Victoria Infirmary Sept 13

HEI Inspection

"We have identified six high priority requirements that we expect NHS Greater Glasgow and Clyde to address within the month. These include a requirement that staff follow the correct procedure for cleaning patient equipment, which we also identified as a requirement in our two previous inspections of the hospital. We will return to ensure action has been taken to improve standards of infection control, cleanliness and hygiene for patients using the Victoria Infirmary."

Susan Brimelow - Chief Inspector

Victoria Infirmary 

Healthcare Environment Inspectorate (HEI) unannounced inspection

Inspection dates: 23 and 24 July 2013

Summary of inspection

The Healthcare Environment Inspectorate (HEI) previously inspected the Victoria Infirmary in February 2012. That inspection resulted in three requirements and one recommendation.

We carried out an unannounced inspection to the Victoria Infirmary on Tuesday 23 and Wednesday 24 July 2013.

Inspection focus

We assessed the hospital against the NHS Quality Improvement Scotland (NHS QIS) healthcare associated infection (HAI) standards and inspected the following areas:

  • high dependency unit
  • intensive care unit
  • renal dialysis (New Victoria Hospital)
  • ward 8 (orthopaedics and trauma)
  • ward 10 (respiratory)
  • ward 15 (elderly care assessment)
  • ward 17 (general medicine)
  • ward south 2 (elderly assessment), and
  • ward Lomond View (elderly rehabilitation)

What the hospital did well

  • we found environmental audits were being carried out in all wards and departments inspected and that relevant action plans were also available, and
  • NHS Greater Glasgow and Clyde continues to comply with the requirements of mandatory surveillance for Clostridium difficile infection (CDI), surgical site infections andStaphylococcus aureus bacteraemias (SABs) as described within Health Department Letter (HDL) (2006)38 and Chief Executive Letter (CEL) 11(2009).

What the hospital could do better

  • ensuring that a managed environment is demonstrated in ward south 2 to minimise the risk of infection and ensure that improvement can be sustained.
  • ensuring that compliance with the national services cleaning specification is maintained in the healthcare environment, and
  • demonstrating compliance with the requirements of CEL 08(2013) and the Health Protection Scotland and National Services Scotland joint document.

This report highlights areas of strength and weakness as well as areas for further improvement, including requirements and recommendations.

This inspection resulted in six requirements and one recommendation.

NHS Greater Glasgow and Clyde must address the requirements and the necessary improvements made, as a matter of priority.

The improvement action plan for this inspection has now been removed from the HEI website, as the inspection took place more than 16 weeks ago. Please contact NHS Greater Glasgow and Clyde for further information on progress against this action plan.

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Published Date: 23 September 2013


Victoria Infirmary overview

Find out more about this hospital, including the latest inspection report, on the Victoria Infirmary 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.