ENVIRONMENTAL CLEANLINESS ANNUAL REPORT 2008/09 Mrs B Cullen Locality Support Services Manager Functional Support Services April 2009 Approved by Board of Directors on 28 May 2009
Contents Page Number 1.0 Introduction. 3 2.0 Strategic Context 3 3.0 Operational Context.. 3 4.0 Governance Arrangements.. 3 5.0 Monitoring and Audit Arrangements 4 6.0 Service Improvements 2008/09... 9 7.0 Terminal / Deep Cleans.... 9 8.0 Action Plan 2009/10...... 10 Appendices 2
1.0 INTRODUCTION This report sets out the Trust s position with regard to environmental cleanliness during the year 1 st April 2008 to 31 st March 2009. It also advises Trust Board of the controls and systems in place to support the delivery and maintenance of high quality environmental cleanliness standards within the Southern Health and Social Care Trust. 2.0 STRATEGIC CONTEXT In 2005, the DHSSPS published Cleanliness Matters a regional strategy for improving the standard of environmental cleanliness in HSS Trusts. The Trust ratified at its Environmental Cleanliness Committee Meeting on 27 th May 2008 that it fully adopted the DHSSPS Cleanliness Matters Regional Strategy. 3.0 OPERATIONAL CONTEXT In 2008/09 work was carried out to harmonise working practices across all Trust facilities and this work will continue during 2009/10. The Trust secured funding of 50,000 from the DHSSPS for the purchase of a PDA hand held computer based system (Maximiser) for the recording of environmental cleanliness audit results. Data is currently being collected for the system which will be implemented during 2009/10. BICs (British Institute of Cleaning Science) accredited training has been agreed as a key training priority within Functional Support Services for domestic staff across the Trust. Training has already commenced and the programme will be rolled out to remaining staff over the next few years. There are approximately 600 staff in Domestic Services and 1 staff have completed the BICs training programme to date. 4.0 GOVERNANCE ARRANGEMENTS 4.1 Managerial Accountability The Director of Acute Services is the designated Executive Director with lead responsibility for Environmental Cleanliness. On a day to day operational basis, three Locality Support Services Managers manage the delivery of domestic services and the achievement and maintenance of environmental cleanliness standards in conjunction with ward managers, and heads of departments, facilities and homes. These Locality Support Services Managers are accountable to the Assistant Director of Acute Services, Functional Support Services. 3
4.2 Trust Environmental Cleanliness Committee The Trust Environmental Cleanliness Committee ensures that a high level of environmental cleanliness is achieved and maintained throughout the Trust. The Committee meets on a quarterly basis and it is chaired by the Assistant Director of Acute Services, Functional Support Services. The Committee includes representatives from support services, infection control, estates, nursing, social services and a service user representative from the Southern Health and Social Services Council. The Trust has sought clarification from the Patient and Client Council regarding service user involvement following the cessation of the Southern Health and Social Services Council. 4.3 Trust Environmental Cleanliness Policy The Trust Environmental Cleanliness Policy was approved by Trust Board on 26 th February 2008. The policy was reviewed in January 2009 and no revisions were made. 5.0 MONITORING AND AUDIT ARRANGEMENTS The regional strategy requires the Trust to perform audits to monitor cleanliness standards within the National Standards of Cleanliness (updated by the National Specifications for Cleanliness). As part of the regional strategy, the DHSSPS issued a toolkit, which provided all HSS Trust facilities with a standardised methodology for assessing the standard of cleanliness. This toolkit which contains 49 elements is used by Trusts to undertake internal departmental and managerial audits. The National Specifications for Cleanliness have been reviewed and revised to take account of changes occurring since the issue of Towards Cleaner Hospitals and Lower Rates of Infection, A Matron s Charter, The Healthcare Commission s Standards for Better Health and the Code of Practice for the Prevention and Control of Healthcare Associated Infections (introduced under the Health Act 2006). The Trust proposes to update its auditing tool to reflect the revised National Specifications during 2009/10. 5.1 Internal Audit Arrangements 5.1.1 Departmental Audits The departmental audit process has been standardised in all hospitals across the Trust and departmental audit results for hospitals are submitted to Performance and Reform Dept on a monthly basis and incorporated in the Trust Board 4
Performance Report. The departmental audit process for community facilities has been agreed and work to roll this out to all community facilities will continue during 2009/10. Departmental Audits have been undertaken in all hospitals and a number of community facilities throughout the Trust during 2008/09. These are normally undertaken by a domestic supervisor and a ward/department/facility manager. The frequency of audit is dependant on the risk categorisation of the area in question. Departmental Audits Functional Frequency Examples of areas Rating Very High Weekly Theatres, Day Surgery, ICU High ly A&E, In-patient Wards, CSSD Moderate Three monthly Out-patients, General Pharmacy, Residential Accommodation, common public areas Low Six monthly Non-sterile supply areas, plant rooms, record storage The overall departmental audit scores for each of the hospitals is shown below: Hospital April May June July Aug Sept Oct Nov Dec Jan Feb Mar Av St Luke's 93 88 86 88 84 94 91 93 89 South 89 89 86 86 87 89 89 92 89 Tyrone Longstone 89 91 89 87 92 91 88 94 93 92 93 Mullinure 93 91 94 91 94 93 94 96 93 CAH 92 92 93 91 91 94 94 93 93 92 93 Lurgan 83 92 86 91 94 93 93 93 94 93 91 DHH 94 93 94 94 94 92 94 93 93 94 Bluestone 89 91 93 93 Average 88 91 91 91 92 93 92 93 93 The scores reflect the overall weighted score for each hospital taking into account all risk categories ie very high, high, moderate and low risk category areas. % or above 5
indicates an acceptable level of cleanliness in accordance with the DHSSPS Cleanliness Matters Strategy. Graphs depicting the overall, very high risk and high risk scores for each of the hospitals are shown at Appendix 1 and a more detailed breakdown of departmental audit scores for each of the hospitals on a month by month basis is shown at Appendix 2. A summary of the average departmental audit scores in community facilities is shown below:- Community Departmental Audit Results 2008/2009 Locality Moderate Low Overall Weighted Armagh/Dungannon % 83% % Newry/Mourne 63% 87% 65% Craigavon/Banbridge 82% % 78% 5.1.2 Managerial Audits Managerial Audits are the only form of internal unannounced inspections carried out within the Trust. Managerial Audits are undertaken throughout the Trust on a rolling basis and the purpose of Managerial Audits is to validate a sample of audit information arising from the Departmental Audits. The Managerial Audits are undertaken by a Managerial Audit Team which provides a level of independence. There is a Managerial Audit Team for each locality which comprises of the following personnel:- Infection Control Nurse Support Services rep Estates rep Service User rep from the Southern Health and Social Services Council During 2008/09 a total of 178 Managerial Audits were undertaken across the Trust. 6
The results of managerial audits are shown below: Managerial Audit Results (Hospitals) 2008/2009 Site Craigavon Daisy Hill South Tyrone St Luke s Longstone Mullinure Lurgan Bluestone Very High High Moderate Low Overall Weighted 83% 77% 52% 77% 74% 77% 83% 73% Nil* 78% 93% 89% 88% 88% % N/A 81% % % % N/A 86% 94% % % N/A 82% Nil* Nil* 82% N/A 64% 87% Nil* 73% N/A % Nil* Nil* % * No Areas Audited Managerial Audit Results (Community Facilities) 2008/2009 Locality Moderate Low Overall Weighted Craigavon/ Banbridge 79% 79% 79% Newry/ Mourne % 87% 79% Armagh/ Dungannon 93% % 89% 7
5.1.3 Controls Assurance Self Assessment In 2008/09, a self assessment of the Trust s position against the Environmental Cleanliness controls assurance standard was undertaken. The overall score for the self assessment was substantive at %. This is currently being quality assured in the Chair/Chief Executive s Department. The Environmental Cleanliness controls assurance working group has been meeting during 2008/09 to take forward and implement the actions required to maintain and further improve compliance with the controls assurance standard. 5.1.4 Complaints 5. 2 External Audits During 2008/09, there was one complaint received within the Trust in respect of environmental cleanliness. This complaint related to concern regarding cleanliness, infection etc from ongoing maintenance works (Ward 3 North, CAH). 5.2.1 HCAI Improvement Team Standards of environmental cleanliness at Craigavon Area Hospital were inspected by the cleaner hospitals team in September 2008 and at that time the team were impressed with the standard of cleanliness. 5.2.2 Bugwatch Craigavon Area Hospital and Daisy Hill Hospital were visited by Bugwatch in October 2008. The reports were generally satisfactory and any recommendations made were actioned. 5.2.3 FM Specific 5.2.4 RQIA Daisy Hill Hospital was reviewed by FM Specific, Specialist Facilities Management Consultants in January 2009. This was part of a review of cleanliness in acute hospitals across NI commissioned by Health Estates. Daisy Hill Hospital was the only hospital from the Trust included in the review. Formal feedback has not yet been received. RQIA undertook an unannounced hygiene inspection at Daisy Hill Hospital on 19 th February 2009. The inspection team visited Accident and Emergency Department, 8
Medical/Stroke Ward, Male Surgical Ward and Outpatients Department. A number of general cleaning issues and waste management issues were identified and an action plan has been developed to address issues raised. 6.0 SERVICE IMPROVEMENTS 2008/09 During 2008/09 there has been major investment in environmental cleanliness initiatives which has led to a significant improvement in hospital environments and addressed some of the issues raised by RQIA at their inspection at Craigavon Area Hospital on the 7 th March 2008. 6.1 SHSSB Funding for Tackling HCAI/RRCT 1. Additional Domestic Services staff, C/B locality 177,000 2. Additional Domestic Services Staff, A/D locality 56,725 3. Sluice replacement CAH 60,000 4. Sluice replacement DHH 30,000 6.2 Priority Funding 1. Replacement Chairs, Outpatients Dept, CAH 20,000 2. Bed screens, CAH 20,000 3. Replacement floor covering, Lurgan Day Hospital 10,000 7.0 TERMINAL / DEEP CLEANS The demand for terminal cleans has risen significantly in all hospitals to try and reduce and control hospital acquired infection. The number of requests for terminal cleans over the past number of years has increased as follows:- TERMINAL CLEANS Hospital 2005 2006 2007 2008 DHH 1460 1825 21 2172 CAH 2521 2827 3263 4012 Lurgan 396 443 4 350* Total 4377 50 5933 6534 * The reduction at Lurgan is due to reduced bed numbers. In additional to terminal cleans deep cleaning programmes had been implemented in all hospitals across the Trust during 2008/09. The 9
programmes have been completed in all hospitals except Craigavon Area Hospital due to difficulties regarding access to wards. 8.0 ACTION PLAN 2009/10 8.1 Work will continue on harmonising systems and processes to ensure consistency in service delivery standards across the Trust. 8.2 Departmental audit process to be rolled out to all community facilities. 8.3 Update internal auditing tool to reflect the revised National Specifications of Cleanliness. 8.4 Implement Maximiser system within all hospitals for the recording of environmental cleanliness audit scores. 8.5 Practice Audits will be developed and implemented across the Trust by the Locality Support Services Managers. 8.6 Review of Managerial Audit process by Locality Support Services Managers. 8.7 BICs training programme to continue to be rolled out to domestic staff across the Trust. 8.8 Develop an audit tool for capturing service user views on environmental cleanliness within Trust facilities. 10
Appendices Appendix 1 - Graphs showing Environmental Cleanliness Departmental Audit scores (overall, very high risk and high risk scores) for each of the hospitals from April 2008 March 2009. Appendix 2 - A breakdown of Environmental Cleanliness Departmental Audit scores for each of the hospitals on a month by month basis from April 2008 March 2009. 11
Appendix 1 The following graphs show Environmental Cleanliness scores (overall, very high risk and high risk scores) from Departmental Audits undertaken in hospitals throughout the Trust from April 2008 March 2009. Craigavon Area Hospital Overall Very High Areas High Areas April May June July Aug Sept Oct Nov Dec Jan Feb Mar Daisy Hill Hospital Overall Very High Areas High Areas April May June July Aug Sept Oct Nov Dec Jan Feb Mar 12
South Tyrone Hospital Overall Very High Areas High Areas April May June July Aug Sept Oct Nov Dec Jan Feb Mar Lurgan Hospital Overall High Areas April May June July Aug Sept Oct Nov Dec Jan Feb Mar 13
St Luke's Hospital Overall High Areas April May June July Aug Sept Oct Nov Dec Jan Feb Mar Mullinure Hospital Overall High Areas April May June July Aug Sept Oct Nov Dec Jan Feb Mar 14
Longstone Hospital Overall High Areas April May June July Aug Sept Oct Nov Dec Jan Feb Mar Bluestone Unit Overall High Areas Sept Oct Nov Dec Jan Feb Mar 15