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Archived: McIndoe Surgical Centre

The provider of this service changed - see new profile

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Inspection report

Date of Inspection: 21 March 2013
Date of Publication: 18 April 2013
Inspection Report published 18 April 2013 PDF

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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 21 March 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

People were protected from the risk of infection because the provider had systems in place to reduce the risks of infection and people were cared for in a clean, hygienic environment.

Reasons for our judgement

There were effective systems in place to reduce the risk and spread of infection.

We found that the hospital had a range of written infection control policies and procedures and a nominated infection prevention nurse lead. The nurse lead, together with senior nurse colleagues and the Quality and Governance Manager, met quarterly to review infection control practice and review concerns. The provider had arranged for the nurse lead to be directed and supported in their role by a consultant medical microbiologist.The microbiologist chaired the quarterly meetings of the provider's infection control committee and was the Director for Infection Prevention and Control at the local NHS trust.

We saw that annual infection prevention and control audits were conducted and that areas requiring improvement were identified and actioned. Clinical staff received mandatory training in infection control at least once each year and this included handwashing techniques. We saw that the provider had used glow boxes to support this training and to underscore the importance of hand hygiene for improved infection control. We reviewed a sample of staff files and found that the training was up to date.

We visited all areas of the hospital including housekeeping, the kitchen and the operating theatre and observed that the hospital was clean and tidy and in good decorative order. We visited patient bedrooms, shower rooms, public and staff toilet facilities and found they were all cleaned to a high standard. There were microbial hand gel dispensers throughout the premises, including both inside and outside patient rooms, and notices asking people to use these on entering and leaving. We also saw that there were devices attached to toilet doors which sprayed the door handles regularly with antimicrobial agents to reduce the risks of infection. Handwashing guidelines based on current best practice were prominently displayed adjacent to sinks.

We watched cleaners and nurses going about their work and saw that they used appropriate personal protection equipment. We also saw that cleaning staff completed checklists to confirm the routines carried out.

People we spoke to told us that bed linens and gowns were changed as desired and we saw that these were stored and collected regularly by an external contractor.

The hospital had its own accredited sterile services department for the decontamination of medical equipment. Wherever possible however the hospital used single use items which were appropriately disposed of after use. We saw that clinical waste bins and sharps bins were located throughout the hospital premises and when full these were removed to locked clinical waste bins in the dedicated storage area at the rear of the hospital.

The providers range of infection control policies included a policy for managing and controlling methicillin resistant Staphylococcus aureas (MRSA). This is a bacteria which is responsible for a number of difficult to treat infections and can be particularly troublesome in hospitals. We saw that the provider took steps to reduce the risk of MRSA by conducting risk assessments and, where indicated, tests for patients prior to admission. The nurses we spoke to were able to explain clearly the increased precautions they would take when nursing people with MRSA. These included a sign on people's rooms to make all staff aware of the presence of MRSA, the use of additional personal protection items such as gowns,gloves and masks and a dedicated clinical waste bin in the room. We also saw other evidence that indicated the provider had assessed the risks and taken appropriate action when a member of staff notified them that they had MRSA.

We reviewed the provider's policy for dealing with needlestick injuries and found this was well understood by staff. The policy was also prominently displayed in the nurses' staff room alongside pre-completed blood test forms ready for urgent use in the event of need. This was becau