Unannounced Inspection Report
Stracathro Hospital | NHS Tayside 28–29 July 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 September 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 (Stracathro Hospital, NHS Tayside): 28–29 July 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 14 Appendix 2 – Inspection process flow chart 15 Appendix 3 – Details of inspection 16 Appendix 4 – Glossary of abbreviations 17
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1 About this report
This report sets out the findings from our unannounced inspection to Stracathro Hospital, NHS Tayside, from Tuesday 28 July to Wednesday 29 July 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 detailing the requirement and recommendation can be found in Appendix 1 on page 14.
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 Stracathro Hospital can be found in Appendix 3.
The flow chart in Appendix 2 summarises 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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2 Summary of inspection
About the hospital we inspected
Stracathro Hospital, Brechin, is a general hospital serving the Tayside area. The hospital has approximately 112 beds and provides services, including outpatients, rehabilitation and geriatric assessment. The Susan Carnegie Centre has 52 beds for inpatients and includes general adult psychiatry, psychiatry of old age and day services for older people.
About our inspection We previously inspected Stracathro Hospital in April 2013. That inspection resulted in four requirements and four recommendations. The inspection report is available on the Healthcare Improvement Scotland website www.healthcareimprovementscotland.org/HEI.aspx
We carried out an unannounced inspection to Stracathro Hospital from Tuesday 28 and Wednesday 29 July 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 Tayside’s self-assessment and previous Stracathro Hospital inspection reports. This informed our decision on which standards to focus on during this inspection. We focused on:
Standard 3: Communication between organisations and with the patient or their representative Standard 6: Infection prevention and control policies, procedures and guidance Standard 8: Decontamination, and Standard 9: Acquisition of equipment.
We inspected the following areas:
ward 2 (medical) ward 7 (stroke and rehabilitation) surgical unit, and Willow unit.
We carried out nine patient interviews and received 10 completed patient questionnaires.
What the hospital did well Patient opinions of care received in the hospital were obtained and acted on. Staff were adhering to standard infection control precautions, such as hand hygiene. There were effective procedures for obtaining infection control advice before acquisitioning equipment.
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What the hospital could do better Put systems in place to provide assurance that equipment is stored clean and ready for use.
What action we expect NHS Tayside to take after our inspection This inspection resulted in one requirement and one recommendation. The requirement is linked to compliance with the Healthcare Improvement Scotland HAI Standards.
A full list of the requirement and recommendation can be found in Appendix 1.
NHS Tayside must address the requirement and make the necessary improvements within the stated timescales.
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 Tayside and in particular all staff and patients at Stracathro Hospital for their assistance during the inspection.
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3 Key findings
Standard 3: Communication between organisations and with the patient or their representative
NHS Tayside’s website has a dedicated infection control section providing easy-to- understand information for patients, their families and the public. It gives specific information on infections such as Clostridium difficile infection (CDI) and meticillin resistant Staphylococcus aureus (MRSA). The website also has hand hygiene guidance, patient leaflets and HAI performance reports.
During the inspection, we found a variety of infection prevention and control leaflets available in the hospital. There is a patient information co-ordinator within NHS Tayside who can help provide leaflets in different languages and formats. Although nurses were generally aware that leaflets could be made available in languages other than English, there was general uncertainty about which ones were available, where and how these could be accessed, and how long this would take. However, all staff knew how to access and use the interpretation service.
We spoke with six members of staff about communication with patients and their representative. Staff described the different types of information they provide to patients. They said they would either speak with the patient or give them printed information, such as leaflets. Staff also said they would decide the most appropriate form of HAI information on a patient by patient basis, based on local policy and advice from the infection prevention and control team.
Staff at Stracathro Hospital use different ways to seek patient feedback which included the following.
‘You Said, We Did’ boards in each ward where patients leave their feedback comments on post-it notes and staff then leave comments about the action they have taken in response. The NHS Tayside website (www.yourtayside.scot.nhs.uk) where we saw examples of recent feedback and responses. In the surgical unit, patient information folders were at patient bedsides, which included information on how patients could leave feedback on the website. Staff on the wards gave questionnaires to patients at the time of their discharge to seek their views about their stay. A member of the infection prevention and control team takes part in ward walkrounds in the hospital. During this process, patient experience questionnaires are used to seek patients’ opinions about their stay in the hospital.
NHS Tayside’s self-assessment describes how the infection prevention and control team provides advice and information to ward staff. An infection prevention and control nurse is based in Stracathro Hospital. They are supported by a lead nurse for infection control for Angus and by team members at Ninewells Hospital. The infection prevention and control nurse communicates with ward staff through ward visits, emails and telephone calls. They are available to speak with patients and their representatives when required.
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Within wards, NHS Tayside uses a variety of methods to communicate infection prevention and control information. These include:
recording information about patients’ infections in nursing notes using ward safety briefs to inform staff about patients with infections, and domestic staff liaising with the nurses in charge of the wards to identify, for example, where enhanced cleaning of a patient’s room is needed for infection control reasons.
NHS Tayside uses a variety of risk assessments, including one which considers infection risks from and to patients during their stay in hospital. These assessments ensure that as a patient’s condition changes during their stay, the appropriate precautions are identified and taken. The assessments are documented in the patient’s healthcare record.
Standard 6: Infection prevention and control policies, procedures and guidance
NHS Tayside has adopted the current version of the National Infection Prevention and Control Manual for NHSScotland (2015). This manual describes standard infection control precautions (SICPs). These are the minimum precautions that all healthcare staff should take when caring for patients. There are 10 SICPs which include hand hygiene, how to safely manage linen and the safe disposal of healthcare waste. The manual also describes transmission-based precautions (TBPs). These are precautions staff should take to help prevent cross-transmission of infections. Staff showed us how they access the manual through the staff intranet. We found review systems in place and all policies and procedures were in date. NHS Tayside uses a service called Policy Tracker which allows staff to receive an automatic notification when a policy has been updated.
We were told how SICPs are audited using the TEACH (Tool for Environmental Auditing of the Clinical Area) audit tool. These audits are undertaken on a monthly basis by senior staff on the wards. Non-compliances identified during this process are brought to the attention of ward staff at the time of the audit. Audit results were displayed in staff meeting rooms. We saw evidence of recent and completed action plans.
Overall, we observed good staff adherence with SICPs. For example, we saw staff taking appropriate opportunities to wash their hands. Alcohol-based hand rub was available at the entrance to the wards. Posters and floor stickers also encourage visitors and staff to use the hand rub before entering the ward environment (see Image 1). Nine of the 10 patients who completed our questionnaire said staff ‘always’ washed their hands.
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Image 1: floor sticker promoting hand hygiene at ward entrance (ward 7)
Staff were aware of which patients had a known or suspected infection. We saw clear signage on isolation doors instructing staff and visitors on which precautions to take when entering the room. We saw staff were adhering to these precautions.
An industrial washing machine on ward 7 was used to wash items such as hoist slings used for lifting patients and heat resistant gloves. We saw no evidence that this washing machine could reach the appropriate temperature and hold times to achieve thermal disinfection as required by Health Protection Scotland’s National Infection Prevention and Control Manual (2015). Thermal disinfection is required to minimise the risk of cross-infection to patients from laundered items. Senior managers in NHS Tayside informed us that the items would now be washed in the hospital mini-laundry where thermal disinfection temperatures and hold times are achieved. We were told that the washing machine on ward 7 will be removed and we will follow this up on future inspections.
During the last inspection of Stracathro Hospital in 2013, a requirement was made for NHS Tayside to introduce a policy to minimise infection risks associated with animals visiting the hospital. NHS Tayside has since introduced an additional ‘Pets in Hospital’ section to its infection prevention and control policy which provides guidance to staff on how to manage visits from approved assistance dogs and therapy animals. The policy also states that domestic pets are only allowed in the hospital in exceptional circumstances, and requests must be discussed with the infection prevention and control team.
The infection prevention and control team is currently testing a ward-based infection control quality improvement programme to share infection control learning across Stracathro Hospital (see Image 2). We were told that it would be introduced in the near future to all wards in the hospital through the cleanliness champions. We were also told there are future plans to introduce the programme to the rest of NHS Tayside.
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Image 2: Ward-based infection control quality improvement programme currently being piloted at Stracathro Hospital
Area for improvement Patients in the Willow unit have their own room with ensuite facilities. During the day, they use toilet facilities in the communal areas. We saw several canisters of partially-used skin cleansing foam in the communal toilets and also in the communal bathroom. Staff told us these canisters are used for more than one patient. We discussed the risk of cross-infection from using this type of skin cleanser for several patients. The nurse in charge told us they would change this practice and no longer use one canister of skin cleansing foam for several patients. Instead, once a patient has used the cleansing foam, the canister will be moved to the patient’s own ensuite bathroom. A new, unopened cleansing foam canister will then be put into the communal bathroom or toilet area. We will follow this up at future inspections.
Standard 8: Decontamination
Nine of the 10 patients who completed our questionnaire described their ward as ‘always’ clean. We received the following comments from patients:
‘The toilets and showers are impeccable.’ ‘It’s first rate.’
We found the standard of environmental cleanliness was very good and the majority of surfaces inspected were clean and intact. However, during the inspection we found some exceptions and these are detailed below in the areas for improvement section.
NHS Tayside’s self-assessment states that domestic staff use work schedules as a method of allocating cleaning tasks. During the inspection, we saw work schedules which had a clear description of staff responsibilities and completed sign-off sheets. We also saw communication sheets used by domestic staff to document outstanding tasks or extra tasks to be done.
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The domestic supervisor completes a quality assurance check of ward cleanliness to make sure the required standards are being met. Ward cleanliness is also audited each month using the Health Facilities Scotland facilities management tool. We were told that if standards fall below an acceptable level, actions would be taken to address this. These actions could include training for domestic staff or the domestic supervisor working alongside the ward domestic.
We also found that the majority of patient equipment was clean and in good repair. Exceptions to this are detailed below in the areas for improvement section. Eight of the 10 patients who responded to our questionnaire described their patient equipment as ‘always’ or ‘mostly’ clean.
We checked 14 mattresses across all the wards inspected. All mattresses were clean and 13 were intact. Staff told us that mattresses were checked each week and on patient discharge, which includes unzipping and visually checking the mattress and the inside cover. We saw completed mattress checklists were in place and equipment cleanliness is audited using the TEACH audit tool. Equipment cleanliness audit results are communicated as described under Standard 6.
Areas for improvement During the inspection, the majority of the patient equipment was clean, but there were some exceptions.
We checked patient beds and bed frames. Five of the seven bed frames we checked on wards 2 and 7 were found to be contaminated on the lower framework, but we were told they were ready for use. We discussed this at the time of the inspection with the nurse in charge of the ward.
We checked a variety of re-usable patient equipment which was tagged as clean and ready for use. We found items that were visibly contaminated, including:
four intravenous pumps (ward 2, see Image 3), and four alarm pads (ward 2).
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Image 3: blood contamination on an intravenous pump, stored as clean (equipment store room, ward 2)
■ Requirement 1: NHS Tayside must ensure that all re-usable patient equipment is properly decontaminated following use. This will minimise the risk of cross- infection to patients.
In Willow unit, we found several items of equipment and furniture in the two store rooms. We were told these items were meant for disposal, but found they were not tagged as such. The items were being stored alongside other equipment that was still in use on the ward. Both store rooms were poorly organised and it was difficult to see which equipment was clean and ready for use and which equipment was waiting for disposal. We also found several chairs stored in the communal bathroom, as the chairs could not be kept in the store room. Staff were unaware of a system for arranging the removal of items requiring disposal.
■ Recommendation a: NHS Tayside should review the storage arrangements in Willow unit. Consideration should be given to an effective process for storing and arranging the collection of broken and condemned equipment.
In the kitchen of the surgical unit, we found an ice machine that had mould on the internal surface of the dispensing channel (see Image 4). We also found dirt on the removable dispenser guard. The cleaning procedure for this machine was displayed on the wall, but only included instructions for cleaning the external surfaces. We discussed this with senior managers and were told that the cleaning procedure would be reviewed to include the cleaning of internal surfaces. We will follow this up at future inspections.
Image 4: mould on the inside of an ice machine dispenser (surgical unit)
Standard 9: Acquisition of equipment
NHS Tayside has a process in place which helps to ensure that all equipment acquired by the NHS board is compliant with national guidance. This includes the ability to effectively decontaminate the equipment.
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Senior managers at the hospital told us that a new tendering process has been introduced which ensures all purchased patient equipment meets the infection control specifications of NHS Tayside. This involves the use of an A-Z catalogue of pre-approved, re-usable equipment which the procurement and infection prevention and control teams have jointly compiled. Ward staff can only request to purchase equipment outwith the A-Z catalogue if they have approval from the infection prevention and control team. This catalogue replaces the previous system, whereby staff had access to a list of products which they had to consult with the infection prevention and control team about before ordering.
At the previous inspection in 2012, staff told us that the material covering some of the chairs in the Willow unit was inappropriate for the patient group and difficult to keep clean. Following that inspection, we made a requirement for NHS Tayside to review this seating and ensure that it is suitable for patients. This has now been done and the material specifications have been discussed with the manufacturer.
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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 8: Decontamination
HAI standard Priority Requirement criterion 1 NHS Tayside must ensure that all re-usable patient 8.1 1 equipment is properly decontaminated following use. This will minimise the risk of cross-infection to patients (see page 12).
Recommendation a NHS Tayside should review the storage arrangements in Willow unit. Consideration should be given to an effective process for storing and arranging the collection of broken and condemned equipment (see page 12).
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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 Stracathro Hospital, NHS Tayside was carried out from Tuesday 28 and Wednesday 29 July 2015.
The members of the inspection team were:
Jacqueline Jowett Inspector (Lead)
Anna Martin Inspector
Fraser Tweedie Public Partner
Supported by:
Orlagh Sheils Project Officer
Observed by:
Cheryl Newton Inspector
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Appendix 4 – Glossary of abbreviations
Abbreviation
CDI Clostridium difficile infection
HAI healthcare associated infection
HEI Healthcare Environment Inspectorate
MRSA meticillin resistant Staphylococcus aureus
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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.
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The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland.