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Improvement Action Plan

NHS Grampian

Aberdeen Maternity Hospital

Healthcare Associated Infection inspection

Inspection Date: 21 August, 5 September and 17 September 2013

File Name: HEI Action Plan – Aberdeen Maternity Hospital Version: 1.4 Date: 24 October 2013 Produced by: HEI / NHS Grampian Page: of 10 Review Date: Circulation type (internal/external): Internal & External

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Improvement Action Plan Declaration

It is essential that the NHS board’s improvement action plan submission is signed off by the NHS board Chair and NHS board Chief Executive. It is the responsibility of the NHS board Chief Executive and NHS board Chair to ensure the improvement action plan is accurate and complete and that a representative from Patient/Public Involvement within the NHS board has been involved in developing the improvement action plan. By signing this document, the NHS board Chief Executive and NHS board Chair are agreeing to the points above.

NHS board Chair NHS board Chief Executive Signature: Signature: Full Name: Full Name: Date: Date:


NHS Grampian





2

Ref: Action Planned Timescale to meet action

Responsibility for taking

action

Progress Date Completed

Req 1

Undertake a review of the current audit tool used in theatre to ensure that it captures best practice

Review the HAI audit tool use in theatres and procedure rooms.

31 January 2014

Infection Prevention and Control Manager

The current HAI audit will be reviewed in all theatre and procedure room environments across NHS Grampian.

In progress

Req 2

Review the content of all HAI policies and procedures to ensure that they are compliant with the national infection prevention and control manual.

Review the NHS Grampian Standard Operating Procedure for the Cleaning of Reusable Patient Equipment, through continued participation in the national expert advisory group, and adopt recommendations made by them.

31 January 2014

Infection Prevention and Control Manager/Nurse Consultant – HAI

NHS Grampian has implemented the national infection prevention and control manual. The document in question (the Standard Operating Procedure for the Cleaning of Reusable Patient Equipment) on Page 10 of the inspection report was developed by Grampian and adopted nationally as part of the manual. The national version has been updated. Our

In progress


NHS Grampian





3

version is in the process of being reviewed (as reported to the inspectors at the time) in light of ongoing national work on the document, in which NHS Grampian continues to participate. It is currently being tested in a number of areas, including one ward in Aberdeen Maternity Hospital.

Req 3

Review the availability of alcohol-based hand gels in Ashgrove ward. This will ensure that, where hand hygiene is required, it is available to staff as near to the point of care as possible.

Review and risk assess the possibility of supplying end of bed/personal/extra wall mounted alcohol gel dispensers in Ashgrove Ward. Assess the need for extra gel dispensers throughout AMH.

Complete

31 October 2013

Infection Prevention and Control Manager/Senior Charge Midwife Head of Midwifery

The Infection Prevention and Control Team have supported the Senior Charge Midwife in Ashgrove Ward to risk assess the installation of end of bed gel dispensers. These have now been installed. End of bed gel dispensers are being installed throughout AMH. The Neonatal Unit have replaced all non-compliant dispensers.

3 October 2013

In progress


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4

Req 4

Ensure that all staff adhere to HPS National Infection Prevention and Control Manual, Appendix 5 – Glove use and selection.

Review the use of sterile polythene gloves and advise staff in the Neonatal Unit of correct glove selection and use.

Complete

Acting Nurse Manager/ Infection Prevention and Control Manager

All polythene gloves were withdrawn from use on 28 August. Clinical teams have been advised that polythene gloves should not be used for any procedures. The team also advised that the practice of double gloving is only recommended for Exposure Prone Procedures (EPP) which does not include suctioning.

28 August 2013

Req 5

Ensure that staff implement standard infection control precautions for linen management in the neonatal unit.

Install a commercial washing machine that will meet the special needs of the Neonatal Unit.

Complete General Manger, Estates and Facilities/ Divisional General Manager, Women and Children

New machine installed to replace a machine which did not consistently maintain the required temperature for infection prevention precautions.

4 September

2013

Req 6

Demonstrate that expressed breast milk is stored appropriately and that documentation reflects best practice.


NHS Grampian





5

Appropriate storage of breast milk guidance and fridge temperature checklists to be adapted to reflect national guidance. Check that all fridges where breast milk is stored are fit for purpose and appropriately monitored. Ensure through regular monitoring that appropriate recording of temperatures for all fridges in Aberdeen Maternity Hospital is undertaken. Carry-out a risk assessment to ensure the process for storage of frozen expressed breast milk is safe and effective.

Complete

Complete

Ongoing

10 October 2013

Acting Nurse Manager Acting Nurse Manager General Manager, Acute Acting Nurse Manager

Guidelines reviewed and now state that fridges should be between 2 and 4 degrees Celsius. Fridge checklists amended with this information and implemented for all fridges on the AMH wards and Neonatal Unit. Fridges were assessed and as a result two replacement fridges were ordered and installed. Further, new thermometers were installed to all fridges. Management walk rounds are ongoing and where issues are identified with the recording of temperatures they are actioned swiftly. Risk assessment being led by Acting Nurse Manager with support from Infection Prevention and Control Team.

4 September

2013

3 September

2013

In progress

In progress

Req 7

Ensure that patient equipment is clean and that the procedure for the cleaning of patient equipment is understood by staff and fully implemented.


NHS Grampian





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Review cleaning schedules for domestic and nursing staff for patient equipment in the Neonatal Unit Review and clarify roles and responsibilities for the cleaning of patient equipment. Conduct a review of mattresses in AMH wards.

Review suitability of the labour ward beds and introduce measures to reduce risk of cross-contamination

Complete

31 October 2013

Complete

30 November 2013

Acting Nurse Manager/Head of Domestic Services General Manager of Estates and Facilities/Head of Nursing In-patient Services Midwifery Manager Nursing Suppliers Co-ordinator/ Head of Midwifery/ IPCT

Domestic cleaning schedule reviewed and signed off by the domestic service and the local team at AMH. A short-life working group to review the roles and responsibilities for cleaning of all patient equipment across NHS Grampian has been set up. This will inform future nursing and domestic cleaning schedules. All mattress inspected by senior management team. Review of labour ward beds by IPCT, Nursing Supplies Co-ordinator, senior management and manufacturer was undertaken on 4 September. The ward is currently trialling new beds from the manufacturer. All existing labour ward

4 October 2013

In progress

22 August 2013

In progress


NHS Grampian





7

Investigate problems with cleaning of the labour ward beds and introduce measures to reduce risk of cross-contamination

Deep clean all high risk patient equipment and areas of immediate concern in AMH. Training requirements for nursing and midwifery staff to be assessed and delivered. Continue to test new national Standard Operating Procedure for Cleaning of Reusable Patient Equipment in Aberdeen Maternity Hospital and

30 November 2013

Complete

30 November

2013 31 December

2013

Consultant Nurse HAI/Infection Prevention and Control Nurses Head of Midwifery Senior Charge Midwives/IPCT Nurse Consultant, HAI

beds have been deep cleaned. Established that the mechanical parts of the bed make it difficult to clean thoroughly without damage occurring. Issue to be raised at national procurement meeting. Following risk assessment, sample covers have been sourced and will be trialled. To support the deep cleaning undertaken an ongoing local programme of cleaning is in place while a system wide approach is agreed by the Short Life Working Group. Initial discussions have identified training needs. Training schedule being developed. Testing complete and feedback provided to Health Protection Scotland. Awaiting next update from national group

In progress

4 September

2013

In progress

In progress


NHS Grampian





8

implement final version. New system of weekly Senior Nurse Back to the Floor protected sessions throughout all acute areas in NHS Grampian to be implemented which will facilitate hot peer audit, education and enhanced visible leadership in support of the quality and safety agenda.

Ongoing

General Manager, Acute

System designed and communicated by General Manager during September and implemented from 1 October.

From 1 October

Rec a

Ensure that senior charge nurses and senior charge midwives have accountability for ward cleanliness.

Ensure senior charge nurses and senior charge midwives are aware of their accountability for the HEI agenda and its implementation in their area.

Complete General Manager, Acute/ Head of Nursing Acute

In 2009 a letter was issued to all SCN’s working at ARI, outlining their responsibilities for HEI. A further letter has been drafted to reaffirm responsibilities and amplify learning around HEI for Senior Charge Nurses & Midwives. This letter was issued to all Senior Charge Nurses and Senior Charge Midwives on all Acute Sector sites.

11 October 2013

Rec b

Ensure that all staff understand and implement the patient placement tool in line with local policy


NHS Grampian





9

Patient Placement Tool implemented across all wards in Aberdeen Maternity Hospital. Patient placement Tool to be used/trialled for use in NNU

Complete

31 October 2013

Head of Midwifery Acting Nurse Manager

The Infection Prevention and Control Team have advised all AMH ward areas on the implementation of the tool. The Head of Midwifery has confirmed that this has now been implemented. Patient Placement Tool trial underway.

16 August 2013

2 September

2013

In progress

Rec c

Review the storage areas in the neonatal unit.

Review storage areas. Complete

Acting Nurse Manager

General declutter and disposal of unnecessary items carried out.

3 Sept 2013

Rec d

Contact Health Protection Scotland to discuss and review the use of sterile polythene gloves in clinical areas and its compliance with the national glove selection policy.

See Requirement 4 response Rec e

Ensure that all staff understand and implement the ‘checklist for discharge bed space cleaning for nursing staff’ in line with the local policy.

Revised checklist to be implemented.

30 November 2013

Head of Midwifery

The revised checklist is now in place on all maternity wards in AMH. The Neonatal Unit are developing a specific version of

In progress


NHS Grampian





10

Monitor correct use of bedspace checklist

Complete

Head of Nursing, Acute

the checklist to account for the difference in bed space equipment. Correct use of the bed space checklist and staff understanding is monitored though sprint audits, spot checks of staff knowledge, quarterly environmental audits and the quality measures incorporated into the ‘Back to the Floor’ inspections now undertaken on a weekly basis across the Acute Sector sites.

10 October

2013

Rec f

Continue to review the monitoring framework for cleaning patient care equipment and its application, in partnership with Health Protection Scotland, to provide assurance that this system is effective.

See Requirement 2 response

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