Unannounced Follow-up Inspection Report Queen Elizabeth University Hospital NHS Greater Glasgow and Clyde www.healthcareimprovementscotland.org
The Healthcare Environment Inspectorate was established in April 2009 and is part of Healthcare Improvement Scotland. We inspect acute and community hospitals across NHSScotland. You can contact us to find out more about our inspections or to raise any concerns you have about cleanliness, hygiene or infection prevention and control in an acute or community hospital or NHS board by letter, telephone or email. Our contact details are: Healthcare Environment Inspectorate Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone: 0131 623 4300 Email: comments.his@nhs.net Healthcare Improvement Scotland 2017 First published October 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 https://creativecommons.org/licenses/by-nc-nd/4.0/ www.healthcareimprovementscotland.org
Contents 1 Summary of inspection 4 2 Progress since last inspection 8 Appendix 1 Requirements and recommendations 18 Appendix 2 Inspection process flow chart 19 3
1 Summary of inspection About the hospital we inspected Queen Elizabeth University Hospital, Glasgow, is a newly built 1,109 bed acute hospital with a full range of healthcare specialties, including a major emergency department. The hospital opened in April 2015. In addition to the 14-floor hospital building, the hospital site retains a number of other services in adjacent facilities. This includes maternity services, neurosciences and the Langlands Unit for medicine of the elderly and rehabilitation. About the previous inspection We previously carried out an unannounced inspection to Queen Elizabeth University Hospital in December 2016, and a subsequent unannounced follow-up inspection to the emergency department, immediate assessment unit and clinical decisions unit in January 2017. One single report detailing our findings was produced following the two inspections. The inspections resulted in 10 requirements and three recommendations. As a result of the inspections, NHS Greater Glasgow and Clyde produced a detailed improvement action plan and submitted this to us. The inspection report and details of the action plan are available on the Healthcare Improvement Scotland website www.healthcareimprovementscotland.org/hei.aspx This follow-up report should be read along with the previous December 2016 and January 2017 report. About this inspection We carried out an unannounced follow-up inspection to Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, from Tuesday 1 to Wednesday 2 August 2017. The purpose of the inspection was to: assess progress with the 10 requirements and three recommendations made at the previous inspections in December 2016 and January 2017, and assess the hospital against the Healthcare Improvement Scotland Healthcare Associated Infection (HAI) Standards (February 2015). The inspection also took account of the information supplied by NHS Greater Glasgow and Clyde in the 16-week improvement action plan submitted in May 2017. This plan details the action taken by the NHS board to address the requirements and recommendations we made at our previous inspections. The inspection team was made up of three inspectors, with support from a project officer. We inspected the following areas: clinical decisions unit emergency department immediate assessment unit, and public toilets in the main hospital atrium and mezzanine level 1. 4
Inspection findings Of the 10 requirements made at the previous inspections in December 2016 and January 2017, the NHS board has: met nine requirements, and partially met 1 one requirement. Previous requirements NHS Greater Glasgow and Clyde must ensure that staff in the immediate assessment unit are aware of, and practice, the safe management of blood and body fluid spillages in line with Health Protection Scotland s National Infection Prevention and Control Manual. NHS Greater Glasgow and Clyde must ensure that all clinical waste is stored in line with Health Facilities Scotland s Scottish Health Technical Note 3 NHSScotland waste management guidance Part A (2015). NHS Greater Glasgow and Clyde must ensure staff in the emergency department comply with hand hygiene and the use of personal protective equipment guidance in line with Health Protection Scotland s National Infection Prevention and Control Manual. NHS Greater Glasgow and Clyde must ensure that patient equipment in the emergency department is clean and ready for use. NHS Greater Glasgow and Clyde must ensure that the environment in the emergency department is safe and clean. NHS Greater Glasgow and Clyde must ensure that: Met / Partially met / Not met Met Met Partially met Met Met Met a) accurate records are kept of domestic cleaning, and b) staff are aware of their responsibilities for environmental cleanliness. 1 Partially met means a requirement has not been achieved in its entirety, but progress has been made. 5
Previous requirements NHS Greater Glasgow and Clyde must ensure that: Met / Partially met / Not met Met a) domestic monitoring assurance systems identify where environmental cleanliness in the emergency department is below the accepted standard, and b) remedial actions are taken to ensure the environment is safe and clean. NHS Greater Glasgow and Clyde must ensure that where audit data identifies deficiencies in the emergency department, remedial actions are taken to reduce risk, prevent recurrence, and promote improvement and compliance with infection prevention and control policies. NHS Greater Glasgow and Clyde must ensure that patient equipment cleaning schedules in the emergency department are accurately completed. NHS Greater Glasgow and Clyde must ensure that mattresses and mattress covers are consistently checked for their integrity and cleanliness, and actions are taken to ensure they are fit for purpose. Met Met Met Detailed findings from our inspection can be found on page 8. What action we expect NHS Greater Glasgow and Clyde to take after our inspection One requirement remains outstanding from the December 2016 and January 2017 inspections and will be carried forward. The requirement is linked to compliance with the Healthcare Improvement Scotland HAI standards (2015) (see Appendix 1 on page 18). An improvement action plan has been developed by the NHS board and is available on the Healthcare Improvement Scotland website www.healthcareimprovementscotland.org/hei.aspx. We 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 timeframe given in Appendix 1. We would like to thank NHS Greater Glasgow and Clyde and, in particular, all staff and patients at Queen Elizabeth University Hospital for their assistance during the inspection. 6
The flow chart in Appendix 2 summarises our inspection process. More information about the Healthcare Environment Inspectorate (HEI), our inspections, methodology and inspection tools can be found at www.healthcareimprovementscotland.org/hei.aspx 7
2 Progress since last inspection Standard 6: Infection prevention and control policies, procedures and guidance Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that staff in the immediate assessment unit are aware of, and practice, the safe management of blood and body fluid spillages in line with Health Protection Scotland s National Infection Prevention and Control Manual. We asked NHS Greater Glasgow and Clyde to action this requirement by early April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that infection control education sessions took place in March and May 2017 for nursing staff from the emergency department and the immediate assessment unit. This involved student nurses, healthcare assistants, staff nurses and charge nurses. The education sessions focused on the safe management of blood and body fluid spillages. Additional posters reinforcing the safe management of blood and body fluid spillages had been displayed throughout the immediate assessment unit. Senior charge nurses had been raising awareness with staff at daily handovers. During this follow-up inspection, all staff we had the opportunity to speak with in the immediate assessment unit had a good level of knowledge about how they would safely manage a blood and body fluid spillage. They told us they make up a solution of chlorinereleasing disinfectant and detergent each day for use when needed. We saw prepared bottles of solution in the sluice. The bottles were dated and situated next to a poster that was signed and dated to identify who had made up the solution and when. Similarly, staff we spoke with in the clinical decisions unit and emergency department also had a good knowledge of the management of blood and body fluid spillages. Guidance was displayed in all three areas describing the use of chlorine-releasing disinfectant and detergent for both general cleaning and for the management of blood and body fluid spillages. This requirement has been met. Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that all clinical waste is stored in line with Health Facilities Scotland s Scottish Health Technical Note 3 NHSScotland waste management guidance Part A (2015). We asked NHS Greater Glasgow and Clyde to action this requirement by early April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that facilities management staff started carrying out daily audits of all waste holding areas and equipment throughout Queen Elizabeth University Hospital in March 2017. They are 8
responsible for logging any issues found and following up on any necessary actions to be taken. During this follow-up inspection, we looked at 11 waste hold rooms across various wards and in the immediate assessment unit. Large, lockable waste hold bins are used to store clinical waste in these rooms whilst awaiting uplift by portering staff. One ward s waste hold room had a broken door lock. The senior change nurse told us this had been reported to the estates department. We saw evidence in the NHS board s waste hold audit data provided to us during the inspection that the ward with the broken waste hold door lock had also been identified through the audit system. We were told this has been reported to the estates helpdesk to be fixed. Of the other 10 waste hold rooms we looked at, nine were locked. All waste hold rooms have a keypad entry system to make sure waste is kept locked away from public access. Guidance posters about the safe disposal of waste were displayed on each waste hold room door. During the inspection, we were told that the frequency of the daily waste hold audits had been reduced to once a week. The facilities management team told us this was due to improvements being made and, as a result, they felt weekly audits would be sufficient at this point. This requirement has been met. Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure staff in the emergency department comply with hand hygiene and the use of personal protective equipment guidance in line with Health Protection Scotland s National Infection Prevention and Control Manual. We asked NHS Greater Glasgow and Clyde to action this requirement by early April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that infection control education sessions took place in March and May 2017. The education sessions covered hand hygiene and the use of personal protective equipment. Two unannounced hand hygiene audits took place in the emergency department and immediate assessment unit in March 2017. Results were shared with staff and any required remedial actions were taken and followed up. A hand hygiene education session was delivered at a junior doctors induction session in April 2017. This will now become a standard education session as part of the junior doctors induction programme. During our follow-up inspection, we were told that a similar education session planned for consultant staff in the emergency department in May 2017 had to be cancelled due to unforeseen circumstances. The 16-week improvement action plan states that specific education was being developed to address clinical situations in the emergency department. This has been included in the infection prevention and control team s work plan for 2017 2018. If successful, this will be further developed for other specialist areas and will be taken forward by the nurse consultant for infection prevention and control. Audits of standard infection control precautions will continue to be carried out, with support from the infection prevention and control team. The emergency department lead nurse and senior charge nurses have carried out unannounced 9
spot checks of compliance with hand hygiene and the use of personal protective equipment. The infection prevention and control team is carrying out unannounced inspections with any issues escalated to senior management. The general manager for emergency care issued an email in March 2017 to all departments clarifying roles and responsibilities and expectations for hand hygiene and the use of personal protective equipment from staff visiting the emergency department. During this follow-up inspection, hand hygiene practice is audited every month in the emergency department. Results for the last 3 months ranged from 85 94%. This is below NHS Greater Glasgow and Clyde s 95% compliance rate target. Staff were aware of hand hygiene audits taking place. They told us that any issues identified during the audits are rectified at the time and fed back to all staff during the daily safety brief. We were told that NHS Greater Glasgow and Clyde continues to raise awareness of the importance of hand hygiene through ward and department safety briefs and hospital huddles. We saw posters in the emergency department reinforcing the importance of hand hygiene, dress code, the use of personal protective equipment and cleaning patient equipment. We saw that the majority of staff in the emergency department were complying with the requirements for personal protective equipment. We saw that hand hygiene compliance was good with nursing and domestic staff. However, a number of medical staff did not take the opportunity to perform hand hygiene at the appropriate times. For example, we noted several occasions where medical staff did not remove gloves following contact with a patient and before starting another task. As a result, they were not performing hand hygiene. This requirement has been partially met. Although the NHS board had made progress towards compliance, we have modified the requirement to reflect our findings on this followup inspection. Requirement 1: NHS Greater Glasgow and Clyde must ensure medical staff in the emergency department remove and dispose of gloves at the point of use or at the earliest opportunity and perform hand hygiene in line with Health Protection Scotland s National Infection Prevention and Control Manual. We saw good compliance with hand hygiene and personal protective equipment by the majority of staff in the immediate assessment unit and clinical decisions unit. This included nursing, medical and domestic staff. Following the previous inspections in December 2016 and January 2017, we recommended that NHS Greater Glasgow and Clyde should: consider the timing of standard infection control precautions audits in the immediate assessment unit to ensure the results of audits are representative of staff practices during busy periods. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that a programme of audits of standard infection control precautions was carried out by the senior charge nurses in the unit with support from the infection prevention and control team. These were completed once a week at different days and times with audit scores ranging between 80 94%. Results were reviewed by the lead nurse to make sure all actions were addressed. Any non-compliances were raised with staff at the daily safety briefs. The infection 10
prevention and control team also carried out an audit in the unit in April 2017. Part of this audit looked at compliance with standard infection control precautions. This part of the audit scored 85% compliance. The lead nurse and medical lead carry out a daily walkround to observe staff practice, compliance with dress code and to review the general fabric of the unit. During this follow-up inspection, we saw evidence that recent audits of standard infection control precautions had been carried out at different times in the week to reflect staff practices during busy periods in the unit. Following the previous inspections in December 2016 and January 2017, we recommended that NHS Greater Glasgow and Clyde should: ensure that single patient use toiletries are only available for single patient use and are discarded when no longer required by the patient. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that a memo was issued to all lead nurses and senior charge nurses in March 2017. This reinforced that single patient use toiletries should only be used by one patient and then disposed of when no longer required to prevent the risk of cross-infection. Spot checks will take place and compliance will also be checked during audits carried out by the infection prevention and control team. During this follow-up inspection, we saw no evidence of reusable patient toiletries in the clinical decisions unit, emergency department or immediate assessment unit. Standard 8: Decontamination Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that patient equipment in the emergency department is clean and ready for use. We asked NHS Greater Glasgow and Clyde to action this requirement by early April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that the current standard operating procedure for cleaning patient equipment had been emphasised to staff. The chief nurse had also discussed the process and importance of cleaning patient equipment with lead nurses and senior charge nurses. Roles and responsibilities have been agreed to ensure accurate sign-off of cleaning schedules takes place. Lead nurses and senior charge nurses will carry out a series of regular spot checks of the cleanliness of patient equipment and will make sure actions are taken to address any areas of noncompliance. During this follow-up inspection, we looked at a variety of patient equipment in the clinical decisions unit, emergency department and immediate assessment unit. This included patient monitoring equipment, intravenous (IV) pumps, pendant lamps, patient transport chairs and trolleys, commodes, toilet grab rails, bed frames and bed rails, mattresses, procedure trolleys, patient chairs, patient tables and lockers, and blood gas analysers. With the exception of blood contamination on one patient transport chair in the emergency 11
department waiting room, we found that all equipment we looked at was clean and ready for use. This requirement has been met. Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that the environment in the emergency department is safe and clean. We asked NHS Greater Glasgow and Clyde to action this requirement by late April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that facilities management staff began carrying out weekly cleanliness environmental audits in the emergency department in March 2017. These include patient transport trolleys. Any noncompliances will be addressed. Daily visual inspections of the emergency department by facilities supervisors also started in March 2017 to validate these audits. The emergency department facilities supervisor meets with the nurse in charge every day to discuss environmental cleanliness needs ahead of the cleaning sign-off process. A representative from the facilities team attends the department s daily safety brief. A process for confirming that cubicles and equipment are clean and ready for use is being developed. During this follow-up inspection, we found the standard of environmental cleanliness in the emergency department was very good. Following our initial inspection in December 2016, domestic staff provision for the emergency department had been reviewed. This had resulted in an increase from one to two full-time staff covering Monday to Friday day shifts. All domestic and nursing staff spoke positively about this improvement. Domestic staff confirmed they are now able to access all patient areas to clean. We were told that the domestic supervisor carries out spot checks in the emergency department at least once a week. We found the standard of environmental cleanliness in the clinical decisions unit and immediate assessment unit was good. This included patient bed spaces and bays, public and patient toilets, corridors, sluices, store rooms and waste holds. This requirement has been met. Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that (a) accurate records are kept of domestic cleaning, and (b) staff are aware of their responsibilities for environmental cleanliness. We asked NHS Greater Glasgow and Clyde to action this requirement by early April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that retraining started in January 2017 for facilities management staff and domestic supervisors. This focused on roles and responsibilities, and the required outcomes and expectations, from Health Facilities Scotland s National Cleaning Services Specification (2009). This looked at ways to ensure domestic monitoring outcomes reflect the standard of cleanliness. 12
A further accredited cleanliness awareness and training programme had been rolled out to domestic supervisors and staff covering the practical aspects of cleaning and the required quality outputs. A series of rapid improvement events started in February 2017 focusing on improving communication between facilities and clinical staff. This included producing a standard operating procedure clarifying when and how domestic staff would have access to clean patient bays. Facilities management staff hold a weekly HAI action plan review meeting to review and assess any actions required. A review of domestic services staff took place to make sure that domestic staff are available at all times to maintain the standard of cleanliness and to respond to any requests for additional cleaning. This review included the role and function of the domestic response team. During this follow-up inspection, domestic staff we spoke with explained the system for signing off domestic cleaning schedules. Once they have signed this off at the end of their shift, the domestic supervisor signs off the cleaning schedule with the nurse in charge on that shift. We saw evidence of this. We also saw evidence of the recording of any cleaning tasks that could not be completed to ensure handover to the next shift. Staff explained any tasks documented would be prioritised by the domestic on the next shift. Domestic staff told us that the system for recording domestic duties worked well. Nursing staff and the domestic supervisor also described the same system of working between the day shifts, back shifts and night shifts and for signing off domestic cleaning. We saw that the senior charge nurse signs the domestic cleaning schedule to provide assurance that cleaning has taken place. All staff spoke positively about the changes made to the domestic service provision and were now happy with the standard of domestic cleaning in their departments. Domestic staff told us they felt supported to perform their role and had sufficient equipment to do this. This requirement has been met. Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that (a) domestic monitoring assurance systems identify where environmental cleanliness in the emergency department is below the accepted standard, and (b) remedial actions are taken to ensure the environment is safe and clean. We asked NHS Greater Glasgow and Clyde to action this requirement by late April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that a standard operating procedure had been produced clarifying when and how domestic staff would have access to clean patient bays. The action plan states that any requests for cleaning in the ground floor areas of the hospital should take place within 2 hours. During this follow-up inspection, we saw evidence of regular facilities management tool audits carried out to identify issues with domestic cleaning in the emergency department. We saw that results from domestic monitoring in the department from May 2017 ranged from 89 97%. We believe this positive approach provides a realistic picture of domestic monitoring in this busy department. 13
We saw evidence that the department s own recent audit of standard infection control precautions scored 33% for the control of the environment (cleanliness). Where remedial actions were necessary, we saw the corresponding action plans. Senior managers told us this audit has been designed to identify different elements from the facilities management tool audits to prevent duplication of work. We saw some damage to the fabric of the department such as damage to walls, doors and cupboard doors. This had been identified in the department s standard infection control precautions audit. The lead nurse told us these issues had been reported to the estates department and work to repair the damage had started. We are encouraged by the transparent reporting of lower compliance rates when applicable, as this will allow actions to be taken and improvements put in place when necessary. This requirement has been met. Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that where audit data identifies deficiencies in the emergency department, remedial actions are taken to reduce risk, prevent recurrence, and promote improvement and compliance with infection prevention and control policies. We asked NHS Greater Glasgow and Clyde to action this requirement by early April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that a programme of audits of standard infection control precautions was carried out in the emergency department in March 2017 by the senior charge nurses with support from the infection prevention and control team. These were completed once a week at different days and times to reflect periods of increased activity. Audit scores ranged between 80 94%. Results were reviewed by the emergency department lead nurse to make sure all actions were addressed. Any non-compliances were raised with staff at the daily safety brief. Audits of standard infection control precautions, spot checks and walkrounds will continue to be carried out, with support from the infection prevention and control team. A series of educational events focusing on specific aspects of standard infection control precautions had been carried out. During this follow-up inspection, we saw evidence of audits of standard infection control precautions, hand hygiene audits, audits carried out by the infection prevention and control team and infection control weekly walkrounds. We also saw evidence of corresponding action plans. Staff we spoke with told us they are aware of these audits, and results are fed back to them during the department s daily safety brief. We saw that audit results are displayed on a noticeboard in the emergency department. In the clinical decisions unit and immediate assessment unit, we saw evidence of audits of standard infection control precautions with remedial actions recorded. In the immediate assessment unit, staff had been carrying out additional audits of standard infection control precautions. The senior charge nurse told us this was to further raise awareness and improve practice in the area. We noted the most recent audits carried out by the infection prevention and control team had identified issues and actions were put in place. Senior 14
charge nurses and staff spoke positively about the audit systems and the changes made in both units since our previous inspection. This requirement has been met. Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that patient equipment cleaning schedules in the emergency department are accurately completed. We asked NHS Greater Glasgow and Clyde to action this requirement by early April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that the chief nurse had discussed the process and importance of cleaning patient equipment with lead nurses and senior charge nurses. Roles and responsibilities have been agreed to ensure accurate sign-off of cleaning schedules takes place. Lead nurses and senior charge nurses will carry out a series of regular spot checks of the cleanliness of patient equipment and will make sure actions are taken to address any areas of non-compliance. On our previous inspection, we found that the majority of patient equipment cleaning schedules were signed and completed in the emergency department. However, we had found a variety of contaminated patient equipment. During this follow-up inspection, we were told that each cubicle or bed space is cleaned after a patient is transferred or discharged from the emergency department. Daily bed space cleaning checklists and weekly deep clean checklists are used to record cleaning carried out by nursing staff. This includes patient equipment and bays. We saw that the daily checklists were completed. However, we found that staff were not consistently completing the weekly deep clean checklists for the cleaning they had carried out. Although we found that the equipment in the department was clean, we highlighted this to the senior charge nurse. Weekly assurance checks of the cleanliness of patient equipment are carried out by the senior charge nurses. As these checklists are part of the NHS board s assurance system to make sure cleaning is carried out, it should ensure that staff complete all relevant documentation following cleaning being carried out. This requirement has been met. Following the previous inspections in December 2016 and January 2017, NHS Greater Glasgow and Clyde was required to: ensure that mattresses and mattress covers are consistently checked for their integrity and cleanliness, and actions are taken to ensure they are fit for purpose. We asked NHS Greater Glasgow and Clyde to action this requirement by early April 2017. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that a process for checking mattresses on a daily basis had been developed and incorporated into 15
the bed space cleaning checklist. Mattresses are checked for integrity and cleanliness. This includes trolley mattresses in the emergency department. The checklist states that any contaminated mattresses are removed from use and the senior charge nurse is informed. During this follow-up inspection, we found that all mattresses and mattress covers we looked at in the clinical decisions unit, emergency department and immediate assessment unit, and on patient trolleys we saw in corridors, were clean and fit for purpose. In the emergency department, we saw a staff member identify a small hole in a mattress cover while cleaning a patient trolley. We saw that the mattress was immediately replaced. Staff in the immediate assessment unit told us that they check patient trolleys are clean when they are brought in from the corridor for use in the department. If any contamination is found, the trolley is cleaned before use. We were told all beds are checked during the discharge clean. This requirement has been met. Following the previous inspections in December 2016 and January 2017, we recommended that NHS Greater Glasgow and Clyde should: review domestic staff access to patient areas in the emergency department allowing them to deliver a safe and clean environment. NHS Greater Glasgow and Clyde told us in its 16-week improvement action plan that a series of rapid improvement events started in February 2017 focusing on improving communication between facilities and clinical staff. This included producing a standard operating procedure clarifying when and how domestic staff will have access to clean patient areas. During this follow-up inspection, we did not identify any issues with domestic staff having difficulties in accessing patient areas in the emergency department to clean effectively. Domestic staff we spoke with confirmed they are able to access patient areas in the emergency department to carry out necessary cleaning. We were told that systems are in place to ensure different areas in the department are kept free to allow domestic access. This ensures all areas are regularly cleaned. Similarly, we found no issues with domestic staff having difficulties in accessing patient areas to clean in the immediate assessment unit or clinical decisions unit. All domestic staff we spoke with described positive working relationships with department staff and that they felt included and worked well as a team. They told us that nursing staff also keep them informed of infection control issues to allow them to plan their workload to make sure all areas can be cleaned. Additional comments During our initial inspection in December 2016, we identified issues with the standard of cleanliness of public toilets in the emergency department, main hospital atrium and mezzanine level 1, and at the entrances to wards and departments. We also found issues with the standard of cleanliness in baby changing facilities. 16
During this follow-up inspection, we looked at public toilets in the emergency department, main hospital atrium and mezzanine level 1. We found that the majority of toilets were clean. We also found that the baby changing facilities were clean. We brought any exceptions we found to the attention of senior management at the time of the inspection. 17
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 Requirement carried forward from December 2016 and January 2017 inspections Requirement 1 NHS Greater Glasgow and Clyde must ensure medical staff in the emergency department remove and dispose of gloves at the point of use or at the earliest opportunity and perform hand hygiene in line with Health Protection Scotland s National Infection Prevention and Control Manual (see page 10). HAI standard criterion Priority 6.11 1 18
Appendix 2 Inspection process flow chart We follow a number of stages in our inspection process. More information about the Healthcare Environment Inspectorate, our inspections, methodology and inspection tools can be found at www.healthcareimprovementscotland.org/hei.aspx 19
Healthcare Improvement Scotland is committed to equality. We have assessed the inspection function for likely impact on the equality protected characteristics in line with the Equality Act 2010. Please contact the Healthcare Improvement Scotland Equality and Diversity Advisor on 0141 225 6999 or email contactpublicinvolvement.his@nhs.net to request a copy of: the equality impact assessment report, or this inspection report in other languages or formats. www.healthcareimprovementscotland.org Edinburgh Office Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone 0131 623 4300 Glasgow Office Delta House 50 West Nile Street Glasgow G1 2NP Telephone 0141 225 6999 The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland.