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
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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
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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
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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.
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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.
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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.
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• The daily hospital huddle provided an opportunity for staff to discuss hospital-wide topics, including infection prevention and control issues.
We saw infection prevention and control communication documented in patient care records. Staff told us they documented discussions with patients and relatives in the patient care record. This included advice about hand hygiene, washing patient clothes at home and the provision of information leaflets.
Areas for improvement While HAI information leaflets were available at each patient bedside, our patient interviews and survey found that not all patients could recall receiving infection prevention and control information. Patients may need to be shown the information available on wards.
On the acute ward, one patient was isolated for infection control reasons in a multi-bedded bay area. While the infection prevention and control team had completed a risk assessment, information about the precautions to take when cleaning this bed space was not effectively communicated to one member of domestic staff. We discussed this with the senior charge nurse at the time and other hospital staff during our discussion session.
■ Recommendation a: NHS Orkney should review the current systems for communicating identified infection risks. This will ensure both risks and actions are effectively communicated with all relevant healthcare teams across different shift patterns.
Standard 6: Infection prevention and control policies, procedures and guidance During the inspection, we found evidence of NHS Orkney using the current version of the Health Protection Scotland National Infection Prevention and Control Manual (2015). The manual describes standard infection control precautions (SICPs), which are the minimum precautions that all healthcare staff should take when caring for patients. These are 10 key precautions which include patient equipment cleanliness, hand hygiene, how to safely manage linen and the safe disposal of healthcare waste. We observed generally good compliance from staff throughout the hospital with these precautions.
We found the standard of environmental and patient equipment cleanliness was good. Some of the equipment we checked included:
• bed frames • commodes and raised toilet seats • intravenous (IV) pumps, and • mattresses.
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The World Health Organization lists ‘5 moments for hand hygiene’ to be followed when caring for patients. These moments are:
• before touching a patient • before clean/aseptic procedures • after body fluid exposure risk • after touching a patient, and • after touching a patient’s immediate surroundings.
We saw staff taking the appropriate opportunities to wash their hands with soap and water or use alcohol-based hand rub. This included visitors to the wards, such as a transport driver collecting specimens from the maternity unit. Alcohol-based hand rub was available at the entrance to the wards and outside bed bay areas. Of the 20 patients who completed our survey, 14 said staff ‘always’ washed their hands.
During the inspection, we saw clinical staff using personal protective equipment at the appropriate times. This included the use of aprons and gloves when going into an isolation room. We saw staff remove and dispose of personal protective equipment appropriately into clinical waste bins.
All 20 patients who completed our survey described their ward as ‘always’ or ‘mostly’ clean.
We spoke with 14 nursing staff about the correct procedure for dealing with a blood spillage. Thirteen members of staff were able to explain the correct procedures. We also saw posters in the ward sluice rooms that described the correct procedures for safely managing blood and body fluid spillages.
In all wards and departments inspected, we found staff were managing the disposal of used linen appropriately. We saw staff managing the safe disposal of domestic and clinical waste. During the inspection, we found waste was stored in a designated and locked area waiting for disposal. Waste on the wards was also correctly segregated.
Senior charge nurses and ward staff carried out monthly standard infection control precaution audits. We were shown evidence of these audits and associated improvement plans.
Areas for improvement On the acute ward, we saw standard infection prevention and control precaution audits from January 2015 onwards. During this time, audits of the safe management of the care environment scored between 60–80%. The main reason for this was the lack of appropriate storage in this ward. During our inspection, we also found the ward had a lack of appropriate storage space and was cluttered. The NHS board’s infection prevention and control quality assurance audit guideline states that any wards or departments scoring below 95% have to put in place appropriate quality improvement measures. We saw no evidence in this ward of quality improvement measures taken to improve compliance with this standard infection control precaution.
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■ Requirement 1: NHS Orkney must ensure that the infection prevention and control team responds to any data suggesting the Health Protection Scotland National Infection Prevention and Control Manual (2015) implementation is not as good as expected, as highlighted in the NHS board’s infection prevention and control quality assurance audit guideline.
While the majority of clean linen was stored in a clean, designated area, we found some linen, pillows and blankets were stored:
• in open storage units and large, open containers (assessment and rehabilitation ward), and • uncovered on open shelving (maternity unit).
■ Requirement 2: NHS Orkney must ensure that all clean linen is stored in a designated and enclosed area, protected from dust and potential contamination.
Standard 7: Insertion and maintenance of invasive devices Peripheral vascular catheter (PVC) care bundles are records used by staff to document the safe management of invasive devices. These bundles include daily checks which prompt staff to check whether devices that have been inserted are free from signs of inflammation and are still needed. This process helps to reduce the risk of device-related bloodstream infections.
During the inspection, we reviewed six PVC devices. We found all devices were being well managed and the associated care bundles were complete. Dressings were intact and any decisions to keep or remove the device were well documented. We spoke with patients and all confirmed staff had told them why they needed the PVC.
One PVC had been inserted by staff in the community, and one PVC had been inserted in the accident and emergency department. Both PVCs had no date of insertion recorded.
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Appendix 1 – Requirements and recommendations
The actions the HEI expects the NHS board to take are called requirements and recommendations.
■ Requirement: A requirement sets out what action is required from an NHS board to comply with the standards published by Healthcare Improvement Scotland, or its predecessors. These are the standards which every patient has the right to expect. A requirement means the hospital or service has not met the standards and the HEI is concerned about the impact this has on patients using the hospital or service. The HEI expects that all requirements are addressed and the necessary improvements are made within the stated timescales.
■ Recommendation: A recommendation relates to national guidance and best practice which the HEI considers a hospital or service should follow to improve standards of care.
Prioritisation of requirements All requirements are priority rated (see table below). Compliance is expected within the highlighted timescale, unless an extension has been agreed in writing with the lead inspector.
Priority Indicative timescale 1 Within 1 week of report publication date 2 Within 1 month of report publication date 3 Within 3 months of report publication date 4 Within 6 months of report publication date
Standard 3: Communication between organisations and with the patient or their representative
Requirement None
Recommendation a NHS Orkney should review the current systems for communicating identified infection risks. This will ensure both risks and actions are effectively communicated with all relevant healthcare teams across different shift patterns (see page 8).
HEI Unannounced Inspection Report (Balfour Hospital, NHS Orkney): 15–16 September 2015
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Standard 6: Infection prevention and control policies, procedures and guidance
HAI standard Priority Requirement criterion 1 NHS Orkney must ensure that the infection prevention 6.4 3 and control team responds to any data suggesting the Health Protection Scotland National Infection Prevention and Control Manual (2015) implementation is not as good as expected, as highlighted in the NHS board’s infection prevention and control quality assurance audit guideline (see page 10).
2 NHS Orkney must ensure that all clean linen is stored 6.11 3 in a designated and enclosed area, protected from dust and potential contamination (see page 10).
Recommendations None
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Appendix 2 – Inspection process flow chart
We follow a number of stages in our inspection process.
More information about the Healthcare Environment Inspectorate, our inspections, methodology and inspection tools can be found at www.healthcareimprovementscotland.org/HEI.aspx
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Appendix 3 – Details of inspection
The inspection to Balfour Hospital, NHS Orkney, was carried out from Tuesday 15 to Wednesday 16 September 2015.
The members of the inspection team were:
Jennifer Macdonald Inspector (Lead)
Jacqueline Jowett Inspector
Kenneth Barker Public Partner
Supported by:
Orlagh Sheils Project Officer
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Appendix 4 – Glossary of abbreviations
Abbreviation
CDI Clostridium difficile infection
HAI healthcare associated infection
HEI Healthcare Environment Inspectorate
IV intravenous
PVC peripheral vascular catheter
SBAR situation, background, assessment and recommendation
SICPs standard infection control precautions
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Healthcare Improvement Scotland is committed to equality. We have assessed the inspection function for likely impact on the equality protected characteristics in line with the Equality Act 2010.
Please contact the Healthcare Improvement Scotland Equality and Diversity Advisor on 0141 225 6999 or email [email protected] to request a copy of:
• the equality impact assessment report, or • this inspection report in other languages or formats.
www.healthcareimprovementscotland.org
Edinburgh Office | Gyle Square | 1 South Gyle Crescent | Edinburgh | EH12 9EB Telephone 0131 623 4300
Glasgow Office | Delta House | 50 West Nile Street | Glasgow | G1 2NP Telephone 0141 225 6999
The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland.