Balfour Hospital Unannounced Inspection Report Nov 2015
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Unannounced Inspection Report Balfour Hospital | NHS Orkney 15–16 September 2015 The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland Ensuring your hospital is safe and clean The Healthcare Environment Inspectorate was established in April 2009 and is part of Healthcare Improvement Scotland. We inspect acute and community hospitals across NHSScotland. You can contact us to find out more about our inspections or to raise any concerns you have about cleanliness, hygiene or infection prevention and control in an acute or community hospital or NHS board by letter, telephone or email. Our contact details are: Healthcare Environment Inspectorate Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone: 0131 623 4300 Email: [email protected] © Healthcare Improvement Scotland 2015 First published November 2015 The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be reproduced, free of charge in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with the document’s date and title specified. Photographic images contained within this report cannot be reproduced without the permission of Healthcare Improvement Scotland. This report was prepared and published by Healthcare Improvement Scotland. www.healthcareimprovementscotland.org HEI Unannounced Inspection Report (Balfour Hospital, NHS Orkney): 15–16 September 2015 2 Ensuring your hospital is safe and clean Contents 1 About this report 4 2 Summary of inspection 5 3 Key findings 7 Appendix 1 – Requirements and recommendations 11 Appendix 2 – Inspection process flow chart 13 Appendix 3 – Details of inspection 14 Appendix 4 – Glossary of abbreviations 15 HEI Unannounced Inspection Report (Balfour Hospital, NHS Orkney): 15–16 September 2015 3 Ensuring your hospital is safe and clean 1 About this report This report sets out the findings from our unannounced inspection to Balfour Hospital, NHS Orkney, from Tuesday 15 to Wednesday 16 September 2015. This report summarises our inspection findings on page 5 and detailed findings from our inspection can be found on page 7. A full list of the requirements and recommendations can be found in Appendix 1 on page 11. The inspection team was made up of two inspectors and a public partner, with support from a project officer. One inspector led the team and was responsible for guiding them and ensuring the team members agreed about the findings reached. A key part of the role of the public partner is to talk with patients about their experience of staying in hospital and listen to what is important to them. Membership of the inspection team visiting Balfour Hospital can be found in Appendix 3. The flow chart in Appendix 2 summarises our inspection process. More information about the Healthcare Environment Inspectorate (HEI), our inspections, methodology and inspection tools can be found at www.healthcareimprovementscotland.org/HEI.aspx HEI Unannounced Inspection Report (Balfour Hospital, NHS Orkney): 15–16 September 2015 4 Ensuring your hospital is safe and clean 2 Summary of inspection About the hospital we inspected Balfour Hospital, Kirkwall, is a small rural general hospital with 48 beds and 5 pop-up beds (beds that can be added to respond to surges in demand). It has a range of inpatient, outpatient, day care and day surgery facilities. Work on replacing the existing hospital and the inclusion of Kirkwall GP practices and dental facilities should begin in early 2016. About our inspection We previously inspected Balfour Hospital in March 2014. That inspection resulted in five requirements and three recommendations. The inspection report is available on the Healthcare Improvement Scotland website www.healthcareimprovementscotland.org/HEI.aspx We carried out an unannounced inspection to Balfour Hospital from Tuesday 15 to Wednesday 16 September 2015. This was the first inspection of the hospital against the new Healthcare Improvement Scotland Healthcare Associated Infection (HAI) Standards (February 2015). Inspection focus Before carrying out this inspection, we reviewed NHS Orkney’s self-assessment and previous Balfour Hospital inspection reports. This informed our decision on which standards to focus on during this inspection. We focused on: • Standard 2: Education to support the prevention and control of infection • Standard 3: Communication between organisations and with the patient or their representative • Standard 6: Infection prevention and control policies, procedures and guidance, and • Standard 7: Insertion and maintenance of invasive devices. We inspected the following areas: • accident and emergency (receiving unit) • acute ward • assessment and rehabilitation ward • maternity unit, and • MacMillan unit. We carried out nine patient interviews and received 20 completed patient questionnaires. HEI Unannounced Inspection Report (Balfour Hospital, NHS Orkney): 15–16 September 2015 5 Ensuring your hospital is safe and clean What NHS Orkney did well • There was appropriate staff education on infection prevention and control. • Maintenance of peripheral vascular catheters (PVCs) was good. What NHS Orkney could do better • Clean linen should be stored in designated and enclosed areas. • Ensure there is effective communication with all staff where patients are isolated for infection prevention and control reasons. What action we expect NHS Orkney to take after our inspection This inspection resulted in two requirements and one recommendation. The requirements are linked to compliance with the Healthcare Improvement Scotland HAI standards. A full list of the requirements and recommendation can be found in Appendix 1. An improvement action plan has been developed by the NHS board and is available on the Healthcare Improvement Scotland website www.healthcareimprovementscotland.org/HEI.aspx We would like to thank NHS Orkney and in particular all staff and patients at Balfour Hospital for their assistance during the inspection. HEI Unannounced Inspection Report (Balfour Hospital, NHS Orkney): 15–16 September 2015 6 Ensuring your hospital is safe and clean 3 Key findings Standard 2: Education to support the prevention and control of infection During the inspection, ward staff told us they have to complete HAI mandatory training every year. The HAI mandatory training includes infection prevention and control training. Staff use an online system called learnPro and they receive automatic email reminders when a course is due. NHS Orkney’s learning team made sure all staff completed necessary training and also supported senior charge nurses to ensure all staff completed this training. The infection prevention and control team provides training when required. We saw evidence of infection control training carried out recently. During our discussion session, staff told us NHS Orkney had recently set up strategic-level education steering and operational learning groups, led by the head of human resources. It is intended that these groups will support staff to improve completing mandatory training. We saw evidence of good rates of compliance with mandatory HAI training across all wards and departments within the hospital. Standard 3: Communication between organisations and with the patient or their representative NHS Orkney’s website has an infection control section providing easy-to-understand information and links for patients, their families and the public. It gives specific information on infections such as Clostridium difficile infection (CDI) and norovirus. The website also has hand hygiene guidance, patient leaflets and HAI performance reports. In all wards inspected, we found a laminated HAI leaflet at each patient bedside. This leaflet provides information about HAIs and what patients and relatives can do to help prevent them. We spoke with one patient being cared for in isolation. This patient knew the reason why they were in isolation and had received infection prevention and control information. We found general infection control information on ward noticeboards. During the inspection, we spoke with staff about how they provide information about infection prevention and control to patients and their representatives. The majority of staff told us they use a range of patient information from NHS Orkney’s online ‘blog’. This blog is used specifically by staff and provides up-to-date infection control advice for staff; the site is managed by the infection control team. During the inspection, we found ward staff used a variety of methods to communicate infection prevention and control information with each other. These included the following. • Ward staff record infection prevention and control advice for individual patient management in the care records. • Staff use SBAR documentation (situation, background, assessment and recommendation) to communicate infection prevention and control information for patient transfer between wards or to other healthcare providers. The SBAR document records information about the patient, including infection prevention and control risks. • Nursing and domestic staff use ward safety briefs to share information about patients with known or suspected infections. HEI Unannounced Inspection Report (Balfour Hospital, NHS Orkney): 15–16 September 2015 7 Ensuring your hospital is safe and clean • The daily hospital huddle provided an opportunity for staff to discuss hospital-wide topics, including infection prevention and control