Yr Amgylchedd

Aed ati i ailgynllunio wardiau ysbyty ac amgylcheddau unedau er mwyn helpu i leihau'r risg o drosglwyddo COVID-19, a chadw'r staff a'r cleifion yn ddiogel. Fodd bynnag, ar adegau nodwyd na chymerwyd camau i fynd i'r afael â phroblemau a godwyd drwy archwiliadau ac asesiadau risg amgylcheddol arferol. Mae'n bwysig bod adrannau a byrddau iechyd yn ystyried hyn, er mwyn sicrhau bod camau prydlon yn cael eu cymryd i gadw eu staff a'u cleifion yn ddiogel ac iach. Tynnir sylw at hyn yn ddiweddarach, yn yr adran ar Atal a Rheoli Heintiau.

Gwelwyd mesurau arloesol ar waith, gyda rhai byrddau iechyd yn sicrhau bod eu cleifion yn cael dyfeisiau electronig personol er mwyn eu helpu i gadw mewn cysylltiad â theulu a ffrindiau yn yr ysbyty. Bu hyn yn hanfodol er mwyn helpu cleifion neu eu teuluoedd i deimlo llai o ofid ac unigrwydd. Dylai adrannau a byrddau iechyd barhau i ystyried effaith bosibl cyfyngu ar ymweliadau ar y cyfle i deulu neu ofalwyr ddarparu cefnogaeth, neu gymryd rhan mewn trafodaethau neu wneud penderfyniadau am ofal cleifion. Er mwyn sicrhau bod systemau cyfathrebu a chefnogaeth effeithiol ar waith o hyd o ran gofal cleifion, a lles cleifion a'u teuluoedd, mae'n bwysig parhau i gymryd camau priodol i hwyluso hyn. Yn yr un modd, dylai fod trefniadau clir i deulu a gofalwyr gadw mewn cysylltiad ag adrannau, yn enwedig lle na all cleifion gysylltu â theulu heb help a chefnogaeth ragweithiol.

Atal a Rheoli Heintiau

Mae trefniadau atal a rheoli heintiau priodol ac effeithiol yn parhau i fod yn hollbwysig yn ystod y pandemig. Dros y misoedd diwethaf, gwelwyd achosion o COVID-19 mewn sawl ysbyty. Rhaid sicrhau bod achosion yn cael eu rheoli'n effeithiol, a bod camau yn cael eu cymryd i leihau'r risg o drosglwyddo COVID-19 ymhellach. Ar y cyfan, cymerwyd camau priodol yn dilyn achosion o COVID-19 mewn ysbytai, a rhannwyd y gwersi a ddysgwyd â'r staff a phob rhan o'r sefydliad dan sylw. Mae hyn yn hanfodol er mwyn helpu i atal lledaeniad COVID-19 mewn ysbytai (trosglwyddiad nosocomiaidd).

Roedd yn gadarnhaol nodi, yn unol â chanllawiau Iechyd y Cyhoedd, fod trefniadau lefel uwch wedi'u cyflwyno ledled Cymru, gyda'r nod o ostwng cyfraddau trosglwyddo nosocomiaidd. Fodd bynnag, mewn rhai ardaloedd, roedd archwiliadau atal a rheoli heintiau yn rhy hen, neu roeddent wedi cael eu cwblhau ond ni ddysgwyd fawr ddim gwersi. Mae hyn yn debyg i'r canfyddiad ar gyfer asesiadau risg amgylcheddol, ac mae'n atgyfnerthu'r neges y dylai pob adran sicrhau bod prosesau archwilio a rheoli risg yn gadarn drwyddi draw.

Mae trefniadau ar waith i sicrhau bod staff yn gallu cael gafael ar Gyfarpar Diogelu Personol (PPE) priodol, a darparwyd hyfforddiant ar sut i'w ddefnyddio'n gywir yn gyffredinol. Fodd bynnag, mae'n bryder bod rhai o'r staff sy'n gweithio mewn ardaloedd risg uwch sydd angen lefel uwch o PPE wedi profi niwed i'r croen, syndrom llygad sych a blinder. Gwyddom fod rhai byrddau iechyd yn darparu llwybrau carlam i wasanaethau dermatoleg ac offthalmoleg i'r rhai sydd angen y cymorth hwn, a dylai byrddau iechyd sicrhau bod hyn yn wir ledled Cymru.

Mae prosesau ar waith yn y rhan fwyaf o ardaloedd i asesu'r risg o adleoli staff sy'n glinigol fregus neu sy'n wynebu mwy o risg o COVID-19, sy'n cynnwys ystyried grwpiau Pobl Dduon, Asiaidd a Lleiafrifoedd Ethnig. Fodd bynnag, lle y bo'n gymwys, gwnaethom uwchgyfeirio pryderon, yn dilyn Gwiriadau Ansawdd, lle nodwyd nad oedd asesiadau risg wedi cael eu cwblhau. Os na chynhelir asesiadau risg, gall beryglu iechyd a diogelwch staff, a rhaid sicrhau bod prosesau cadarn ar waith ym mhob adran i sicrhau bod staff risg uchel yn cael eu nodi'n brydlon.

Yr Amgylchedd

Drwy gydol y pandemig, defnyddiwyd ysbytai annibynnol fel amgylcheddau heb COVID-19 er mwyn darparu gofal brys wedi'i drefnu, fel llawdriniaeth ar ran y GIG. Bu'r gefnogaeth hon yn hanfodol a gwelwyd cryn ymdrech i gadw ysbytai annibynnol ar agor. Fel rhan o hyn cynhaliwyd asesiadau risg amgylcheddol cadarn, cynhaliwyd profion COVID-19 cyn derbyn cleifion, a gofynnwyd i gleifion hunanynysu cyn iddynt ddod i'r ysbyty. Mae prosesau profi a brysbennu newydd ar waith ym mhob ysbyty, sy'n anelu at nodi unrhyw gleifion â symptomau COVID-19 posibl.

Rydym yn ymwybodol o fentrau newydd a gyflwynwyd i helpu i gadw cleifion yn ddiogel yn ystod pandemig COVID-19. Mae hyn yn cynnwys un darparwr a gyflwynodd 'llwybrau cleifion' mewn lliw er mwyn helpu i dywys cleifion o amgylch yr ysbyty. O dan y model hwn, mae'r llwybr y bydd y claf yn ei ddilyn yn dibynnu ar y gofyniad i gael prawf COVID-19 a hunanynysu cyn yr apwyntiad, a'r rheswm dros yr ymweliad. Credwn fod hyn yn fenter gadarnhaol, gan ei bod yn diffinio taith gofal iechyd briodol i'r cleifion ac, yn enwedig, y rhai sy'n fregus yn glinigol er mwyn helpu i leihau'r risg o haint posibl.

Atal a Rheoli Heintiau

Mae trefniadau atal a rheoli heintiau priodol ac effeithiol yn parhau i fod yn flaenoriaeth, ac maent yn hanfodol yn ystod y pandemig. Wrth lunio'r bwletin Arsylwi ar Ansawdd hwn, nid ydym wedi cael gwybod am unrhyw achosion o gleifion yn dal COVID-19 mewn ysbyty annibynnol.

Roedd yn gadarnhaol nodi, yn unol â chanllawiau Iechyd y Cyhoedd, fod trefniadau lefel uwch wedi'u cyflwyno ledled Cymru, gyda'r nod o ostwng cyfraddau trosglwyddo nosocomiaidd. Fodd bynnag, roedd un ward lle na chafodd archwiliad atal a rheoli heintiau ei gwblhau am dri mis. Mae hwn yn bryder, ac mae'n bwysig bod darparwyr yn parhau i ganolbwyntio ar y maes hwn.

Mae trefniadau ar waith i sicrhau bod staff yn gallu cael gafael ar Gyfarpar Diogelu Personol (PPE) priodol, a darparwyd hyfforddiant ar sut i'w ddefnyddio'n gywir. Mae hyn yn cynnwys rhoi hyfforddiant diweddaru i staff sy'n dychwelyd i'r gwaith ar ôl bod ar ffyrlo. Rydym hefyd yn ymwybodol o fentrau newydd sydd wedi cael eu cyflwyno mewn ysbytai annibynnol er mwyn helpu i leihau'r risg o drosglwyddiad nosocomiaidd. Un fenter o'r fath oedd sicrhau bod 'sgrybs' ychwanegol ar gael i'r staff, sy'n golygu y gellir golchi dillad gwaith ar y safle yn hytrach na bod staff yn gorfod mynd â dillad adref i'w golchi.

Drwy ein proses digwyddiadau hysbysadwy, nodwyd un ysbyty annibynnol lle roedd nifer bach o'r staff wedi cael canlyniad prawf COVID-19 positif. Ers hyn, mae'r gwasanaeth wedi ein sicrhau ei fod wedi ymchwilio i'r digwyddiad ac wedi ymateb yn briodol, gan roi hyfforddiant ychwanegol i'r holl staff. Mae'n hanfodol bod pob aelod o'r staff yn cael ei atgoffa'n rheolaidd o sut i ddefnyddio PPE yn gywir, a bod angen cadw pellter cymdeithasol wrth ryngweithio â'i gilydd.

• Roedd deintyddfa yn anniben ac roedd eitemau ynddi nad oedd modd eu glanhau'n effeithiol
• Nid oedd PPE yn cael ei newid ar ôl Gweithdrefn sy'n Cynhyrchu Aerosol, a chyn dechrau glanhau
• Tystiolaeth annigonol o gydymffurfio â'r cyfnod segur rhwng gweithdrefnau, a heb gofnodi'r amser lle gorffennodd y rhan o'r driniaeth a oedd yn cynhyrchu aerosol
• Ni chadarnhawyd nifer y cyfnewidiadau aer yr awr gan arbenigwr
• Nid oedd cryfder y glanedydd a ddefnyddiwyd yn unol â'r argymhellion
• Defnyddiwyd teclynnau puro at ddiben domestig yn hytrach na diben masnachol, heb unrhyw dystiolaeth bod y rhain yn helpu i leihau'r risg o COVID-19.

We carried out 43 Quality Checks from August to October 2020, which included:

• 19 NHS Hospitals
• 5 Independent Hospitals
• 8 NHS Mental Health settings
• 9 Independent Mental Health settings, and
• 2 GP Practices

Although our routine programme of inspections was paused at the onset of the COVID-19 pandemic, we have continued to conduct some onsite inspections in response to concerns or intelligence indicating that there may be a high risk to patient safety. However, this has only happened when other means of gaining assurance and evidence have been exhausted, and where we have conducted a full risk assessment to ensure the safety of our staff.

During this period, and as a result of serious concerns reported to HIW, we conducted three onsite inspections. These took place at two dental practices and one independent mental health setting. We also completed an onsite inspection of a field hospital to check the arrangements for patient care. The reports can be found on our website.

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A significant amount of time and effort has been spent on redesigning hospital wards and unit environments to help reduce the transmission of COVID-19 and to keep staff and patients safe. However, we found at times that action had not been taken following issues identified via routine environmental risk assessments and audits. This is an important issue for departments and health boards to consider, to ensure that actions are completed in a timely manner to maintain the health and safety of staff and patients. This is highlighted later with other examples, within the Infection Prevention and Control section.

Innovation has been demonstrated, with some health boards ensuring that patients are provided with personal electronic devices to help maintain contact with friends and family during their time in hospital. This has been essential to help minimise the distress and isolation that patients or their families may experience. Departments and health boards should continue to evaluate how restrictions on visiting may impact on the opportunity for family members or carers to provide support, or to be involved in discussions or decisions regarding the care of patients. To maintain effective support and communication in relation to patient care and both their and their family’s well-being, it is important that appropriate mechanisms remain in place to facilitate this. Similarly, there should be clear arrangements for families and carers to keep in touch with departments, particularly where patients are unable to have any contact with family members, without proactive help and support.

Governance

An important factor requiring consideration during the pandemic relates to staff well-being. It is clear that staff have been working in a hugely challenging environment these past months. Consequently we are concerned that staff working in healthcare may be suffering significant anxiety and fatigue at this time. Across Wales, we have noted the implementation of positive interventions to help support the well-being and mental health of staff. It is vital that all departments continue to ensure they do all they can to support their workforce through these very challenging times.  

It was positive to find that specific training on COVID-19 has been provided for staff in all settings. However, as might be expected, the lack of opportunities for face to face training and increased work pressures has significantly impacted on the completion of mandatory training in some departments. This was more prevalent during the early stages of the pandemic, and throughout Wales we were told that the emphasis on e-learning has been promoted to help with compliance. Whilst dealing with the heightened workload associated with responding to the pandemic, completion of mandatory training requires close monitoring. Failure to ensure that staff training is up to date may potentially result in unsafe practice and increased risk to patients, so it is important that all health boards strive to ensure their workforce receives timely training appropriate to their roles. This also relates to the use of temporary staff, who may be unfamiliar with a particular environment of care. Departments should ensure robust processes are in place for familiarisation and induction of temporary staff in new areas, and to provide appropriate training where applicable.

Positive steps have been taken to meet the need for more frequent communication during the pandemic, to ensure staff are aware of changing guidance. This includes the use of daily staff huddles, which have replaced monthly meetings, as an agile approach to keep staff up to date with accurate advice and guidance. The need for ongoing frequent communication is essential as the COVID-19 pandemic evolves, particularly where there is a heavy reliance on temporary staffing arrangements, including where care is being managed in reconfigured or temporary settings.

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Governance

The consideration of staff well-being during the pandemic is essential. It is clear that staff have been working in hugely challenging environments since the start of the pandemic. As with all frontline staff, those within independent healthcare settings can present with fatigue, anxiety or stress, and employers should ensure their staff are appropriate assessed and monitored. We have noted the positive implementation of supportive interventions, to help maintain the well-being and mental health of staff. The take up of these interventions should be closely monitored, to ensure staff are fully supported through these challenging times.

It was positive to find that specific training on COVID-19 has been provided to staff in all settings. Completion of mandatory training has also remained high throughout the pandemic, with e-learning replacing the traditional face to face and classroom based training. In addition, training compliance is being closely monitored, along with training for COVID-19 arrangements.

Independent hospitals in Wales do not provide emergency care and the pathway is based on outpatient services and scheduled care. As a result, healthcare providers are more able to plan staffing levels in advance of hospital appointments or admissions. Consequently we found that overall staffing levels have remained stable throughout the pandemic. Hospital managers told us how they held early conversations with staff to support them to feel confident in the workplace; these included discussions with staff who may need to shield or self-isolate.

Keeping staff up to date with changing guidance and operating procedures has been a key challenge for all healthcare providers during the pandemic. Hospital managers have recognised this and described the new arrangements in place to keep staff updated on the rapidly changing guidance and advice for COVID-19. They highlighted to us that more frequent communication was essential, and this had been addressed through virtual team meetings and video calls to maintain frequent engagement with staff. It was positive to find that such communication has also been extended to all staff working on the site, including those from the NHS. As the pandemic progresses, it is essential that independent providers maintain frequent communication and guidance to all staff.

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Governance

The consideration of staff well-being during the pandemic is essential. It is clear that staff have been working in hugely challenging environments since the start of the pandemic. As with all frontline staff, those within independent healthcare settings can present with fatigue, anxiety or stress, and employers should ensure their staff are appropriate assessed and monitored. We have noted the positive implementation of supportive interventions, to help maintain the well-being and mental health of staff. The take up of these interventions should be closely monitored, to ensure staff are fully supported through these challenging times.

Through our quality checks we were able to confirm that regular multidisciplinary team meetings have continued throughout the pandemic. These are essential to ensure patients are cared for and managed appropriately and effectively. In addition, emergency appointments with other key mental health professionals have been available to maintain appropriate care.

It was positive to find that specific training on COVID-19 has been provided to staff in all settings. However, the inability to attend face to face training, and increased work pressures has significantly impacted on mandatory training compliance in some areas. This was more prevalent during the early stages of the pandemic, and has been addressed by the promotion of online training options. However, we are concerned that some key areas of mandatory training, such as physical intervention and restraint, which is required at times to de-escalate challenging behaviour cannot be effectively delivered online. This is an important area for providers to consider, along with robust risk assessments, particularly in environments with high incidences of challenging behaviours.

Patients have a right to have their detention reviewed by the Mental Health Review Tribunal for Wales. All hospitals were able to demonstrate that this right had been maintained, with the majority of tribunal meetings taking place on time, through virtual means. Whilst virtual meetings have enabled this type of meeting to take place, we would encourage hospital managers to obtain feedback from patients on whether they felt as engaged and enabled to participate appropriately, as they may have previously. Patients will also be best placed to identify how their experience could have been improved.

Keeping staff up to date with changing guidance and operating procedures has been a key challenge for all healthcare providers during the pandemic. It has also been essential to ensure patients are communicated with effectively, to help them understand the changing restrictions placed upon them, as a result of COVID-19. We found that hospital managers had approached this in a variety of ways, but the most important factor was an increase in the frequency of direct communication, through updates provided at daily staff meetings and patient briefings. The need for ongoing frequent communication with patients and staff is essential as the COVID-19 pandemic evolves.

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Whilst we conducted only two quality checks of GP practices, we need to highlight concerns regarding the use of remote consultations, and the risk that some patients may not be able to access services due to technical or logistical challenges.

Although there are many benefits to remote consultations, there is a clear risk that some cohorts of patients may be digitally excluded, and are unable to conduct a video call. It is therefore important that relevant patient groups are still able to safely access in person appointments.

At the time of writing this Quality Insight bulletin, we have undertaken two onsite dental inspections during the COVID-19 pandemic. These were risk based inspections as a result of concerns that standard operating procedures were not being followed in line with Public Health guidance. Our inspections in the main have validated these concerns. The key findings are as follows:

• A dental surgery had not been de-cluttered and contained items that could not be cleaned effectively
• PPE not being changed post-Aerosol Generating Procedure (AGP), and before cleaning commences
• Insufficient evidence of fallow time compliance between procedures, with no record of the time at which the AGP element of the treatment had finished
• No expert verification of air changes per hour
• The strength of the detergent being used was not in accordance with recommendations
• Use of purifiers designed for domestic rather than commercial use, with no evidence to support the assertion that these reduce the presence of the COVID-19 virus.

This final point is very concerning, as we are aware that many practices are using air purifiers in the absence of mechanical ventilation. We would urge all practices to check the manufacturer’s guidance and instructions, and or contact the manufacturer to confirm if the device is appropriate for use in a dental surgery.