In light of the incidences of patient deaths in hospital in June caused by an outbreak of listeria in prepacked sandwiches and salads it is important to examine how hospital-acquired infection is prevented and how the Care Quality Commission (CQC) inspections help hospitals to remain safe.
Background
One of the specific domains examined by CQC inspectors is safety. The safety domain encompasses many components and key lines of enquiry, but several of them pertain to cleanliness, infection control and hygiene, which CQC inspectors scrutinise as part of the inspection process. Specifically, they talk with nurses to ascertain their understanding of how infection control is managed at ward and pan-hospital level. They look for evidence that nurses know who the infection prevention and control (IPC) lead is in their trust and that individual wards and units have appointed link nurses for IPC. Furthermore, they will seek evidence that the trust holds regular IPC meetings, and how the lessons learnt from infection incidents are cascaded.
The CQC teams also examine the electronic training records of nurses to determine that they have received IPC preparation as part of mandatory training and that they have been appropriately updated. It is important to stress that all hospitals need to ensure staff have access to up-to-date policies and procedures on infection control, and the inspectors will appraise the trust intranet to see that staff can easily access these and, crucially, that policies are up to date and evidence based.
It is clear that in hospitals infection control is everyone's business: for this reason, all aspects of infection control information—and how visible this is to staff and visitors—are examined by CQC inspectors and their specialist advisors. Good clinical areas will routinely display their IPC data on visible dashboards, which are usually wall-mounted in public view, displaying, for example, data on handwashing audits. Inspectors will look at several months' worth of infection control data and discuss with nurses how patients requiring isolation are managed and how staff use personal protective equipment. How the results of IPC audits are communicated to staff is vital, and inspectors do ask nurses about IPC actions plans in light of audit results.
Cleanliness
Members of housekeeping and domestic teams are crucial to ward cleanliness and infection control. They are pivotal in ensuring patients are cared for in a clean environment and they work hard to ensure wards and equipment are kept hygienically clean at all times.
Cleaning services were one of the first parts of the NHS to be contracted out to private providers in the early 1980s when competitive tendering was introduced for cleaning, catering and other ancillary services. However, the impact of outsourcing cleaning services to the private sector has proved controversial, not least because although the outsourcing is associated with lower costs it is has also been associated with a greater incidence of MRSA.
Furthermore, Toffolutti et al (2016) concluded that it has led to a reduction in the numbers of cleaning staff, a worsening of patient perceptions of cleanliness, and staff perceptions of availability of handwashing facilities. This notwithstanding, it is the use of regular and permanent cleaning staff at ward level that appears to improve cleaning performance, especially when these staff are fully welcomed as part of the ward team and when they feel they are valued. Guidance on the frequency of cleaning should be available to domestic staff and CQC inspectors should regularly meet with members of the domestic staff workforce during inspections and ask to see cleaning schedules and protocols. Additionally, CQC inspectors observe that waste management is in line with national guidance and that colour-coded cleaning equipment (ie bin bags) is appropriately used.
The inspectors do conduct examinations of ward areas to determine if they are visibly clean, and talk with patients, friends and relatives to seek their opinions on the state of cleanliness of ward areas. They likewise ask patients if they have witnessed staff washing their hands before and after any procedure. Inspectors will also observe that staff hand hygiene practices are carried out correctly; they will also ask to see nurses' ward cleaning schedules for patient equipment, which are usually daily and weekly activities. Good clinical environments will have logbooks to record these cleaning activities, in which staff tick and sign them off. A sample of such patient equipment, for example, blood pressure cuffs, hoists and wheelchairs, will be examined for cleanliness during any inspection.
The dirty utility room (sluice area) is an obvious potential source of infection and CQC inspectors examine these for adherence to recognised cleaning practices. Many wards and departments now use dated and timed, green stick-on ‘clean’ labels, which are a visible method of implementing effective hygiene procedures. These stickers, which state ‘I am clean’, can be attached after disinfection to a range of patient equipment such as commodes to show that the object had been sanitised.
Other aspects of overall IPC compliance such as correct storage of linen, and sharps bin assembly and use are routinely assessed.
Food storage and hygiene
Outcome five of the CQC standards states that food and drink should meet people's individual dietary needs. Food and drink storage is an essential component of IPC practice. In context, CQC inspectors will routinely check to ascertain that the Control of Substances Hazardous to Health Regulations 2002 (COSHH) are fully applied within the clinical domain. The case of an 85-year-old woman who died after drinking floor cleaner that had been left in a water jug by her bedside can be used to illustrate this. Criticism of the NHS trust in question included that managers had failed to direct and monitor staff, adhere to and enforce COSHH (Mohdin, 2018).
CQC inspectors will always check that food is not being stored at higher than the recommended temperatures and examine the refrigerator temperature logs to ascertain that staff are following good practices, and that nothing other than food or drink is being stored. Similarly, when inspecting neonatal units, CQC inspectors will check the storage of human breast milk. Anecdotally, some years ago a CQC inspector discovered a tub of strawberry ice cream in the breast milk freezer! The storage of breast milk is important; Gharaibeh et al (2016) showed that some neonatal nurses have inadequate knowledge about issues such as the thawing process for frozen breast milk and the importance of maintaining storage temperatures.
In many hospitals, catering services have been outsourced, but because of the recent listeria outbreak some are considering a return to in-house catering. The latest outbreak has been attributed to a meat supplier whose produce was used in sandwiches and prepacked salads made by a company based in Staffordshire, which had been supplying 43 NHS trusts. After the death of 5 patients, products from the company were withdrawn and production halted (BBC News, 2019). However, NHS England, NHS Improvement and the Food Standards Agency (FSA) have confirmed that, although investigation into the outbreak continues, the risk to public health remains low (Public Health England, 2019).
Listeriosis is caused by the bacteria Listeria. It is uncommon and is usually transmitted via food products such as sandwiches and soft cheeses. Although not a significant bacterial infection risk in healthy humans, it can be fatal in groups such as debilitated elderly people or those with suppressed immunity. It can also pose a risk to pregnant women and their unborn babies (NHS website, 2017).
The sandwich, as we know it today, was allegedly invented in the 18th century by the 4th Earl of Sandwich, who is said to have asked for meat to be placed between two slices of bread to allow him to eat without leaving the gambling table (Food Timeline, 2015). Since then, sandwiches have been widely eaten in many societies and they remain a popular meal substitute, including among nurses.
The process of preparing a sandwich poses inherent risks, primarily because it involves significant food handling, following which the sandwich is consumed by the customer/patient without further cooking. This is not the first incidence of food poisoning in a hospital attributed to sandwiches. Mason et al (2001) discussed an outbreak of Salmonella that occurred in a Welsh hospital in December 2000, which affected 17 staff, relatives and patients. Subsequent epidemiological investigation identified egg mayonnaise sandwiches as the vehicle of infection.
Discussion
The humble sandwich is an extremely useful food product for various patients. It can be configured to contain all the nutrients necessary for recovery, such as protein, carbohydrate, fat, vitamins and vegetables. Sick children who may not eat a regular meal, causing their parents to worry about their lack of calorific intake, will readily nibble on a sandwich of their choice. Likewise, frail older patients who are often overwhelmed by a standard hospital plate of food will eat a sandwich. Sandwiches are useful in many clinical domains where patients will need to eat but where the timing or clinical venue is not appropriate for the serving of regular meals. For example, emergency departments and short-stay units depend on a regular supply of sandwiches to sustain their patients outside normal mealtimes.
However, although the sandwich is a useful food product for many patients most still need a wholesome breakfast, lunch, dinner and snacks in between. As with cleaning services, many catering services have been outsourced. This notwithstanding, hospital food standards became mandatory in the NHS in England in 2014. Since then, many trusts have embraced the recommended standards and 2 years on from their implementation patient surveys, including the annual Patient-Led Assessments of the Care Environment, have recorded improvements in the quality of food and, importantly, the overall quality of care around nutrition (Department of Health, 2017).
During CQC hospital inspections patient menus are examined and usually an inspector meets with one of the trust dietitians to assess how the dietetic department has been involved in developing the menus. The inspection team will observe how meals are served and how they are heated, especially if the hospital is using the common cook-chill method of food delivery. As with other aspects of infection control, food hygiene remains a high priority for NHS trusts.