Summary of Objective Key Elements of Programme Strategic Cleanliness Improvement Plan: Summary 1. Board Assurance on Cleanliness Strengthen information in Board Report on cleanliness Board assurance and approval of HDUHB Environmental Cleanliness Strategy 2. Compliance with National Standards of Cleaning for Conduct Gap Analysis Wales Complete actions identified in the gap analysis Monthly monitoring report to demonstrate performance & trends Put in place resource to ensure cleaning standards meet specification 3. Effective Governance Framework Formalise reporting and escalation processes from Ward to Board in relation to cleanliness, via Local & Strategic Groups 4. Effective communication mechanisms between Hard & Soft Facilities Management and Ward sisters Hospital Cleaning Groups. Dedicated representatives from each Hospital to be identified as the focal point for communication Develop Cleanliness Champions on each ward & department Nurses are the guardians of cleanliness standards at clinical level 5. Leadership and Personal Responsibility for Ensure all staff are aware of their personal responsibilities for cleanliness Cleanliness is understood Generic statement in relation to cleanliness to be included in all Health Board Job Descriptions 6. Standardising Responsibilities for Cleaning Review cleaning responsibilities framework document presently in place for nursing and domestic staff 7. Robust Cleanliness Monitoring Systems (Credits 4 Cleaning) Robust auditing process to be put in place to include routine participation by Nursing, Domestic, Estates and Infection Prevention Team. Ensure closure of all actions from audits, particularly estates issues 8. Programme of Validation Audits to be set up Implement a process to verify supervisor audit results on each site using a dedicated audit team. 9. Deep Cleaning Programme Ensure this is taking place on all sites and monitor outcomes 10. Standardising infection-cleans Robustly implemented tiered system of enhanced cleaning when there have been cases of identified infection 11. Standardise cleaning products across all sites Complete work to standardise cleaning products on all sites 12. Cleanliness of Ward Kitchens Implement a programme of kitchen-specific monitoring visits Ensure compliance with Food Safety Act reference cleaning responsibilities 13. Refurbishment/Redecoration Programme Ensure refurbishment/redecoration programmes are in place as required across all sites 14. Staff Training and Competence Training for domestic staff, to NVQ standards Training for clinical staff in cleaning as part of statutory and mandatory training Strategic Cleanliness Improvement Plan RAG status code: Green = on target, Amber = delay but progress being made, Red = progress not being made, Blue = action completed and item to be hidden in next update to plan. Outcome Required Action Measure of Progress Status Progress to Date 1. Board Assurance on cleanliness: The Health Board will put into place an Environmental Cleanliness Strategy and framework to provide assurance to the Board on standards of cleanliness as required in the National Standards of Cleaning for Wales Environmental Cleanliness Strategy to be approved by Infection Prevention & Control committee (IPCC) reporting to Quality and safety commitee. IP&C Team to conduct environmental audits. Annual environmental audits n by Infection Control/ & Estates. Estates & will action findings of Infection Control Audits where possible currently C4C audits Development of Risk Register of non-compliances. Hotel Facilities to C4C audits in accordance with National Standards of Cleanliness. Annual environmental audits n by Infection Control/ & Estates. Estates & will action findings of Infection Control are currently Green Green Green Green Infection control audits on a quarterly-annually Infection control audits on a quarterlyannually Infection control audits on a quarterlyannually 1
2. National Standards Compliance with National Standards of Cleaning for Wales (2009) for all categories. 3. Effective Governance Framework: In addition to regular reporting to the IPCC, cleanliness will feature in Directorate Quality & Safety governance reports. 4. Effective Communication Mechanisms between Facilities and Ward sisters: On each site there will be a recognised group for communication between Cleaning Services and Clinical Leaders?? Regular assurance to be provided to the Board on environmental cleanliness National Standards for Cleaning (2009) document, has been reviewed and actions Remaining issues in gap analysis to be completed. Review of Ward to Board reporting and escalation processes in relation to environmental cleanliness. Identify the forums to be used for this purpose on each site, agenda the issue routinely and ensure attendance by nominated members or deputies. undertaking manual audits in line with the monthly target determined.. Revised Supervisor structure will address this issue monthly and issues involving cleanliness are discussed, minuted and forwarded to the relevant directorate head. Supervisors visit all ward areas on a daily Infection control discusses ward audit results and cleanliness on a quarterly basis whereby ward sisters and managers are present to discuss the on-going issues. Revised Supervisor structure will address this issue monthly and issues involving cleanliness are discussed, minuted and forwarded to the relevant directorate head. Ward communication visits n by Hotel Facilities Supervisor. IP &C Environmental IP & C scrutiny Revised Supervisor structure will address this issue monthly and any issues involving cleanliness are discussed, minuted and forwarded to the relevant directorate head. Supervisors visit all ward areas on a daily Infection control discuss ward audit results and cleanliness on a quarterly basis whereby ward sisters and managers are present to discuss on-going issues. Green Green Green Amber IT/Software upgrade agreed. Green Green Green Green Local IPC meeting established along with scrutiny Green Green Green Green Supervisors/Manager s to join group, next meeting to be held in mid October 2015. Ward Staff & Supervisors need to work closer together. Glangwili do weekly/monthly C4C audits. IT/Software upgrade agreed. Local IPC meeting established along with scrutiny Supervisors visit wards/depts. daily. IP&C audits n annually with Hard and Soft FM managers in attendance. IT/Software upgrade agreed. Local IPC meeting established along with scrutiny Supervisors/Manag ers to join group, next meeting to be held in mid October 2015. 5. Leadership and Personal Responsibility for Cleanliness Ward Sisters will continue to be actively engaged in leadership of the cleanliness agenda at clinical level in their own areas of responsibility, and all staff disciplines will understand their personal responsibility to keep areas clean and free of clutter. Identify key members of clinical/ward teams to promote the cleanliness agenda Ensure all staff are aware of their personal responsibilities for cleanliness Generic statement in relation to cleanliness to be included in all Health Board Job Regarding statement placed in post holder s job description. All job descriptions to be updated: Hotel Facilities Assistant Hotel Facilities Supervisor Hard/Soft FM Managers Nurses Junior/Senior Sisters Regarding statement placed in post holder s job description. Green Green Green Green. IP&C scrutiny attended by Hard & Soft FM managers. Included in new JD for supervisors Included in new JD for supervisors 2
6. Standardising Responsibilities for Cleaning: Cleaning responsibilities will be standardised across all sites in the Health Board and all staff will be aware of their responsibilities, to ensure all items are cleaned to a high standard. 7. Robust monitoring systems Environmental Credit 4 Cleaning Audits: The Health Board will have in place a robust system for monitoring standards of cleanliness, which ensures action is taken on issues identified, accurately reflects standards achieved and provides assurance to the Health Board. 8. Validation Audit Programme: Implement a process to verify internal audit results on each site Descriptions Cleaning Schedules to be checked and reissued/reviewed as required in all acute & community sites. Cleanliness Responsibilities Framework to be renewed and adopted by all Health Board staff. Put into place a robust mechanism to ensure Credits 4 cleaning monitoring to a performed consistent standard across HDUHB Clear defined responsibilities for Nursing & Cleaning Staff Work to drive up standards will continue via this action plan. This will include a programme of external audits to quantify internal audit reporting Senior Nurse Managers Standard cleaning specification for all areas. Regarding - cleaning schedules currently in place however will need to be reviewed. Communication sheets currently filled daily and returned to Hotel Service s office on a weekly Additionally fridge temp forms; tea trolley forms; legionella forms completed for all areas. Roles and responsibilities defined. Targets VHR (weekly) = 98% HR (monthly) = 95% Sig (quarterly) = 85% Low (6 monthly) = 75% Senior Nurse Managers with Hard and Soft FM Managers: audits to take place Regarding cleaning schedules currently in place, however, will need to be reviewed. Communication sheets currently filled daily and returned to Hotel Service s office on a weekly Additionally fridge temp forms, tea trolley forms, legionella forms completed for all areas. Audits are n by officers outside the Ceredigion division, i e Infection Control, HIW, CHC. To be reviewed and updated following installation of new software To be reviewed and updated following installation of new software To be reviewed and updated following installation of new software Green Green Green Green Manually monthly n in BGH Green Green Green Gr een No validation audits n. Programme to be developed. 9. Deep Cleaning Programme: To be implemented on all Health Board sites. Methodology of Deep Cleaning to be agreed for acute & community sites. Process for monitoring progress of deepcleaning to be put into place. A rapid response team in place to clean areas as and when required and each bed space is clean on patient discharge. A deep clean is n on the request of the infection control/management team. A systematic programme to deep clean all in patient areas A rapid response team in place to clean areas as and when required and each bed space is cleaned on patient discharge. A deep clean is n on the request of the infection control/management team. Green Green Green Green A prioritised deep cleaning programme has been agreed by the county IP&C group. This is presently being auctioned. 10. Standardising Infectioncleans: The Health Board will standardise terminology and methods for different Work in progress to be completed and agreed. Then to be This needs to be agreed Health Board wide. Consistent approach throughout HB to cleaning products, applications and techniques. This needs to be agreed on Health Board wide. Board to advise. Glangwili to work in line with Infection Control guidelines; Task & Finish Group established. Presently Board to advise 3
categories of cleans required, to ensure post-infection cleaning is completed effectively to remove pathogenic bacteria incorporated into policy and protocols and communicated widely to nursing, domestic and infection prevention staff have asked for list to be updated. IPC Team developing protocol through Task and Finish Groups reviewing and considering techniques deployed across the HB. 11. Standardising Cleaning Products Across All Sites: A set of standardised cleaning products to be agreed and used in all locations. Welsh Health Supplies to stock all items as catalogue products 12. Cleanliness of Ward Kitchens: The Health Board will put into place a specific programme to ensure ward kitchens are consistently clean and in good condition in compliance with the Food Safety Act (1990). Complete work to standardise cleaning products. Internal Audit programme to be agreed and Local EHO s inspect as part of there annual audit programme chemicals are purchased on a contract from Bridgend stores; however other items are purchased from other suppliers, i e Newhall/Arrow/Ecolab. Catering lead has been asked to audits of process and conditions of areas. Consistent approach throughout HB to cleaning products, applications and techniques. Ward kitchen audit n as part of C4C audit process. Hotel Facilities Supervisors to spot checks to ensure compliance with HACCP requirements. chemicals are purchased on a contract from Bridgend stores; however other items are purchased from other suppliers, i e Newhall/Arrow/Ecolab. Catering lead has been asked to audits of process and conditions of areas.. A cleaning strategy group has been set up to look at standardising products & cleaning methods. Green Green Green Green Additional Housekeepers have been employed on 3 areas to beverage/cleaning on ward areas. Kitchen are part of C4C. Task & Finish Group established. Presently reviewing and considering techniques deployed across the HB Kitchen audited as part of C4C audits. Daily checks by Hotel Facilities Supervisors. A cleaning strategy group has been set up to look at standardising products & cleaning methods. Additionally Housekeepers have been employed on 3 areas to beverage/cleaning on ward. 13. Refurbishment/Redecoration Programme: The Health Board will ensure that a programme of refurbishment and redecoration takes place across each site. Programme for refurbishment, and release of clinical areas to facilitate this agreed. Estates to advise in conjunction with nursing team. Identified on Capital Programme/ward upgrades Forms an integral part of the deep cleaning programme. Estates to advise in conjunction with nursing team. HB wide Ward kitchen refurb programme being developed No access available and/or no decant space Capital Programme has been developed with prioritise ward refurbishments. 14. Staff Training and Competence: All staff that perform cleaning will be trained and competent to perform their role. Training programme for domestic staff to be reviewed, aiming to achieve NVQ-standard training for all staff. staff on commencement a rigid training programme in line with departmental cleaning manual. Staff who have been in post for longer than 5 years need to be retrained. Detailed workplace induction on commencement. Additional training/re-training identified through the PADR process. BISCs COPC/NVQ staff on commencement a rigid training programme in line with departmental cleaning manual. Staff who have been in post for longer than 5 years need to be retrained. HB wide training programme being planned when new supervisors structure is in place April 16 All staff n departmental training. PADR system in place. Approx 32% compliant. Training programme for clinical staff to be 80% of staff have n NVQ hospitality. 80% of staff have n NVQ hospitality. 4
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