"International excellence in improving health care is our aim."

The Healthcare Environment Inspectorate (HEI) today (Monday) published its report relating to an inspection visit to Inverclyde Royal Hospital, NHS Greater Glasgow and Clyde on 28 and 29 January 2010.

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 Greater Glasgow and Clyde’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 two requirements (which are linked to compliance with NHS Quality Improvement Scotland healthcare associated infection standards) that NHS Greater Glasgow and Clyde is fully expected to address, plus six recommendations for improvement.

The full HEI inspection report and an improvement action plan developed by NHS Greater Glasgow and Clyde to address the identified issues are available to view at http://www.nhshealthquality.org/nhsqis/7429.html

Speaking of the report, Susan Brimelow, HEI Chief Inspector, said: “The Inspection team observed some good practice at Inverclyde Royal Hospital with clear arrangements evident for leading and managing infection control. The hospital was also able to show inspectors how they looked after patients with a suspected infection. However inspectors also identified a small number of concerns and identified two requirements which highlight the need to improve cleaning records and training for staff on infection prevention and control. The report also identifies six recommendations for improvement and we fully expect the report’s requirements and recommendations, which have been agreed by senior staff at NHS Greater Glasgow and Clyde, will be addressed and the necessary improvements made as a matter of priority.”

Requirements

1.      NHS Greater Glasgow and Clyde is required to ensure that the assurance systems for cleaning are more consistently implemented by ward staff.

2.      NHS Greater Glasgow and Clyde is required to review its education strategy to include mandatory updates for all staff in the prevention and control of infection. This will ensure that staff regularly receive the necessary up-to-date knowledge and skills essential to deliver the highest possible quality of patient care in relation to infection control practices.

Recommendations

1.      It is recommended that NHS Greater Glasgow and Clyde reviews the communication of audit results within wards in order to ensure that all staff are made aware of the current performance of their ward.

2.      It is recommended that NHS Greater Glasgow and Clyde ensures the dress code policy is implemented and monitored throughout Inverclyde Royal Hospital and adhered to by all staff to further reduce the risk of spread of infection.

3.      It is recommended that NHS Greater Glasgow and Clyde reviews the document control procedures related to the prescribing posters and prescribing handbook to ensure outdated information is removed from use.

4.      It is recommended that NHS Greater Glasgow and Clyde develops and implements a quality assurance mechanism to complement the prescribing audits undertaken by junior doctors.

5.      It is recommended that NHS Greater Glasgow and Clyde considers additional measures to protect doors and door frames to maintain the surfaces in a condition that can be effectively cleaned.

6.      It is recommended that NHS Greater Glasgow and Clyde ensures that the procedures it has in place for the dissemination of HAI information are consistently and effectively implemented in order that patients and visitors are suitably informed.

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:

• 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
• 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.

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