Trust must maintain momentum and make further improvements
The Healthcare Commission today (Friday) welcomed substantial improvements in infection control at Maidstone and Tunbridge Wells NHS Trust since an investigation by the watchdog in 2007 identified serious failings.
An estimated 90 people definitely or probably died as a result of Clostridium difficile, during two outbreaks of the infection at the trust in 2005 and 2006. It is estimated that a further 30 patients definitely or probably 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.
Today, in line with its normal practice after an investigation, the Commission published a 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. The most serious breach 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.
Key improvements identified in the investigation follow-up report include:
- 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.
- 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.
- 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.
- Specific wards have been allocated for the isolation of infected patients.
- Better standards of cleaning and improvements to the hospital environment. Extra cleaning staff have been appointed, new audit systems implemented, and nurses find urgent cleaning needs are more rapidly addressed.
- The removal of beds and the installation of new wash basins to ensure appropriate spacing between beds and 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.
Areas requiring further work include:
- The recruitment of further nursing staff and continued work to ensure good basic nursing care.
- Improvements to how the trust learns from complaints, incidents and serious untoward incidents (SUIs). The system for responding to complaints also needs to be reviewed.
- The trust is currently in the process of appointing a new medical director to the board. It must ensure this happens as soon as possible.
- The trust must embed the new clinical governance structure in day-to-day practice, ensuring that staff at all levels understand and follow the new ways of reviewing clinical care.
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 for the trust to relax. The trust's 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 in order 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.
Hygiene code inspection report: Maidstone and Tunbridge Wells NHS Trust
Maidstone and Tunbridge Wells NHS review of progress
More information on Maidstone and Tunbridge Wells NHS Trust