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Archived: Claremont Hospital

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Inspection report

Date of Inspection: 15 February 2011
Date of Publication: 4 March 2011
Inspection Report published 4 March 2011 PDF

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People should be cared for in a clean environment and protected from the risk of infection (outcome 8)

Meeting this standard

We checked that people who use this service

  • Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance.

How this check was done

Our judgement

We found people who use services had received care and treatment in a reasonably clean environment with various infection control measures in place to minimise the risk of infection. No gaps in assurance or areas of concern were identified during the assessment of this outcome for this location.

User experience

Our QRP contained one negative comment from NHS Choices intelligence (dated 15-03-2010) which is referred to in outcome four. The person outlined "poor housekeeping in my room".

The hospital extracts monthly patient comments (positive and negative) from the patient surveys and these were submitted as supporting evidence. A small number of examples are set out below relevant to this outcome.

"Impressed by the cleanliness of the hospital" (September 2010).

"I felt very comfortable and happy with the treatment and the hospital was very clean" (October 2010).

"Staff very friendly and polite. Room very good and clean" (October 2010).

"Very clean, tidy and pleasant environment" (November 2010).

On the site visit we asked patients about cleanliness. Patients felt the ward area was clean and had seen nurses wash hands and use gels regularly.

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC October 2010.

As part of the assessment of this location the provider submitted a 'provider compliance assessment' record for this outcome. The hospital set out information, which explained in detail how this outcome was being met, with references to supporting evidence. The hospital explained that it has a range of processes and systems in place relevant to this outcome. Some examples include having a set of infection prevention procedure file available in all clinical areas. The hospital has an infection prevention committee and a monthly operational meeting takes place to allow review of audit, sharing of laboratory data and discharge surveillance. All patients are reported as being screened for MRSA prior to admission and the hospital reports that it has a 'very low' incidence of infection. All clinical areas have cleaning schedules. Several members of staff are specifically trained as 'infection prevention link practitioners'. Infection prevention training is reported as being provided annually along with sharps awareness training.

The hospital also voluntarily provided additional supporting evidence to demonstrate compliance with this outcome, including an infection prevention annual report.

As part of the planned review some external bodies were also contacted to contribute to this review. NHS Sheffield explained in a letter received 11 February 2011 how Claremont contributes data on a monthly basis via a medical laboratory report, and has also implemented MRSA screening policy in line with Department of Health (DH) guidance. NHS Sheffield also stated "The organisation is currently pursuing adopting the MRSA screening and decolonisation procedure undertaken within the local acute hospital trust. This would ensure that decolonisation for MRSA is standardised across the whole health economy of Sheffield".

In November 2010 we received an anonymous concern, which outlined a number of issues in relation to practices within the operating theatre department. Most centred on moving and handling, training of staff (see outcome 14) along with two matters that relate to this outcome.

The first allegation concerned patients gaining infection following surgical procedures and the second was an allegation that staff members in theatres were working without being injected against hepatitis B exposure, which is known as prevention of occupational exposure to blood-borne viruses (BBV's). We requested a range of information during November 2010 to demonstrate that the allegations had been investigated and actions taken to improve where necessary. By the end of November 2010 only 28% of theatre staff had received infection prevention mandatory training though the provider explained that further sessions were being held in December.

We were concerned that the location may not be fully compliant with this outcome so we decided to follow up some of these issues via a site visit.

On the site visit 15 February 2011 we conducted a tour of the premises and spent time on the ward area and in the theatre department. We found all areas were clean, with appropriate infection prevention measures in place such as alcohol gels and colour coded clinical waste bins. We asked a number of staff members if they had received relevant occupational BBV injections and all those confirmed they had.

Some staff members confirmed they had not had any recent infection prevention training. This was confirmed when the hospital management team checked its training records. Current figures indicated approximately 60 percent of staff have received mandatory infection prevention training in the last 12 months (85% of clinical staff). Additional staff members had received advanced forms infection prevention training. Though we are concerned overall figures for mandatory training are lower than expected we noted that 85% of clinical staff had received this training, therefor