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Archived: RNIB Wavertree House

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Inspection report

Date of Inspection: 19, 27 February 2014
Date of Publication: 27 March 2014
Inspection Report published 27 March 2014 PDF | 80.77 KB

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

Not met 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 19 February 2014 and 27 February 2014, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

People were not fully protected from the risk of infection because policies and procedures did not reflect current guidance and there was no system in place to monitor standards of cleanliness and infection control.

Reasons for our judgement

At the last inspection in November 2013, we found RNIB Wavertree House non-compliant with cleanliness infection control. This was because the service did not have an infection control lead and infection control audits had not been completed to identify any possible risks with infection control.

Following our inspection, the provider sent us an action plan outlining the steps they intended to take to rectify the issues identified. The action plan submitted identified how the service would make improvements in infection control. Actions included the appointment of an infection control lead, audits to be completed and for policies and procedures to be updated. The provider indicated that these changes would be completed by 31 January 2014.

In 2010 the Government issued advice to all providers of health and social care entitled, 'The Code of Practice on the Prevention and Control of Infections and Related Guidance' (CoP). This gave all providers a framework for managing the control and prevention of infection in the provision of health and social care services. Providers must follow the guidance or have equivalent or better systems in place.

At the last visit to RNIB Wavertree House, we found that the service’s ‘infection control policy’ had not been reviewed to include the requirements of the CoP. The action plan submitted identified that the policy would be amended to reflect the guidance. We reviewed the ‘infection control policy’ and found it included detailed information on infectious diseases and standard universal infection control procedures such as hand washing and protective clothing. The policy though had not been updated to include the requirements of the CoP or standards equivalent to the CoP. In order to have achieved compliance with the CoP, providers were expected to have demonstrated how they meet each criterion of the CoP. The CoP contained 10 criterions, these included quality assurance systems such as audits. We found that RNIB Wavertree policies and procedures did not reflect how each criterion would be met or how compliance would be achieved. We also identified that policies and procedures referenced the ‘Care Standards Act 2000’. Cleanliness and Infection Control was previously governed by the ‘Care Standards Act 2000’. The CoP was implemented in 2010 and was now the official body of guidance for cleanliness and infection control. This meant that the service’s infection control policy did not follow or reflect current legislation and guidance.

The service had not undertaken quality assurance audits on infection control. Criterion one of the CoP documented that all social care organisations needed a quality assurance framework to monitor the standards of cleanliness and infection control and to identify any shortfalls in practice or where procedures had not been followed. Social care organisations must either follow the CoP or had equivalent standards in place. On the day of the inspection, we could not find any evidence that RNIB Wavertree House had a quality assurance framework in place, thereby reducing the risk of healthcare associated infections and ensuring people are cared for in a clean environment. We saw that the service had a cleaning rota and dedicated domestic care workers were employed on a full time basis. The assistant manager told us that each floor was dedicated a domestic care worker. We were informed that the domestic staff undertook daily cleaning tasks but did not record that the task had been undertaken. The lack of documentation meant that the provider would be unable to audit whether daily cleaning tasks had been undertaken in line with protocol and procedure. This meant that cleanliness and infection control was not governed by an assurance framework and the provider had no mechanisms to monitor, review and assess standards of cleanliness and infection control.

The CoP (framework for compliance) documented that an individual was designated lead in this area and was directly