ENSURING YOUR HOSPITAL IS SAFE AND CLEAN · HEI Annual Report 2013–2014 Report on standards of...

HEI Annual Report 2013–2014

Report on standards of cleanliness, hygiene, infection prevention and control in acute and community hospitals in NHSScotland: October 2013–December 2014

ENSURING YOUR HOSPITAL IS SAFE AND CLEAN

The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland and is committed to equality. We have assessed the inspection function for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Advisor on 0141 225 6999 or email [email protected]

© Healthcare Improvement Scotland 2015 First published March 2015

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This report was prepared and published by Healthcare Improvement Scotland.

www.healthcareimprovementscotland.org

HEI Annual report 2013–2014Report on standards of cleanliness, hygiene, infection prevention and control in acute and community hospitals in NHSScotland: October 2013–December 2014

Contents

Foreword by Chief Inspector 06

About this report 07

What we found 11

Putting patients first: how our work is improving patient care 21

How well did we do our inspections? 23

How the way we inspect is changing 25

What happens next? 29

Appendix 1: Who we are and what we do 31

Appendix 2: The hospitals and NHS boards we inspected 34

Appendix 3: Useful publications 40

Appendix 4: Terms we use in this report 41

06 Ensuring your hospital is safe and clean

Foreword by Chief Inspector

NHSScotland must not slip in the fight against infection

This report marks the end of the fifth year of the Healthcare Environment Inspectorate’s work in ensuring your hospital is safe and clean.

This is the first full year of inspections to community hospitals. As with the acute hospitals, the aim of these inspections is to provide public assurance that community hospitals are safe and clean.

This report shows that progress continues to be made in raising standards of safety and cleanliness in hospitals. In my first annual report, I highlighted that we had made 352 requirements and recommendations over 36 inspections. In this report, I am pleased to note that the number of requirements and recommendations has fallen to 204, over a larger number of inspections.

During the period October 2013-December 2014, we published six inspection reports where we made no requirements. This is the first time since we started inspections in 2009 that an inspection has resulted in no requirements. These hospitals are to be commended for their commitment to ensuring they are safe and clean.

The Healthcare Environment Inspectorate has played an important role in contributing to the reduction in healthcare associated infections, as rates have dropped significantly over the last 5 years.

However, there is a need to remain vigilant. Even after 5 years of inspections to drive improvements in cleanliness, hygiene, infection prevention and control, standards in some NHS boards continue to fall short of what patients have a right to expect. That is not to say improvements have not been made. There have been big steps forward in Scotland’s hospitals, which have had a direct impact on patient safety and cleanliness.

In this inspection year, our focus has been on follow-up inspections to make sure actions are taken quickly on areas of concern we have found. We carried out 23 follow-up inspections.

We inspected 17 emergency departments as this is a busy patient care area in acute hospitals. We found seven emergency departments where improvement was urgently needed.

We have carried out almost 200 inspections since our inception and, as the Chief Inspector, I am proud of our contribution in supporting safer and cleaner hospitals for patients. We will continue to shine a light on poor standards through independent and rigorous inspections, and to share good practice. NHSScotland must not slip in the fight against infection.

Susan Brimelow OBE | Chief Inspector

Ensuring your hospital is safe and clean 07

About this report

The Healthcare Environment Inspectorate (HEI) was established in April 2009 and is part of Healthcare Improvement Scotland. Each year we carry out at least 30 inspections across NHSScotland, most of which are unannounced. Although most of our inspections are to acute hospitals, we also inspect community hospitals. More information about HEI can be found in Appendix 1.

Our report reflects what we found during 51 inspections to 34 hospitals in 14 NHS boards and two special health boards. This includes inspections where we have gone back to check on progress with concerns we found. Where we identify significant concerns during an inspection, we inform the NHS board at the time of inspection. Our inspections took place between 1 October 2013 and 31 December 2014. We list the hospitals and NHS boards we inspected in Appendix 2.

By looking at our findings, we are able to build up a picture of the quality of cleanliness, hygiene, infection prevention and control in the hospitals we inspected across Scotland. We make a number of recommendations in this report about improvements that hospitals, NHS boards and the Scottish Government need to make.

Of the 51 inspections we carried out, 10 were announced and 41 were unannounced. An announced inspection means that we give the NHS board at least 4 weeks’ notice of the inspection. This allows us to arrange to speak with key staff and public representatives during the inspection. Nine of our announced inspections were to community hospitals. Our first inspection of any hospital is always announced.

An unannounced inspection means that the NHS board does not get any warning of our inspection. Forty of these unannounced inspections were to acute hospitals and one was to a special health board.

We have increased our focus on follow-up inspections this year. Of the 51 inspections we carried out, 23 were follow-up inspections. • During 11 follow-up inspections, we returned unannounced within 1-2 weeks of the initial inspection

to check progress with concerns we had (typically, NHS boards’ compliance with standard infection control precautions, in particular the standard of cleanliness of patient equipment and the ward environment). The findings from these follow-up inspections were published with the original inspection report.

• During 12 follow-up inspections, we returned unannounced within 6 months of the initial inspection. On these inspections we were looking for NHS boards to demonstrate that they had acted on their requirements and had made sustained improvements across the NHS board. The findings from these follow-up inspections were published using our new follow-up inspection report template.


Requirements and recommendations

Our inspection reports include requirements and recommendations for NHS boards to take action. Requirements and recommendations help NHS boards identify where they need to raise standards.

A requirement sets out what action we require from an NHS board to comply with the standards published by Healthcare Improvement Scotland or its predecessor organisations. These are the standards that every patient has the right to expect. A requirement means the hospital has not met these standards and we are concerned about the impact this has on patients using the hospital. The requirement sets out what the hospital must do to meet the standards. We expect all NHS boards and hospitals to take action on any requirements and implement the necessary improvements.

During our inspections in 2013–2014, we made 143 requirements over 51 inspections.

Of the 143 requirements we made this year, 119 (83%) were a high priority ranging from immediate to within 1 month of the inspection report being published.

A recommendation relates to national guidance and best practice that we consider a hospital should follow to improve standards of care.

During our inspections in 2013–2014, we made 61 recommendations over 51 inspections.


This year, we introduced a new reporting template for follow-up inspections where we return unannounced within 6 months of the initial inspection. This lets us report publicly on the progress NHS boards have made since their previous inspection. On these inspections we are looking for NHS boards to demonstrate that they have acted on their requirements and have made sustained improvements across the NHS board. Our reporting template is designed to make it easier for the public to see the progress an NHS board has made against the requirements in the last inspection.

In 12 of the 23 follow-up inspections, we formally followed up on 58 requirements made at previous inspections and we found:

• 43 of these requirements were met

• 12 were partially met, and

• three were not met.

Partially met means an NHS board has not achieved a requirement in its entirety, but we see evidence that it has made progress towards meeting the requirement. For example, an NHS board may have started a programme of refurbishment which is not yet complete.

Three hospitals had met all their requirements when we returned to carry out their follow-up inspection. We will continue to focus on making sure all hospitals progress with acting on their requirements to provide safe and clean environments for patients, staff and visitors.

We list the terms we use in this report in Appendix 4.


What we found

We continue to see NHS boards working hard to raise standards of cleanliness, hygiene, infection prevention and control. However, we have found that some NHS boards continue to fall short of what patients have a right to expect. In this section of the report, we highlight areas where we have found improvements during our inspections and areas where further improvements are needed.

Audit and surveillance

We looked at how NHS boards carry out audit and surveillance activities in 29 of our 51 inspections.

We saw evidence that NHS boards have made auditing part of their routine activities. For example, we saw:

• infection prevention and control staff carrying out audits

• ward-based audits covering the standard infection control precautions

• domestic monitoring audits (cleaning)

• hand hygiene audits, and

• mattress audits.

We also saw senior managers carrying out ‘walkrounds’ in the wards and departments.

However, in some cases, we found that audit results were not being shared with all appropriate staff groups. We also found discrepancies between the ward-based audits and what we found when we inspected the wards, for example staff compliance with standard infection control precautions. Not all NHS boards have practices in place to quality assure ward-based audits. Therefore, in such instances, NHS boards cannot be confident that data from audits reflect practice.

What needs to improve

NHS boards and hospitals need to use the data they gather from audits to help them identify areas where improvement is needed.


Risk assessment and patient management

Water sources can be a potential infection risk to patients in high risk units. This includes legionella and Pseudomonas aeruginosa. We reviewed NHS boards’ water management processes in 17 inspections this year to make sure all the appropriate measures were being taken to minimise patients’ potential risk of infection. All NHS boards we inspected had identified the high risk areas in their hospitals where patients may be at increased risk of water-related infections. This included intensive care units, high dependency units, neonatal units and special care baby units. NHS boards had set up water safety management groups and had water safety management procedures. These generally covered how to manage Pseudomonas aeruginosa, legionella bacteria and other harmful micro-organisms from water systems. Flushing regimes and records were in place in most areas.

Peripheral vascular catheter management

NHS boards use peripheral vascular catheter (PVC) care bundles to help to reduce the risk of device-related bloodstream infections. This includes a record to document the safe management of the inserted catheter.

We reported an improvement in compliance with PVC care bundles in the Healthcare Improvement Scotland annual report (2013–2014).

Our own inspections this year show continued improvements. Last year, we made 15 requirements about the management of PVCs. This year we made 8 requirements across 22 inspections where we looked at this. While improvements have been made, we are still finding occasions when staff are only partially completing the PVC records. There is no room for complacency and we will continue to look at PVC compliance on our inspections.


NHS boards and hospitals should ensure staff follow the PVC care bundle and complete the relevant record to provide assurance that PVCs are being managed appropriately. This would improve patient safety by helping to reduce the risk of infection.


Standard infection control precautions

During our inspections, we focus on how staff implement standard infection control precautions and transmission-based precautions. These are the precautions staff should take when caring for patients to prevent infections spreading. They include:

• patient placement/assessment for infection risk

• hand hygiene

• respiratory and cough hygiene

• use of personal protective equipment (PPE), for example, aprons and gloves

• safe management of patient equipment (cleaning)

• safe management of the care environment (cleaning)

• safe management of linen

• safe management of blood and body fluid spillages

• safe disposal of waste (including sharps), and

• occupational safety: prevention and exposure management (including sharps).



NHS boards and hospitals must ensure that they comply with standard infection control precautions particularly in relation to:

• safe management of blood and body fluid spillages

• safe disposal of waste (including sharps), and

• hand hygiene.

During our inspections in 2013– 2014, we spoke with a range of staff groups about standard infection control precautions. For example, we asked them about how they manage blood and body fluid spillages, and cleaning patient equipment and the ward environment. Generally, staff demonstrated a good working knowledge of these topics. However, we made 48 requirements across all of our inspections about staff not complying with standard infection control precautions. For example:

• safe management of blood and body fluid spillages (14 requirements)

• safe disposal of waste (including sharps) (13 requirements), and

• hand hygiene (12 requirements).


Cleaning (patient equipment and ward environments)

We looked at cleaning of patient equipment and the environment in all of our inspections. This included ambulances as part of our inspection of the Scottish Ambulance Service.

We saw many examples of positive team-working to provide a safe and clean environment for patients. Domestics and nursing staff work as a team to make wards and departments safe and clean. Generally, nursing staff are responsible for cleaning patient equipment and domestic staff are responsible for cleaning wards and departments. For nursing staff, this includes managing any blood or body fluid spillages.

Label showing patient equipment is clean and ready for use

Healthcare Environment Ispectorate ©


However, we continue to find issues with cleanliness on our inspections. We found occasions where some cleaning responsibilities were not clear between nursing and domestic staff, for example the cleaning of patient beds. In some instances, we were told ‘there is no time to clean’ between patient use. We also found the cleanliness of patient equipment was not always being monitored effectively to ensure it was clean and ready for use.

We made 42 requirements about the cleanliness of wards and departments, and patient equipment; 31 related specifically to the cleanliness of patient equipment.


NHS boards and hospitals must ensure that the ward environment and patient equipment are clean and that they monitor compliance to reduce the risk of infection for patients, visitors and staff.

In last year’s annual report (2012–2013), we recommended that NHSScotland considers dedicated patient equipment teams and equipment stores to make sure patient equipment is clean and ready for use, as used in other healthcare systems.


Scottish Government should take a Scotland-wide approach to addressing solutions to the widespread problem of dirty patient equipment.


A common theme from our inspections this year is the poor standard of cleaning in emergency departments. We inspected emergency departments as part of 17 inspections this year. Of these, two were follow-up inspections as we had previously identified concerns with the standard of cleanliness of patient equipment or the environment.

Of the other 15 inspections, seven inspections identified significant shortcomings with either the cleanliness of the department, patient equipment, or both. We were particularly concerned that this included resuscitation areas used to care for critically-ill patients. We went back to inspect all seven emergency departments to gain assurance that they had dealt with the cleanliness issues we had identified.

NHS boards were required to produce a specific action plan detailing how they would act on our concerns. From the information we received, and from what we then saw on our follow-up inspections, NHS boards were taking action to improve the systems and processes for cleaning the department and patient equipment.

Examples included:

• immediately cleaning the department or patient equipment

• reviewing domestic resource (staff and time) requirements and responsibility

• reviewing nursing and domestic cleaning processes and cleaning schedules to make sure they meet the needs of the department

• ensuring relevant staff groups understand and implement local cleaning policies, particularly for the management of blood and body fluid spillages

• reviewing communication processes between nursing and domestic staff, such as how and when domestic staff gain access to effectively clean the department

• carrying out their own unannounced audits of the department, and

• developing staff training and education packages to reflect new processes.


Many of our concerns, particularly about the cleanliness of patient equipment, were due to contaminated trolley beds. We are aware that emergency departments can be very busy and challenging places to provide patient care. While finding the time to clean in busy areas like this is demanding, it is essential to provide patient confidence that the hospital is safe and clean. Emergency trolley beds are also used to transport patients to wards following treatment.Blood smear on patient trolley


NHS boards and hospitals need to establish clear systems for emergency trolley beds to allow a ‘time to clean’ between patients to avoid any risk of infection.

Healthcare Environment Ispectorate ©


Communication between staff

We found generally good communication between the various staff groups including ward staff, the infection control team, domestic and estates. Estates staff are responsible for maintaining hospital buildings and property.

We saw good examples of nursing, domestic and estates staff working well together on the wards to make sure the ward environment is safe and clean. In the majority of hospitals we inspected, staff were able to tell us how they report any estates or infection control issues. We were pleased to see some wards using daily safety briefings to share information about infection prevention and control.

We saw a range of posters, signs and guidance for staff, patients and visitors on infection control and hand hygiene in the hospitals we inspected.

Public involvement

We are aware of many ways for public representatives to get involved in hospital activities, such as infection control and cleanliness monitoring. This includes involvement in voluntary groups, public partnership forums and hospital patient forums. During some of our inspections, we spoke with members of these forums to gain an understanding of the work they do in their hospitals. We found many public representatives take an active role in infection control committees. For example, they carry out unannounced visitor walkrounds and work with NHS boards to produce patient information leaflets to raise awareness of infection control.

Education

We asked staff about training and education in infection control and healthcare associated infection (HAI) in 15 of our inspections. We also looked at staff training plans. Generally, staff had HAI objectives in their personal development plans and were up to date with infection control education.


Putting patients first: how our work is improving patient care

What patients told us during our inspections

What patients tell us is very important and we always include their views in our reports. Each inspection team has at least one trained volunteer member of the public to talk with patients, their relatives and carers. We also invite patients to complete our questionnaires anonymously. These questionnaires ask patients for their views on the cleanliness of the hospital.

We spoke with 395 patients, relatives and carers and received 1,320 completed questionnaires.

From the patients we spoke with, the majority told us they were satisfied with the standards of cleanliness, hygiene, infection prevention and control in hospital. Patients’ different experiences and perspectives can, at times, contradict what inspectors find and may reflect people’s different expectations about standards of care.

We ask patients whether they felt their ward was clean. Some comments we received from patients this year include:

• ‘I must say that cleanliness in this hospital is much improved over the past few years.’

• ‘I felt the level of cleanliness was very good. I had no concerns regarding infections as I felt everyone took responsibility for their cleanliness.’

• ‘Bathroom needs attention more often. The ward was clean but the bathroom was not so clean. On occasion I did talk to someone about the bathroom it wasn’t resolved.’

• ‘The ward is excellent, seriously clean and the staff always smart, very competent, professional and friendly.’

• ‘The floor of this ward is very poorly cleansed – there are splash marks on the floor that has been there for over 2 months.’

We also ask patients if they received information about preventing infections. Some comments we received from patients include:

• ‘Detailed information leaflet on preventing infection including hand washing provided on top of locker.’

• ‘Advised about hand cleaning on entering and leaving ward.’

• ‘The ward is probably clean but no advice given on hand washing. I suppose staff too busy to be constantly reminding patients . . .’

• ‘Told about various hand washes and hand soaps but no written information provided.’


How well did we do our inspections?

In June 2014, we published our HEI evaluation report “How well did we do our inspections?”. The report summarises responses to our national survey, which we circulated to 14 NHS boards and one special health board. The aim of the survey was to evaluate how well we performed our inspections and to use these findings to help us plan and carry out future inspections. The survey was based on questions from the first evaluation report, which we published in October 2011. We received a total of 183 responses from the survey.

Our survey findings

The survey highlighted many positive findings including:

• 95% of staff told us that independent inspection has value and leads to improvement

• 91% of staff told us that action was taken as a result of verbal feedback from inspectors on the dayof inspection, and

• 86% of staff told us that actions for improvement had been taken following publication of theinspection report.

The findings from the survey showed that the majority of respondents understood our role and purpose. Many of those who responded felt that inspections lead to improvement for patients and staff. We recognise that we can improve our methods of communication, particularly how we inform staff and patients about the purpose of our inspections. We have taken action on this by introducing a new leaflet for staff explaining the purpose of our inspections. We give this leaflet to staff on wards and departments when we arrive. We also display posters so that patients and visitors know that an inspection is taking place.


Our response to the survey

Our inspection focus continues to expand in response to new evidence of potential for harm such as risk of Pseudomonas aeruginosa in high risk patient areas. We are committed to informing NHS boards of any changes to our methodology and the tools we use on our inspection. Our Chief Inspector will write to NHS board chief executives when changes take place. We also publish our inspection tools and methodology on our website.

Before inspection, we ask NHS boards to assess their own performance by completing a self-assessment and providing supporting evidence. We recognise this is an administrative burden. With the publication of the new HAI standards in February 2015, we are now developing a new self-assessment. We aim to make this self-assessment less time consuming for NHS boards to complete.

We asked external writers to review published HEI inspection reports to make sure the reports are written in plain English. In our survey, 92.7% of respondents found inspection reports accessible and easy to read.

Almost 50% of respondents were uncertain if relevant staff members were involved in group discussions and interviews during the inspection. Our inspection teams will now be clearer about what topics will be discussed on inspection. This will ensure that appropriate staff groups are represented during group discussions and interviews. We will review the methods we use to gather staff information, during the inspection, to provide an opportunity for other staff groups to work with us and share their views.


How the way we inspect is changing

Implementing the new HAI standards

In our 2012–2013 annual report, we recommended that the NHS Quality Improvement Scotland Standards for Healthcare Associated Infections (2008) should be updated. Healthcare Improvement Scotland published new HAI standards in February 2015. We welcome the publication of these new HAI standards.

The standards are in line with the National Infection Prevention and Control Manual (2013). They apply to all patients and members of the public, and all healthcare organisations and staff, including independent healthcare providers, such as independent hospitals and hospices. There are nine standards and we will begin inspecting against these standards from June 2015, to allow NHS boards time to implement them. The standards cover the following areas:

• leadership

• education

• communication

• HAI surveillance

• antimicrobial stewardship (covering procedures for prescribing antimicrobials, such as antibiotics)

• infection prevention and control policies, procedures and guidance

• insertion and maintenance of invasive devices

• decontamination, and

• acquisition of equipment (for example equipment that is bought or borrowed).


How we prioritise requirements

In March 2014, we introduced a new system for prioritising how quickly we expect NHS boards to act on requirements. In the new system, we prioritise requirements using a 1–6 priority rating scale (see table below).

Priority rating Indicative timescale

1 Immediately on receipt of report

2 Within 1 month of report publication date

3 Within 3 months of report publication date




For consistency in this report, those inspections we scored using the new priority system have been mapped across to the old priority rating scale (high, medium, low and minor) - see Appendix 2.

We expect NHS boards to comply within the relevant timescale.


Inspection planning procedure

Since the last annual report, we have introduced a new inspection planning procedure which helps inspectors to decide how often to inspect individual hospitals. This helps to focus on hospitals that most need to improve the quality of their cleanliness, hygiene, infection prevention and control. This is what we mean by taking a risk-based and proportionate approach to our scrutiny and inspection role.


What happens next?

We will continue to carry out a minimum of 30 inspections each year. Most of our acute hospital inspections will be unannounced. We will continue to focus on both acute and community hospitals that most need to improve the quality of their cleanliness, hygiene, infection prevention and control.

New HAI standards

As part of implementing the new HAI standards, we are reviewing our inspection processes. We are reviewing our self-assessment and supporting guidance for NHS boards and revising our inspection tools so that our inspections take account of the new standards.

Vale of Leven Hospital Inquiry

In our 2012–20 13 annual report, we said we would implement the recommendations from the Vale of Leven Hospital Inquiry. This inquiry was set up in 2009 by the Scottish Government to investigate the patient deaths associated with a Clostridium difficile infection (CDI) at the Vale of Leven Hospital, Alexandria, NHS Greater Glasgow and Clyde. The findings from the inquiry were published in November 2014. The report includes 75 recommendations for NHS boards and the Scottish Government. The Cabinet Secretary for Health, Wellbeing and Sport issued a statement to the Scottish Parliament on 25 November 2014 accepting all 75 recommendations. One of the recommendations for the Scottish Government is to ensure that we have the power to close a ward to new patient admissions if our Chief Inspector feels there is a real risk to the safety of patients. We will work with Scottish Government and NHS boards to implement this recommendation to protect patient safety.

Introducing antimicrobial stewardship in acute hospitals using pharmacists

The Scottish Antimicrobial Prescribing Group (SAPG)1 works to ensure antimicrobials, such as antibiotics, are used safely to treat and prevent infection, and to minimise harm. This is known as antimicrobial stewardship.

We have been working with SAPG and pharmacists to develop methods of inspecting antimicrobial prescribing to meet the new HAI standards. This will look at the process of prescribing antimicrobials to patients, and records for how they are being administered. We will start inspecting antimicrobial prescribing later in 2015.

1 www.scottishmedicines.org.uk/SAPG/Scottish_Antimicrobial_Prescribing_Group__SAPG_


Introducing inspections to theatres

Since our 2012–2013 annual report, we have developed an inspection tool for the inspection of hospital theatres. We may now choose to include hospital theatres as part of our inspections.

Core services

We will continue to focus on the following core services for inspection:

• emergency departments

• acute medical units, including frail elderly

• surgical care

• intensive and critical care, and

• maternity.


Appendix 1: Who we are and what we do

Who we are

The Healthcare Environment Inspectorate (HEI) carries out safety and cleanliness inspections across NHSScotland hospitals. We are part of Healthcare Improvement Scotland.

We have a team of inspectors who assess how clean a hospital is, and if it is meeting national standards and guidance which every patient in hospital has the right to expect.

The inspection team includes volunteers known as public partners who work with us and take part in inspections. We talk to patients and listen to what is important to them. We also visit wards and departments to inspect the environment and talk to staff.

If we find problems we make sure the NHS boards take action to reduce the risks of infection for patients and staff.


What we do

We:

• work to ensure that patients are at the heart of everything we do

• measure things that are important to patients

• are firm, but fair

• have members of the public on our inspection teams

• ensure our staff are trained properly

• tell people what we are doing and explain why we are doing it

• treat everyone fairly and equally, respecting their rights

• take action when there are serious risks to people using the hospitals and services we inspect

• if necessary, inspect hospitals and services again after we have reported the findings

• check to make sure our work is making hospitals and services cleaner and safer

• publish reports on our inspection findings which will be available to the public in a range of formats on request, and

• listen to your concerns and use them to inform our inspections.

We do not:

• assess the fitness to practise or performance of staff

• investigate complaints, and

• investigate the cause of outbreaks of infection.


Our inspection process

Before inspection

The NHS board undertakes a self-assessment exercise and submits the outcome to us.

We review the self-assessment submission to help us prepare for on-site inspections.

During inspection

We arrive at the hospital or service and undertake physical inspection.

We use audit tools to help us assess the physical environment and compliance with standard infection control precautions.

We have discussions with senior staff and/or operational staff, people who use the hospital or service and their carers.

We give feedback to the hospital or service senior staff.

We undertake further inspection of hospitals or services if significant concern is identified.

After inspection

We publish reports for patients and the public based on what we find during inspections. NHS staff can use our reports to find out what other hospitals and services do well and use this information to help make improvements. Our reports are available on our website at www.healthcareimprovementscotland.org

We require NHS boards to develop and then update an improvement action plan to address the requirements and recommendations we make. We check progress against the improvement action plan.

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Appendix 2: The hospitals and NHS boards we inspected

The hospitals and NHS boards we inspected between 1 October 2013 and 31 December 2014 are listed below. Inspection reports for each hospital are available on our website at www.healthcareimprovementscotland.org

Date inspected Type of inspection

Number and priority rating of requirements

Number of recommendations

NHS Ayrshire & Arran

Ayrshire CentralHospital, Irvine(community hospital)

3–4 December 2013 Announced 1 High0 Medium0 Low0 Minor

1

University Hospital Ayr

1–2 April 2014

11 April 2014

Unannounced

Unannounced follow-up

*both inspections combined in one published report

5 High1 Medium0 Low0 Minor

1

University Hospital Ayr

13–14 August 2014 Unannounced follow-up


2

University Hospital Crosshouse, Kilmarnock

28–29 October 2014

6 November 2014

Unannounced




0





NHS Borders

Borders General Hospital, Melrose

22 October 2013 1 November 2013

Unannounced




1

Borders General Hospital, Melrose

10–11 June 2014 Unannounced follow-up


0

NHS Dumfries & Galloway

Dumfries & Galloway Royal Infirmary

15–16 January 2014

22 January 2014

Unannounced




3

Dumfries & Galloway Royal Infirmary

24–25 June 2014 Unannounced follow-up


1

NHS Fife

Glenrothes Hospital(community hospital)

29–30 April 2014 Announced 1 High0 Medium0 Low0 Minor

4

Victoria Hospital, Kirkcaldy

2–3 December 2014

11 December 2014

Unannounced




2





NHS Forth Valley

Falkirk CommunityHospital

28–29 May 2014 Announced 0 0

NHS Grampian

Aberdeen Maternity Hospital

9 October 2013 Unannounced follow-up


1

Woodend Hospital, Aberdeen (community hospital)

12–13 February 2014 Announced 3 High1 Medium0 Low0 Minor

2


19–20 March 2014 Unannounced follow-up


2


30 June–1 July 2014



0

Inverurie Hospital(community hospital)

15–16 July 2014 Announced 0 0

NHS Greater Glasgow and Clyde

Victoria Infirmary, Glasgow

27 November 2013 Unannounced follow-up

0 0

Vale of Leven Hospital, Alexandria

16 January 2014 Unannounced 2 High0 Medium0 Low0 Minor

2

Princess Royal Maternity Hospital, Glasgow

30 April 2014 Unannounced 6 High0 Medium0 Low0 Minor

0





NHS Greater Glasgow and Clyde

Glasgow Royal Infirmary

7–8 October 2014

15 October 2014

Unannounced




1

Royal Hospital for Sick Children (Yorkhill), Glasgow

16–17 December 2014 Unannounced 3 High0 Medium0 Low0 Minor

1

NHS Highland

Caithness General Hospital, Wick

6–7 May 2014 Unannounced follow-up

0 0

Raigmore Hospital, Inverness

13–14 May 2014

20 May 2014

Unannounced




2

Mid Argyll CommunityHospital and Integrated Care Centre, Lochgilphead

29–30 July 2014 Announced 3 High1 Medium0 Low0 Minor

4

Raigmore Hospital, Inverness

4–5 November 2014 Unannounced follow-up

0 0





NHS Lanarkshire

Hairmyres Hospital, East Kilbride

16–17 September 2014

3 October 2014

Unannounced




3

Wishaw General Hospital

11–12 November 2014

26 November 2014

Unannounced




1

NHS Lothian

Royal Infirmary of Edinburgh



0

Liberton Hospital, Edinburgh (community hospital)

23–24 October 2013 Announced 5 High0 Medium0 Low0 Minor

3

Astley AinslieHospital, Edinburgh (community hospital)

28–29 January 2014 Announced 4 High2 Medium0 Low0 Minor

4

St John’s Hospital, Livingston

20–21 August 2014

27 August 2014

Unannounced




3

Western General Hospital, Edinburgh

18–19 November 2014

27 November 2014

Unannounced




1





NHS Orkney

Balfour Hospital, Kirkwall

4–5 March 2014 Unannounced 5 High0 Medium0 Low0 Minor

3

NHS Shetland

Gilbert Bain Hospital, Lerwick

4–5 November 2013 Unannounced 4 High1 Medium0 Low0 Minor

2

NHS Tayside

Perth Royal Infirmary 10–11 December 2013

Unannounced 3 High1 Medium0 Low0 Minor

1

Ninewells Hospital, Dundee

11–12 March 2014 Unannounced 9 High0 Medium0 Low0 Minor

0

NHS Western Isles

Western Isles Hospital, Stornoway



3

Uist and Barra Hospital, Benbecula(community hospital)

1–2 July 2014 Announced 0 1

Scottish Ambulance Service

Scottish Ambulance Service

10–13 June 2014 Announced 0 High3 Medium0 Low0 Minor

3

State Hospitals Board for Scotland

The State Hospital, Carstairs

13 November 2013 Unannounced follow-up


3


Appendix 3: Useful publications

1. Healthcare Improvement Scotland. Healthcare Associated Infection standards. 2015 [cited 2015 Feb 19]; Available from http://www.healthcareimprovementscotland.org/our_work/patient_safety/programme_resources/hai_standards.aspx

2. NHS Quality Improvement Scotland. Healthcare Associated Infection standards. 2008 [cited 2014 Dec 02]; Available from http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_policies_and_procedures/hai_standards.aspx

3. Healthcare Improvement Scotland. How well did we do our inspections? A survey to evaluate the Healthcare Environment Inspectorate’s inspection programme (September 2012–September 2013) [cited 2014 Dec 02]; Available from: http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/other_reports/hei_evaluation_report_2012-13.aspx

4. Health Facilities Scotland. NHSScotland National Cleaning Services Specification. 2009 [cited 2014 Dec 02]; Available from http://www.hfs.scot.nhs.uk/publications/1265120830-The%20NHSScotland%20National%20Cleaning%20Services%20Specification.pdf

5. NHSScotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection (2004) [cited 2014 Dec 02]. Available from http://www.scotland.gov.uk/Resource/Doc/25954/0013320.pdf

6. Health Protection Scotland. National Infection Prevention and Control Manual. 2013 [cited 2014 Dec 02] http://www.hps.scot.nhs.uk/haiic/ic/guidelinedetail.aspx?id=49785

7. Healthcare Improvement Scotland. HEI Annual Report 2012-2013. 2014 [cited 2014 Dec 02]; Available from http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/hei_annual_report_2012-13.aspx

8. Healthcare Improvement Scotland. HEI Annual Report 2011-2012. 2012 [cited 2014 Dec 02]; Available from http://www.healthcareimprovementscotland.org/programmes/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2011-12.aspx

9. Healthcare Improvement Scotland. HEI Annual report 2010-2011. 2011 [cited 2014 Dec 02]; Available from http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2010-11.aspx

10. Healthcare Environment Inspectorate. Annual Report 2009-2010. 2010 [cited 2014 Dec 02]; Available from http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2009-10.aspx

http://www.healthcareimprovementscotland.org/our_work/patient_safety/programme_resources/hai_standards.aspxhttp://www.healthcareimprovementscotland.org/our_work/patient_safety/programme_resources/hai_standards.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_policies_and_procedures/hai_standards.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_policies_and_procedures/hai_standards.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/other_reports/hei_evaluation_report_2012-13.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/other_reports/hei_evaluation_report_2012-13.aspxhttp://www.hfs.scot.nhs.uk/publications/1265120830-The%20NHSScotland%20National%20Cleaning%20Services%20Specification.pdfhttp://www.hfs.scot.nhs.uk/publications/1265120830-The%20NHSScotland%20National%20Cleaning%20Services%20Specification.pdfhttp://www.scotland.gov.uk/Resource/Doc/25954/0013320.pdfhttp://www.scotland.gov.uk/Resource/Doc/25954/0013320.pdfhttp://www.hps.scot.nhs.uk/haiic/ic/guidelinedetail.aspx?id=49785http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/hei_annual_report_2012-13.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/hei_annual_report_2012-13.aspxhttp://www.healthcareimprovementscotland.org/programmes/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2011-12.aspxhttp://www.healthcareimprovementscotland.org/programmes/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2011-12.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2010-11.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2010-11.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2009-10.aspxhttp://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/hei_annual_reports/chief_inspector_report_2009-10.aspx


Appendix 4: Terms we use in this report

acute hospital A hospital which provides a wide range of specialist care and treatment for patients. Acute hospitals are for short-term medical, surgical, and mental health treatment and care.

antimicrobial prescribing

Maintains the effectiveness of treatment and prevention of microbial infections.

antimicrobial stewardship

Antimicrobial stewardship is making the best use of antimicrobials to manage infection and to ensure optimal outcomes and minimal harm to patients and the wider society. The Scottish Antimicrobial Prescribing Group (SAPG) works closely with clinical staff in NHS boards and with public partners to promote the safe and effective use of antibiotics both in hospital and primary care.

Clostridium difficile infection (CDI)

Clostridium difficile (C. difficile) is a bacterium that is present naturally in the gut of some children and adults. It does not cause any problems in healthy people. However, some antibiotics that are used to treat other health conditions can interfere with the balance of ‘good’ bacteria in the gut. When this happens, C. difficile bacteria can multiply and produce toxins (poisons), which cause illness such as diarrhoea and fever. At this point, a person is said to be infected with C. difficile.

community hospital Community hospitals provide a wide range of locally available services to local populations in urban and rural communities. They provide diagnostic and treatment services locally so that individuals do not have to travel significant distances. They often are a bridge between home and specialist acute hospital care. There are 87 community hospitals in Scotland.

decontamination Removing or destroying contamination. Three processes are commonly used: cleaning, disinfection and sterilisation.

healthcare associated infection (HAI)

Infection acquired in the hospital or other healthcare setting.

Healthcare Improvement Scotland

Supports healthcare providers in Scotland to deliver high quality, evidence-based, safe, effective and person-centred care; and scrutinises services to provide public assurance about the quality and safety of that care. Healthcare Improvement Scotland was formed on 1 April 2011, marking a change in the way the quality of healthcare across Scotland is supported nationally. Website address: www.healthcareimprovementscotland.org

infection control team A team within an NHS board which has prime responsibility for all aspects of surveillance, prevention and control of infection.


legionella The legionella bacterium can be found in purpose-built water systems such as cooling towers, evaporative condensers and hot and cold water systems. If conditions are favourable, the bacteria may grow increasing the risks of Legionnaires’ disease (a severe form of pneumonia).

NHS board There are 20 NHS boards in Scotland. Fourteen are territorial boards, 11 covering the mainland and three covering the island groups of Orkney, Shetland and the Western Isles. They are responsible for care and services in their areas. Each plans and delivers health services in a way that suits the geography and population of the areas it serves. NHS boards also work together to provide some services. The other NHS boards are special health boards which provide national clinical and non-clinical care and services. More information about the territorial boards is available online at: www.show.scot.nhs.uk/organisations/index.aspx. See special health board.

peripheral vascular catheter (PVC)

A tube that is used to get long-term access to blood vessels. PVC related infections are the third leading cause of device related bacteraemia. PVCs can cause bloodstream infections by enabling microorganisms to gain direct access to the bloodstream.

Pseudomonas aeruginosa

Pseudomonas aeruginosa is a tough bacterial strain commonly found in soil and stagnant water and can infect humans and plants. It does not usually cause illness in healthy people, but can cause serious infection when our normal defences are weakened. This means that the most vulnerable hospital patients are at threat such as intensive care patients, cancer patients, people with severe burns and premature babies in neonatal units. The usual route is through contaminated hands or medical equipment such as catheters and feeding tubes. Infection control measures such as regular hand washing and decontamination of equipment are the most effective ways to prevent its spread.

risk The likelihood, high or low, that somebody or something will be harmed by an unwanted event or incident, multiplied by the severity of the potential harm. Risks are measured in terms of the likelihood and consequences.

risk assessment The systematic process to identifying risk and evaluating the potential likelihood and consequences.

self-assessment Measurement of performance against standards by the individual, clinical team, or NHS board providing the service to which the standards relate.


special health board Provides national clinical and non-clinical care and services to NHSScotland. There are six special health boards: NHS 24; NHS Education for Scotland; NHS Health Scotland; Scottish Ambulance Service; State Hospitals Board for Scotland, and the NHS National Waiting Times Centre. Online directory – website address: www.show.scot.nhs.uk/organisations/index.aspx

standard infection control precautions

Standard infection control precautions are the precautions staff should take when caring for patients to prevent the spread of infection. This includes the management of sharps, linen and waste, hand hygiene and the use of personal protective equipment such as aprons and gloves.

surveillance The ongoing, systematic collection, analysis and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know.

You can read and download this document from our website. We are happy to consider requests for other languages or formats. Please contact our Equality and Diversity Advisor on 0141 225 6999 or email [email protected]

The Healthcare Environment Inspectorate, the Scottish Health Council, the Scottish Health Technologies Group, the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium are part of our organisation.

Edinburgh Office: Gyle Square | 1 South Gyle Crescent | Edinburgh | EH12 9EBTelephone: 0131 623 4300

Glasgow Office: Delta House | 50 West Nile Street | Glasgow | G1 2NPTelephone: 0141 225 6999

www.healthcareimprovementscotland.org

Foreword by Chief InspectorAbout this reportWhat we foundPutting patients first: how our work is improving patient careHow well did we do our inspections?How the way we inspect is changingWhat happens next?Appendix 1: Who we are and what we doAppendix 2: The hospitals and NHS boards we inspectedAppendix 3: Useful publicationsAppendix 4: Terms we use in this report

ENSURING YOUR HOSPITAL IS SAFE AND CLEAN · HEI Annual Report 2013–2014 Report on standards of...

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