PAPER: SFT3379 Hospital Cleanliness Report March 2013 PURPOSE: To update the Trust Board on the Cleanliness Compliance against national specifications that support the Clean Hospital Agenda MAIN ISSUES: - Excellent PEAT Score achieved in 2013 - Change nationally to replace PEAT with Patient Led Assessment of the Care Environment (PLACE) - Deep Clean Programme for 2013/2014 - Increase in Enhanced Cleaning and Terminal Cleaning in 2013 - Trial of Glossair Decontamination System ACTION REQUIRED BY THE BOARD: To note the report and to agree that the quarterly cleaning report will be replaced by a six monthly cleaning report as part of the bi-annual DIPC Report. ATTACHMENT/S AVAILABLE TO VIEW ON WEBSITE: AUTHOR: TITLE: Tracey Nutter Director of Nursing Approved.doc - 1 -
PAPER: SFT3379 Hospital Cleanliness Report Patient Environment Action Team (PEAT) 2012 Assessment The Trusts formal PEAT assessment was undertaken in February 2012 the Department of Health have confirmed our award of Excellent for the patient environment. PLACE PLACE replaces PEAT which was naturally regarded as having reached the end of it s life. There is a move away from the verbal descriptors used in PEAT, e.g. Excellent, to visual indicators against the national average, i.e. dashboard s. The exact presentation of this has not been confirmed. We have organised training for staff and patient assessors in April 2013. Patient-led assessments will in future assess what matters to patients/the public. Report what matters to patients/the public Ensure the patient/public voice plays a significant role in determining the outcome. There will be a requirement to write action plans that detail the Trust response(s) in the area(s) where a pass was not achieved In- House PEAT audits A programme of in-house PEAT audits is in place, these remain well supported by the Director of Nursing, Foundation Trust Governors volunteers and the Infection, Prevention and Control team. Individual ward/departmental PEAT reports are sent to Ward Leaders immediately following an inspection and presented each month at the Matrons Monitoring Meeting. Housekeeping Auditing System. From March 2008 the Housekeeping Department has audited environmental cleanliness using software developed by the Department of Health, using the national specifications of cleanliness (NPSA, 2007) to identify the frequency of audits and risk categories. With the introduction of PLACE from April 2013, there is no longer a requirement to report nationally a cleaning score in its current format. The Housekeeping and Infection Control Team are developing a new local audit system focussing on improved outcomes and accountability. Cleanliness scores by risk category Risk Category Areas (examples) Trust Target Score Trust Score @ 10/03/2013 Very High Risk Main Theatres, Radnor, ED, 98% 99% +1% Pembroke Ward/Suite High Risk Main Entrance, In-Patient wards, 95% 97% +2% SDU, DSU. Significant Risk Wessex rehab, Rheumatology, 85% 94% +9% Spinal Pool, Sight Centre. Low Risk Education Centre, Chapel, Offices. 85% 90% +5% +/- Approved.doc - 2 -
Overall Trust Cleanliness Score The Trusts cleanliness audit score, as measured against the National Specifications for Cleanliness (NPSA, 2007.) As of the 10 th March 2013, the Trust s overall score is 95%. Cleaning Schedules In accordance with the Health Act (2006), in January (2009) revised cleaning schedules were published, publically displayed from April 2009. To provide added assurance Cleaning Task lists were put into place in February (2010) and are reviewed by the Matrons Monitoring Group. Weekly updates are reported at the Infection Control Update Meetings with Directorate Senior Nurses and the Facilities Matron and Head of Housekeeping. Compliance is improving Further improvements are planned in 2013/14 to rag rate compliance with ward and cleaners task lists and the use of pictorial cleaning schedules to make them more accessible to staff,patients and visitors. Extra Cleaning Additional cleaning undertaken to manage infection is carried out by a rapid response team reducing but not removing, the requirement to use cleaning staff assigned to other duties (i.e. ward cleaning). The average of 168 terminal cleans per month (2005 baseline) is used by the Housekeeping Department to measure service pressure against. An audit trail for each terminal clean is provided via the Housekeeping Department decontamination certificate. The tables below show the additional cleaning undertaken in clinical areas between September 2012, and February 2013. Post Infection Cleans: Enhanced Cleaning Hours Month/Year 2011/12 Number of cleans 2012/13 Number of cleans Month/Year 2012/3 Cleaning hours September 242 196 September 48.50 October 239 213 October 48 November 229 276 November 128.25 December 194 319 December 137.25 January 229 212 January 104.75 February 259 355 February 246.50 Year to date Total 1586 1571 Year to date Total 713.25 Deep Clean Programme The Trust Board agreed 37,000 of funding for a year long deep clean programme to cover all wards and clinical departments. The programme is led by a Senior Team Leader with a dedicated team of 2 cleaners and ETS support if required. The Deep Clean team work closely with the ward leaders to maximise the effectiveness and efficiency of the programme. Feedback from staff and patients has been very positive and the close co-operation between wards and the deep clean team have enabled more areas to be cleaned in 2013. The extended Deep Clean Programme is attached with extra areas included being Antenatal, Level 2 corridor, Cardiac Suite, All ward kitchens, Clinical Team offices. Approved.doc - 3 -
The programme has run successfully to schedule, with the only delay occurring in February when the Programme was suspended to support the extra Infection Control requirement on the wards. The programme will now be completed in mid April 2013. Approved.doc - 4-
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Room decontamination system (RDS) Glosair 400 machine During quarter 4 (2012/13), a 5 week trial was completed using the Glosair 400 room decontamination system. The machine uses a low dose/concentration of hydrogen peroxide vapour to decontaminate an area/room. The trial was facilitated by the Infection Prevention & Control Team (IP&CT), with the involvement of the Housekeeping Supervisors. The use of this process compliments existing environmental cleaning undertaken by the Housekeeping Department. During the trial, every opportunity was identified to use the system in siderooms and bay areas to assess the potential for use in the Trust long-term. The machine was successfully used in areas within the medical and musculoskeletal directorates, and promoted interest from the ward staff involved. Formal evaluation feedback will be reported to the Infection Prevention & Control Working Group (IPCWG) including how this technology might be used in the future by the Trust. This technology is commonly used in other Trusts/hospitals to reduce the incidence of healthcare associated infection (HCAIs) e.g. Clostridium difficile. New hand wash soap Installation work Following the successful trial of an improved skin cleansing product (hand wash soap), the Trust will be installing this new product during quarter 1 of 2013/14. This work continues to support the Trust dermatitis prevention strategy. Real Time Feedback Below are the real time feedback results from April 2011 to February 2013. Questions about patients experience and comments on cleanliness will be included in the 2013 Real Time Feedback Programme, supported by Governors and Volunteers. Average Apr11-Mar12 Goal Cleanliness of ward 100 90 80 70 Mean Score 60 50 40 30 20 10 0 Mar-13 Feb-13 Jan-13 Dec-12 Nov-12 Oct-12 Sep-12 Aug-12 Jul-12 Jun-12 May-12 Apr-12 Mar-12 Feb-12 Jan-12 Dec-11 Nov-11 Oct-11 Sep-11 Aug-11 Jul-11 Jun-11 May-11 Apr-11 AUTHOR: TITLE: Tracey Nutter Director of Infection Prevention and Control Approved.doc - 6 -