The Healthcare Environment Inspectorate (HEI) today (Monday) published its report relating to an inspection visit to Gilbert Bain Hospital, NHS Shetland on Tuesday 15 December 2009.
HEI has been set up to help reduce healthcare associated infection risk to patients through a rigorous inspection framework. The HEI inspection team examined NHS Shetland’s self-assessment information and then inspected the hospital to validate this information, meet patients and staff, and visit wards and departments.
During the visit, the inspection team also assessed the hospital’s physical environment for issues related to healthcare associated infection. The findings from the visit are set out below, and cover five requirements (which are linked to compliance with NHS Quality Improvement Scotland healthcare associated infection standards) that NHS Shetland is fully expected to address, plus seven recommendations for improvement.
The full HEI inspection report and an improvement action plan developed by NHS Shetland to address the identified issues are available to view here
Speaking of the report, Susan Brimelow, HEI Chief Inspector, said: “The inspection team observed that the majority of areas inspected were very clean and that there were some innovative ways to communicate and reinforce the importance of good hand hygiene. However inspectors also found areas for improvement and have identified five requirements and seven recommendations to help reduce the risk of healthcare associated infection. In particular NHS Shetland must look at the design and number of hand washing facilities provided in some clinical areas, to ensure they meet with current guidance. We fully expect the report’s requirements and recommendations, which have been agreed by senior staff at NHS Shetland, will be addressed urgently, and the necessary improvements made as a matter of priority.”
Requirements
1. NHS Shetland must ensure that there is effective communication between the infection control team and staff to ensure staff are fully aware of audit results and surveillance data and how they should be interpreted and used.
2. NHS Shetland must review its Service Level Agreement with NHS Grampian to include gathering and reviewing infection control information for patients who are treated by NHS Grampian on behalf of NHS Shetland.
3. NHS Shetland must ensure that clinical sinks of the appropriate dimensions are readily available in all clinical areas in line with national guidance.
4. NHS Shetland must ensure that the appropriate ratio of beds to clinical sinks is available in all clinical areas in line with national guidance.
5. NHS Shetland must review the patient equipment cleaning schedules to ensure that responsibility for the cleaning of patient equipment is clearly assigned to a defined staff group.
Recommendations
1. It is recommended that NHS Shetland ensures that it has adequate measures in place to demonstrate that general environmental audits are undertaken on a frequency which is appropriate to the risks identified.
2. It is recommended that NHS Shetland ensures that the renal unit is provided with an appropriate number of clinical waste bins.
3. It is recommended that NHS Shetland reviews its refrigerator temperature monitoring procedures to ensure temperatures are recorded appropriately.
4. It is recommended that NHS Shetland commences monthly audits of antimicrobial prescribing policy for a sample of 20 patient records within the acute receiving units.
5. It is recommended that NHS Shetland reiterates the correct use of indicator tape to staff.
6. It is recommended that NHS Shetland develops its communications systems to ensure more emphasis is placed on formal communication between senior staff and ward staff, particularly in relation to operational matters.
7. It is recommended that NHS Shetland reviews its procedure for the dissemination of patient leaflets to ensure that patients are receiving appropriate information regarding infection control and healthcare associated infections.
Notes to Editors
The Healthcare Environment Inspectorate (HEI) was established in April 2009 to undertake announced and unannounced inspections to each acute hospital in NHSScotland at least once every 3 years.
The HEI focus is to reduce the healthcare associated infection risk to patients through a rigorous inspection framework. Specifically HEI focus on:
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providing assurance to the public, NHS boards, and the Scottish Government that patients are as safe as possible from HAIs and their consequences; HAI standards in NHS acute hospitals are high; and any HAI issues are being tackled, and
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improving infection prevention measures across NHSScotland through an inspection framework, leading to a decrease in HAIs and their consequences over time.
Each inspection is led by an experienced inspector, and supported by a small team which includes a volunteer inspector to make sure members of the public are involved in the work of the Inspectorate.
Further information about HEI, its inspection visits, and methodology and audit tools used can be found at http://www.nhshealthquality.org/nhsqis/6710.140.1366.html.
All requirements in this report are linked to compliance with national Healthcare Associated Infection (HAI) Standards – published in March 2008 by NHS Quality Improvement Scotland.
HEI is a key component of NHS Quality Improvement Scotland, a Special Health Board that advises, supports and assesses NHS boards to help improve the quality of healthcare.
All media enquiries should be directed to:
Ken Miller, Head of Communications, NHS Quality Improvement Scotland on 07812 731 362.
Stephen Ferguson, Communications Officer, NHS Quality Improvement Scotland on 0777 932 9689.
