New cleaning regimes improve prognosis for a Kent hospital Trust

A Kent hospital that was at the centre of an investigation in 2007, following the deaths of an estimated 120 patients from C.difficile, has made "substantial improvements", according to a report issued by the Healthcare Commission last Friday. The report says that the Maidstone and Tunbridge Wells NHS Trust must maintain momentum and make further improvements.

Better standards of cleaning and staff training - helped by an extra £1million allocated to the cleaning budget - have been identified as key improvements. Extra cleaning staff have been appointed, new audit systems implemented, and urgent cleaning needs are being more rapidly addressed.

Improvements have also been made to the hospital environment: beds have been removed and new wash basins installed, to allow for appropriate spacing between beds and ensure improved levels of cleanliness. An ongoing process for infection control training has been implemented, including areas such as hand hygiene techniques and sharps handling. The infection control team also runs an extensive training programme for other members of staff.

Trust Chief Executive Glenn Douglas welcomed the report's findings, saying:

  "This very positive report. We are particularly pleased that our progress in implementing our action plan has been praised, as have the excellent infection control practices we have in place, and that the general high standards of cleanliness are recognised. The Trust is now spending £1 million a year more on cleaning than it used to. It has also launched a new nationally-recognised training scheme for its domestic staff ending in industry standard qualifications."

Other key improvements include:

* Specific wards allocated for the isolation of infected patients.

* Increased leadership, size and effectiveness of the infection control team led by a new director of infection prevention and control. There are two additional senior infection control nurses and a new microbiologist.

* C. difficile is now recognised as a serious diagnosis in its own right, and a 'care pathway' has been designed and implemented for patients with the infection, ensuring they receive timely and appropriate care.

* A re-structured board, with new non-executive directors and many new directors. This new structure has clear lines of reporting and processes for escalating issues up to the board. Infection control is a consistent item at the top of the board's agenda.

* There are also new clinical governance and risk reporting structures which allow the Trust to address key risks. A new head of governance and quality has been appointed who has revised the governance committee structure, creating four clinical governance directorates within the Trust.

An estimated 90 people are estimated to have died as a result of C. difficile, during two outbreaks of the infection at the Trust in 2005 and 2006. It is estimated that a further 30 patients may have died of C. difficile between April 2004 and September 2005.

Immediately following its investigation, the Commission called for a range of changes to the way the Trust cares for patients with infections and to its wider systems of prevention and control.

Now, in line with its normal practice after an investigation, the Commission has published its follow-up report detailing the Trust's progress in implementing the recommendations. It also published a report outlining findings from a routine spotcheck made in October 2008 to assess compliance with the hygiene code.

The Commission says the Trust has made "huge strides", putting considerable effort and resource into improving infection control. It commends the Trust for reporting its lowest rate of C. difficile infection in three years, for the period January to March 2008.

However the Commission has highlighted some areas that still require further work such as recruiting more nursing staff and learning from complaints and incidents.

The spotcheck in October found a number of breaches of the hygiene code and these included inconsistencies in the preparation of cleaning solutions. The most serious breach though related to decontamination of equipment in the endoscopy unit. This had been addressed by the time the Commission made its final investigation follow-up visit to the Trust in November.

Healthcare Commission head of investigations Nigel Ellis said: "This is a very different Trust to the one we investigated in 2007. It was never going to be easy to turn things around in just 12 months and indeed, there is still some way to go. But the substantial progress the Trust has made to improve the prevention and control of infection is commendable.

"Staff at every level have put in considerable effort to make these improvements and should be recognised for their hard work. Senior staff have demonstrated strong leadership and it is clear that infection control is now a top priority at the trust.

"However now is not the time to relax. The infection control systems still need further improvement. More nurses are needed and the Trust must make sure it learns from complaints and serious incidents. Above all, it must make sure the changes they have made are embedded in day-to-day practice and that improvements are sustained.

"The Trust must also address the remaining breaches of the hygiene code. Although these breaches are not considered to be an immediate threat to the safety of patients, they must be dealt with to ensure all necessary systems and processes are in place.

"What happened to patients at Maidstone and Tunbridge Wells NHS Trust was a tragedy. We have been working to make sure those lessons are learnt throughout the entire NHS so this is never allowed to happen again.

"Along with the South East Coast Strategic Health Authority, we will continue to monitor progress at the Trust and we look forward to seeing further improvements in the future."

Throughout last year, the Commission made a number of announced and unannounced visits to the Trust to check on progress in implementing the recommendations from the investigation.

In October, it also conducted a spotcheck to assess compliance with the hygiene code, as part of the Commission's ongoing programme of visits to every acute NHS Trust in England.

On this inspection, the Commission found that the Trust had invested in adequate isolation facilities, including a new C. Difficile ward. It also found that proper processes were in place to keep the board informed of issues relating to infection control and that the board demonstrated responsibility for infection control.

However, the Commission found the Trust breached parts of Duty 2 relating to infection control audits not being reflected in all Trust policies, low compliance with some audits and recommendations from audits not being followed through.

The Trust also breached several areas relating to Duty 4 including having inaccessible hand wash basins in one ward and inconsistencies in the preparation of cleaning solutions.

More seriously, in an endoscopy suite on the Kent and Sussex site the Commission found unclear manual cleaning processes, inappropriate movement of equipment to and through the room and a hand wash basin which was not easy to access and had inappropriate taps.

Immediately following this inspection the Commission asked the Trust to urgently conduct a risk assessment of all of the decontamination facilities in the endoscopy suite, identifying actions to be carried out.

The Commission checked the Trust had addressed the issues in the endoscopy suite when it visited the trust a month later as part of its review of progress in November.

It found the trust had reviewed and revised protocols, training and the movement of equipment in and to the suite. The hand wash basin taps had been replaced and a double sink for manual washing and rinsing of endoscopes had been ordered.

The Commission will check with the Trust in six months to ensure the remaining breaches identified in the hygiene code spotcheck have been addressed.

The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

www.healthcarecommission.org.uk

15th January 2009