VH QMH Oct 17

Urinary catheters are required at times to enable short or long term bladder drainage. However, their use is associated with an increased risk of infections by enabling micro organisms to gain entry to the bladder. For this reason, Healthcare Improvement Scotland has begun to target the safe management of urinary catheters through inspections of acute hospitals.

“During the inspection of acute hospitals in NHS Fife, we found good staff awareness of the need to consider alternatives to urinary catheterisation and saw that urinary catheter insertion checklists were being used in the majority of areas and their use was well embedded in ward areas. However, NHS Fife must ensure that all staff adopt an approved method of glove usage during the preparation and insertion of urinary catheters.”

Alastair McGown, Senior Inspector for Healthcare Improvement Scotland

NHS Fife: Victoria Hospital, Queen Margaret Hospital

Healthcare Environment Inspectorate (HEI) unannounced inspection of urinary catheter care

Inspection dates: 22–24 August 2017

Summary of inspection

During these inspections, we will focus on each NHS boards’ management of invasive devices (urinary catheter care) and review the key areas of the patient journey and their performance against Standard 7 of Healthcare Improvement Scotland’s Healthcare Associated Infection (HAI) Standards (February 2015). Standard 7 states: "Systems and processes are in place to ensure the safe and effective use of invasive devices, for example peripheral venous catheters, central venous catheters and urinary catheters."

We may also inspect against other Healthcare Improvement Scotland’s HAI standards during these inspections.

We carried out an unannounced inspection reviewing invasive devices (urinary catheter care) in NHS Fife from Tuesday 22 to Thursday 24 August 2017. We carried out this inspection in the following NHS Fife hospitals, across multiple ward areas.

  • Victoria Hospital,Kirkcaldy,is a 640-bedded hospital providing a wide range of services to patients across the region, including accident and emergency and minor injuries services.
  • Queen Margaret Hospital, Dunfermline, is a 193-bedded hospital providing healthcare services to people within the Fife area.

What NHS Fife did well

  • Urinary catheter insertion checklists were being used in the majority of areas.
  • Urinary catheter daily maintenance care plans have been well embedded in ward areas.

What NHS Fife could do better

  • Agree clear guidelines on the approved method of glove use during the insertion of urinary catheters and ensure all staff adhere to these guidelines.
  • Staff should beaware of audit activity and results relating to urinary catheter insertion checklists and daily maintenance care plans. Staff should know what actions must be taken to improve practices.

This inspection resulted in two requirements and two recommendations. The requirements are linked to compliance with the Healthcare Improvement Scotland HAI standards. A full list of the requirements and recommendations can be found in Appendix 1 on page 14.

NHS Fife must address the requirement and make the necessary improvements within the stated timescales.

Published Date: 31 October 2017


Victoria Hospital overview

Find out more about this hospital, including the latest inspection report, on the Victoria Hospital overview page.

Queen Margaret Hospital overview

Find out more about this hospital, including the latest inspection report, on the Queen Margaret Hospital overview page.

Types of inspections

Inspections may be announced or unannounced and will involve physical inspection of the clinical areas, and interviews with staff and patients. We will publish a written report 8 weeks after the inspection.

  • Announced inspection: the service provider will be given at least 4 weeks’ notice of the inspection by letter or email.
  • Unannounced inspection: the service provider will not be given any advance warning of the inspection.
  • Follow-up inspection: the NHS board and hospital may or may not be given advance notice of the inspection. A safety and cleanliness follow-up inspection will take place no later than 26 weeks from the publication of the initial report.