Hygiene inspections: trusts must clean up in fear of harsh penalties

If there is one thing that undermines public confidence in the NHS, it is failings in cleanliness and hygiene.

Since HSJ reported that 250 hospitals were given red ratings in the first patient environment action team inspections in 2001 - with one hospital toilet being described as similar to the filthy one in the film Trainspotting - the media has been obsessed with the cleanliness or otherwise of hospitals.

Last week, a Healthcare Commission report revealed 90 per cent of acute trusts subject to spot checks had failed to comply completely with the hygiene code.

Some of these failures were minor breaches, such as not displaying schedules of cleaning inspections, but in three cases there were material breaches, defined as an immediate risk to patients, leading to the commission serving an improvement notice. These three have now been re-inspected and have complied with the notices.

No immediate risk to patients

Despite the commission's arguments that many trusts were actually making good progress, it was the 90 per cent figure that caught the headlines.

The commission pointed out 97 per cent of the lapses did not represent an immediate risk to patients.

However, more than half the trusts inspected failed to keep all areas clean and well maintained.

One in five did not comply with all the requirements for decontamination and one in eight lacked adequate isolation facilities.

Three fifths did not set out cleaning standards in arrangements and schedules for cleaning.

Astonishingly, given the stress on this area, more than one in five did not meet standards for facilities for hand washing and hand rubs.

Not good enough

The Patients Association is unimpressed. "It's not enough," says head of special projects Vanessa Bourne. "It is perfectly possible to sort things out now."

She calls for disciplinary action against staff and for boards to be replaced if a safe service is not being provided.

But overall the report does show the NHS is moving forward - although whether this will be sufficient for all trusts to meet the requirements of the new Care Quality Commission when it starts work in April is far from certain.

NHS Confederation deputy policy director Jo Webber argues trusts are taking the hygiene code seriously.

"This is as much reputational as it is about quality and safety," she says. "Organisations do understand that they have to meet this code. For some of them it is more of a challenge than others."

Healthcare Commission acquired infections programme lead Christine Braithwaite says: "I think while we are finding areas where improvement is needed we have not found anywhere so filthy we want to shut the whole place down.

"But trusts are clearly taking the hygiene code seriously and implementing it."

She highlights two areas that caused most concern: decontamination, not just of surgical instruments but of other patient equipment such as commodes, and generally having a clean and well maintained environment.

"Cleanliness is seen as a proxy by patients for good care," she points out. Trusts served with improvement notices mainly had problems with decontamination.

NHS leadership

What lessons come out of this report? Leadership is important, says Ms Braithwaite. "We found a correlation between trust boards that were clearly exercising leadership and cleanliness on the wards."

This goes beyond just hearing about what is happening - although having an infection control director with direct access to the board is important - to include having assurance systems to ascertain what is actually happening.

The inspection regime is so well developed that it is not sufficient to have the skeleton of a policy without something to back it up. Training is an example of this: trusts were generally putting on training sessions for staff, which should ensure they are aware of their responsibilities and know how to carry them out. But some were not monitoring whether staff had attended or if they were putting what they had learned into practice.

Many of the trusts that failed to meet all the requirements of the hygiene code still met the annual health check standards on infection prevention and control, which look across a whole year and do not go into the level of detail of the code.

Good management

Is good management of cleanliness and infection control a marker for good management of trusts generally?

There is nothing in the commission's report to point directly to this. But successfully implementing the complex hygiene code and the monitoring and assurance framework needed to ensure it is in place and is working could demonstrate that a trust can use these methods in other areas of management.

So the public perception that cleanliness says something about the whole organisation may turn out to be true.

That said, there are a number of unanswered questions in the report. The first is around the link between finance and cleanliness and infection control. One trust served with an improvement notice was in financial difficulties, but some other trusts performed exceptionally well, despite having financial problems.

The commission did not examine correlations between the results and trusts' financial standing, although foundation trusts came out slightly better than other trusts overall.

However, both the reports into C difficile outbreaks at Buckinghamshire Hospitals and Maidstone and Tunbridge Wells trusts painted a picture of managers struggling with multiple priorities, including managing difficult financial situations.

Contract cleaners

And there is no indication of whether the way cleaning is provided affects cleanliness. While it has often been argued that contract cleaners can lead to lower standards of cleanliness, it is unlikely to be a straightforward link.

Unison points instead to the downward pressure on wages and hours that the tendering process puts on in-house cleaners as well as contractors. In theory, the agreement to raise contract wages to a normal NHS minimum or above should have reduced this - although this has yet to happen in all trusts.

But Unison national officer for health Dave Godson argues that in-house cleaning gives additional flexibility to deal with cleaning problems that arise.

Unison has commissioned research to look at possible links between the number of cleaning staff and changes in the incidence of MRSA. Although this has yet to be published, it is expected to show a link between reducing rates of MRSA and higher numbers of cleaners.

"We are continually trying to raise the profile of cleaning as we believe that it is the way forward to maintain a safe environment," Mr Godson says.

Safety imperative

Association of Healthcare Cleaning Professionals national chair Carina Bale argues that the money available for cleaning is important but on the whole, boards are now more willing to invest in it.

"I think most chief executives now have cleanliness tattooed on their foreheads - which is good, because we have had it tattooed on ours for years."

But some initiatives have been short term, making it impossible to invest in staff. "What the industry needs and does not have is staff on the ground," she says. "If you increase the number of staff you have to clean then your hospital will be cleaner."

Jo Webber suggests the position with cleaning and finance is likely to be very complex.

"The amount of cleaning you need is very variable," she says. "It depends on your building stock, for example."

Some buildings - mainly older ones - will be harder to keep clean and will involve more hours of work.

Preparing for the checks

So what happens in April when the Care Quality Commission comes into being?

All trusts must show they are protecting staff, patients and others from identifiable risks of healthcare associated infections if they are to register - although it is unlikely that minor breaches would result in the trust not being registered or having registration taken away.

But trusts that fail to do this could face sanctions and have conditions imposed on their registration.

More serious breaches could lead to temporary suspension or to registration being refused - although this would have to involve a significant risk to patient safety. However, the CQC has indicated it could use the power of suspension in cases where there is a large scale outbreak of an infectious disease - raising the possibility that hospitals could be closed temporarily. The commission can take this action immediately if patients are at risk.

Self-audit

The new regulator suggests trusts should audit themselves against the revised hygiene code and produce action plans before registration. Given the tight timescale (trusts must register between 12 January and 6 February, and will be notified of decisions in March), the CQC may be limited in how much checking it can carry out. But trusts that declared themselves non-compliant in the last health checks may get attention.

On paper, therefore, the powers of the CQC seem formidable - it could put hospitals out of business. But will these powers be used? No-one is certain how tough it will be, given the disruption that would be caused if wards or whole hospitals were suddenly closed.

Jo Webber says: "It is still about working with the organisation and trying to get things done."

However tough the new regulator turns out to be, trusts will have scant time for remedial action before it comes into being - and is able to impose sanctions - in April. Expect cleaners to be working overtime this coming spring.