The Healthcare Environment Inspectorate has issued its report following an unannounced theatre inspection at the Borders General Hospital on May 13 and 14.
NHS Borders has said it welcomes the report.
The purpose of the inspection was to assess the theatres against the NHS Quality Improvement Scotland (NHS QIS) healthcare associated infection (HAI) standards and took place across the five operating theatres and the theatre recovery area.
The report states that, based on evidence found over the two days of the inspection, ‘NHS Borders had varying compliance with the NHS QIS HAI standards to protect patients, staff and visitors from the risk of acquiring an infection’ and that ‘further improvement is required.’
The report makes seven requirements, all of which were rapidly implemented by NHS Borders.
Accepting the findings of the report, Director of Nursing and Midwifery at NHS Borders, Evelyn Rodger, said: “Feedback from the Inspectors indicated a number of instances where policies and procedures were not being correctly followed, in particular in relation to cleaning methods.
“In these instances our standards fell below those expected by our patients and staff, and I would like to stress that staff from theatres and beyond took immediate action to address the issues that were pointed out to us during the inspection, which is acknowledged within the report.
“All inspections are a snapshot of a point in time, and provide learning opportunities for us. As an organisation we responded immediately to the findings. Cleaning methods and documentation have been reviewed and a new training programme has been completed through which every member of staff has been assessed on their knowledge, understanding and practical skills in relation to the correct cleaning methods.
“Inspections are part of a national improvement plan. It is helpful that Healthcare Improvement Scotland inspectors work with us to be the best we can be and we would like to thank them for their professionalism.
“We are committed to ensuring that our patients receive the best possible care and are confident that our theatres reflect that commitment. Our focus is to ensure that the improvements made after this inspection are sustained.”
Medical Director, Dr Sheena MacDonald explained: “The main risk of poor standards of cleanliness would be an infection in a patient’s wound resulting from surgery.
“We investigate every single instance of infection and identify and take action in order to continuously improve.”
Dr David Love, Consultant in Anaesthesia and Critical Care and Associate Medical Director in Clinical Governance and Quality at NHS Borders said: “I accept this report as an important contribution to our operating theatres continuous quality improvement programme.
“Whilst being disappointed with the findings, changes were immediately made, both to practice and training, and our continued vigilance and monitoring will provide assurance of sustained improvement.”
“It is also appropriate to acknowledge that, despite these findings, our measured outcomes and quality indicators remain good.
“By using our learning from this report we will ensure that the people of the Borders continue to receive the high standard of safe surgical care they expect and deserve.”