Latest ratings on hospital cleanliness and food suggest things are getting better. From modern matrons to the ‘deep clean’, Lisa Hitchen examines the driving forces behind the changes
Patient Environment Action Team (PEAT) assessment scores for hospitals in England, published this month, suggest significant improvements in standards of cleanliness and food since last year.
The National Patient Safety Agency oversees the PEAT programme, which sends teams into all inpatient health facilities with 10 or more beds to inspect standards on food and the patient environment, including cleanliness. Both nurses and patients form part of these teams. The programme is voluntary but all hospital trusts took part this year.
Overall in 2008, 98.5% of organisations scored a rating of ‘acceptable’, ‘good’ or ‘excellent’ for their patient environment and 99.5% scored ‘acceptable’ or above on food. The overall numbers scoring in one of these three categories has not changed significantly from the year before but there has been a noticeable change in numbers scoring ‘excellent’ on both environment and food standards. These have risen significantly between 2007 and 2008 (see box) – jumping by 5% and 8%, respectively.
Scores of ‘unacceptable’ or ‘poor’ for hospital environment have also fallen dramatically.
So what has prompted this seemingly positive trend?
Graham Jacob is the NPSA’s lead on the PEAT programme. ‘This has been the trend since 2000 – an upward curve,’ he said.
‘That is what we are seeing with increasing resources and increasing focus with the 2006 Department of Health’s hygiene code of practice and the 2008–2009 Operating Framework, which places cleanliness as one of the five priorities of the NHS.’
He cites specific factors that he believes have helped achieve the improvements, such as the government’s controversial ‘deep clean’, ordered in September last year, and carried out by most trusts in March this year.
He said this could have had a positive effect on PEAT ratings, depending on whether assessments were carried out before or after the cleaning was completed. ‘But we would not want to suggest it was down to the deep clean. This is a year-on-year increase,’ he added.
However, Martin Kiernan, vice-president of the Infection Prevention Society and nurse consultant in infection prevention and control at Southport and Ormskirk NHS Trust, in Lancashire, felt the deep clean did not affect scores.
‘I would say that the improvements are likely to be due to continued investment and refurbishment of clinical areas, coupled with the closure of older facilities. Increasing public expectation and patient choice may also be drivers,’ he said.
Mr Jacob also cited the introduction of modern matrons and their increased responsibility for cleaning as a contributory factor in the improvements.
Combined with this was the Credit for Cleaning software programme that was introduced in at least 42 trusts, which enabled them to quantify the cleaning time requirements and allocate cleaning credits for each area, he said. While domestic cleaning services were allocated the majority of credits, some were given to modern matrons or ward sisters to use in their specific areas of responsibility.
‘They would have the other credits and use them as they wanted, for example for washing walls on a particular week,’ said Mr Jacob. ‘This is the accumulation of many things. If any one of these things had not been happened we would not have the result that we have.’
But exactly how trustworthy are PEAT scores?
The ratings in the Healthcare Commission’s latest inpatient survey on hospital trusts, published in May, present a different picture.
On food, trusts scored poorly, with 46% of patients surveyed rating it as ‘poor’ or ‘fair’ in both 2006 and 2007.
On cleanliness, patients’ views have remained fairly constant over the 2005–2007 period, with 6% rating hospital rooms as ‘not very clean’ and 9% over the last two years rating the toilets and bathrooms as ‘not very clean’.
But Mr Jacob said he considered the difference on cleanliness between the two rating systems as pretty marginal, with the low negative percentages in both sets of research being ‘broadly similar’ – although PEAT goes into more details with questions on decor, linen and other specifics.
On food the gap between the two was much greater. Again PEAT assessments ask more questions than the Healthcare Commission, which asks whether patients like the food.
‘We look at it in a more holistic sense – protected mealtimes, if choice is available, if the temperature of the food is acceptable and actually taste is only one of 15 components,’ said Mr Jacob.
‘But we have got a real issue with food even more than with cleanliness. You either like it or you don’t. It is a much greater gap but I’m not sure that we will ever bridge that gap,’ he added.
Another discrepancy arises when you consider organisations known to have had serious infection control issues, which appear to have shined under the latest PEAT assessments.
Ashford and St Peter’s Hospitals NHS Trust was recently issued with an improvement notice by the Healthcare Commission over a mattress cleaning facility that was an infection control risk and problems over decontamination of medical instruments.
However, the trust had PEAT scores of ‘acceptable’ and ‘good’ for patient environment and food respectively in 2007, rising to ‘acceptable’ and ‘excellent’ in 2008.
Mr Jacob is confident that he can explain the discrepancy. ‘This was an infection control issue not a cleanliness issue. We must recognise the distinction,’ he said.
He pointed out that PEAT does not have a technical manner of auditing nor does it go into details on infection control. And while infection control does form a part of its assessment, the focus is mainly on hand hygiene – the presence of alcohol handrubs and basins.
So why do some hospitals score better than others?
Under latest PEAT inspections, for example, Harrogate District Hospital has received ‘excellent’ ratings for both environment and food in the last two years.
An in-house domestic team was a contributing factor, according to Stuart Kelly, head of domestic services at Harrogate and District Foundation NHS Trust, which runs the hospital.
‘Our in-house domestic team are able to offer a consistent level of training and ongoing development to ensure that cleanliness standards are maintained,’ he said.
Food is also prepared fresh daily by trained chefs with a wide choice of meals available.
The trust has focus group sessions based on the views of its 14,000 members and members of the public to gauge opinion on hospital services. ‘This ensures that when assessments such as PEAT [happen], our facilities and standards of patient care are just what our patients have asked for and their views have made a difference,’ said Angela Monaghan, the trust’s chief nurse.
Only one organisation, Sussex Rehabilitation Centre in Shoreham for people who have had a stroke or brain injury, had the double negative ratings of ‘unacceptable’ for patient environment and ‘poor’ for food.
‘We know that food is a vital part of our care for patients and so we looked carefully at the issues raised by the inspection,’ said Wendy Jehan, director of nursing and governance at South Downs Health NHS Trust, which runs the centre.
‘Staff are ensuring that food is served quickly so that it is hot and we check the size of portions to make sure they are right for the needs of particular patients,’ she said.
‘As part of our commitment to improve the service we offer, we are now finalising plans to move our beds from Shoreham to
the Princess Royal Hospital at Haywards Heath later this year, where we can provide better surroundings close to related facilities such as a neurological centre,’ she added.
Taking the issues of food and cleanliness seriously, as Sussex Rehabilitation Centre were doing, was vital if poorly performing organisations were to up their game, said Mr Jacob.
‘In reported surveys, cleanliness has come up by the public as one of the top five priorities and in an NPSA survey, 99% of respondents said cleanliness was important in getting infections,’ he said.
Recognising the importance of cleanliness will remain key in an era of patient choice, he warned.
However, for now the NPSA is upbeat. Martin Fletcher, chief executive, said: ‘Both NHS trusts and the public can now view how their local hospitals have performed on making their facilities clean, comfortable and safer for patients.’