Monday 11 February 2013
HEI Inspection Report: Queen
Margaret Hospital, NHS Fife
The Healthcare Environment Inspectorate
(HEI) today (Monday) published its report relating to an
unannounced inspection visit to Queen Margaret Hospital on 29
HEI has been set up to help reduce
healthcare associated infection risk to patients through a rigorous
inspection framework. The HEI inspection team examined NHS Fife’s
self-assessment information and then inspected the hospital to
validate this information, meet patients and staff, and visit wards
and departments to assess how clean the hospital was and if it was
meeting national standards.
The findings from the visit are set out
below, and cover four requirements that NHS Fife is fully expected
to address, plus seven recommendations for improvement.
The full HEI inspection report and an
improvement action plan developed by NHS Fife to address the
identified issues are available to view at
Speaking of the report, Susan Brimelow, HEI Chief Inspector,
said “Overall we found that NHS Fife is complying with the majority
of standards to protect patients, staff and visitors from acquiring
an infection. Staff were aware of their individual responsibilities
for infection prevention and control, and we noted good compliance
with uniform and dress code among staff. However, we also
identified a number of areas for improvement including that NHS
Fife must ensure that staff comply with standard operating
procedures for cleaning patient equipment, including commodes. NHS
Fife must also formalise a plan, with an identified date, for
removing carpets in clinical areas in order to comply with national
guidance on infection prevention and control. We expect NHS Fife to
address these areas as a matter of priority.”
NHS Fife must:
- Formalise a plan, with an identified
date, for removing carpets in clinical areas in order to comply
with national guidance on infection prevention and control in the
- Ensure that staff are made aware of,
and implement, the cleaning schedule relevant to each individual
unit, ward or department.
- Ensure that where a Peripheral
Vascular Catheter (PVC)* is in place, staff are adhering to the
local policy and completing the care bundle documentation**. This
is to ensure that the PVC care bundle is implemented consistently
and the risk of infection to the patient is reduced.
- Ensure that staff comply with
the standard operating procedure for the cleaning of patient
equipment, including commodes. This will ensure satisfactory
standards of cleanliness and ensure compliance with the NHS
Scotland code of practice for the local management of hygiene and
healthcare associated infection (HAI)(2004).
NHS Fife should:
- Ensure there are systems in place that
provide assurance that the senior charge nurse has a responsibility
for all aspects of ward environment cleanliness. This is in
accordance with Health Department Letter (HDL) 2005(7).
- Ensure that policies in relation to mattress
checks are consistently implemented and recorded. This will provide
assurance that mattresses are clean and fit for purpose at all
- Carry out a risk assessment and take any
appropriate actions on the continued use of sinks, which have
plugs, and non-compliant taps. This is to meet national published
guidelines advising that such taps and plugs should not be used in
- Undertake an evaluation of the damage to the
fabric in the minor injuries unit to ensure remedial works are
appropriately prioritised and action taken.
- Ensure a suitable and effective cleaning
system is implemented for items of equipment such as patient
transport chairs and trolleys.
- Ensure that the system for estates work is
used fully, which includes recording when works have been
completed. This will ensure staff are aware of what work has been
completed and what work is outstanding.
- Ensure that HAI information is easily
accessible to all patients and visitors. This will ensure that
patients and visitors are receiving appropriate information on
infection prevention and control and HAIs.
Notes to Editors
* PVCs (peripheral vascular catheters)
are tubes which are inserted into peripheral veins to administer
medicines, fluids etc.
** PVC (peripheral vascular catheter)
care bundle refers to documentation relating to the use of
catheters which are inserted into peripheral veins.
The Healthcare Environment Inspectorate (HEI)
was established in April 2009 to undertake at least one announced
and one unannounced inspection to each acute hospital in
NHSScotland every 3 years. The Scottish Ambulance Service and the
State Hospitals Board for Scotland have been included in this
inspection programme since October 2010.
The HEI focus is to reduce the healthcare
associated infection risk to patients through a rigorous inspection
framework. Specifically HEI focus on:
- providing assurance to the public, NHS
boards, and the Scottish Government that patients are as safe as
possible from HAIs and their consequences; HAI standards in NHS
acute hospitals are high; and any HAI issues are being tackled,
- improving infection prevention
measures across NHSScotland through an inspection framework,
leading to a decrease in HAIs and their consequences over
Each inspection is led by an experienced
inspector, and supported by a small team which includes a volunteer
inspector to make sure members of the public are involved in the
work of the Inspectorate.
Further information about HEI, its inspection
visits, and methodology and audit tools used can be found at
All requirements in this report are linked to
compliance with national Healthcare Associated Infection (HAI)
Standards – published in March 2008 by NHS Quality Improvement
HEI is a key component of Healthcare
Improvement Scotland, a health body that provides evidence,
improvement support and scrutiny to help improve the quality of
healthcare provided by the NHS and independent healthcare providers
All media enquiries should be
Rob MacPhail, Communications Officer,
Healthcare Improvement Scotland on 0141 225 6992; mobile 07855 838
Published Date: default