Unannounced Inspection Report Aberdeen Maternity Hospital NHS Grampian 9 October 2013 The Healthcare Environment Inspectorate is a part of Healthcare Improvement Scotland
Healthcare Improvement Scotland is committed to equality. We have assessed the inspection function for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Officer on 0141 225 6999 or email contactpublicinvolvement.his@nhs.net Healthcare Improvement Scotland 2013 First published December 2013 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. www.healthcareimprovementscotland.org 2
Contents 1 Background 4 2 Summary of inspection 6 3 Key findings 8 Appendix 1 Requirements and recommendations 12 Appendix 2 Inspection process 13 Appendix 3 Inspection process flow chart 15 Appendix 4 Details of inspection 16 Appendix 5 Glossary of abbreviations 17 3
1 Background The Healthcare Environment Inspectorate (HEI) was established in April 2009 to undertake inspections of all acute hospitals across NHSScotland. In addition to the acute hospitals, the NHS National Waiting Times Centre (Golden Jubilee National Hospital, Clydebank), the Scottish Ambulance Service and the State Hospitals Board for Scotland (State Hospital, Carstairs) will also be inspected. Our focus is to improve the standards of care for patients through a rigorous inspection framework. Specifically we will focus on: providing public assurance and protection, to restore public trust and confidence ensuring care is delivered in an environment which is safe and clean, and contributing to the broader quality improvement agenda across NHSScotland. In keeping with our philosophy, we will use an open and transparent method for inspecting hospitals, using published processes and documentation. Our philosophy We will: work to ensure that patients are at the heart of everything we do measure things that are important to patients be firm, but fair have members of the public on our inspection teams ensure our staff are trained properly tell people what we are doing and explain why we are doing it treat everyone fairly and equally, respecting their rights take action when there are serious risks to people using the hospitals we inspect if necessary, inspect hospitals again after we have reported the findings check to make sure our work is making hospitals cleaner and safer publish reports on our inspection findings which are available to the public in a range of formats on request, and listen to the concerns of patients and the public and use them to inform our inspections. We will not: assess the fitness to practise or performance of staff investigate complaints, and investigate the cause of outbreaks of infection. More information about our inspection process can be found in Appendix 2. 4
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 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: hcis.chiefinspector@nhs.net 5
2 Summary of inspection Aberdeen Maternity Hospital provides a consultant-led obstetric service, supported by a midwife-led unit. The hospital serves the region of Grampian, the islands of Shetland and Orkney, and also cares for babies requiring neonatal surgery transferred from the Highlands. It contains 133 staffed beds and deals with approximately 5,500 6,000 births each year. We previously inspected Aberdeen Maternity Hospital on three occasions in August and September 2013. That inspection resulted in seven requirements and six recommendations. The inspection report is available on the Healthcare Improvement Scotland website: http://www.healthcareimprovementscotland.org/hei.aspx. We carried out an unannounced inspection to Aberdeen Maternity Hospital on Wednesday 9 October 2013. This was to follow up on the cleanliness issues identified at the previous inspections. We assessed the hospital against the NHS Quality Improvement Scotland (NHS QIS) healthcare associated infection (HAI) standards and inspected the following areas: labour ward neonatal unit Summerfield ward, and Westburn ward. 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 were in agreement about the findings reached. Membership of the inspection team visiting Aberdeen Maternity Hospital can be found in Appendix 4. During our inspection, we handed out patient questionnaires. We received completed questionnaires from 24 patients. We also spoke with three patients and one visitor. Overall, we found evidence of improvement, in particular: the cleanliness of the ward environment and patient equipment has improved the introduction of the back to the floor initiative which involves a senior manager being on the wards for four hours once a week to review what is happening on the ward the review of the roles and responsibilities of senior nurses and midwives, and the work carried out to review the types of beds in use, in terms of function and ease of cleaning. However, we did find that further improvement is required in the following areas. Wheelchairs should be included in the ward cleaning schedules and kept in a clean condition ready for patient use. Cleaning frequencies in the neonatal intensive care unit should meet the minimum frequency requirements. 6
What action we expect NHS boards to take after our inspection This inspection resulted in one requirement and one recommendation. The requirement is linked to compliance with the NHS QIS HAI standards. A full list showing the requirement and recommendation can be found in Appendix 1. NHS Grampian must address the requirements and the necessary improvements made, as a matter of priority. An action plan for areas of improvement has been developed by the NHS board and is available to view on the Healthcare Improvement Scotland website http://www.healthcareimprovementscotland.org/hei.aspx. We would like to thank NHS Grampian and in particular all staff at Aberdeen Maternity Hospital for their assistance during the inspection. 7
3 Key findings 3.1 Governance and compliance Cleaning We previously inspected Aberdeen Maternity Hospital on three occasions in August and September 2013. During those inspections, we identified a number of serious concerns with the cleanliness of patient equipment. We carried out this inspection to follow up on those cleanliness issues. We visited four ward areas and spoke with a variety of staff groups. We looked at a range of patient equipment including patient beds, stands, monitors, chairs and locker fixtures and fittings. The wards inspected were found to be clean with only a few exceptions. Any areas of concern were brought to the attention of the nurse in charge. Staff spoken with confirmed that there had been an increased focus on cleaning patient equipment since our last inspections. Staff could also explain which types of chemicals were to be used for general cleaning and which were to be used for the cleaning of blood and bodily fluids. Staff were able to refer to guidance on chemical usage which was displayed in the sluice rooms. In the labour ward, a comprehensive cleaning checklist has been introduced. In addition to the cleaning checklist, guidance is also available on how blood spillages should be managed and the decontamination of patient equipment. The checklist also includes a procedure for the checking of the mattresses and mattress covers. We saw that additional covers had been introduced to the beds used in the labour ward to protect them from potential contamination. All the areas inspected, including the beds, were found to be clean. On Summerfield ward, we were told that a number of beds had been identified as being difficult to clean. These beds have since been replaced. On this ward, we found that the majority of patient equipment was clean, apart from wheelchairs which were stored in the patient sitting room. It was not clear how often the wheelchairs should be cleaned and who had responsibility for cleaning this equipment. Recommendation a: NHS Grampian should ensure that the wheelchairs in all wards are included in the ward cleaning schedules and are maintained in a clean condition ready for use by patients. In the neonatal unit, we found that the standard of cleanliness had significantly improved since the previous inspections. We looked at a variety of patient equipment including incubators, drip stands and monitors. All were found to be clean with a few minor exceptions. During the inspection, we spoke with members of domestic staff in all wards. Staff could clearly explain their roles and responsibilities in cleaning patient equipment and which chemicals should be used. We were told that domestic staff do not record the cleaning tasks which are carried out on a daily basis. However, domestic staff follow guidance on daily checks and record if there are any tasks which have not been completed. These tasks are then handed over to the next member of domestic staff on the later shift. There was no evidence to demonstrate that tasks, which have not been completed, are communicated to the nurse in charge of the ward during this handover. 8
In one ward, we spoke with a member of domestic staff about the cleaning of isolation rooms. We were told that actichlor solution would be used to clean this type of area. Yellow coloured patient protective equipment, such as aprons, and yellow coloured cloths would also be used in this instance. We observed a member of domestic staff disposing of used yellow cloths in a waste bag located on the domestic trolley. We spoke with the domestic services manager who confirmed that used yellow cloths should be disposed of in individual clinical waste bags and disposed of in the sluice to reduce the risk of cross contamination. During the inspection, we met with senior managers to discuss the actions taken for the cleaning of patient equipment and the environment. We were told that the cleaning of patient beds in the labour ward has been reviewed and discussions have been held with the bed manufacturers. The labour ward beds have a number of moving parts and sections which can be removed. We were told that NHS Grampian is currently reviewing the types of beds in use, both in terms of functionality and the ease by which they can be cleaned. The NHS board has established a multidisciplinary short-life working group to discuss the cleaning of patient beds in the labour ward. Following discussions, additional coverings have been introduced to prevent contamination of areas of the beds which are difficult to clean. Members of the infection control team will also be providing additional training to staff involved in the cleaning of patient beds. We were told that NHS Grampian has been in contact with other NHS boards to discuss the difficulties in cleaning the labour ward beds and neonatal unit cots and incubators. This is to determine if there is any additional learning from their experiences. During the previous inspection, we noted that a number of senior nurses worked in the neonatal unit. Since this inspection, a review of the roles and responsibilities of the senior nurses has been carried out. We were told that one senior nurse has been given the lead for infection prevention and control in the neonatal unit, which includes education. We were told that a mattress audit was carried out for all beds within the hospital in September 2013. During this inspection, all mattresses inspected were found to be clean and ready for use. During discussions with ward-based staff, some concerns were raised about the amount of time available to clean patient equipment. The head of midwifery advised us that this has been reviewed and that the roles and responsibilities of nursing assistants are being reviewed following the increased number of cleaning tasks. We were also told that the hospital is considering the introduction of a housekeeper to focus on the cleanliness of the ward environments. As part of looking at the roles and responsibilities of staff, a letter is also being sent to all senior nurses and senior midwives to reinforce and clarify their role and responsibilities. NHS Grampian brought forward the introduction of the back to the floor initiative as a result of our previous inspections. This involves a senior manager, such as the unit operational manager, divisional lead nurse or divisional clinical director being on the wards for 4 hours once a week to review what is happening on the ward. The NHS Scotland National Cleaning Services Specification (2009) states that neonatal intensive care beds are classified as very high risk areas. These areas require daily cleaning of high level areas, such as ledges. The specification states that high dependency beds are classified as high risk areas. These areas require weekly cleaning of high level areas. The 9
neonatal unit at Aberdeen Maternity Hospital comprises of intensive care, high dependency, special care and parent and baby rooms which means they have different cleaning frequencies for different parts of the unit. One room is classified as intensive care and the other four are high dependency care. We spoke with the domestic services manager and a member of domestic staff to discuss the cleaning frequency in the neonatal unit. We were told that a decision has been made to complete high level dusting twice a week in all areas of the neonatal unit. This frequency does not meet the national requirements for cleaning of the neonatal intensive care unit but is compliant with the national requirements for cleaning of the neonatal high dependency unit. At the time of the inspection, high level surfaces were free from dust. Requirement 1: NHS Grampian must ensure that the cleaning frequencies in the neonatal intensive care unit meet the minimum frequencies set out in the NHSScotland National Cleaning Services Specification (2009). During the inspection, we asked patients to complete patient questionnaires. Patients were complimentary about the care and treatment they had received at Aberdeen Maternity Hospital. Of the 24 patients who responded to our survey: 83% stated that their ward was always or mostly clean, and 92% stated that equipment used for care was always or mostly clean and in good repair. Some quotes from the patient questionnaires included: staff are always demonstrating great cleaning feel adequate with the cleanliness of the room... there are plenty of sinks/wash basins toilets need more frequent cleaning, especially postnatal wards been in [the ward for] 3 days... floor mopped once... the mop looked very dirty and [the floor was] never swept first. Risk assessment and patient management Although this was not the focus of the inspection, we saw that fridges used for the storage of expressed breast milk were not operating within the correct temperature limits. The NHS Grampian policy for the storage and handling of expressed breast milk states that the critical temperature range, under refrigeration, is 2 4 C. During the inspection, we looked at the refrigerator temperature recordings in the neonatal unit (special care A and B) and the high dependency unit and noted the following. In special care A, we saw that the refrigerator had not achieved the critical temperature limit on 1, 5 and 6 October. There was no temperature recording carried out on 7 October. The refrigerator was removed from use, for defrosting, on 9 October. In special care B, we saw that the refrigerator temperatures recorded between 4 8 October showed that the temperature was outwith the critical temperature range of 2 4 C. The refrigerator was removed from use, for defrosting, on 9 October. In the high dependency unit, we saw that the operating temperature of the refrigerator was 5 C. We discussed this with a staff nurse who advised that the expressed breast milk had been moved to another refrigerator located in the intensive care unit. 10
Overall, we found that corrective action taken was not always recorded on the temperature record sheet when the refrigerators were operating outwith the critical temperature limits. Following the previous inspection, NHS Grampian was required to demonstrate that expressed breast milk is stored appropriately and that documentation reflects best practice. NHS Grampian is still progressing remedial action as part of its improvement action plan. 11
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 are 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 implemented. 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 have been priority rated (see table below). Compliance is expected within the highlighted timescale. Priority MINOR LOW MEDIUM HIGH Timescale 9 months 6 months 3 months 1 month Governance and compliance Requirement NHS Grampian must: 1 ensure that the cleaning frequencies in the neonatal intensive care unit meet the minimum frequencies set out in the NHSScotland National Cleaning Services Specification (2009) (see page 10). HAI standard criterion Priority Timescale 4a.2 HIGH 1 MONTH Recommendation NHS Grampian should: a ensure that the wheelchairs in all wards are included in the ward cleaning schedules and are maintained in a clean condition ready for use by patients (see page 8). 12
Appendix 2 Inspection process Inspection is a process which starts with local self-assessment, includes at least one inspection to a hospital and ends with the publication of the inspection report and improvement action plan. First, each NHS board assesses its own performance against the Standards for Healthcare Associated Infection (HAI), published by NHS Quality Improvement Scotland (NHS QIS) in March 2008, by completing an online self-assessment and providing supporting evidence. The self-assessment focuses on three key areas: governance/compliance communication/public involvement, and education and development. We assess performance both by considering the self-assessment data and inspecting acute hospitals within the NHS board area to validate this information and discuss related issues. We use audit tools to assist in the assessment of the physical environment and practices by noting compliance against a further nine areas: environment and facilities handling and disposal of linen departmental waste handling and disposal safe handling and disposal of sharps patient equipment hand hygiene ward/department kitchen clinical practice, and antimicrobial prescribing. The complete inspection process is described in the flow chart in Appendix 3. Types of inspections Inspections may be announced or unannounced and will involve the physical inspection of the clinical areas, interviews with staff and patients on the wards, interviews with key staff and a discussion session with senior members of staff from the NHS board and hospital. We will publish a written report 8 weeks after the inspection. Announced inspection: the NHS board and hospital will be given at least 4 weeks notice of the inspection by letter or email. Unannounced inspection: the NHS board and hospital will not be given any advance warning of the inspection. 13
Follow-up activity The inspection team will follow up on the progress made by the NHS board in relation to their improvement action plan. This will take place no later than 16 weeks after the inspection. The exact timing will depend on the severity of the issues highlighted by the inspection and the impact on patient care. The follow-up activity will be determined by the risk presented and may involve one or more of the following: an announced or unannounced inspection a targeted announced or unannounced inspection looking at specific areas of concern an on-site meeting a meeting by video conference a written submission by the NHS board on progress with supporting documented evidence, or another intervention deemed appropriate by the inspection team based on the findings of an inspection. Depending on the format and findings of the follow-up activity, we may publish a written report. More information about the HEI, our inspections, methodology and inspection tools can be found at http://www.healthcareimprovementscotland.org/hei.aspx. 14
Appendix 3 Inspection process flow chart How we inspect hospitals and services: We follow a number of stages in our inspection process. 15
Appendix 4 Details of inspection The unannounced inspection to Aberdeen Maternity Hospital, NHS Grampian was conducted on Wednesday 9 October 2013. The inspection team was made up of the following members: Alastair McGown Senior Inspector Allison Wilson Inspector Supported by: Jill Sands Project Officer 16
Appendix 5 Glossary of abbreviations Abbreviation HAI HEI NHS QIS healthcare associated infection Healthcare Environment Inspectorate NHS Quality Improvement Scotland 17
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