Unannounced Inspection Report

Transcription

1 Unannounced Inspection Report Stobhill Hospital Glasgow Royal Infirmary NHS Greater Glasgow and Clyde

2 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 . Our contact details are: Healthcare Environment Inspectorate Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone: comments.his@nhs.net Healthcare Improvement Scotland 2017 First published May 2017 This document is licensed under the Creative Commons Attribution-Noncommercial-NoDerivatives 4.0 International Licence. This allows for the copy and redistribution of this document as long as Healthcare Improvement Scotland is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit

3 Contents 1 About this report 4 2 Summary of inspection 5 3 Key findings 7 Appendix 1 Requirements and recommendations 15 Appendix 2 Inspection process flow chart 17 3

4 1 About this report This report sets out the findings from our unannounced inspection to Stobhill Hospital, Glasgow, and Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, from Tuesday 21 to Thursday 23 March 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 can be found in Appendix 1 on page 15. The inspection team was made up of three inspectors and a public partner, with support from a project officer. 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. 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 4

5 2 Summary of inspection About the hospitals we inspected Stobhill Hospital, located in Springburn, north Glasgow, has approximately 60 beds and provides general outpatient treatment and diagnostic services. It serves the population of north Glasgow and part of east Dunbartonshire. Glasgow Royal Infirmary is a large teaching hospital in the east of the city. It has approximately 970 inpatient beds and provides a wide range of services, including an accident and emergency department and medicine for the elderly. About our inspection This is the first multi-site inspection we have carried out in NHS Greater Glasgow and Clyde. We carried out unannounced inspections to Stobhill Hospital on Tuesday 21 March and Glasgow Royal Infirmary from Wednesday 22 to Thursday 23 March We previously inspected both hospitals in separate inspections: Stobhill Hospital in October 2015 and Glasgow Royal Infirmary in February Stobhill Hospital s inspection resulted in four requirements and one recommendation. Glasgow Royal Infirmary s follow-up inspection resulted in no requirements or recommendations. The previous inspection to Glasgow Royal Infirmary in October 2014 resulted in eight requirements and one recommendation. These inspection reports are available on the Healthcare Improvement Scotland website Inspection focus Before carrying out this inspection, we reviewed NHS Greater Glasgow and Clyde s selfassessment and previous Stobhill Hospital and Glasgow Royal Infirmary inspection reports. This informed our decision on which standards to focus on during this inspection: Standard 1: Leadership in the prevention and control of infection 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 8: Decontamination. In Stobhill Hospital, we inspected the following areas: ward A (elective surgery) ward C (stroke rehabilitation) minor injuries unit renal dialysis unit day surgery, and day hospital. 5

6 In Stobhill Hospital, we carried out 12 patient interviews and received 35 completed patient questionnaires. In Glasgow Royal Infirmary, we inspected the following areas: accident and emergency department acute assessment unit ward 30 (elderly assessment) ward 50/51 (general medical receiving) ward 62 (orthopaedic trauma), and ward 63 (general surgery). In Glasgow Royal Infirmary, we carried out 18 patient interviews and received 23 completed patient questionnaires. What NHS Greater Glasgow and Clyde did well Across both sites, environmental cleanliness in the majority of areas was generally good. Staff felt supported by the infection prevention and control team and lead nurses. Senior charge nurses in Stobhill Hospital could demonstrate good levels of staff compliance with HAI education. A systematic programme of infection prevention and control audits is in place. What NHS Greater Glasgow and Clyde could do better In Glasgow Royal Infirmary, patient equipment must be safe and clean. Across both sites, hand hygiene must be improved after contact with patient surroundings. A standardised approach to monitor and report staff compliance with HAI education must be in place across the NHS board. In Glasgow Royal Infirmary, estates issues must be acted on in a reasonable timescale and staff kept informed of progress. What action we expect NHS Greater Glasgow and Clyde to take after our inspection This inspection resulted in six requirements. The requirements are linked to compliance with the Healthcare Improvement Scotland HAI standards. A full list of the requirements 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 We expect NHS Greater Glasgow and Clyde to carry out the actions described in its improvement action plan to address the issues we raised during this inspection. These actions should be completed within the timeframes given in Appendix 1. We would like to thank NHS Greater Glasgow and Clyde and, in particular, all staff and patients at Stobhill Hospital and Glasgow Royal Infirmary for their assistance during the inspection. 6

7 3 Key findings Standard 1: Leadership in the prevention and control of infection During the inspection, we saw evidence that NHS Greater Glasgow and Clyde monitors key infection prevention and control indicators. These are reported to the executive leadership through the Board papers and are available for the public to view on the NHS board s website. NHS Greater Glasgow and Clyde has an infection prevention and control accountability framework. The NHS board s self-assessment details the reporting structure and governance of infection prevention and control in the NHS board. The medical director is the executive Board member for infection prevention and control for NHS Greater Glasgow and Clyde. Across both hospital sites, the majority of staff we spoke with understood the local arrangements in place to ensure that HAI issues experienced on wards are escalated to senior management. Staff told us they felt supported by lead nurses and the infection prevention and control team. The majority of staff told us they felt satisfied that this system worked well. NHS Greater Glasgow and Clyde holds daily safety huddles at Glasgow Royal Infirmary. These huddles include representation from each ward area from both sites. We were told that the safety huddles can include discussion on: staffing infection prevention and control issues outstanding estates issues, and domestic requirements. Senior managers at both hospital sites told us the lead nurses attending the daily safety huddle are responsible for sharing all relevant information with staff. The majority of staff we spoke with said communication from the daily safety huddle worked well. During the inspection, all staff across both hospital sites spoken with said they had a positive and supportive working relationship with the infection prevention and control team. Staff said the team visits the wards regularly and can provide face-to-face training. Staff also explained how they contact the team for advice during office hours. Out of hours, staff would either contact the on-call co-ordinator for infection prevention and control advice or the on-call microbiologist. Senior managers from both hospital sites told us that senior charge nurses liaise with their appropriate lead nurse and the infection prevention and control team about infection control issues. If ward staff identify any issues, the team provides support directly to ward staff. If the situation cannot be managed locally, this would be escalated through the infection prevention and control team management structure. 7

8 Standard 2: Education to support the prevention and control of infection NHS Greater Glasgow and Clyde s infection prevention and control education strategy describes staff roles and responsibilities for training and education. It also details the education programme provided to meet the HAI education needs of staff. The strategy includes expectations for mandatory induction, other mandatory modules and recommended modules depending on the area of work. Staff told us that all mandatory infection prevention and control training is done through online modules and face-to-face training with members of the infection prevention and control team. Staff told us that the online system alerts them when their update training is due for renewal. All staff across both hospital sites we spoke with said they discuss their training with their senior charge nurse once a year at their personal development review. During the inspection, we found evidence across both sites of senior charge nurses recording and monitoring the mandatory training of staff. We saw that compliance with the majority of the mandatory infection prevention and control modules was generally good at Stobhill Hospital. Areas for improvement In ward 50/51 of Glasgow Royal Infirmary, we found that staff compliance with mandatory training was varied. Approximately only 50% of staff had completed the mandatory standard infection control precautions modules. We also found poor staff compliance with other online mandatory training modules. We were told that the high workload in the ward made it difficult for staff to meet their training and education needs. We highlighted these issues to senior managers. They told us that when staff cannot leave the ward for training, the infection prevention and control team will go to that ward to provide training during the shift. The infection prevention and control team confirmed that these sessions are counted as mandatory face-to-face infection control training. However, we found that this training is currently not recorded and shared with the senior charge nurses to allow them to record staff training. The infection prevention and control team said they will look at developing ways to share this information with senior charge nurses to allow them to record and monitor staff mandatory training. In Glasgow Royal Infirmary, we found that the HAI infection prevention and control training records are not currently standardised. Wards and departments are collecting information on different modules that do not all align with the NHS board s infection prevention and control education strategy. Senior managers told us they will look further at developing a more standardised approach to gathering training and education information. For example, an education portfolio is to be piloted in the North sector which will allow individual staff members to detail their completed mandatory training. The passport will transfer with staff if they move to a new role or work area. The infection prevention and control education strategy states staff compliance with infection prevention and control modules are reported to: the area infection control committee the NHS board infection control committee, and 8

9 the NHS board clinical governance committee. Senior managers provided us with the acute sector report, sent to the area and NHS board infection control committees every 2 months. This report provides information on the completion of infection prevention and control modules. However, we were unable to determine compliance rates with mandatory infection prevention and control modules from this report as it does not detail the total number of staff in the organisation, or how many of those staff have completed the infection prevention and control training within the mandatory 3-year cycle. Requirement 1: NHS Greater Glasgow and Clyde must ensure a reliable system is put in place to monitor compliance with mandatory infection prevention and control training. This will ensure staff who are not meeting the mandatory requirements can be identified, and unmet infection prevention and control education needs can be addressed. Standard 3: Communication between organisations and with the patient or their representative Our public partner spoke with nursing staff across both hospital sites. They described what information they provide to patients where there is an identified specific infection risk. The information describes: what procedures need to be taken by staff, patients, family members and other visitors, specifically in relation to isolation and hand hygiene, and what personal protective equipment should be used, such as aprons and gloves. This information is usually provided to the patient verbally but leaflets are also available. Ward staff told us that they use their knowledge of the patient to decide what information to provide. On both hospital sites, the majority of patients told us they had been advised about hand hygiene. In the renal unit at Stobhill Hospital, all patients had access to their own alcoholbased hand gel dispensers on their bedside trays. Nursing staff we spoke with were aware of how to contact the interpreter service. They were aware that information was also available on the NHS board s staff intranet site in languages other than English. Standard 6: Infection prevention and control policies, procedures and guidance Health Protection Scotland s National Infection Prevention and Control Manual describes standard infection control precautions and transmission-based precautions. These are the minimum precautions that healthcare staff should take when caring for patients to help prevent cross-transmission of infections. There are 10 standard infection control precautions, including hand hygiene, the use of personal protective equipment (such as aprons and gloves), how to care for patients with an infection, and the management of linen, waste and sharps. 9

10 The manual is available on NHS Greater Glasgow and Clyde s staff intranet site. Across both hospital sites, all staff we spoke with could tell us how to access the manual. During the inspection, all staff across both hospital sites we spoke with had a good level of knowledge and understanding of the various standard infection control precautions, for example how to safely manage a blood spillage and the actions to be taken in the event of a needlestick injury. Across both hospital sites, we observed nursing staff adhering to standard infection control precautions. In particular, we saw generally good compliance with: patient placement use of personal protective equipment the safe management of linen, and management of waste. We raised any exceptions with senior charge nurses at the time of the inspection. Of the 35 people who responded to our survey during our inspection in Stobhill Hospital, 94% said staff always wash their hands. All 23 people who responded to our survey during our inspection in Glasgow Royal Infirmary stated that ward staff always wash their hands. NHS boards are required to measure staff compliance with standard infection control precautions. Across both hospital sites, we saw evidence of a systematic programme of infection prevention and control environmental audits and standard infection prevention and control audits carried out with associated action plans. This included: a rolling programme of infection prevention and control environmental audits carried out by the infection prevention and control team standard infection control precaution audits carried out by ward staff at least every 6 months, and monthly hand hygiene audits. The infection prevention and control team s environmental audit includes standard infection control precautions and produces an overall compliance score. This will result in a red, amber, green or gold score. This scoring determines the frequency of re-audit. We saw that many areas across Glasgow Royal Infirmary had poor results in the quality assurance element of the infection prevention and control environmental audit. This looks at compliance with improvement care bundles such as peripheral vascular catheters. We were told that a new peripheral vascular catheter care bundle is currently being piloted. A proposal is also being considered where, if the quality assurance element of the infection prevention and control environmental audit results in a poor score, two unannounced infection prevention and control visits will take place within 1 month with the aim of improving compliance. We will follow up progress with the new peripheral vascular catheter care bundle and the infection prevention and control environmental audit proposal at future inspections. 10

11 The majority of staff across both hospital sites told us that audit results are shared verbally and by . We were told that results are also shared with lead nurses at monthly meetings, and the clinical services managers and general managers can access these results at any time. During the inspection, we were told how the infection prevention and control team respond to poor audit compliance by visiting wards, and providing education and support to staff. We saw evidence of this in ward 50/51 of Glasgow Royal Infirmary. A recent audit had led to the infection prevention and control team carrying out a number of education sessions with ward staff. Ward staff also carried out more frequent standard infection prevention and control audits. Areas for improvement We saw varied staff compliance with hand hygiene across both hospital sites. For example, some staff were not taking the opportunity to perform hand hygiene after contact with the patient and the patient s surroundings. We observed the following. Domestic staff put out cutlery, food and tea for patients and did not decontaminate their hands after contact with the patient s surroundings. Nursing staff monitored patients blood pressure and did not decontaminate their hands after contact with the patient and their surroundings. Monitoring equipment was also not decontaminated between patients. Requirement 2: NHS Greater Glasgow and Clyde must ensure staff in both Stobhill Hospital and Glasgow Royal Infirmary comply with the guidance in Health Protection Scotland s National Infection Prevention and Control Manual on hand hygiene and the management of patient care equipment to ensure monitoring equipment is decontaminated between each patient use. During our inspections of the minor injuries unit at Stobhill Hospital and the accident and emergency department at Glasgow Royal Infirmary, we found staff were unaware of the frequency of audits and could not explain how audit information is shared. Requirement 3: NHS Greater Glasgow and Clyde must ensure staff in the minor injuries unit at Stobhill Hospital and the accident and emergency department at Glasgow Royal Infirmary are informed of audit results and know what actions must be taken to improve practices. This will ensure learning from the audit process drives improvement in practice by all staff. During the inspection, we saw evidence of hand hygiene audits in all wards inspected across both sites. We were also provided with audit results for wards not inspected in Glasgow Royal Infirmary. From the information provided, we noted six wards that we had not inspected had consistently reported 100% staff compliance with hand hygiene going back to This consistently high score achieved over several years is out of line with the other wards who report generally good but varied compliance. Senior managers told us that the NHS board s hand hygiene co-ordinator monitors and follows up on areas that consistently show a score of 100%. They carry out independent audits to quality assure the results. The NHS board could only provide evidence of one quality assurance audit carried out in 2014 for one of the six wards discussed. We will follow this up at future inspections. 11

12 In ward 50/51 in Glasgow Royal Infirmary, we saw several disconnected intravenous infusions left hanging to be reconnected to patients at a later time. The senior charge nurse told us this was normal practice in this area. We discussed this with the infection prevention and control team who told us used intravenous lines should not be reconnected as this can increase the risk of infection. Senior managers told us the NHS board s venous access policy is currently under review. They will ensure guidance is included on not re-connecting intravenous infusions. They also told us they would work with the practice development team to produce guidance detailing this information for all staff. We will follow this up with the NHS board at future inspections. Standard 8: Decontamination We found the standard of environmental cleanliness was good in Stobhill Hospital and in the majority of areas of Glasgow Royal Infirmary. Domestic staff spoken with had good knowledge of the national colour coding system for hospital cleaning materials and equipment. They described to us the procedure for cleaning an isolation room. They told us they had a good working relationship with the ward teams and domestic supervisors. Nursing staff alert them to any additional duties required and they would be made aware of patients in isolation verbally and by signage on doors. We saw isolation signage during the inspection. Domestic staff described how they would hand over any unfinished tasks to the next shift and we saw evidence of this being documented on daily checklists. They told us they feel they have enough time and equipment to perform their role. We inspected a variety of patient equipment such as bed frames, patient lockers and tables, intravenous stands, infusion pumps and commodes. We found these to be clean in the majority of areas across both sites. Cleaning schedules were available at the patient bed spaces and the majority of these were completed. In the accident and emergency department at Glasgow Royal Infirmary, we saw that children s toys in the waiting area were on a daily cleaning schedule. In ward C, Stobhill Hospital, and ward 50/51, Glasgow Royal Infirmary, the bed space checklists in place were inconsistently completed. However, all areas we inspected in these wards were clean. Of the 35 people who responded to our survey during our inspection of Stobhill Hospital: 100% stated they thought the standard of cleanliness on their ward was good, and 100% stated that the equipment used by staff for their care was clean. Of the 23 people who responded to our survey during our inspection of Glasgow Royal Infirmary: 96% stated they thought the standard of cleanliness on their ward was good, and 100% stated that the equipment used by staff for their care was clean. Some patients who responded to our survey said: Everything looked clean. (Stobhill Hospital) 12

13 All nurses are really friendly...room and environment really clean. (Stobhill Hospital) Very clean. (Glasgow Royal Infirmary) During my stay I couldn't find any fault with the cleanliness of the staff and ward. (Glasgow Royal Infirmary) Areas for improvement In ward 63 of Glasgow Royal Infirmary, we saw: faecal contamination on the underside of several toilet roll dispensers removable contamination on a clinical wash hand basin and the taps a used incontinence pad on the floor, and a used, disposable razor on a clinical wash hand basin in the en-suite bathroom of a shared bay. In a single patient s en-suite bathroom, we also found faecal contamination on the underside of a toilet grab rail. We returned to the room after it had been cleaned and found the contamination had not been removed completely. In ward 62 in Glasgow Royal Infirmary, we found five out of nine mattress covers inspected were visibly contaminated on the inside of the mattress covers. We saw that mattresses were included on the bed space checklist. The checklist had been signed to state that the equipment had been checked and was clean. We were told that daily mattress checks take place where staff unzip bed mattresses every day to ensure there is no break in the integrity of the mattress cover potentially contaminating the inner lining. During our inspection of the accident and emergency department in Glasgow Royal Infirmary, we found two patient trolleys, ready for use at the ambulance entrance, were contaminated with blood and body fluids and one had sticky residue at the base. We found that domestic and nursing staff were not clear who was responsible for cleaning patient trolleys at the ambulance entrance. Requirement 4: NHS Greater Glasgow and Clyde must provide equipment and an environment in wards 62, 63 and the ambulance entrance of accident and emergency of Glasgow Royal Infirmary that is safe and clean. Across both hospital sites, we saw dust and dirt on patient and visitor chairs where the chair cushions could be removed for cleaning (day surgery, Stobhill Hospital and ward 63, Glasgow Royal Infirmary). We raised this with the senior charge nurse who told us that the cushions were not currently on the patient equipment cleaning schedule. We were told that, following this inspection, they would be added to the cleaning schedule. We will follow this up at future inspections. Across both hospital sites, we found a number of the beds, bedrails and patient tables were chipped and damaged. This makes it difficult to effectively clean them. For example, in the accident and emergency department in Glasgow Royal Infirmary, we found chipped and damaged patient trolleys. Senior managers told us there is currently no rolling programme for replacing this type of equipment. There is also no formal risk assessment for the continued use of this equipment. The infection prevention and control team told us that they only provide advice on continued use of damaged equipment when asked specifically by the senior charge nurse. 13

14 Requirement 5: NHS Greater Glasgow and Clyde must carry out a formal risk assessment with the infection prevention and control team for the continued use of any chipped and damaged equipment that is difficult to clean and cannot be replaced. In ward C, Stobhill Hospital, we saw damaged walls and bed bumper bars coming away from the walls. Senior managers told us funding had recently been secured to replace the bed bumpers. We will follow this up at future inspections. In Glasgow Royal Infirmary, we saw damaged and crumbling walls, exposed pipes, torn and damaged flooring, and shower rooms with broken floor-to-wall sealant (wards 30 and 50/51). In ward 50/51, these issues had been identified in recent infection prevention and control environmental audits. Ward staff told us they had reported these issues but had not received feedback on when the remedial work would be carried out. Staff told us they feel frustrated with the estates reporting system and that it can take time to follow up outstanding jobs. We saw that some jobs had been outstanding for long periods of time. For example, we saw evidence that some jobs had been outstanding for over 6 months. We were told that ward 30 was part of a refurbishment programme but there was no date for these works. Senior managers and the infection prevention and control team told us that larger, planned works could not be carried out as there was no scope to move the patients from this ward. Staff were not aware of this communication between the estates department and senior managers and continued to report the outstanding issues. Senior managers told us that any reported jobs that require either specific equipment or significant amounts of money may be placed on hold until the equipment or money is available. The NHS board acknowledged that progress of estate jobs may not be effectively communicated with ward staff. Requirement 6: NHS Greater Glasgow and Clyde must ensure estates and maintenance issues are acted on within a reasonable timescale in Glasgow Royal Infirmary and ward staff are informed of progress and timescales for completion. 14

15 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 2: Education to support the prevention and control of infection Requirement 1 NHS Greater Glasgow and Clyde must ensure a reliable system is put in place to monitor compliance with mandatory infection prevention and control training. This will ensure staff who are not meeting the mandatory requirements can be identified, and unmet infection prevention and control education needs can be addressed (see page 9). HAI standard criterion Priority

16 Standard 6: Infection prevention and control policies, procedures and guidance Requirements 2 NHS Greater Glasgow and Clyde must ensure staff in both Stobhill Hospital and Glasgow Royal Infirmary comply with the guidance in Health Protection Scotland s National Infection Prevention and Control Manual on hand hygiene and the management of patient care equipment to ensure monitoring equipment is decontaminated between each patient use (see page 11). 3 NHS Greater Glasgow and Clyde must ensure staff in the minor injuries unit at Stobhill Hospital and the accident and emergency department at Glasgow Royal Infirmary are informed of audit results and know what actions must be taken to improve practices. This will ensure learning from the audit process drives improvement in practice by all staff (see page 11). HAI standard criterion Priority Standard 8: Decontamination Requirements 4 NHS Greater Glasgow and Clyde must provide equipment and an environment in wards 62, 63 and the ambulance entrance of accident and emergency of Glasgow Royal Infirmary that is safe and clean (see page 13). 5 NHS Greater Glasgow and Clyde must carry out a formal risk assessment with the infection prevention and control team for the continued use of any chipped and damaged equipment that is difficult to clean and cannot be replaced (see page 14). 6 NHS Greater Glasgow and Clyde must ensure estates and maintenance issues are acted on within a reasonable timescale in Glasgow Royal Infirmary and ward staff are informed of progress and timescales for completion (see page 14). HAI standard criterion Priority

17 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 17

18 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 Please contact the Healthcare Improvement Scotland Equality and Diversity Advisor on or to request a copy of: the equality impact assessment report, or this inspection report in other languages or formats. Edinburgh Office Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone Glasgow Office Delta House 50 West Nile Street Glasgow G1 2NP Telephone The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland.