, when well maintained, can still provide an environment conducive to good infection control.
• The drug preparation room is an excellent example of a well organised easy to clean area.
Specific issues and actions to be taken:
• There is a policy for the laundering and storage of mop heads. However, staff knowledge varied between sites as to how long they should be used for.
8 Special Medical, Mason Ward. Wrexham Maelor Hospital
2.1.10 The cleanliness of the ward was generally sub optimal. The patient bays were satisfactory but other areas and rooms were of an unacceptable standard. This is particularly concerning due to the nature of some of the patients on the ward whose immune systems are suppressed and they are therefore more susceptible to picking up infections.
Specific issues and actions to be taken:
• The ward is struggling with some estates issues and is in need of redecorating and upgrading of fixtures and fittings.
• There were dirty commodes and bed pan holders observed during our visit that had been put ready for use, this is unacceptable and all staff should ensure that equipment is cleaned correctly.
• The ward was cluttered and there was an extensive amount of overstocking of supplies such as gloves. Equipment was inappropriately stored, especially in the bathroom making it difficult to clean and use. The storage of equipment and ordering of stock
9 needs to be reviewed. • The side rooms contained a large amount of patients own personal items, while it is important for patients to have their own items around them it can make cleaning the room extremely difficult and patients should be encouraged to only have a small number of personal effects on the ward.
Trauma/Orthopaedic, Pantomime Ward. Wrexham Maelor Hospital
2.1.11 We found the ward to be in a generally acceptable condition, however, there was some high and low surface dust. There were also issues relating to estates and storage.
Specific issues and actions to be taken:
• There were a number of inappropriate items stored on the ward. The shower room was no longer available for use and the shower facilities had been removed in order to accommodate equipment. The current usage of this room is unacceptable, the equipment should be stored off the ward and the shower facilities should be re utilised. • Items were being stored inappropriately, including pillow wedges in the sluice. This is unacceptable due to the potential contamination of the wedges and these should be removed immediately and stored appropriately.
10 Urology/General Surgery, Glyndwr Ward. Wrexham Maelor Hospital 2.1.12 The ward was generally clean, however, there were some slight issues in regards to estates. The ward lacks storage but the space within the ward is generally utilised well.
• The nurses workstation was an example of good practice, it was clean, free from clutter and paperwork was stored appropriately.
Specific issues and actions to be taken:
• The worktop in the sluice has been in a state of disrepair for some time, we understand that staff have reported the issue but the work has yet to be undertaken. This is unacceptable, as appropriate cleaning is not able to take place when it is in this condition.
• The commodes used on this ward are quite old and worn. When inspected one of the commodes was found to have a rip. This is not conducive to good cleaning practice, we recommend that the commodes are upgraded to ones that are more practical and easier to clean.
11 2.2 Handling and Disposal of Linen
General observations common to all areas visited
2.2.1 All of the wards, with the exceptions of Pantomime and Glyndwr wards at Wrexham Maelor Hospital, had designated linen rooms and linen was being stored appropriately.
Specific issues for individual wards and actions to be taken:
• The above named wards have a supply of linen stored on trolleys, which are situated in the main corridor of the ward. These wards lack storage space as some items of equipment which are only utilised occasionally are stored on the ward, such as traction beams, these items should be stored off the ward. This will ensure that there is room for essential items, such as linen, to be stored appropriately rather than on trolleys in the main corridor of the ward.
2.3 Departmental Waste Handling and Disposal
General observations common to all areas visited
2.3.1 All of the areas visited were observed to handle and dispose of waste in an appropriate manner.
Specific issues for individual wards and actions to be taken:
• All wards visited at Wrexham Maelor hospital have yellow bins for general as well as clinical waste. All bins were appropriately labelled and had the correct bag inside. However, there is a potential risk that clinical waste will be placed in the incorrect bin if staff are in a hurry and the Trust should review this policy and undertake a risk assessment of the potential impact.
12 2.4 Safe Handling and Disposal of Sharps
General observations common to all areas visited
2.4.1 From our observations all wards with the exception of Mason Ward at Wrexham Maelor Hospital, complied with national standards in relation to the safe handling and disposal of sharps.
Specific issues for individual wards and actions to be taken:
• Mason Ward – The sharps bin in the treatment room situated behind the nurses station was of an unacceptable height. The bin was at a low level and was accessible to members of the public and was low enough for a young child to put their hand in and could cause them serious injury. We recommend that the bin is moved to a higher level in order to be out of the reach of young children.
2.5 Equipment
General observations common to all areas visited
2.5.1 Equipment on the wards visited was found to be clean and instruments were appropriately and safely stored. Staff were generally aware of who was responsible for the cleaning of equipment e.g. beds and IV stands.
2.6 Hand Hygiene
General observations common to all areas visited
2.6.1 Good hand hygiene was well promoted and is clearly a high priority throughout the Trust. Hand hygiene facilities were clearly visible at the entrances of all wards and visitors were observed to cleanse their hands on visiting the wards. The Trust is trialing a number of methods to raise awareness, these include:
13 • Large signage on entrance to the wards.
• Highly visible signs on the floor on the entrances to the ward.
• Movement activated spoken reminders.
14 2.6.2 Staff had a good knowledge of when they should clean their hands and when they should use gloves. Hand hygiene practices were observed as being acceptable in all areas visit.
2.6.3 A number of staff indicated that they had not received infection control training within the last year. We understand this has been due to a shortage of infection control staff within the former Conwy and Denbighshire NHS Trust, which has recently been addressed with a number of new staff appointed.
2.6.4 A number of the wards visited require additional clinical hand washing sinks:
• Ward 6 Abergele Hospital, additional sinks required in the Sluice and Treatment Room. • Ward 5 and 12 at Yysbyty Glan Clywd, additional sinks in the Drug Preparation room and Sluice. There were also only 3 sinks for 24 patients on the wards and these are situated outside the patient bays, which means that staff have to leave the bay to cleanse their hands. • Glyndawr Ward, Wrexham Maelor Hospital, additional sinks in the Sluice and Drug Preparation Room.
2.6.5 Although in most of the wards hand hygiene posters were visible, there were not very many on the three wards visited at Ysbyty Glan Clywd.
Actions to be taken:
• All staff should undertake infection control training/updates annually.
• All wards should conform to national guidance in relation to the sufficient number of clinical hand washing sinks per bed.
15 Elective Orthopaedics, Ward 6, Abergele Hospital
Specific issues and actions to be taken:
• The sinks within the sluice do not conform to national guidance and should be replaced to reflect this.
Special Medical, Mason Ward, Wrexham Maelor Hospital
Specific issues and actions to be taken:
• Clinical hand washing sinks within the ward were observed and found to have inappropriate items such as razors and these should be removed.
Trauma/Orthopaedic, Pantomime Ward, Wrexham Maelor Hospital
Specific issues and actions to be taken:
• Within the ward clinical hand washing sinks had inappropriate items on/in them including bars of soap, these should be removed as there is a risk if cross contamination.
2.7 Ward/Departmental Kitchens
2.7.1 Generally ward kitchens were in a poor condition. Some of the wards we visited shared a kitchen with another ward. This practice does not always work as ownership and responsibility for the kitchen is often unclear and therefore cleaning regimes may not be effectively carried out.
16 Ward 6, Elective Orthopaedics, Abergele Hospital
Specific issues and actions to be taken:
• The kitchen was generally in a poor condition including work surfaces and cupboards. The kitchen needs to be upgraded as the surfaces are not conducive to effective cleaning. The taps on the hand washing sink also need replacing as they are incorrect and wrist taps should be put in place.
Colorectal Surgery, Ward 5. Ysbyty Glan Clwyd
Specific issues and actions to be taken:
• The taps on the hand washing sink in the kitchen need replacing as they are incorrect and wrist taps should be put in place.
Respiratory, Ward 12, Ysbyty Glan Clwyd
Specific issues and actions to be taken:
• The taps on the hand washing sink in the kitchen need replacing as they are incorrect and wrist taps should be put in place.
• There was also a kitchen schedule visible within the kitchen, however, it had not been completed since 2006. An up to date cleaning schedule should be maintained by staff.
17 Elderly Care, Llweni Ward. Denbigh Community Hospital
Specific issues and actions to be taken:
• The kitchen was generally in a poor condition including work surfaces and cupboards. During our visit we were informed that refurbishment was going to take place the following week.
Special Medical, Mason Ward. Wrexham Maelor Hospital
Specific issues and actions to be taken:
• The hand wash sink, fixtures and fittings were all in a poor condition and dirty.
• Food was stored inappropriately in the kitchen and there was no visible date on the items. This is unacceptable and can potentially cause cross contamination.
Trauma/Orthopaedics, Pantomime Ward. Wrexham Maelor Hospital
Specific issues and actions to be taken:
• The kitchen was considered to be in a reasonable condition, however, there was a small amount of dust found on the cupboards and shelves and the fridge was in poor condition.
18