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NORTHERN HEALTH AND SOCIAL CARE TRUST DOMESTIC SERVICES DEPARTMENT ANNUAL REPORT INDEX Page Objectives of the Domestic Services Department 3 Organisational Structure 4 Introduction 5 Monitoring
NORTHERN HEALTH AND SOCIAL CARE TRUST DOMESTIC SERVICES DEPARTMENT ANNUAL REPORT INDEX Page Objectives of the Domestic Services Department 3 Organisational Structure 4 Introduction 5 Monitoring of cleaning standards in Northern Health and Social Care facilities 6 Rapid Response Cleaning Teams in Antrim and Causeway Hospitals 7 Regulation and Quality Improvement Authority 8 Intensive clean programme 8 British Institute of Cleaning Science (BICS) cleaners operative Proficiency certificate level one 8 Environmental Cleanliness Focus Group s 9 User Involvement 10 Challenges 2012/ Retirement of Ann Hamilton, General Manager, Trustwide Domestic Services 12 2 OBJECTIVES OF THE DOMESTIC SERVICES DEPARTMENT The objective of the Domestic Services Department is to provide a high quality, safe and effective service to patients/clients, staff and visitors. The service provided by the department includes delivering a cleaning service to health care facilities, providing a food and beverage service to patients and clients, operating patient s personal clothing launderettes, operating the auto valet service at Causeway Hospital, managing staff on-call accommodation and staff residential accommodation. Domestic Service are delivered throughout the Trust in the most efficient and cost effective manner in the support of medical, nursing and allied services in the Northern Health and Social Care Trust by: Preventing the spread of infection by effective cleaning Provision of a socially acceptable environment Maintaining cleaning standards by frequent auditing of the patient environment Meeting the requirements of health and safety, food safety and other legislation Providing a trained and professional domestic services workforce Providing an appropriate managerial and supervisory structure Obtaining user feedback on the delivery of the domestic service within the Trust. 3 DIRECTORATE OF NURSING & USER EXPERIENCE CORPORATE SUPPORT SERVICES Maire Bermingham Assistant Director Corporate Support Services Ann Hamilton General Manager Trustwide Domestic Services Holywell Hospital Clare Medland Community Domestic & Portering Manager- Holywell Hospital Alan Stewart Domestic Services Manager- Antrim Area Hospital Francis Rocks Support Services Manager- Mid Ulster Hospital Doreen Reid Domestic Services Manager- Causeway Hospital Donald McWhirter Support Services Manager Whiteabbey Hospital 4 1. INTRODUCTION The year was a busy one for the Domestic Services Department in the Trust with the main emphasis on reducing the spread of infection by effective cleaning. Cleaning standards in hospitals and healthcare facilities were audited, in conjunction with nursing colleagues on a daily/monthly/quarterly and annual basis. Annual or managerial Environmental Cleanliness audits were undertaken in conjunction with Control of Infection personnel. Action plans were completed for all the audits. The Maximiser electronic auditing Tool was introduced in the Acute/Community Hospitals in December This system replaced paper audits using touch screen handheld devises. The Tool captures audit scores (PASS /FAIL) against checklist items and calculates scores for each area inspected i.e. Nursing, Estates and Support Services. A Full Report with an Action Plan is produced immediately, countersigned and forwarded to the appropriate Head of Service. The Tool also has a comprehensive reporting functionality that can demonstrate trends in service delivery and highlight where failures occur most frequently. The Maximiser system protocol has been produced to ensure that all staff involved in the monthly environmental audits for health and social care services understand the steps to be carried out emphasising the importance of their role. The Regulation and Quality Improvement authority (RQIA) carried out announced and unannounced hygiene and cleanliness inspections of the Trust s hospitals throughout the year. The NHSCT was a pilot site for the new Augmented Care Audit tool which was introduced following the Pseudomonas Outbreak and the recommendations outlined in the Professor Troop report. The Rapid Response Cleaning Teams in Antrim and Causeway hospitals continued to deliver an effective and responsive service in providing a safe and clean bed space/room for the admission of a new patient. The Rapid Response Cleaning Teams also played a vital role in the management of control of infection outbreaks. The number of terminal cleans, level 2 and 3, carried out by the Rapid Response Cleaning Teams at Antrim and Causeway hospitals was 32,263. Following the Listeria Outbreak in 2012 Domestic Assistants with Ward Pantry duties underwent Food Safety refresher training with the emphasis on maintaining food/refrigerator temperature records. Improving Clinical Environments funding was secured to refurbish a number of Ward Pantries in Antrim Hospital, addressing storage issues and to assist in reducing clutter. 5 Environmental Cleanliness focus groups were established for a number of hospitals/ facilities during , with the aim of improving the patient environment and overall experience. User Feedback questionnaires on the standard of domestic services were issued to patients and other service users in 2012/13 A more in-depth service satisfaction questionnaire was devised in 2012/13 and issued to inpatients and ward/department managers at Causeway Hospital. Positive comments regarding the domestic services were received. 2. MONITORING OF CLEANING STANDARDS IN NORTHERN HEALTH AND SOCIAL CARE FACILITIES their cleanliness matters scores Daily Observational Audit over the past year e.g. Dalriada Hospital and Holywell Hospital. The audit results are published in the Trust s Performance Report on a monthly basis and any facilities not achieving 85% are reported to the Director of Nursing and Patient User Experience along with an action plan for improvement. Daily observational audits are carried out each afternoon between 2pm and 4pm in Acute, Psychiatric and Community Hospitals. This is to ensure a high standard of cleanliness is being maintained on wards at all times. The audit is carried out by, the Team Leader or Domestic Supervisor and verified by the Ward Managers. This enables any issues arising to be dealt with immediately. Monthly Departmental Environmental Cleanliness Audit In accordance with the DHSSPS Cleanliness Matters Strategy, audits of cleaning standards are carried out on a once monthly basis using the Maximiser Electronic Auditing Tool. It is completed for very high risk areas e.g. ICU and high risk areas e.g. wards once per month, and once per quarter for moderate risk areas such as residential homes for the elderly, day centres and once every six months for low risk areas such as community services offices. The DHSSPS pass mark for the cleanliness matters audit is 85%. Several facilities have improved Annual/Managerial Environmental Cleanliness Audits An annual Managerial Cleanliness Audit is carried out by domestic services managers in conjunction with control of infection personnel. These audits assist in verifying the monthly departmental environmental cleanliness audit scores. Leading on from the Pseudomonas Outbreak an Augmented Care Audit tool was introduced as recommended by the RQIA. An action plan is compiled following the audit and a follow up meeting is carried out after 6-8 weeks to ensure all actions for improvement have been implemented. Senior managers in the Trust are informed of any issues not actioned and which may require funding to implement. 6 Patient Environment Leadership Walkabouts To ensure the Trust has a Board to Ward approach in reducing the spread of infection, senior managers including the Medical Director, Director of Nursing and User Experience, Assistant Director of Corporate Support Services, Assistant Director of Estate Services, General Manager Domestic Services Trustwide, Lead Nurses and Control of Infection sisters carry out Patient Environment Leadership Walkabouts. Any issues arising are noted and an action plan for improvement is devised for the appropriate personnel to take forward. The patient environment leadership walkabouts take place twice per month in the Antrim and Causeway Hospitals, monthly in Whiteabbey, Mid Ulster, Braid Valley and Moyle Hospitals and bimonthly in Community Facilities. 3. RAPID RESPONSE CLEANING TEAMS IN ANTRIM AND CAUSEWAY HOSPITALS The Rapid Response Cleaning Teams consist of domestic services staff who provide a 24 hour service, carrying out terminal cleans following the vacation of a room/bed space by a patient diagnosed with an infection or suspected infection. The terminal cleans level 2 and level 3, are carried out in accordance with control of infection protocols. The objectives of the Rapid Response Cleaning Teams are 1/ To carry out cleaning tasks as laid down in the control of infection protocol to reduce the transmission of healthcare acquired infections such as MRSA and C Difficile. 2/ To ensure bed spaces/rooms are cleaned effectively following an infection or suspected infection, in a timely manner to assist with patient flow throughout the hospitals. During the Rapid Response Cleaning Team completed 32,263 level two and three terminal cleans. 4. REGULATION AND QUALITY IMPROVEMENT AUTHORITY The Regulation and Quality Improvement Authority (RQIA) visited four Trust hospitals during Unannounced Cleanliness and Hygiene Inspections took place at Antrim Hospital on the 9 th October 2012 in C1, C4, C5, and A3, Causeway Hospital on the 14 th June 2012 in the Elective Surgical Unit and Medical 2, and at Whiteabbey Hospital on the 31 st May 2012 in Ward 3. Action plans were devised to address issues raised by RQIA during their visits. Feedback from the RQIA Inspections which included cleaning standards, reducing clutter, knowledge of staff on control of infection protocols and maintenance of the patient environment was generally satisfactory. 6. BRITISH INSTITUTE OF CLEANING SCIENCE (BICS) CLEANERS OPERATIVE PROFICIENCY CERTIFICATE LEVEL ONE. Since 2009 the Trust has been involved in the delivery of the BICS- Cleaning Operative Proficiency Certificate level one to domestic services staff. Up until March 2010 the training and assessment of the BICS COPC level one was delivered by BELBclean (Belfast Education and 5. INTENSIVE CLEAN PROGRAMME In all Trust hospitals there is a rolling programme of intensive cleans. An intensive clean is a multidisciplinary model where domestic services, nursing and estate services are involved in carrying out enhanced cleaning of wards, to ensure all reservoirs of bacteria are removed. The intensive cleans take place on a six monthly basis. Patients are decanted from ward bed spaces/rooms usually during a weekend, and the area is thoroughly cleaned. Items such as behind radiators, ceiling vents and light diffusers are included in the process. Specialised cleaning equipment is used for patient equipment such as commodes and hard to reach areas, for example, behind sanitary appliances. Library Board). However the Northern Health and Social Care Trust is now an accredited centre for BICS training and assessment. Mrs Doreen Reid, Domestic Services Manager, Causeway Hospital, delivers the BICS COPC level one training and she now has a team of three assessors and four trainers. During , 27 domestic services staff achieved the BICS COPC level one accredited qualification. 8 A celebration of achievement was held in December 2012 when Domestic Services staff received their certificates from Mr Jim Stewart, Trust Chairman. The terms of reference for the focus groups are as follows: 1/ To develop a multi-disciplinary forum to work together to improve standards. 2/ To highlight training needs for staff in relation to environmental cleanliness. 7. ENVIRONMENTAL CLEANLINESS FOCUS GROUP Environmental cleanliness standards in healthcare facilities require to be maintained in order to contribute to the prevention and control of healthcare acquired infections. Environmental Cleanliness Focus groups are well established in the Trust for: Holywell Hospital Dalriada Hospital Antrim Hospital ED A2 Causeway Hospital ED, and Surgical Wards Laundry Facility- Route Site The environmental cleanliness focus groups are chaired by the General Manager Domestic Services Trustwide and members of the groups include representatives from Control of Infection, Estate Services, Nursing, Governance Manager, Heads of Service, Assistant Director of Corporate Support Services and Domestic Services Manager. 3/ To explore how domestic services can be delivered more effectively. 4/ To provide a forum where regional strategies regarding environmental cleanliness can be discussed and implemented. 5/ To identify estate services issues which may prevent effective cleaning being carried out and agree a mechanism whereby these issues which cannot be rectified and require funding are highlighted to the appropriate directorate for action. Since the establishment of the environmental cleanliness focus groups there have been Improvement s in the standards of cleanliness in all of the targeted hospitals/facilities. Dalriada Hospital in particular was redecorated, new PVC windows installed and the domestic services in the hospital reorganised. These Action s improved the environmental audit Cleanliness Matters results. Audit scores are now reaching over 90% each month. The pass mark for DHSSPS cleanliness matters Audit s is 85%. 9 8. USER INVOLVEMENT In July 2012 a patient and ward manager satisfaction survey on domestic services was carried out at Antrim Hospital. A total of 75 Patients completed questionnaires which were sent to the Governance Department where a report was compiled. 78.7% of the patients commented that the standard of cleanliness at Antrim Hospital was very clean. 21.3% indicated that the standard was clean / acceptable. The Ward Manager questionnaire was issued to 31 managers and 22 completed replies were returned (71%). 81% of ward managers commented that their ward/department /facility was very clean with the remaining 18.2% indicating it was clean/ acceptable. Overall both the patients and Ward Managers at Antrim Hospital indicated that they were receiving a good standard of cleaning. Domestic Services staff have been informed of the results and this has improved staff morale in the hospital. There was a roll out programme in place for user satisfactory surveys to be issued to patients/clients and ward managers/departmental heads in the remainder of the Trust s Acute/ Community hospitals and the Psychiatric hospital in 2012/ CHALLENGES 2012/13 Financial pressures Domestic Services is an integral part of the delivery of care to patients and clients. Any increase in patient activity must be matched with adequate funding to ensure a clean and safe environment is provided for patients. New and refurbishment projects must be adequately funded for an effective domestic service to be provided. In light of the above the following challenges remain; The Domestic Services Department awaits funding from the Commissioner of 300,000 which is required to maintain the current standard of cleanliness throughout the Hospitals and reduce the spread of infection by effective cleaning. Funding for cleaning programmes linked to the Troop Report (15 recommendations) Funding for the continued rollout of BICSc training. Future Developments Challenges include; The possible replacement of the Maximiser Electronic Audit Tool. Closing outstanding actions on all Action Plans emanating from all audits to provide greater accountability for Governance. Waste Management review and roll out of training on new procedures. There will be new Transforming Your Care projects in the Trust in 2013/2014 and the domestic services management and staff will co-operate in meeting the challenge of change and providing improved services for patients and clients. 10 Retirement of Ann Hamilton, General Manager, Trustwide Domestic Services On Friday 29 th March 2013 after 32.5 years service to Domestic Services throughout the NHSCT, Ann Hamilton retired from her post. Her many colleagues and friends from all disciplines paid tribute to her long and valued commitment to the service by presenting her with gifts. Maire Bermingham, Assistant Director of Corporate Support Services thanked Ann for her many years of service to the Trust and wished her well for the future. Ann paid tribute to her many staff with whom she had worked over the years amidst all the changes that were encountered up to the present day. Over the years she valued the friendship and support of her colleagues and said she felt the time was right to change direction and explore new challenges. The Corporate Support Services Team presenting Ann with a gift to mark her retirement. From left: Maire Bermingham, Assistant Director of Corporate Support Services, Elsa Witherspoon, Tom Nelson, Judy Nelson & Violet Davidson. 11 12
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