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Inspection report

Date of Inspection: 14 September 2010 and 11 July 2011
Date of Publication: 3 February 2011
Inspection Report published 3 February 2011 PDF | 320.95 KB

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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

We reviewed all the information we hold about this provider, carried out a visit on 14/09/2010, 11/07/2011, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

Overall, we found that the Churchill Hospital was meeting this essential standard.

User experience

The inpatient survey (2009) found that in relation to cleanliness and hand washing, the trust scored similarly when benchmarked against other trusts. The trust scored:

• 8.8 out of 10 in response to how clean was the ward.

• 8.6 out of 10 in relation to the cleanliness of toilets and bathrooms.

• 9.7 out of in response to whether hand-wash gel was available and

• 8.2 and 9.2 out of 10 respectively as to whether nurses and doctors were seen to be washing their hands between touching patients.

During the visit to the hospital, patients reported that staff used hand-wash gel to clean their hands and that nurses often wear aprons and gloves when with a patient. Patients felt that the wards and hospital was of a good standard of cleanliness.

Other evidence

The trust has a large number of policies and procedures that relate to infection control. A sample of job descriptions were reviewed and were found to include reference to responsibilities for infection control. The hospital has an infection control team and the medical director is the director of infection prevention and control.

The trust annual infection control report for 1 April 2009 to 31 March 2010 states that the trust has continued to meet both national and locally agreed infection control targets for Meticillin Resistant Staphylococcus Aureus (MRSA) blood stream infections and Clostridium difficile. A hygiene code visit was under taken by the Care Quality Commission in November 2009. This visit found no breaches against the regulations in place to protect patients, workers and others against healthcare associated infection.

The trust demonstrated that it has processes in place to monitor and address the cleanliness of wards and departments. Cleaning services are outsourced at the Churchill Hospital. Cleaning audits are routinely undertaken. These assess patient wards and very high risk areas on a monthly basis, out-patients and public corridors every three months and office areas six monthly. The team also uses the National Patient Safety Agency audit tool which analyses cleaning performance by the responsibility categories for domestics, nursing and estates staff.

The trust outlined the processes for reporting results. The matrons declare their departmental cleaning score and this forms part of their monthly divisional report. The trust also maintains a site specific spread sheet, which is updated daily. This details the overall cleaning scores. Results for these from August 2010 show that scores varied from 84 – 94 % across a range of areas, rated by level of risk and that there is scope for improvement.

The trust’s Patient Environment Action Team assessment was completed in February 2010. This is an annual assessment of non clinical aspects of care such as the environment, food and privacy and dignity, for healthcare sites in England that have more than ten inpatient beds. The scores for each of the trust’s three sites is achieved through self assessment and verified by the National Patient Safety Agency. An external assessor was part of the inspection team. The Churchill Hospital achieved a score of good for cleanliness. However, it scored less well in relation to the proportion of wards that had adequate hand decontamination provision.

The trust provided evidence that it is targeting and addressing cleanliness in high risk areas, including operating theatres. There is also a system in place to request enhanced cleaning for wards where patients are suspected or confirmed as having an infectious organism.

The wards visited during our visit were found to be clean and tidy. Hand washing facilities were available and paper towels, soap, hand gel and protective clothing (plastic aprons and latex gloves) were well stocked. Hand washing facilities were available by the bays throughout the ward and within single rooms and alcohol gel was by the nurses station. Staff were observed cleaning their hands as they moved between patients and clinical areas. They were also observed using protective clothing when entering the rooms of patients who had been isolated due to an infection. Corridors were free from hazards, with equipment i.e. hoists and wheelchairs stored in one place. Information was displayed on one ward of cleaning audits undertaken from December 2009 to June 2010. Most wards also had infection control signs and posters in place to promote infection control. Colour coded plastic bags were in use for the disposal of waste.

Attendance at infection prevention and control is mandatory for all staff. Mandatory updates are tailored for each staff group including contractors. The infection control team are developing a new e-learning (learning via electronic media such as the internet) tool for 2010/2011. The trus