Before the programme was broadcast, the programme's producers and our Undercover Cleaner, Shabnam Grewal sat down with the Chief Executive of the 'Heart of England NHS Foundation Trust', Dr Mark Goldman and showed him and hospital staff some of the evidence she had gathered. Dr Mark Goldman was then interviewed by Shabnam for the programme. This is an edited transcript of that interview.
Let's just start off by talking about your relationship with the company that does your cleaning. On what basis did you select Initial Hospital Services to clean your hospital ?
We've had outside contractors here on this site for some time and we went through a tendering process. Amongst the tenders was a tender from an in-house team and that tender was evaluated on the basis of financial reasons and non-financial reasons such as quality of service and what we could expect from them, and the board made the decision to appoint Initial.
Was there anything in particular that stood out in their bid that made you choose them?
Well they weren't the cheapest bid, but we were impressed with the likelihood that they would provide a higher quality of service, because at that time, we ourselves were not content with the company that were doing the cleaning, and of course they didn't get the contract.
When you came to negotiating the contract with them and sorting out how the staff and the budgets would be allocated, did you look at how long it takes to clean a ward?
This tender was based on NHS standards. So we did evaluate the hours and we did make a judgement against the hours. I actually can't say per ward, and I do believe that different parts of the trust are very different in their requirements, but we did evaluate the hours and we believed that the hours were enough to meet the conditions of the contract which was to NHS specification.
There's an agreement and an Initial about the standards for each ward, those are shared by ourselves and by the staff on the ward so that the modern matrons know exactly what it is that the cleaning contractors are supposed to do on their wards.
So, how do you decide the amount of cleaning hours and cleaners that are required for each ward, say for example a cystic fibrosis ward compared to an elderly ward?
I don't think it actually works quite like that. I think it's about what the standards of hygiene and cleanliness should be on the ward. The professional contract cleaner decides what they need to put in and agrees that they will achieve those standards.
So Rentokil Initial, the cleaning company, makes the decision as to how many staff should be put on each ward?
That's true, but we do know how many hours they put in because when I sign off the payment to Initial I am advised of the number of hours in addition and of the outcome of the standards of cleanliness that have been achieved by them during the periods I'm signing off.
Are you aware that some of your cleaners are working seven days a week on a regular basis?
I know that amongst the hours that I sign off there is a percentage of hours of overtime and I would guess that certain cleaners would be working their routine shifts and doing some overtime, but actually, between the two, the percentage of overtime is not that high.
But does it worry you that there are people who are cleaning your hospital who work every single day of the week?
Does it worry me? If that's what they want to do and they are cleaning to a high standard, I suppose I would prefer it if it wasn't so, but if you ask me does it worry me, I worry most about the standards of cleanliness.
I have met cleaners in your hospital who are working twelve hours a day, Monday to Friday. Then working on Saturday and Sunday and then they come in the following Monday and they work another twelve hour shift. Is it reasonable to expect them to clean the hospital to the standard you want when they are working those hours?
I don't think it's good for anybody to work those hours, whether they're a cleaner or any other kind of worker. As you know, with regard to hospital staff, particularly doctors, we're very particular to ensure that they get enough rest and enough personal life to do their job properly. So it's a matter I wasn't aware of and I am aware of it now. Thank you for that.
What input do you have into how the cleaners who work in this hospital are trained?
They have their own training programme, run by Initial (the cleaning company). I believe you were on it. Our Infection Control people go into that programme, know the content and approve the content.
How important do you think cleaning is in stopping the spread of infection?
It's very important. We have reduced MRSA infection here by quite a considerable margin in the last year. Cleaning is not by any means the only thing contributing to that. There is the control of drugs for example, the use of isolation facilities, advice given to doctors, nurses and patients - all of those are contributory, but cleaning is a very important thing.
I chair the Control of Infection committee. All of my staff who are involved with managing the cleaning contracts, managing the cleaners; the nurses, the Control of Infection people - we all sit together and we work on the Control of Infection of which cleanliness is a part. The staff who are specific to cleanliness meet on a regular basis, try to understand what the problems are and do whatever they have to do to improve standards. And we've had a number of external inspections on cleanliness and we always pass them. We pass them well. We achieve excellent scores on the outside ratings of many different independent groups.
One of the cleaners who I worked with, who is featured in the film (Habib) , regularly got awarded marks of over 90% on his internal inspections. Do you think that gives us much faith in the inspection process?
I've seen this morning the material that you've gathered on camera and I'm sure you saw many other instances. I am disappointed that there are people who clearly know what they're supposed to do but aren't carrying out what they're supposed to do. I understand that when you look at a floor, and it looks clean, you do not know with what it was cleaned, because there's a difference between cleanliness and control of infection. Having seen all the material this morning for the first time, my overwhelming impression is that the rules by which all staff manage the patients, need to be rapidly communicated and clearly communicated from one group of staff to another. Also we actually have to have a methodology of observing practice as well as observing cleanliness. Interestingly, we do have such a method of practice with regard to a different aspect of hygiene, Control of Infection. We do our own audits of hand hygiene, and we regularly monitor hand hygiene by observation studies. In other words, on each ward, every quarter, a member of staff on a day not known to the other staff, observes practice and records practice. Now there is the basis, I think, for us to do something with regard to the practice of the cleaning staff for example. I'm going to have to have a lot of discussions with Initial about the detail of how we monitor what goes on and they in turn are going to have to think very, very carefully about how they supervise the practice of their staff.
When "Rentokil Initial" (the cleaning company) carry out their own internal inspections which they do on a regular basis with supervisors and other people, do you get much feedback on how these inspections are carried out and what the results are?
I do. I won't sign off the payment to Initial unless I have seen the standards and I meet with the facilities team who monitor those standards on a regular basis and interrogate them about the achievement of those standards. We have penalty clauses which we levy against initial, not in the recent past I have to say, and if they don't achieve those standards, then I get personally involved in dealing with their senior management.
Were you aware that sometimes cleaners are informed by their supervisors that an inspection is coming so that they can make an extra effort on that ward, on that particular day?
I wasn't aware of that. It does tend to suggest that we need to change our method of inspection so there isn't that awareness.
Can we talk a bit about barrier room and infection control procedures. What are your guidelines or your rules around barrier rooms and what needs to be done?
This morning when I looked at your material I had around me all the most important, most knowledgeable doctors in the Trust and the Director of Nursing, the Director of Infection Control, a Professor of Microbiology, a Consultant in Infectious Diseases etc, and what emerged from their comments is that there is a wide variety of different organisms involved here. With some organisms the focus of attention is on not moving the organism from the patient to the doctor. With some patients the focus of attention is not moving the germ from the doctor to the patient who is immunocompromised, that is, susceptible to infection. There is an incredible complexity about the needs of patients who have drug resistant TB as against someone who, say, came in last night with vomiting and maybe has a neurovirus. The doctors, because of their greater weight of knowledge, are able to behave in different ways towards these different patients.
The staff, who have good training, but it's days of training, not seven years in medical school, they need clear rules. And I think we need to go away and establish absolutely clear behaviour amongst the staff, who are carrying out these really important duties. They need to absolutely understand what the requirements are of them, and then they have to do it.
Unlike the cleaners, the nurses here do know about infection control. What have they been taught about how to behave with patients who may be vulnerable to infection or be infected?
All doctors and nurses learn about microbiology as part of their training to different extents. When they come here they get additional practical training about what to do. Their knowledge level is quite high so the focus of the training for them here is mostly practical. 'How do you wash your hands?' for example. There is one way to wash your hands which gets your hands clean from a medical perspective and there's a way you wash your hands when you're at home which is different. So we do a situation with work stations where staff go round and they are actually observed by members of our Infection Control Team carrying out simple tasks. One of the tasks is how to put on gloves and an apron. So they get very specific practical training in what to do and when to do it.
As regards some of your nursing and health care staff, there does seem to be confusion about the right procedures and the right way to behave when it comes to barrier nursing.
I've seen really wrong things said (in your footage), and those particular members of staff do need to be further trained and their level of knowledge has to be reassessed. We have to make sure that these issues are clarified for them.
Do you think we have any chance of beating hospital acquired infection when we're seeing this kind of confusion in your hospital?
Well we have demonstrated that it is possible to make significant improvements and we've made them year on year. In the last year our figures show we have made very important strides with MRSA. It's down, we've made the biggest improvements in our sector, the fifth best improvement in the National Health Service, so that tells me that it's possible to make improvements. To make those improvements we have to have increasing awareness and understand of the issues, and that starts with knowledge about MRSA.
We don't know enough about MRSA. As someone who has become very, very engaged with the control of infection debate, I've learnt a lot about MRSA and it's a very complex issue, we don't know enough about it, so we have to do basic research.
Some of the behaviours of members of the public who visit the Trust need to be constrained, with their agreement, so that they help us. Prescribing of drugs has to be changed, and I think the pharmaceutical industry needs to reignite its interest in control of infection which has actually been somewhat dormant in recent years. You also have to accept that MRSA has been around for a long time and it's a very adaptable bacteria.
In answer to can we improve things, out there other countries have better performance than the NHS and so we should acknowledge that and aspire to achieving what they have. Unfortunately we've let ourselves get into a very difficult position, so we've got to pull together and move away from that.
But are you worried at the message that some of your nurses are giving to cleaners and also to people visiting the hospital?
That's part of what we have to do. We have to tidy up the way we communicate between different staff groups so the different staff groups who have a different level of scientific knowledge all know exactly what they're doing about individual patients, very, very clearly. That's something that I have to take away. I've had that agreement already from the people who sat with me this morning, the senior people here, and watched the material that you had acquired during the period you were with us. Establishing clear lines of communication between the various grades of staff is absolutely paramount and we'll start to do that, and we'll work with Initial on that.
Do you think some of this is about the priority that we give cleaning and hygiene, the importance that we give to cleaners, and the money that we make available for cleaning?
Well you and I both have worked as domestics in this Trust because I've done time on the ward and I do think that it's very interesting that when you put a cleaner's outfit on, people don't treat you in the same way, and that's a pity because it doesn't recognise the contribution that they're making. So there may be some work we have to do in that direction. But on the issue of cleanliness, you can't make a hospital too clean. People expect a hospital to be clean. It should be clean. It cannot be too clean. So we have to keep making it as clean as we can but it's getting more difficult to do that. We're quite fortunate in this hospital to have a lot of new estate (new buildings) but not every hospital does. They weren't designed to store or manage all the equipment that we now manage. If you look at a modern hospital hydraulic bed, you can't wipe it over quickly. You remember the old iron beds? Probably, a nurse could wipe those down very quickly. The newer beds are very complicated pieces of equipment, they take a lot longer to do. So we have to bring ourselves up to date and we have to make the investment. We're making year on year increases in our investment in cleaning in recognition of this problem.
A very, very significant uplift this year compared to last year for example. And in terms of the attention that the Trust is giving this, it is currently our number one issue.
But to go back to that, are you going to employ more cleaners and spend more money?
I have asked the medical director and the control of infection director to bring to me as the Chief Executive, what they think they need to make this hospital safer from a control of infection point of view. That piece of work is already underway, and when it comes to the board, as it will do, for investment, it is the number one issue facing this Trust. You ask 'Will it be more cleaners?' I have to say that it's up to them to advise me where that investment should best be spent in order to control infection.
Are you concerned that I was employed at this hospital for nearly six weeks as a cleaner with access to patients and availability of patients without ever having any references taken up or a police check done?
I'm very disappointed that that happened and I have spoken to Initial services about that already, and I will speak to them again in the future that they have to satisfy me that their recruitment procedures are going to ensure that we have safe staff on site. It isn't satisfactory and it has to change.
Do you think you'll continue to work with Initial?
I think Initial and ourselves have made a good relationship under difficult circumstances. Now I would like to see how far we can take that because we have put a big investment into building that relationship, and if they can demonstrate that they can continue to improve, as they have done, and they've contributed to this improvement in MRSA rates, there's no question about that we will continue to work with them, but in the end, as with every tender, the tender will come up for renewal and the Trust will have to make choices about where it goes in the future. And just as we changed contracts the last time, so Initial will have to put in their bid and be judged against other bids, one of which will be against our own in-house team as was the case last time.
Do you think they're to blame for some of the bad cleaning practices that I've seen?
I think they have some individuals who have let them down, and they are aware of that and I'm sure they will advise you that they are going to deal with that, and I expect them to. That's part of the deal. That is their business.
Can I ask you again, how important do you think cleaners are in this whole process of fighting infection?
Cleaning is really, really important to control of infection. Cleaning is really, really important to the confidence that the patients have when they come into the building and allow us to treat them. Now if we can't get the confidence of the patients they wont come here and we wont be able to treat them, so what I'm saying is, it's really important.
Are you happy that your cleaners are paid minimum wage?
Our cleaners are paid since our agreements with Initial of Last year at NHS hourly pay rates, and we have an agreement with Initial to continue to develop their terms and conditions over a two year period until they're equivalent to NHS terms and conditions. Now in terms of the hourly pay rate that they receive, they already are equivalent to every other NHS employee at that grade.
People work in hospitals in the NHS, in the public sector, for reasons other than the money. So in terms of commitment and motivation it's not always about the money, it's about other things. Some of our agreements with Initial were about improved education and training and there's clearly a need for that and there's agreement on that. For some people having the best possible equipment so that they can do the job really well is what motivates them. So money is part of the package but it's not the only thing.
Do you think you deserve your foundation status?
We achieved foundation status because everybody in the Trust delivered against the performance targets against which you're measured to get foundation status. We had to achieve three star status on two consecutive years which we did, and I do believe we will achieve it this year. We had to satisfy interrogation on our management and finances by a relentless succession of management consultancies who are household names. We earned our foundation status and we have our foundation status and we're going to use that to improve the quality of service in the hospital. It's the staff here and their commitment that got us that foundation status. I believe they deserve it and I believe we deserve it.
What steps will you take to ensure that from now on patients are not put at risk?
All of the things that I have indicated, I will take personal responsibility for. The communication issues, the efforts that we will have to make with Initial to get good staff recruitment, of safe, conscientious staff who are well trained, all of those issues are down to me. I'm the responsible officer, it goes with the turf. So it's my job to make sure that the hospital becomes safer and that the patients have the appropriate level of confidence in us.
Can nurses develop an immunity to infection as I was told?
I think that's an absurd notion and the individual who made that comment we will have to advise and make sure they have a more appropriate level of knowledge.
Are you going to be stricter about enforcement of barrier room procedures so that, for example, signs are put up much more readily and staff are much more aware of what they should be doing?
The first thing we need to do is ensure that there is absolute clarity about the needs of patients who are being assigned barrier nursing isolation procedures. Once that clarity is established it has to be rigorously followed, and the information has to be transmitted and received by all the members of staff and rigorously followed.
Were you surprised at what you saw?
I was very disappointed. There are clearly issues that we have to understand and we have to get on and deal with them.
Six thousand people who work at this Trust will watch that programme and feel ashamed to think that those sort of things were going on here, and in the aftermath of that public shaming, I will be given an opportunity to deal with many of those issues. That is my expectation. That is how the staff here respond to issues of concern when they're raised. So it's my job to translate this into something positive for us.