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NSS Health Facilities Scotland

Professional Advice, Guidance and Support

NHS Scotland National Cleaning Compliance Report Domestic and Estates Cleaning Services Performance 2019/2020 Quarter 1: April 2019 – June 2019

August 2019

Version 2.0 - PUBLISHED: August 2019

Contents 1. Introduction ........................................................................................ 1

2. Background ........................................................................................ 3

NHSScotland Cleaning Compliance Map ........................................ 5

3. Domestic Services – Key Findings for 1st

4. Domestic Services - Graphs .................................................................. 9

Quarter .............................. 7

5. Estates Services – Key Findings for 1st

6. Estates Services - Graphs ................................................................... 14

Quarter ................................ 12

Appendix 1 – Methodology ....................................................................... 17

Version 2.0 - PUBLISHED: August 2019 Page 1 of 17

1. Introduction 1.1 Cleaning functions in NHSScotland are carried out as part of the duties of a

number of healthcare professionals; this includes Nurses, Domestics, Estates Officers, and Ambulance staff to name a few. Specific responsibilities for cleaning duties vary by Health Board and sometimes within each Health Board.

This report covers the cleaning functions carried out by Domestic staff and Estates staff.

As one part of their duties Domestic staff clean parts of the ward environment like the floors, toilets, sinks etc. They also clean other areas of the healthcare facility such as corridors, offices, foyer etc. They generally do not clean near patient equipment e.g. the patient bed tray, the upper half of the patient bed or drip stands etc.

In the context of this report, ‘Estates’ reporting refers to issues with the fabric of the building which impede effective cleaning activity. This report does not present information on the whole of the Estates function e.g. water systems, heating, ventilation etc across all healthcare facilities.

This report presents data on compliance with the requirements set out in the NHSScotland National Cleaning Services Specification (NCSS). The NCSS set out the requirements for the minimum frequency and methods of cleaning carried out by Domestic staff. It sets out the same requirements for Estates staff when cleaning the Estates fabric.

The report includes data on the 18 Scottish NHS Boards that offer inpatient services or deal directly with patients, as follows:

• the 14 NHSScotland Territorial Boards;

• 4 Special Health Boards - Golden Jubilee National Hospital, The State Hospitals Board for Scotland, Scottish Ambulance Service and the Scottish Blood Transfusion Service (part of NHS National Services Scotland).

All healthcare facilities and component parts e.g. wards, treatment rooms, corridors etc are expected to be at least 90% compliant with the requirements set out in the NCSS. Boards, zones or major sites (A1 and A2 hospitals) which receive an Amber or Red compliance rating must develop an action plan to address the issues identified through the monitoring process.

This will be submitted to Health Facilities Scotland, and a summary of the action plan will be included in this report.


The report indicates the status of each NHS Board using a traffic light system as below:

Colour Description Green compliance level 90% and above - Compliant

Amber compliance level between 70% and 90% - Partially compliant

Red compliance level below 70% - Non-compliant


2. Background 2.1 Healthcare Associated Infection (HAI) is a priority issue for NHSScotland, in

terms of the safety and well being of patients, staff and the public.

The HAI Task Force was established in 2003 to take forward the Ministerial HAI Action Plan ‘Preventing Infections Acquired While Receiving Healthcare’ (October 2002). Cleaning services are an essential part of the multidisciplinary approach to tackling HAI. For prevention and control of infection to work effectively, critical activities such as cleaning and hand hygiene have to be embedded into everyday practice.

As part of its work programme, the HAI Task Force developed the ‘NHSScotland Code of Practice for the Local Management of Hygiene and HAI’ and the ‘NHSScotland National Cleaning Services Specification’. These documents include guidance on cleanliness and hygiene, effectively setting minimum standards for the healthcare environment. They were issued to NHS Boards in May 2004.

The HAI Task Force commissioned Health Facilities Scotland (HFS) to develop a monitoring framework for the NHSScotland National Cleaning Services Specification. This was developed in consultation with a range of stakeholders within NHSScotland and was implemented in April 2006. The first quarterly report was published in August 2006 and covered cleaning provided by Domestic services in NHS facilities.

Estates Monitoring 2.2 In 2009 the HAI Task Force asked HFS to look at extending the scope of the

cleaning monitoring tool to cover Estates services as well as Domestic services.

HFS took forward this work in partnership with NHSScotland Boards and built the Estates monitoring system as an extension to the existing Domestic monitoring system.

In the context of this report, ‘Estates’ reporting refers to issues with the fabric of the building which impede effective cleaning activity. This report does not present information on the whole of the Estates function e.g. water systems, heating, ventilation etc across all healthcare facilities.

Monitoring and Improvement 2.3 Monitoring, in this context, is defined as the ongoing assessment of the

outcome of cleaning and Estates maintenance processes to assess the extent to which corrective procedures are being carried out correctly, to identify any remedial action which is required and to provide an audit trail.

An essential component of any monitoring framework is the fundamental principle of continuous improvement. Therefore, the monitoring framework not


only provides a reporting mechanism, but a rectification process that can be used locally to identify, prioritise and address issues of non-compliance.

Further information on the monitoring framework is available from www.hfs.scot.nhs.uk. The methodology behind the monitoring process is described in Appendix 1.

Facilities Monitoring Tool 2.4 From April 2012 a new Facilities Management Tool (FMT) became operational

across Scotland. The new tool has moved data collection from a paper and spreadsheet based data collection to a system that uses handheld devices and web based data transfer. This report is produced using data from the new system.

Facilities Support Team 2.5 The Facilities Support Team within Health Facilities Services is available to

boards as an additional support mechanism, to provide day-to-day support to FMT system users, and training and guidance where needed. In addition to this activity, the support team can provide site or board specific support if areas are experiencing issues meeting the compliance levels described in this report, or are seeking to improve the general quality and consistency of audit practice.

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3. Domestic Services – Key Findings for 1st

Key Findings – Pan Scotland

Quarter

3.1 Scotland’s overall total score in Quarter 1 for 2019/20 was Green at 95.3% which is slightly down on the previous quarter’s score of 95.6%.

Health Board Level Data • All NHS Boards have achieved an overall Green compliance rating except

NHS National Services Scotland (NSS)

• All A1 and A2 sites have achieved an overall Green compliance for Domestic services

Zone Level Data 3.2 In each NHS Board there are a number of zones reflecting how domestic

cleaning is managed and reported locally across the NHS Board. In larger NHS Boards there are a number of zones, in smaller NHS Boards there may only be one zone, which covers the whole of the NHS Board.

NHS Board and zone level cleaning audit data is presented graphically on pages 5 and 6.

NHS Orkney 3.3 NHS Orkney reported an Amber (partially compliant) board level domestic score

of 88.6% in Quarter 1, a decline from the previous Quarter result of 93.5%. NHS Orkney provided the following explanation:

“The 1st quarter was a real challenge for us, particularly from May onwards during the handover of our new facility. We were double running many services and struggled with the auditing process in the old Balfour Hospital during the May & June periods. We had to prioritise clinical cleaning and some of the non-clinical areas where items were being packed up for removal were not very accessible. We were also unable to complete some of our audits due to the system being down. We fully migrated to our new facility on 14th

HFS Perspective - NHS Orkney

June 2019 and our old site is now archived on the FMT system”.

3.3.1 NHS Orkney have described the challenges faced while moving into their new facility leading to a partial compliant score being recorded for this Quarter. HFS would expect to see a return to compliant scores in the next Quarter given the completed move to the new site within the board.


NHS National Services Scotland SNBTS 3.4 NSS SNBTS reported a compliant domestic score of 92.7%, presenting an

improvement on the previous Quarter score of 87.2%. NSS SNBTS provided the following describing how the improvement has been achieved:

“National Services Scotland audit results for April to June 2019 show significant improvements from audits carried out in quarter’s three and four of 2018/19 which were both found partial compliant.

As a result of the hard work and review carried out by Service leads, Supervisors, Domestic teams and HFS colleagues, as well as investment on equipment and training and development of staff the standards have improved and NSS are able to report a compliant standard of cleaning in quarter one of 2019/20.

It is important to acknowledge that an essential part of the NSS performance management has been utilising the FMT system appropriately to carry our reflective audits, providing a focus on the service standards. The involvement of Domestic teams throughout the review has provided them with better knowledge and understanding of the audit process, including the essential rectification process.

Investment has been made into training and development of staff; Environmental Excellence Training & Development Ltd (EET&D) were commissioned by NSS to provide training. EET&D delivered a number of training workshops focused on embedding cleaning related skills, knowledge of compliance, preparation to clean, infection prevention and control and the auditing process. Supervisors were also trained at award level to teach, with the expected outcome being they cascade the prior learning to their teams.

In an effort to further improve and focus on performance, work continues on training, development and the introduction of improved processes and procedures across National Services Scotland Domestic service”.

HFS Perspective – NSS SNBTS 3.4.1 NSS SNBTS have made a considerable effort in bringing there scores into a

compliant rating. Health Facilities Scotland commends the effort that has been made and continues to offer support to the team.


4. Domestic Services - Graphs 4.1 Domestic Cleaning Services Monitoring Tool – NHS Boards’ Performance

Health Board 1st

Apr - June 2019/2020

Quarter 2nd

July - Sept 2019/2020

Quarter 3rd

Oct - Dec 2019/2020

Quarter 4th

Jan - March 2019/2020

Quarter

NHSSCOTLAND 95.3 NHS Ayrshire and Arran 95.4 NHS Borders 97 NHS Dumfries and Galloway 96.2 NHS Fife 95.4 NHS Forth Valley 95.7 NHS Greater Glasgow and Clyde 94.9 NHS Golden Jubilee 99 NHS Grampian 93.3 NHS Highland 96.2 NHS Lanarkshire 96 NHS Lothian 95.6 NHS NSS SNBTS 92.7 NHS Orkney 88.6 NHS Scottish Ambulance Service 95.9 NHS Shetland 97.3 NHS State Hospital 97.4 NHS Tayside 94.8 NHS Western Isles 97.7

0 10 20 30 40 50 60 70 80 90

100

Perc

enta

ge C

ompl

ianc

e

Quarter 1 FY 19/20 - Domestic Results

Q1 - Dom Q2 - Dom Q3 - Dom Q4 - Dom

Green Amber Red


4.2 Domestic Cleaning Services Monitoring Tool – A1 Hospital Performance

4.3 Domestic Cleaning Services Monitoring Tool – A2 Hospital Performance

0 20 40 60 80

100

Aberdeen Royal

Infirmary

Edinburgh Royal

Infirmary

Gartnavel General Hospital

Glasgow Royal

Infirmary

Ninewells Hospital

Queen Elizabeth Uni Hosp

Western General Hospital Pe

rcen

tage

Com

plia

nce

Domestic Cleaning Services Monitoring Tool - A1 Hospital Performance

Q1 - Dom Q2 - Dom Q3 - Dom Q4 - Dom Green Amber Red

0 20 40 60 80

100

Perc

enta

ge C

ompl

ianc

e

Domestic Services Monitoring Tool - A2 Hospital Performance

Q1 - Dom Q2 - Dom Q3 - Dom Q4 - Dom


4.4 Domestic Cleaning Services Monitoring Tool – A1 Hospital performance

Hos

pita

l Ty

pe

Site 1st

Apr - June 2019/2020

Quarter 2nd

July - Sept 2019/2020

Quarter 3rd

Oct - Dec 2019/2020

Quarter 4th

Jan - March 2019/2020

Quarter

A1

Aberdeen Royal Infirmary 92.2

Edinburgh Royal Infirmary 96.5

Gartnavel General Hospital 95.5

Glasgow Royal Infirmary 95.3

Ninewells Hospital 93.6

Queen Elizabeth Uni Hosp 93.1

Western General Hospital 95.6

4.5 Domestic Cleaning Services Monitoring Tool – A2 Hospital performance

Hos

pita

l Ty

pe

Site 1st

Apr - June 2019/2020

Quarter 2nd

July - Sept 2019/2020

Quarter 3rd

Oct - Dec 2019/2020

Quarter 4th

Jan - March 2019/2020

Quarter

A2

Ayr Hospital 94.7 Borders General Hospital 97.6 Crosshouse Hospital 96 Dumfries & Galloway Royal Infirmary 96.3

Forth Valley Royal Hospital 96.8 Hairmyres Hospital 95.7 Inverclyde Royal Hospital 95 Monklands Hospital 95.2 Perth Royal Infirmary 95.3 Queen Margaret Hospital 96.9 Raigmore Hospital 95.2 Royal Alexandra Hospital 95.1 St. John's Hospital 96.1 Victoria Hospital, Fife 95.1 Wishaw General Hospital 96.4


5. Estates Services - Key Findings for 1st

Key Findings – Pan Scotland

Quarter

5.1 Scotland’s overall total score in Quarter 1 for 2019/20 was Green at 97%. This is a very slight decrease from the 97.7% achieved in the previous Quarter.

Health Board Level Data • All Health Boards have achieved an overall Green compliance rating

• All A1 and A2 hospitals have achieved a Green compliance rating

Zone Level Data In each NHS Board there are a number of zones, reflecting how domestic cleaning is managed and reported locally across the NHS Board. In larger NHS Boards there is a number of zones, in smaller NHS Boards there may only be one zone, which covers the whole of the NHS Board.

NHS Board and zone level cleaning audit data is presented graphically on pages 5 and 6.

NHS Forth Valley 5.2 NHS Forth Valley has reported three zones as Amber (partially compliant) for

Estates in Quarter 1. Bells’dyke improved slightly from 82.5% in the previous Quarter to 84.4% in Quarter 1, Falkirk Community Hospital showed a very slight improvement at 87.2% from the previous Quarter score of 87%, and FV North Sector marginally decreased from 90.6% to 87.7%.

NHS Forth Valley provided the following explanation:

“In an effort to pull our performance back into green compliance, NHS Forth Valley continues to invest considerably in implementing improvements to the physical environment within our properties and we continue to work closely with our Soft FM colleagues to ensure that this resource is targeted appropriately. We currently have a number of environment improvement projects underway with further capital expenditure planned during this and next financial years”.

HFS Perspective - NHS Forth Valley 5.2.1 NHS Forth Valley have described the investment which has been made for

implementing improvements to the physical environment. HFS would expect to see these improvement projects having a positive affect on the environment and ultimately move into a compliant audit and overall improvement in conditions at these sites over the coming Quarters.


NHS Grampian 5.3 NHS Grampian has reported one zone as Amber (partially compliant) for

Estates in Quarter 1. Dr Gray’s Hospital decreased slightly from 88.9% to 88.8% for this Quarter.

NHS Grampian provided the following explanation:

“Grampian continues to invest considerable resources targeting high priority areas using a risk based approach involving IPCT and Soft FM to include backlog maintenance issues. Day to day maintenance issues are prioritised in a similar fashion. During the Q1 period the sites that make up the Dr Grays audit area also had over 1000 planned maintenance tasks to undertake. NHSG strive to make best use of its limited resources”.

HFS Perspective - NHS Grampian 5.3.1 NHS Grampian have described the continuous issues they are facing within

their Estates and have a plan in place to target high priority areas using a risk based approach.

For the next Quarter HFS would expect to see an improvement in the score following the risk based approach which is currently being used within NHS Grampian with a sustained focus and continuous monitoring in order to achieve an overall improvement in the conditions at these sites.


6. Estates Services - Graphs 6.1 Estates Fabric Monitoring Tool – NHS Boards’ Performance

Health Board 1st

Apr - June 2019/2020

Quarter 2nd

July - Sept 2019/2020

Quarter 3rd

Oct - Dec 2019/2020

Quarter 4th

Jan - March 2019/2020

Quarter

NHSSCOTLAND 97.0 NHS Ayrshire and Arran 97.8 NHS Borders 99.5 NHS Dumfries and Galloway 99.1 NHS Fife 96.2 NHS Forth Valley 95.1 NHS Greater Glasgow and Clyde 96.6 NHS Golden Jubilee 99.9 NHS Grampian 94.1 NHS Highland 96.1 NHS Lanarkshire 98.6 NHS Lothian 96.7 NHS NSS SNBTS 96.8 NHS Orkney 99.5 NHS Scottish Ambulance Service 92.5 NHS Shetland 99.9 NHS State Hospital 98.1 NHS Tayside 99.0 NHS Western Isles 99.6

0 10 20 30 40 50 60 70 80 90

100

Perc

enta

ge C

ompl

ianc

e

Quarter 1 FY 19/20 - Estates Results

Q1 - Est Q2 - Est Q3 - Est Q4 - Est Green Amber Red


6.2 Estates Fabric Monitoring Tool – A1 Hospital performance

6.3 Estates Fabric Monitoring Tool – A2 Hospital Performance

0

20

40

60

80

100

Aberdeen Royal

Infirmary

Edinburgh Royal

Infirmary

Gartnavel General Hospital

Glasgow Royal

Infirmary

Ninewells Hospital

Queen Elizabeth Uni Hosp

Western General Hospital

Perc

enta

ge C

ompl

ianc

e Estates Fabric Monitoring Tool - A1 Hospital Performance


0 10 20 30 40 50 60 70 80 90

100

Perc

enta

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ompl

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e

Estates Fabric Monitoring Tool - A2 Hospital Performance




H

ospi

tal

Type

Site

1st

Apr - June 2018/2019

Quarter 2nd

July - Sept 2018/2019

Quarter 3rd

Oct - Dec 2018/2019

Quarter 4th

Jan - March 2018/2019

Quarter

A1

Aberdeen Royal Infirmary 95.4

Edinburgh Royal Infirmary 97.4

Gartnavel General Hospital 98.4

Glasgow Royal Infirmary 96.6

Ninewells Hospital 99.8

Queen Elizabeth Uni Hosp 94.5

Western General Hospital 95.6


Hos

pita

l Ty

pe

Site 1st

Apr - June 2018/2019

Quarter 2nd

July - Sept 2018/2019

Quarter 3rd

Oct - Dec 2018/2019

Quarter 4th

Jan - March

2018/2019

Quarter

A2

Ayr Hospital 95.6

Borders General Hospital 99.8

Crosshouse Hospital 98.3 Dumfries & Galloway Royal Infirmary* 98.9

Forth Valley Royal Hospital 98.1

Hairmyres Hospital 98.9

Inverclyde Royal Hospital 96.7

Monklands Hospital 96.6

Perth Royal Infirmary 100

Queen Margaret Hospital 95.6

Raigmore Hospital 95.7

Royal Alexandra Hospital 96.1

St. John's Hospital 94.8

Victoria Hospital, Fife 96.3

Wishaw General Hospital 99.3

* Dumfries and Galloway Royal Infirmary in a new location monitored from Q4 2017/18


Appendix 1 - Methodology Over the year, NHS Boards will monitor all facilities. Each Quarterly report covers monitoring of a proportion of the facilities/areas within an NHS Board area.

Compliance is assessed within NHS Boards using a standardised monitoring system, available online or offline on a handheld device.

There are two components to the monitoring:

• Audits carried out on a routine basis by Domestic Services Managers

• Audits carried out by Peer Review teams, incorporating a Public Involvement element

Cleanliness and the state of the Estate fabric are assessed using an observational process and according to the technical requirements set out in the NHSScotland National Cleaning Services Specification. The requirements vary depending on the type of area being assessed and the scores are weighted to reflect risk. For example, an operating theatre receives a higher weighting.

The rooms to be audited within the audit areas are selected at random in accordance with the monitoring framework guidance.

NHS Boards results are available to Health Facilities Scotland via the live online system. This data is used to compile the national Quarterly report and for local NHS Board reporting.

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