Unannounced Inspection Report. Stirling Community Hospital NHS Forth Valley. 6 7 September 2016

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1 Unannounced Inspection Report Stirling Community Hospital NHS Forth Valley 6 7 September 2016 The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland

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 2016 First published November 2016 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. 2

3 Contents 1 About this report 4 2 Summary of inspection 5 3 Key findings 7 Appendix 1 Requirements and recommendations 13 Appendix 2 Inspection process flow chart 14 Appendix 3 Glossary of abbreviations 15 3

4 1 About this report This report sets out the findings from our unannounced inspection to Stirling Community Hospital, NHS Forth Valley, from Tuesday 6 to Wednesday 7 September This report summarises our inspection findings on page 5 and detailed findings from our inspection can be found on page 7. The inspection team was made up of two inspectors, 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. Although we try hard to involve members of the public as public partners on our inspections, none were available for this inspection. 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. A member of the inspection team took on this role during this inspection. The flow chart in Appendix 2 summarises our inspection process. More information about the Healthcare Environment Inspectorate (HEI), our inspections, methodology and inspection tools can be found at 4

5 2 Summary of inspection About the hospital we inspected Stirling Community Hospital provides a wide range of local health services, including inpatient wards (93 beds), a range of outpatients clinics and a new minor injuries unit. Acute services transferred from this site (Stirling Royal Infirmary) to Forth Valley Royal Hospital, Larbert, in July Work has begun on building a new care village on the site of the community hospital. This will include health and social care facilities. About our inspection We carried out an unannounced inspection to Stirling Community Hospital from Tuesday 6 to Wednesday 7 September This was the first inspection to this site as a community hospital following the transfer of services from acute to community, against the new Healthcare Improvement Scotland Healthcare Associated Infection (HAI) Standards (February 2015). Inspection focus Before carrying out this inspection, we reviewed NHS Forth Valley s self-assessment. 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, and Standard 8: Decontamination. We inspected the following areas: minor injuries unit outpatients department ward 2 (old age and psychiatry) ward 3 (assessment of needs/palliative care) ward 4 (geriatric rehabilitation/stroke), and X-ray department. We carried out three patient interviews and received 20 completed patient questionnaires. What NHS Forth Valley did well Frontline staff had a positive relationship with the infection prevention and control team, and the team was highly visible on the wards. The standard of cleanliness of the environment and patient equipment was good throughout the hospital. 5

6 What NHS Forth Valley could do better Staff awareness and understanding of the information within the infection prevention and control monthly directorate reports should be improved. What action we expect NHS Forth Valley to take after our inspection This inspection resulted in no requirements and recommendations. We would like to thank NHS Forth Valley and in particular all staff and patients at Stirling Community Hospital for their assistance during the inspection. 6

7 3 Key findings Standard 3: Communication between organisations and with the patient or their representative Throughout the hospital, we saw a variety of posters, signs and guidance for staff, patients and visitors on infection control and hand hygiene. We also saw a range of HAI information leaflets displayed at the entrance to the wards and departments inspected. This included leaflets on topics such as: hand hygiene infections such as meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection (CDI) washing patient clothes at home, and general HAI information. Staff told us that they actively hand out information leaflets to patients and relatives on admission. For example, staff in ward 2 told us they give out a relatives pack on admission which includes a variety of HAI and information leaflets. Staff in ward 4 showed us the work they were doing to develop a similar approach to improve communication between staff and patients, relatives and carers. Staff confirmed they were content with the level of HAI communication they received. They told us that HAI information, such as patient infectious status and information about standard infection control precautions, was communicated through daily ward safety briefs, shift handovers and ward communication books. A safety brief is used as a communication tool which focuses on patient safety issues. Audit and surveillance information was displayed on all wards. We saw that there had been no recent recorded incidence of Staphylococcus aureus bacteraemia (SAB) or CDI in the hospital. We were also told audit outcomes were communicated verbally to the nurse in charge and then shared with staff through a variety of methods, for example the ward communications book. All staff told us they had a positive relationship with the infection prevention and control team. They described how and when they would contact the infection prevention and control team for advice and support to help with care planning and patient placement in the ward area. For example, if they had any concerns about a potential infection with a patient they would take immediate action to alert the infection prevention and control team who would visit the ward or provide telephone advice. We were told the infection prevention and control team visits the wards every week. Staff told us they could contact the team at any time for advice and that an on-call consultant microbiologist was available during the out-of-hours period for guidance and patient-specific advice. We spoke with staff about the communication of microbiology results and infection prevention and control advice. All staff confirmed they would record advice they received in patients case notes. Staff told us that any discussions with the patient s relatives or carers would also be documented in their case notes. We were also told the infection prevention and control team would record information in patients case notes if they visited the ward. At the time of our inspection, only one patient was in isolation in the hospital. We saw evidence of advice received from the infection prevention and control team recorded in this patient s case notes. However, we saw no evidence of discussion with the patient s relatives or carers about the status of their infection in their case notes. 7

8 We were shown how the infection prevention and control electronic system works to support infection surveillance. Positive laboratory results were reported promptly to the infection prevention and control team through the laboratory reporting system. This allows the infection prevention and control team to respond quickly. Ward staff told us they would also receive a call from the laboratory to confirm an infection. We saw evidence of opportunities for patients and relatives to provide feedback for staff to help make improvements. For example, post boxes are available on the wards for patients and relatives to use. Area for improvement Of the three patients we spoke with in ward 3, two could not recall or said they did not receive any information about HAI or infection control. Approximately one third of returned questionnaires noted that patients had not or were unsure if they had received information (verbal or written) about HAI or infection control. Standard 6: Infection prevention and control policies, procedures and guidance NHS Forth Valley has adopted Health Protection Scotland s National Infection Prevention and Control Manual. All staff spoken with told us the manual was available for staff to access on the NHS board s staff intranet system. It 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 (aprons, gloves), how to care for patients with an infection, and the management of linen, waste and sharps. Staff told us that any updates to infection prevention and control policies and procedures would be communicated to them by from senior charge nurses or were discussed at daily ward safety briefs. Staff told us they felt happy and supported to challenge any staff members who were not correctly complying with standard infection control precautions. Although our observation of staff compliance with standard infection control precautions was limited, we saw good compliance throughout the areas inspected, in particular with the use of personal protective equipment and hand hygiene. Staff we spoke with also displayed a good knowledge and understanding of the various standard infection control precautions, such as linen and waste management, and how and when to apply them to their practice. We spoke with staff about how they would safely manage a blood or body fluid spillage. Staff could explain the process they would follow, the equipment they would use, the precautions they would take and the correct dilution strength of chlorine-releasing disinfectant and detergent. Across the wards and departments inspected, staff could explain the correct assessment and isolation procedures for managing patients with a suspected or known infection, patients at risk of an infection or during an outbreak of infection. Staff told us that any patients requiring to be cared for in side rooms would be risk assessed for their suitability due to the nature of their existing conditions. We were shown the enteric illness care pathway used by staff to record key information in the management of a patient with a suspected infection. Domestic services staff confirmed they would be informed about the need for additional 8

9 precautions for patients in isolation or any additional cleaning duties required in isolation rooms. They said that clear signage would be displayed alerting them to seek advice from nursing staff. Health Protection Scotland s National Infection Prevention and Control Manual describes when staff should carry out hand hygiene. Alcohol-based hand rub or soap and water must be used to decontaminate (clean) hands. We saw good hand hygiene compliance by staff groups we observed during our inspection. We saw that alcohol-based hand rub dispensers were available at the entrance to the wards. Staff in ward 2 had personal alcohol-based hand rub dispensers attached to their uniforms. All patients we spoke with told us they saw staff washing their hands or using the alcoholbased hand rubs before attending to them. Of the 20 people who responded to our survey during our inspection, 94% stated that ward staff always washed their hands. During the inspection, we saw good compliance by staff with the national uniform and dress code policy, in line with Chief Executive Letter (CEL) 42(2010). NHS boards are required to measure staff compliance with standard infection control precautions. The frequency of this compliance monitoring is determined by individual NHS boards. In NHS Forth Valley, weekly infection control visits to wards are carried out by an infection prevention and control nurse. We were told that compliance with standard infection control precautions is monitored during these visits. Ward staff were aware of these visits and received verbal or written feedback on any non-compliances identified during the visits. We saw evidence of feedback recorded in some ward communication books. Some staff also told us they were ed information following a visit by their senior manager. We were told that the infection prevention and control nurse records their findings on a hand-held tablet device which is then uploaded to the infection prevention and control electronic system. A monthly infection prevention and control update report is produced for each directorate. This includes a variety of information such as surveillance, education and training and any non-compliances identified through the infection prevention and control nurse visits. We were told this directorate report is sent to senior charge nurses, service managers and nurse managers and is published on the staff intranet so that all staff can access it. We reviewed a number of the reports and found that outcomes from these audits were consistently positive. Senior charge nurses also carry out an HAI audit every month on their wards using a monthly managers checklist. This is similar to the weekly infection control visits and includes reviewing compliance with standard infection control precautions. We saw evidence of completed audits. Staff told us they submit information from the audits electronically and a compliance score is generated. Staff then enter this score into the NHS board s performance management balanced scorecard system. One component of this scorecard reviews safe and effective practice, including monthly hand hygiene audit results and infection prevention and control. Most staff were aware that these audits were carried out and that they could access this system at any time. The infection prevention and control team and senior managers can also access the system to review audit results. This provides an opportunity to check that actions or non-compliances are resolved. This ensures oversight, governance and quality assurance of audit activity. We spoke with the head of nursing for the medical directorate about the reporting mechanisms and assurance systems in place. They told us that information from the reports was used as part of monthly quality assurance meetings with senior charge nurses and as part of unannounced care assurance visits. The head of nursing had a good oversight of the 9

10 activity taking place in their area of responsibility and used the information in the balanced scorecard to support safe and effective practice. Domestic services staff spoken with could clearly explain the duties they carried out and describe the national colour coding system for hospital cleaning materials and equipment when carrying out certain tasks. For example, red cloths are used for cleaning sanitary areas like toilets and yellow cloths are used for cleaning isolation areas. Most could describe how and when they use personal protective equipment. Domestic services staff also clearly described the processes they used for managing soiled mop heads or those used in isolation rooms. Any construction and build activity on healthcare premises is subject to Health Facilities Scotland s Healthcare Associated Infection System for Controlling Risk in the Built Environment (HAI-SCRIBE) process. The guidance includes key stages of construction and build activity from design to implementation. During each stage of the project, staff must consider how the works will be carried out to make sure that infection risks to patients, staff and others arising from construction activities are identified and controlled. The HAI-SCRIBE guidance also describes key personnel who should be involved in the project. Work had recently been carried out to refurbish the hospital s outpatients area 3. We discussed this refurbishment with the senior charge nurse for that area, representatives from estates, the infection prevention and control team, and domestic services. The senior charge nurse confirmed they were included in the design and management of the project. This included input into the control measures needed to protect the services that were being delivered. The refurbishment of outpatients area 3 took place while the department remained open. They told us they could readily raise any concerns with the site representatives when required. For example, input from domestic services staff was increased as the building works progressed in response to concerns about dust levels. We were told that plans are now under way to refurbish outpatients areas 1 and 2. Learning from the refurbishment of outpatients area 3 should be reflected in the HAI-SCRIBE process for the new refurbishment project. Areas for improvement We found frontline staff were not aware that the infection prevention and control team weekly visits were part of a formal audit process, with results collated into the monthly directorate report. Ward staff considered the weekly visits by the infection prevention and control nurse to have a focus on the environment, hand hygiene practice and use of personal protective equipment. Staff awareness could be improved on the full scope, remit or purpose of these visits. Ward staff did not readily connect the directorate report to the weekly visit by the infection prevention and control nurse. We discussed this with the infection prevention and control team and were assured that work would be carried out to improve communication and understanding with frontline staff. We found that most clinical and domestic waste was appropriately managed. Clinical waste bags were stored in a locked large clinical waste hold bin before being removed from the wards by portering staff. However, on one ward, we saw there were no clinical waste bins in patient bedroom areas. These were only located in the patient shower rooms. We noted that a domestic bin contained waste that may be more appropriately disposed of in a clinical waste bin. This was raised with the senior charge nurse at the time of the inspection. On one ward, domestic services staff told us they use the same personal protective equipment when cleaning an entire bay. Aprons and gloves should be changed between each patient bed space. 10

11 Standard 8: Decontamination During this unannounced inspection, we found the wards and departments inspected were clean and well maintained. We discussed any exceptions we found with staff at the time of inspection. This included the tops of some patient wardrobes being dusty. We spoke with domestic services staff about their cleaning responsibilities and saw evidence of completed domestic cleaning schedules. Domestic services staff told us that if they were unable to carry out any of their duties, this would be reported for the next shift to action. We were consistently told about the positive collaborative working relationship between nursing and domestic services staff throughout our inspection. Staff described a team approach and how everyone worked together. We inspected a variety of patient equipment and found that the standard of cleaning was good. Staff told us how they would decontaminate (clean) patient equipment between each use. We saw evidence of patient equipment cleaning schedules and weekly mattress checks. All mattresses we inspected were clean and free from damage. We noted the use of I am clean stickers to provide clear indication that equipment was clean and ready for use. All staff were aware of their own responsibilities for maintaining the environment and equipment, with clear communication for day-to-day duties. Patients we spoke with were very impressed by the standard of cleaning. Of the 20 people who responded to our survey during our inspection: 100% stated that they thought the standard of cleanliness on their wards was good, and 100% stated that the equipment used by staff for their care was clean. Some patients we spoke with or who responded to our survey said: I feel everything is done as it needs to be, place looks very spick and span. Staff always cleaning. We looked at the fabric of the building as part of the inspection. We were told that a review of the fabric of the building had been carried out with the different departments, the infection prevention and control team, estates department and senior managers. We were shown the master list of the repairs and maintenance jobs that had been identified. We were told that a concentrated effort was under way to work through the job master list. We spoke with staff about the current paper-based system for reporting repair and maintenance jobs to the estates department. Ward staff telephone the estates department to report a job and are provided with a job reference number. Staff record this number in a ward log book. However, there is little feedback or communication with the ward or department when a job is completed. As a result, staff on some wards have developed their own assurance systems to ensure completion and sign-off for jobs. We spoke with representatives from the estates department about the issues of demonstrating that jobs are completed. The estates department was aware of the issues around the lack of assurance systems. A number of short and long-term actions were under way to improve communication between the estates department and ward staff. Representatives from the estates department have recently started to attend senior charge nurse meetings every month to provide an opportunity to discuss any concerns. A system is to be introduced to ensure jobs are signed off by ward staff when reported jobs are completed. Plans are also under way to implement an electronic estates reporting system by the end of Jobs will 11

12 be reported to the estates department by and ward staff can review the status of jobs. This system will link directly with the national facilities management tool. NHS Forth Valley uses the national facilities management tool to monitor the cleanliness and condition of estates. Any issues with the fabric and cleanliness of the building are identified through this audit tool which randomly selects the areas in wards and departments to be audited each month. We discussed how the national facilities management tool is used and reviewed the supporting documentation and audit results. The domestic services and estates teams had a good understanding of the system. We were told that Health Facilities Scotland had recently provided additional training for staff on the use of the tool. We saw that audit results were positive and that action plans were produced for any rectifications needed. Rectification is the terminology that health services use to identify non-compliances identified during the facilities management tool s audit process. We found that a number of the action plans identified similar issues to those we had found during our inspection such as the tops of some patient wardrobes being dusty. Ward staff were aware of domestic monitoring audits taking place. However, we found that they had limited understanding of this audit process. Staff were keen to be involved further in this process. We were told that plans were under way to improve communication with staff and awareness of this audit process. 12

13 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 This inspection resulted in no requirements and no recommendations. 13

14 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 14

15 Appendix 3 Glossary of abbreviations Abbreviation CDI CEL HAI Clostridium difficile infection Chief Executive Letter healthcare associated infection HAI-SCRIBE Healthcare Associated Infection System for Controlling Risk in the Built Environment HEI MRSA SAB Healthcare Environment Inspectorate meticillin resistant Staphylococcus aureus Staphylococcus aureus bacteraemia 15

16 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.