An unannounced inspection was undertaken on 16 August 2018. Areas of good practice observed by HIQA during this inspection included:

• clear lines of accountability and responsibility in relation to governance and management arrangements for decontamination and reprocessing of reusable medical devices were in place
• a risk management system to identify, evaluate, control and monitor hazards and risks associated with the decontamination process was in operation
• training and education for staff working in decontamination was established
• quality improvement initiatives had been introduced
• management was in the process of addressing deficiencies in relation to decontamination facilities in the Endoscopy Unit; consideration was also given to centralising decontamination activity across the hospital.

Opportunities for improvement included:

• progression to automated validated systems for decontamination of all semi-critical ultrasound probes was required
• hospital management need to address challenges faced by equipment that goes beyond expected lifecycles
• timely review of policies and procedures is required.

An unannounced inspection was undertaken on 23 August 2018. Areas of good practice observed by HIQA included:

• following a risk assessment and previous concerns raised by HIQA around surgical instrument decontamination practices in theatres, the hospital had taken the decision to outsource decontamination to an external company as a risk mitigation measure
• clear lines of accountability and responsibility in relation to governance and management arrangements for decontamination and reprocessing of reusable medical devices
• a risk management system to identify, evaluate, control and monitor hazards and risks associated with the decontamination process
• monitoring, testing and evaluation systems, and outcome measures had been implemented
• validated automated systems for decontamination of all critical and semi-critical reusable medical devices were available at the hospital in line with best practice guidance.

Opportunities for improvement included:

• the hospital must continue to work towards a centralised model of endoscope decontamination
• infrastructure in the interventional radiology department should support the implementation of best infection prevention and control practices for semi-critical ultrasound probes
• frequency of hygiene audits requires review.

An unannounced inspection was undertaken on 11 September 2018.

It was identified during the course of the inspection that the hospital had not implemented a track and trace system in relation to nasopharyngeal endoscopes in the Outpatient Department. HIQA sought assurances from hospital management in relation to managing this risk and such assurances were provided.

Areas of good practice observed by HIQA included:

• clear lines of accountability and responsibility in relation to governance and management arrangements for decontamination and reprocessing of reusable medical devices; the hospital had appointed a dedicated decontamination lead
• a risk management system was in place to identify, evaluate, monitor hazards and risks associated with the decontamination process
• training and education for staff working in decontamination was well established.

Opportunities for improvement included:

• progression to automated validated systems for decontamination of all semi-critical reusable medical devices was required
• hospital management need to address challenges faced by equipment that goes beyond expected lifecycles
• a need to address deficiencies in relation to decontamination facilities across the hospital.

An unannounced inspection was undertaken on 27 September 2018. HIQA identified a lack of clarity in relation to reporting relationships at the hospital. In line with national guidance, the hospital should ensure that a designated person with responsibility for reusable invasive medical device reprocessing within Ennis Hospital is in place. 

Management needs to ensure adherence to national guidelines with a system of feedback to the quality and risk committee (or appropriate committee) on the action taken by wards and departments.

National guidelines recommend that decontamination services should be provided within central locations such as Endoscopy Decontamination Units and Central Decontamination Unit to remove the need for decontamination to take place in or near patient areas. The hospital had also identified and escalated these risks in line with the HSE risk management system.

It is recommended that the hospital reviews decontamination technologies in order to facilitate the recommended national standards of disinfection for nasopharyngeal endoscope decontamination.

An unannounced inspection was undertaken on 12 October 2018. Areas of good practice observed by HIQA included:

• hospital management had almost completed the process of addressing deficiencies in relation to the satellite decontamination facility in the Operating Theatre Department by outsourcing decontamination service provision to an external service provider in the interim of proposed on-site capital development plans
• clear lines of accountability and responsibility and management arrangements in relation to decontamination and reprocessing of reusable medical devices
• a risk management system was in place to identify, evaluate, monitor hazards and risks associated with the decontamination process
• training and education for staff working in decontamination was established
• up-to-date policies, procedures and guidelines were available to support staff
• validated automated systems for decontamination of all critical and semi-critical reusable medical devices were available
• frequency of hygiene audits conducted was appropriate to the risk associated with the functional area.

Opportunities for improvement included:

• a suitable dedicated non‐clinical space for decontamination of semi‐critical ultrasound probes in the X-ray Department is identified
• ventilation systems in the Operating Theatre are in line with best practice guidance
• delays in uploading incidents to the National Incident Management System be addressed.

An unannounced inspection was undertaken on 2 November 2018. Areas of good practice observed by HIQA included:

• following a risk assessment and previous concerns raised by HIQA around surgical instrument decontamination facilities and infrastructure in the Operating Theatre Department, the hospital had taken the decision to outsource decontamination to an external company as a risk mitigation measure
• there were clear lines of accountability, responsibility and management arrangements in relation to decontamination and reprocessing of reusable medical devices
• a risk management system was in place
• good reporting of decontamination-related incidents
• training and education for staff working in decontamination was well established.

Opportunities for improvement included:

• a suitable dedicated non‐clinical space for decontamination and storage of semi‐critical ultrasound probes in the Radiology Department is identified
• validated automated systems for decontamination of all semi-critical reusable medical devices are progressed
• policies, procedures, standard operating procedures and guidelines are reviewed promptly to ensure that staff have access to the most up-to-date documents to support practice
• frequency of hygiene audits needs to be appropriate to the risk associated with the functional area  
• ongoing validation of processes based on outcome measurements and microbiological testing on surgical instruments or endoscopes kept overnight and transported for decontamination the following day takes place.