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Inspection report

Date of Inspection: 11 January 2011
Date of Publication: 9 February 2011
Inspection Report published 9 February 2011 PDF

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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

Our judgement

We found most of the location was generally meeting this outcome. However during the site visit performed 11 January 2011 we found that the seclusion room on Maple ward had not been cleaned following use, did not include a recommended soap dispenser secured to the wall and did not include a toilet roll holder.

User experience

We asked some patients what they thought about cleanliness during our site visit performed 6 January 2011:

“Ward kept clean and tidy”,

“Bedding clean”,

“Some areas need more attention but generally clean”,

“Environment on ward, is always clean and tidy, if its not it’s because of people here who are ill, if you get my meaning, can’t help it, but staff then clean up after them”.

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC in April 2010. Our provider level QRP for this outcome contained mostly positive information of which a number related to PEAT assessments of hygiene and infection control measures for this location. One individual PEAT assessment for this location found the proportion of applicable wards with adequate hand decontamination provision was rated negatively. However this should be considered against the NHS staff survey 2009 finding for 'availability of hand washing materials' which was rated positively.

None of the external stakeholders referred to within outcome one who responded raised any areas of concern specifically relating to this location or outcome. NHS Sheffield contributed the following commentary “Infection Control - Last year the trust made a significant investment, appointing a senior infection control nurse and also secured microbiology support from Sheffield Teaching Hospitals NHS Foundation Trust. The trust is compliant with the hygiene code of practice and has set up assurance systems at ward level via regular audits and training programmes.”

As part of the assessment of this location the provider submitted a provider compliance assessment for this outcome which explained how the provider was meeting the applicable criterion of the Code of Practice for health and social care on the prevention or control of infections and related guidance. We found no gaps in assurance when this self assessment was reviewed.

Additional evidence was sought from the provider in the form of an annual team governance report for Rowan ward covering the period April 2009 to March 2010. The report included a detailed section on infection control written by the staff member on Rowan ward who takes the lead on infection control. The report demonstrated that positive actions had been undertaken following audit, for example, a mattress audit resulted in the removal of unfit ones which was replaced by new mattresses.

During the site visit performed 11 January 2011 we found that the location was generally clean and tidy in all areas of the building we walked through with the exception of one area. On Maple ward while undertaking a tour of the ward we reviewed the seclusion room. The room was found to have a washable stain on the floor that mirrored the shape of the specialist seclusion bed, which showed that the room had most likely not been cleaned following it’s last use by a patient. We asked for this to be cleaned straight away. The seclusion room’s toilet facility is located in an adjoining room. The toilet roll was on the floor and there was no toilet roll holder in the room. The stainless steel hand basin had a used soap bar on the sink and no soap dispenser was located in the room. The room did not meet current infection control guidelines.