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Last Updated: Wednesday, 13 July, 2005, 18:28 GMT 19:28 UK
Programme transcript
What follows is a transcript of "A Panorama special - Undercover hospital cleaner", first broadcast Wednesday 13 July 2005, 19:00 BST on BBC One.

This should be checked against transmission for accuracy and to ensure the clear identification of individual speakers.

Shabnam Grewal
My name is Shabnam Grewal. I work for Panorama. I've been leading a double life -undercover, working as a cleaner in one of the country's biggest hospitals. I wanted to see how they're fighting the war against hospital infections like MRSA which kill 5,000 people a year. It was a frightening experience. And the evidence I gathered has shaken a top hospital which had been so proud of its reputation.

Dr Mark Goldman - Chief Executive, Heart of England NHS Foundation Trust
6000 people who work at this Trust will watch that programme and feel ashamed to think that those sort of things were going on here

Shabnam
I'm on my way to a job interview at Heartlands Hospital in Birmingham and it's got a three star rating. Which means its performance is excellent. But like most other hospitals, it's got problems with MRSA and other infections people catch in hospital. Cleaning is done by a private company Rentokil Initial. I didn't realise how desperate they were for staff.

Georgina
When can you start?"

Shabnam
As soon as possible, whenever you like.

Georgina
Right , its Monday today um

Shabnam
I can start as soon as you want me to

Georgina
Can you start tomorrow?

Shabnam
Yes

Shabnam
The early signs weren't great - I started without my references being checked and without a Criminal Record check - supposed to be essential for all employees with access to patients. But hardly a day goes by without hospital infections being in the news.

Broadcaster on Radio
" 10 mins to 8. Over the past 20 yrs there has been a massive increase in infections of the hospital superbug MRSA. And over the same period there has been massive decline in the number of cleaners in the NHS

Shabnam
The job started well. The training was good - there's more to the job than just a mop and a bucket.

Georgina
We have a three colour code system in this hospital - that is for all ward areas, and office areas, doing kitchen work , anything blue like mop buckets or anything is that colour. Bathrooms, toilets, barrier rooms is this colour - red.

Shabnam
Hospital cleaning is very strict. You have to use different coloured cloths and mops and buckets for different areas. You should regularly change gloves and aprons and keep your hands clean with washing and alcohol gel. You soon get the point. Cleaning and hygiene are in the front line of the fight against MRSA and other 'hospital acquired infections.' A government video backs up the message.

Video commentary
Cleanliness matters to patients to staff to everyone...

We often say that infection control is everyone's business and so cleanliness and tidiness of the health care environment is also everybody's business - if you see a piece of dirt or litter why not pick it up?

Shabnam
To find out more about the importance of cleanliness, I travel to Glasgow to meet one of the country's leading authorities on infection control. Dr Stephanie Dancer has many years experience fighting hospital acquired infections.

Dr Stephanie Dancer
I don't think there's any excuse for a hospital to be grubby or cluttered or ascetically filthy for a patient coming in. It destroys the patient's confidence in their treatment, it destroys the staff morale and it upsets relatives, particularly if that patient then goes on to acquire a hospital infection. Cleaning could be the last remaining defence we have against infection, the removal of dirt.

Shabnam
Training continues well when I'm sent to work alongside Vicky, on the cystic fibrosis ward. It has to be kept scrupulously clean - patients here are especially vulnerable to infections. Vicky's an experienced cleaner - and she works hard. She has to - two people should normally be cleaning this ward but Vicky's been doing it on her own. Still if the rest of the hospital is like this I can see why it got its 3 star award. But a few days in, and things start to change. I'm back on the cystic fibrosis ward, Vicky's ill now I'm working with Stephen.

Shabnam
Hi I've been sent up to work with you.

Stephen
Have you?

Shabnam
I don't think Vicky's in today

Stephen
No she's not. Shabnam
And Stephen is a very different story..

Shabnam
How often do you change them

Stephen
Gloves

Shabnam
Yes

Stephen
When you want to, it's up to you. When you want to, it's up to you. I just work all through, then after I've finished, take them off and wash my hands.'

Shabnam
But hand hygiene is absolutely essential. You're supposed to change gloves without fail after cleaning each toilet, room or ward to stop possible infection spreading. But Stephen seems unaware of this! We were told in training that all jewellery like this was prohibited.

It could carry infection from place to place. And at Heartlands, the rules for cleaning toilets are particularly strict. Five cloths, for five different areas. And throw each one away.

But, guess what...

Shabnam
The sink

Stephen
See that's ok ...

Shabnam
Yeah

Stephen
That's OK. If you have to, if there is a mark in there that won't come off put a bit of blue water and then just go round it... see that's done.

Toilet aint too bad, that's clean . See that's clean ... under there , any marks ...done . do the sink first before you do this because you can't before can't transfer germs on to sink.

Shabnam
Sure

Stephen
So the sink first, then toilets. Down there ... done ... there's a bit of dirt there look

Give it a little scrub

Gone.. done .. floors clean, check the bin , empty, done.

Shabnam
OK

Stephen
Lights off

Shabnam
The toilet clean took less than a minute and he used just one wet wipe for everything. When he finished he didn't change his gloves or wash his hands. He went straight into a bedroom. The bedroom was cleaned in under four minutes. And then, still without changing gloves or washing his hands, we moved on to the next room. His method is disarmingly simple...

Stephen
Thing is if it looks clean, right just leave it ,just quick quick rub , quick quick rub

Shabnam
What about the floor in toilet? Stephen
Uh?

Shabnam
The floor in the toilet

Stephen
The floors alright, it will be alright

(Knock)

Stephen
Can we clean, yeah ?

Shabnam
The second bedroom and toilet we do together -even faster this time! Remember, this is a cystic fibrosis ward, with patients highly susceptible to infections. Stephen seems completely unaware of the risks. Not a bit like Vicky.

He joined Initial seven months ago and says that he only got half a days training. If that's true, it certainly shows. In another room, a patient is wheeled away to x-ray. Perhaps now with an empty room there's a chance of a thorough clean...

Stephen
I'll give you ,I'll Give you a little tip, if see it now, right there's nothing there, you leave it, all you do is like that bit there ....

Shabnam
Yes

Stephen
That's done , that's done, that's

Shabnam
I've done the bin

Stephen
The idea of kexxing is

Shabnam
Yeah

Stephen
Bits of paper, bits of fluff , that it

Shabnam
OK

Stephen
It's like a mop

Shabnam Sure

Stephen
Bits of paper , whatever

Shabnam
OK

Stephen
You can kexx in a minute

Shabnam
A kexx is a big, wide brush - great for sweeping up dust but it doesn't kill germs. You're supposed to use it before disinfecting with a mop. Not instead of it.

Stephen
Thing with the hoover, see a bit of paper... gone... done. Over there, over there, one two done, finish

Shabnam
OK

Stephen
There some people make a mistake of using a hoover, you don't need to - nothing there so don't do it.

Shabnam
Working with Stephen is a revelation ... We've done about 6 or 7 rooms we haven't washed, mopped a single toilet yet.... We aren't changing our gloves at all.

[Woman walks in at end]

Stephen's contribution to hospital hygiene was just to make things look superficially clean. But behind that, who knows how much infection he is actually spreading around.

Stephen
Do you want me to kexx or mop?

Shabnam
When you have more than 20 rooms and toilets to clean in just a few hours you obviously you have to work quickly - but I couldn't help worrying that what we were doing was frankly dangerous. Especially in what were called barrier rooms. They're isolation rooms for vulnerable patients or those with infections. They're effectively cordoned off. The idea is to contain infection and protect patients. These rooms are a front line in controlling infection. That had been impressed on me by the expert I'd spoken to.

Dr Stephanie Dancer
If a member of staff, whether it be a cleaner, or a junior doctor, or a nurse is going into an isolation room where you've got a patient with a bacterial organism such as MRSA and not even touching the patient, they don't even have to touch the patient, they could come out, there is a chance they are carrying that organism and they could then take that organism to another patient in another isolation room who may or may not have the same organism, they could even then go into the rest of the ward carrying all sorts of different organisms with them, from waltzing in and out of side rooms without the proper precautions.

Shabnam
So the rules for cleaning barrier rooms are really strict. We have to put on aprons and gloves before we go in - and throw them away as we come out. We wash our hands going in and out. Each room must have clean water and separate mop heads and cloths, which are sterilised or thrown away after use. Well, that's what's supposed to happen.

Stephen
And you're telling me we have to change the water for four rooms every room you want to change the water. I'm afraid not, Sorry I want to get these rooms done today not tomorrow. They haven't got a clue over there. They haven't got a clue.

Shabnam
It seems he hasn't got a clue either that we could be spreading infections between barrier rooms with his sloppy practices. The final clean was in a room used by a patient with suspected tuberculosis.

Stephen
Do the three barriers and then the TB one last. Shabnam
OK, with the same water?

Stephen
Same water

Shabnam
You sure?

Stephen
Sure, trust me - I'm a gynaecologist. Trust me - I'm a gynaecologist.

Shabnam
TB is an infectious disease often spread by coughs and sneezes. We were careful to wear a mask and apron to protect ourselves but with water in the bucket from the other rooms we could easily have brought in infection. Stephen told me he works a 52 hour 7 day week, to make ends meet. I don't know what he earns but I get the national minimum wage just 4.85 an hour. That may explain some of his obvious dissatisfaction.

Stephen
Between you and me, this company you don't really want to hard for because they pay you peanuts. You don't want to come to work and work hard Do what you can, do it quick, and just get out.

Shabnam
And there's another problem. If staff are off sick - they only get statutory sick pay which is even less than their normal wages. So some staff come in to work even when they are ill.

Stephen
Not feeling sick just headache and sore throat, coughing and sneezing.

Shabnam
Can you not call in sick?

Stephen
Make you have 2 days. Shabnam
This can't be good for them - or for patients being put at risk of infection [Stephen coughs as he walks away]

Shabnam
Two weeks in to my time at Heartlands and one thing has become very clear. No matter how thorough the training is it can all fall apart back on the ward. While some cleaners like Vicky are obviously good, Stephen breaches many of the basic rules - even when he's working around especially vulnerable patients. But maybe it's not that bad. Maybe he is just a one off.

Maybe.

Monday morning and I'm given my orders - I'm off to join... the rapid response unit. Known in the hospital as ...The rapid. Honest.

Shabnam
How are you doing?

Stephen
Not too bad

Shabnam
Have you been ill, weren't well on Thursday.

Stephen
I've got a bit of a sore throat.

Bev
Feel like a bag of shit myself.

Lynn
I felt terrible yesterday.

Shabnam
The rapid response team is Heartlands crack cleaning squad. Their job is to blitz dirty wards, consigning dust and dirt to history.

Lynn
We all look like we don't want to start work today.

Stephen
F*** don't! Shabnam
I was told to report for duty at eight. I'd been warned it would be really hard work. Lynn is the unit's squadron leader.

Ellen
Lynn you'd better show her where all the bags and that

Lynn
Come on.

Shabnam
But when I started cleaning according to the rules I'd been taught some of them got very irritated. Just like Stephen, it seems, some of them just make things look superficially clean without doing the job properly. Ellen
Shabnam you've got to get a move on now, you've gotta come and help me now.Have you finished with them toilets.

Shabnam
I haven't no , I've got.... Ellen
How many more have you got?

Shabnam
Two left , this one and that one

Ellen
You've gotta mop & I'll vacuum all the bays, all right

Have to be quick now Shad ... you've gotta get four bays done

Shabnam
I leave the toilets, cleaning them later at the end of my shift, so I can catch up with the team on the ward. Here I had to mop the floors which Ellen has already hoovered. Well, that's the theory.

Ellen
This obviously has not been hoovered round here there's a magazine and lots of dust."

Shabnam
What's the harm in a bit of dust you might ask. Well, dust is mainly dead human skin cells. Believe it or not, each of us sheds 4 kilos of skin every year. And it can easily harbour infectious germs. Even perfectly healthy people can be carrying MRSA in their noses or on their skin.

Shabnam
So, having rushed the hovering and left dust at the back ... she's standing there chatting."

Ellen
Come on Shad hurry...

Shabnam
But again, my real worry is the barrier rooms. The isolation rooms, where patients with serious infections are treated. Rooms which are supposed to be barriers to stop those infections spreading. NHS guidelines are clear and strict - gloves and aprons must be worn by everybody in barrier rooms and changed every time you enter or leave one. But my colleagues appear to know better...

Ellen
You don't have to do that, as long as you don't go near the patients you're all right.

Shabnam
You sure Ellen
Yes , as long you don't touch the patient you're alright

Shabnam
I don't have to put gloves on or an apron?."

Ellen
No, well you could just stick gloves on but you don't need to put an apron on."

Shabnam
But I thought that if I do them together, hoover then mop...

Ellen
No because you're going to take up time and we're not going to get finished, I mean you're to mop up all these side rooms yet."

Shabnam
And rules about using clean water for every barrier isolation room were also being broken.

Is this where change my water,

Lynn
Yes you can ,yes

Shabnam
Between the barrier rooms? Lynn
No, it doesn't matter today. Sshh... just get on with it.

Shabnam
So do this one without... with this water.

We're using the same dirty water from room to room. Who knows what we're spreading around.

Cleaner
Do the job quick and get out .

As long as you don't go near the patients you're all right

Shabnam
Around 300,000 people catch a serious infection in hospital every year. About 5,000 of them will die as a result. And what's really scary about what I've seen is how the rules are being broken wholesale just where it really matters. In the barrier rooms. Where infection is supposed to be isolated. And the people breaking them don't seem to have a clue just how dangerous what they're doing is.

Cleaner
Shh just get on with it.

Shabnam
It's Thursday of my fourth week and I've decided to do an experiment. I wondered if part of the problem, even for hardworking cleaners, is that they're just not given enough time to do the job properly. Could this be one of the reasons they take so many short cuts? Let's find out. Do you mind if I clean? So far it's five minutes 11 mins and 37 seconds

I've got over 20 rooms to clean, so at that rate it'll take me just over four hours. Officially I've only got three. The problem is that 3 hours is the time allowed for two people to do the work. But I'm on my own - and I've been given no extra time to do it. Understaffing seems to be a frequent problem - adding to the pressure on the cleaners.

Stephen
If you do things the way you've been told, it'll make your job a hell of a lot harder. They don't realise you've got all these jobs to do in a certain time , and if you're gonna change the water every one, every other one , you'll be there all day I mean get behind and you leave and at the end of the day , hardly half your works done , they'll be saying what you been doing then, what've you been doing why ain't it done. Never mind excuses why weren't it done.

Shabnam
And when you're on very low wages I guess it can be pretty de-motivating. As I found out earlier, cleaners like Stephen feel they're at the bottom of the hospital heap. Stephen
These physios don't care you know , they just storm in, you're working around, just storm in and expect you to move out, that's wrong that is, they've no respect, I feel like saying can't you F** wait? Know what I mean?"

Shabnam
So even a perfectly reasonable request from relatives for cleaning to be done later, seems like another rebuff.

Shabnam
Can I come and clean?

Family
Not now later, no I think probably a bit later, thanks all the same .

Shabnam
We should do it every day though Family: "Well, where can we go?"

Stephen
What's that.

Shabnam (to Stephen)
Later.

Stephen
No I shan't later sod 'em.

Dr Stephanie Dancer
I think the message I want to give out is that cleaners.. we can't do anything without them, it's absolutely impossible to run a hospital without cleaners. In a hospital I worked at about 3 or 4 years ago I heard a manager tell a cleaner that she wasn't part of the health care team and I was furious. Cleaners are not only part of the health care team, they're actually an integral part of the infection control team, that's why cleaning representatives come to our infection control meetings

Shabnam
And if government plans to further reduce MRSA and infection rates is to work as they promise - every member of staff has a part to play.

Government Video "Think Clean"
None of this can be put in to practice without those key team members the cleaning staff - nurses and doctors cannot do their jobs. We have to stay alert.

Shabnam
So far, it's been the cleaners who I've seen driving a coach and horses through the rules aimed at stopping infection spreading. But I'm amazed to find it's not just them. I also witnessed medical professionals, who really should know better, doing exactly the same things. This nurse is in a barrier isolation room, adjusting a patient's drip. She should be wearing gloves and an apron. But she's not. Even though she's handling equipment which is very close to the patient. I'm still anxious to know just how widespread the problem is. So I've asked for extra hours hoping to see what it's like in other parts of the hospital.

My supervisor Joy comes back with an answer almost at once.

Joy
Shabnam - can you come in 5 till 8 tonight."

Shabnam
Yep

Joy
Go down the office ,erm see Debbie,

Shabnam
Debbie

Joy
Tell her them want you working , they have sent you to work in the day hospital with Habib...

Debbie
This is the day hospital, this is where it begins,

Shabnam
The Heartlands Day Hospital is used mainly for physiotherapy for older patients. I'm told it's a job for three cleaners but one man actually cleans the whole place on his own. I wonder how he manages that?

Debbie
Habib like to introduce you to some-one, she will be working with us....

Habib
With us here or with me?

Debbie
With you

Habib
You said with us.

Debbie
Yes with us. Shabnam
Meet Habib - the supercleaner. He gives me a guided tour of the day hospital. This is a gym where patients have physiotherapy, there are examination rooms, offices and 5 toilets. And Habib cleans this all by himself? Well, we'll see. Like many cleaners, earning little more than the minimum wage, Habib puts in long, extra hours to make ends meet. He tells me he works seven days a week. Shabnam
So are you here permanently then?

Habib
I am permanent here for up to 5/6 months, Four to eight. Its my overtime.

Shabnam
And your day job is 8 till1. In the morning you do 8-1?

Habib
8 until 4 ... 4 to 8

Shabnam
8 till 4 an then 4 till 8

Habib
4 to 8

Shabnam
So do you do offices every week?

Habib
Four months, six months, but my report is good report because everything's done, why, all offices are closed, right, no dust going inside."

Shabnam
In the gym I get Habib's first top tip for supercleaners - only mop the bits where you can actually see some dirt. He's obviously not heard of infection control.

Shabnam
What are you going to do?"

Shabnam
That's a red mop."

Habib
No problem nobody looking here, you know last three months four months I have done all toilet with yellow mop."

Shabnam
Really

Habib
Nobody looking (out is finger click)

Shabnam
I've just cleaned five toilets under Habib's direction - now he's using the same mop to clean part of the gym floor. Then it's off to the waiting area - and another top tip...

Shabnam
Do you have to mop this first?

Habib
Don't need mop, everything is done. If ask any supervisor you can tell him yes we have done everything. No need mop."

Shabnam
And that wasn't the end of it. Here's another top tip - when washing sinks don't bother with time consuming frills like....disinfectant

Shabnam
Don't you need disinfectant or something?

Habib
Calm down - no problem.

Shabnam
Don't you worry about the germs?

Habib
What germs?

Shabnam
Don't you worry about the germs?

Habib
No.

Shabnam
And then there were the self cleaning chairs....

Shabnam
I've done all the chairs and the sink... No need, everybody, everybody sitting in the chairs so it will clean. everyday patient clean" Shabnam
What with their bottoms!"

Habib
Yeah well, never mind.

Shabnam
And the rather less than rigorous approach to dusting...

Where's it gone?

Habib
Don't know.

Shabnam
1st April and a government announcement gives the hospital a reason to celebrate.

Radio News
Heartlands and Solihull NHS trust has achieved Foundation status which will also give patients more say over the kind of treatments their hospitals will provide.

Shabnam
Foundation status is indeed something to be proud of. It means all aspects of the hospital's work have been thoroughly scrutinised and come through with flying colours. And that includes the cleaning. In the restaurant, there's free food to celebrate. Everyone's congratulating themselves - but I'm afraid when it comes to hygiene and cleanliness, I don't much share that confidence.

And then it's back to Habib.

He helps himself to a drink in a ward kitchen. Then the glass, unwashed, is put straight back into the cupboard. Later it could be offered to a patient who'd assume it's clean ....

Habib
Juice?

Shabnam
No I'm fine thank you

Habib
Sandwich, milk, pudding .... No good! Shabnam
And here's my favourite top tip. How to look busy without actually doing anything. The secret is walking around with a parcel of hand towels under your arm...

Habib
If you are finished get one hand towels here and one hands towels here... and the movement... we are going to job... you understand me. (Giggles)

Habib
I'm going to get tea trolley.

Shabnam
You're going to get it, ok.

Habib
Tea trolley

Shabnam
Tea trolley.

Habib
Yeah. If anybody asks about me, any supervisor you say in 27/28 for bags and rooms?

Shabnam
Maybe.

Shabnam
But the master of the top tip is proud of his supercleaner reputation Habib
You see, nobody's there to watch me

Shabnam
No I haven't.

Habib
But you know there is my good reputation in the hospital for my job, so Debbie can trust in me, she told you?"

Shabnam
Yeah, she said you were very good.

Habib
Yeah, she can trust me.

Shabnam
It's a reputation he has plenty of time to contemplate... Habib
Twenty to, wait four five more minutes, sit down.

Shabnam
Before going home early.

It's over 4 weeks since I started working undercover as a cleaner at Birmingham's Heartlands Hospital. In those 4 weeks, I've discovered appallingly bad cleaning practises which must be putting patients at risk. It would be funny if it wasn't so vital. Hygiene in a hospital can be a matter of life or death. But why isn't this bad cleaning being picked up?

I know there are supposed to be inspections by both the company, Initial, and by the hospital.

So what's going on? Habib told me he sails through his internal inspections.

Shabnam
How many times do they come to do inspections, how often?

Habib
No time no date, no day.

Shabnam
Just turn up. Habib
Anytime, anytime they can check.

Shabnam
When's the last time they came?

Habib
Today early morning came there in my ward on the ward, today.

Shabnam
Which ward 30.

Habib
29/30.

Shabnam
And what did they say, it was good or?

Habib
Nothing .

Shabnam
But there are also external assessments by teams of hospital professionals and patients groups. In 2004, Heartlands Hospital was rated excellent on a number of factors including hospital cleanliness. The problem seems to be that they only inspect what they can see. If it looks clean, it passes the inspection.

Dr Stephanie Dancer
Just looking at the visual appearance of a ward does not tell you enough information about what is going on, on that ward from the point of view of infection. We have to take this a step forward, we have to get more scientific evidence, where upon... and ways of measuring how clean a hospital is microbiologically.

Shabnam
Yet it seems that some areas in Heartlands have been having trouble even with these limited inspections.

Joy
We had a meeting on Friday now I've just had to have a word with the gang of girls right...you've .got to be on wards at 8 & start, I know you are, in the last five months, where I've just been, they didn't get a pass once.

Shabnam
Didn't get a what?

Joy
Didn't get a pass, Because they come round monitoring , all the bad areas are gonna be monitored by me, Jill or Annette they will just come out and monitor... these failed, you may have had one pass in the last five months, I mean I didn't fail them but people have coming round them have failed them so have to be on our toes.

Shabnam
But fear not - there is a plan to tackle these shortcomings. More cleaners? No. More training? No, not that either. There'll be tip offs about when the inspections are going to happen.... what they'll be looking for - and where! A supervisor explains:

Supervisor
We'll tell you that we're having these inspections for the simple fact that you'll know so that we can get the work done so it can be done properly.

Shabnam
Sure.

Week five and I'm sent to another ward which will test the hospitals infection control procedures. It's a chest ward and some of the patients either have or are suspected of having infectious diseases. They're being nursed in barrier isolation rooms. I already know how strict the rules are for these rooms. My colleague Sandra and I were told not to enter the room and things were handed out to us. I picked up the lid of a water jug and was told I should immediately wash my hands. So far, so good.

Sandra (to patient)
Morning...

Shabnam
But these precautions were repeatedly breached as Sandra walked in and out of barrier rooms without changing gloves, aprons or washing her hands. She could easily have been spreading infection from one room to the next.

Sandra (to patient)
Morning love

Shabnam
Sandra then goes to work on to the main ward - still without changing gloves or apron or washing her hands. And yet, when I check what we're supposed to do, the rules are clear.

Shabnam
You know the barrier rooms, what I do about them in terms of putting jugs of water in there.

Nurse
You need to put aprons and things on to go into the room. Shabnam
Even just to go in and put a jug in.

Nurse
Yeah, as far as I know. I mean If somebody's in there with them

Shabnam
Hand it to them. I change them between each room because there are three?

Nurse
Yes.

Shabnam
So that's what I do for the rest of the morning. It's time consuming and slow but at least we weren't spreading germs. But then another member of nursing staff gives me completely different advice.

Nurse
When it's ticked wear what they advise you to wear. I mean you wear gloves anyway don't you.

Shabnam
I know But there was one all the way round the corner that I saw nurses going in and out with nothing but I saw the did have the ball ticked so I went in and did it. I just went and got the bin and got it out.

Nurse
Sometimes what happens is if they are only in and out within minutes they don't bother because nurses build up immunity when they have worked with these sorts of patients for some time.

Shabnam
What sort of ward is this

Nurse
Infections, they build up an immunity and that's probably what it was. But you do what you feel you're safe doing.

Shabnam
It's not so much my safety I am worried about it's their safety.

Nurse
But if there was anything really really bad we'd tell you anyway.

Shabnam
So for example over there that says ' gloves and apron, so do you want me to go and put on an apron before and go in and if I do, do I have to change it every time I go in ?

Nurse
No this is more for the nurses than for you.

Shabnam
She appears not to have a clue about why barrier nursing is necessary. On another occasion I walk straight into a barrier room without even knowing.

Nurse
This is isolation.

Shabnam
Sorry?

Nurse
This is isolation

Shabnam
This is an isolation room?

Nurse
Urm

Shabnam
Although it's an isolation room, these nursing staff are working without any gloves or aprons. That's why I just walked in I thought it was a normal room. Wrong. The barrier warning sign is missing.

Nurse
Where's barrier sign gone? Some one has took the sign off. It should have a barrier sign on yeah but for future reference if you see any yellow bags outside any of the rooms, just in case there isn't a barrier sign there always should be a barrier sign, I'm going to put one up in a minute, but if you see any yellow bags outside and some gloves it means it's barrier"

Shabnam
Yellow aprons, you mean.

Nurse
Sorry. It should have been put up. I'll go and sort it out for you alright.

Shabnam
When I check the ward three hours later the sign has still not been put up.

Dr Stephanie Dancer
If you've got a patient with a potentially transmissible infection in a side room, then it doesn't matter which member of staff is going in there to do whatever, they should adhere to proper procedure, that is gloves and aprons and masks if appropriate and there should also be a very distinct notice on the door telling people who wish to enter that they should actually seek permission from the nurse in charge before they go in there.

Shabnam
If there's one place in a hospital where you would expect to find everything being done to the highest standards, it's here. In the isolation unit are patients some of whom have had treatments for cancer which has seriously weakened their immune systems. They're particularly vulnerable to infection. I worked here for just a day when another cleaner left suddenly.

Shabnam
So this is the isolation area, we are now in it yeah?

Brenda
Yes

Shabnam
OK

I'm warned that I must observe the rules strictly as all these patients are seriously ill and have little immunity to infection. When patients have no immunity, staff should only go into their rooms through a special scrub room making sure equipment is clean.

Cleaner
You automatically have to look on the doors to make sure it not an isolation room because if it does you have to go through like here. That's the main thing on this ward is putting on gloves and aprons.

Shabnam
Brenda, the cleaner I work with, is diligent and works hard. But she can't always follow all the rules even when she wants to - because she sometimes doesn't have the basic supplies she needs. Today, the problem is mop handles, which in this unit are supposed to be changed between all the rooms

Brenda
We haven't got enough stakes, there are supposed to be four stakes here - can you see any stakes, for the mop handles. There are supposed to be four in here, two for each room, can you see any here. We've had to order some.

Shabnam
Even mop handles could carry infection from one room to the next, and are supposed to be changed. We spend the morning cleaning carefully, changing our gloves and aprons in each room. But I soon hear of a serious breach of isolation room rules. A patient told us of a visit he had from another cleaner.

Patient
The one yesterday with his vacuum just opened that door and walked in. I said I'm in isolation mate, me family stand out there if I've a bit of a cold and you've just buggered the whole lot up. He said nobody's told me. Like it's my fault! I said I'd rather you didn't come in and he went and complained to the nurse.

Shabnam
And then, one of the scariest things so far - , discovering that Stephen and Habib - two of the worst cleaners I had encountered - were sometimes involved in cleaning the isolation ward.

Stephen
Me and your mate Habib...

Shabnam
Habib, oh

Stephen
We did seven rooms between , between quarter to three and twenty to four , seven of them , mopped and vacuumed them, room and toilets.

Shabnam
The patients here are amongst the most vulnerable to infection in the whole hospital. Even minor infections could have devastating effects. Hospitals are in a difficult position. They're under enormous political pressure to reduce infection rates which cost the NHS a billion pounds a year. Yet they're under pressure to cut costs - which has led to cleaning services being contracted out in almost a third of hospitals. Despite the difficulties in some hospitals -Heartlands is one - MRSA numbers have recently fallen. But it's still a huge problem. Mid-April and I'm back with the Rapid response team... and not much has changed. Shabnam
How many j cloths am I supposed to use on the toilets, just so I know finally ...

Lynn
Well you can use more but they don't over here

Shabnam
No I just need to know what everyone does so I don't do ....

Lynn
Because if you were working down there you would have a cloth for every procedure.

Shabnam
That's what Vicky does

Lynn
But being as you are on this side you don't . so if you want to just use one or two you can. As long as they are red , OK.

Shabnam
Yes I know ill use red definitely

Lynn
So just use one or two , when you get half way just change it . you know what im saying.. as long as you use red on the toilets and sink your are ok

Shabnam
Sorry Lynn
As long as you use your red... if you were on the dependency wards down there then you have to change your cloth on every ward you go in to

Shabnam
That's what I thought

Lynn
Over here you don't , so if you want to use a couple of them, have you got any

Shabnam
I've got loads, yes

Lynn
So when you get half way you change it. Shabnam so don't worry about it.

Shabnam
Some of the rapid complain that changing my gloves is slowing us all down. But this was what I'd been trained to do. And what I'd been shown by Vicky, the first cleaner I'd worked alongside. But now, the supervisor, who should be ensuring that proper standards of cleaning are maintained, joins in with some startling advice. Cleaner
Who told you that?

Shabnam
Vicky.

Cleaner
Load of bullshit man -you'd be here forever. Just put on gloves on. You clean the toilets and I will do all the bays. Just put one pair of gloves on.

Shabnam
Are you sure?

Cleaner
Vicky told her to change her gloves every toilet.

Joy
Who told her?

Shabnam:
Vicky. Yeah, so each bathroom I go into I change my gloves.

Joy
That was because it was cystic fibrosis on 26, they don't down here.

Shabnam
So they're a bit extra strict.

Joy
Just change them when you feel like changing them.

Shabnam
OK

Joy
You don't have to do it in every toilet down here.

Shabnam
And what about the jay cloth, do I to change that each time, she used to do both?

Joy
No

Shabnam
She used to just dump them after each room. Joy
No, no because it's a different type of ward altogether, so don't worry about them.

Shabnam
Another day, another shift with the Rapid, and again I'm being pressured to cut corners.

Lynn
Shabnam you don't have to have all that on to go in there you know!

Shabnam
I might be touching stuff, like I may have to move the bin or something you know.

Lynn
Just put gloves on, you don't have to put an apron on.

Shabnam
But I've been cleaning toilets.

Lynn
You're not cleaning toilets.

Shabnam
But I did earlier and I'm still wearing the same clothes.

Lynn
Yeah as long as you put gloves on to go in there you are alright. Do you want to put that on... but remember we've got four wards to do.

Shabnam
I know

Lynn
We haven't just got one. Shabnam
This was becoming a joke. So I did as I was trained to do. I changed gloves and aprons with each room. But then, I was much slower than the rest of the team. Later, in the break, I talked to my rapid response team colleagues about the risks of working the way they do. Shabnam
If we try and get it done in time and then one of the patients becomes ill then they're going to blame us.

Lynn
They always do, they always come back to us Shabnam what ever we do.

Ellen
They can't blame you if the patients get ill.

Lynn
No, they can't blame us for the patient' s getting ill, but like I said....

Shabnam
But they can say you didn't do barrier stuff or something you know and you didn't do that and therefore you are the one that has passed on the infection or something, carried it from one person to another. they can blame us for that.

Lynn
We haven't got time to do them but at the end of the day it should come back on them because they are the ones that told us in the first place.... We do a lot of things here we're not supposed to do, Shabnam by rights but in the end you've gotta do it, haven't you?

Shabnam
Because of time?

Lynn
Yeah

Shabnam
So, the cleaners don't seem to have a clue about why the cleaning rules are so important. Nor does the supervisor. I decided to take my concerns to the one person I knew understood the importance of correct cleaning. The person who trained me - Georgina. Georgina
Each bay that you mop you should be changing.

Shabnam
So in a ward if there's four bays?

Georgina
You change for every bay.

Shabnam
But that's not what I am doing or what anybody I'm working with is doing.

Georgina
You do it how I showed you, how I trained you - it's a bay, a bucket per bay.

Shabnam
Well At moment it's a bucket per ward.

Georgina
Eh?

Shabnam
You know like for the whole ward we are using one bucket.

Georgina
No.

Shabnam
Then I ask her about barrier room procedure

Georgina
Each barrier room or isolation room that you go in to it is fresh cloths and fresh water.

Shabnam
Again that's not what's happening

Georgina
No wonder we've got infection going round like wildfire.

Shabnam
Back at work the following Monday and I'm less popular than ever. The Rapid Response team have obviously heard about my complaints.

Shabnam
I'm. supposed to mop the floor and I can't find any clean yellow mops r that liquid that you put in them, ehm.. visosol.

Lynn
Are you supposed to be doing this one?

Shabnam
I'm supposed to be doing all the corridors starting one end. Then I'm told to report to Initial's senior manager Annette, and Joy its rapid response supervisor. Annette
You know when you came in the other day and you were speaking to Georgina. I spoke to the rapid response team and they wasn't happy with what you said.

Shabnam
No, well I'm not surprised.

Annette
Lynn herself was not happy cos she said I was taking her with me to fill the mop bucket up. I think if they actually worked the way you said we would have had a lot of complaints that day.

Shabnam
What about idea of using same red j cloth from room to room to room?

Joy
No, you should be throwing that away anyway, you should be coming out of one room and throwing it...

Annette
I honestly cannot see that happening!

Joy
You should throw that away.

Shabnam
Well, that wasn't quite what I remembered Joy the supervisor saying only a few days earlier.

And what about j cloths, do I change those each time, she used to do both, she used to just dump them both after each room ?

Joy
No because it's a different type of ward altogether don't, so worry about that.

Annette
So you went into a toilet and cleaned the toilet, you came out you took your gloves off and whatever, you went to throw your cloth away and they went no you carry on to the next?

Shabnam
Yes. I just really don't know if there is enough time to do things the right way. I don't blame those women at all because there is a time pressure, you have to get everything done in this time - how do you do it?

Annette
It's not down to us. The times that are put down on the boards is given to us by the trust.

Shabnam
But someone needs to say to trust how can you do it?

Both
It can be done, if you have the right team it can be done.

Shabnam
It's July, and three months since I left Heartlands Hospital.

Now Panorama has shown them some of the evidence that I'd gathered, and I'm travelling back to hear what they and the cleaning company Initial, have got to say about it.

Dr Mark Goldman, Chief Executive, Birmingham Heartlands Hospital
6000 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.

The communication issues, the efforts that we will have to make with Initial to get good staff recruitment, of safe staff, 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.

I asked them specifically about their reaction to some of the things I found - like Stephen's approach to cleaning barrier isolation rooms.

Stephen
You're telling me we have to change the water for the four rooms? Every room, you gotta change the water, I'm afraid not, sorry. I want to get these rooms done today not tomorrow. They ain't got a clue over there... they ain't got a clue.

Mike Jepson, Managing Director, Initial Hospital Services
Obviously from the clips that we saw from your film, there are quite clearly that there are some people who need further education, but I'm absolutely convinced that the majority of staff here provide an excellent service to the hospital and hence our contribution to the reduction of MRSA by over 30%.

Shabnam
Don't you need disinfectant or something ?

And I asked what they thought about Habib, the supercleaner, whose approach to infection control left quite a lot to be desired. Habib
Calm down no problem...

Shabnam
Don't you worry about the germs?

Habib
What germ?

Shabnam
Don't you worry about the germs?

Habib
No

Mike Jepson, Managing Director, Initial Hospital Services
Having looked at his training programme he has been through the proper training programme. In terms of the vast majority of staff I feel they have adapted and understood the training programmes. However, there will always be some people within the organisation that do not follow the correct procedure and we are dealing with that as we speak.

Shabnam
There are members of staff that I worked with who told me they only had half a day training and they started work within the last 12 months.

Mike Jepson
Well obviously I will look into those. I'm passionate about the training within our company. I'm passionate that I should set up the training programmes for our managers to conduct the training, and obviously if there are any gaps in that I will ensure that that is improved upon.

Shabnam
Initial have now suspended both Stephen and Habib.

Mike Jepson, Managing Director, Initial Hospital Services
Looking at some of the aspects of the clips that we saw, then there may be an issue in terms of the supervision. Shabnam
This was one of the most worrying things I found - how people supposed to supervise and inspect cleaning were advising me to cut corners and break the rules.

Shabnam
What about the j cloths do I change that each time , she used to do both

Joy
No ?

Shabnam
She used to just dump them both after each room

Joy
No it's a different type of ward altogether , don't worry about that

Dr Mark Goldman, Chief Executive, Birmingham Heartlands Hospital
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.

Shabnam
But it wasn't just Initial's cleaning staff- some medical staff, who really should have known better, and who are employed by the trust itself, were just as bad - even in barrier rooms. Nurse
Because nurses build up an immunity when they have worked with this sort of patient for some time.

Shabnam
What kind of ward is this?

Nurse
Infections , they build up an immunity

Nurse
This is isolation

Shabnam
Sorry?

Nurse
This is isolation

Shabnam
This is an isolation room

Nurse
mmm

Healthcare assistant
Where's the barrier sign gone? Someone took the barrier sign off . It should have a barrier sign on yeah.

Nurse
This is more for the nurses than for you

Dr Mark Goldman
I've seen ah... really wrong things said, and for those particular members of staff they do need to be further trained and their level of knowledge has to be reassessed and we have to make sure that these issues are clarified for them.

Shabnam
Do you think there is any chance that we're going to be able to beat hospital acquired infections when this kind of confusion is seen around the hospital?

Dr Goldman
Well I do, I do and I know that because I've been so closely involved in the work that we've done here, and we have seen some improvements particularly with MRSA. Very substantial reductions over the last year. It's great, you know, in our sector the best.. the best improvement, and we can still make some further improvements I'm sure of that.

Shabnam
But is the contracting system itself a problem - under competitive tendering - did the company reduce its costs so much that they end up having to cut corners?

Mike Jepson, Managing Director, Initial Hospital Services
We put the... what we felt was the right amount of resource into the contract in order to meet the national standards of cleanliness. We feel that with the right training and the right motivation, then we have the right resources to provide the level of standard of cleanliness that is required, and again we feel that is born out by the consistently high marks that we're getting.

Shabnam
But at Heartlands at least, our investigation has helped focus minds on working out what it will take to make sure that a hospital doesn't just look clean - but is clean.

Dr Mark Goldman
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. So whatever investment we can make, has to be made against that number one risk.

Shabnam
This investigation has been a bruising experience for Heartlands Hospital. To be fair, they responded to what we found quickly and openly. But the big mistake would be to think that Heartlands is unique, that you wouldn't find the same in many other hospitals. It's not just Heartlands that should be looking carefully at how its cleaning is really done. How good its standards of hygiene really are. And we should all be asking ourselves if these are the risks we take if we treat hospital cleaning as something we get on the cheap.

Next week I'm undercover again in another NHS hospital - and I've got a recruit to help me. We'll show you what life is like for elderly people consigned to a forgotten ward in a failing hospital. Where Nurses don't care;

Patient
Please help me!

Nurse
No I'm not helping you, can you sit down please. Sit down thank you

Patient
Oh Christ. You're a bully!

Nurse
You're the one who's bully, not me!

SHABNAM
Patients are left for hours in agonising pain;

Patient
Help please, get a nurse...

Shabnam
And some lose the will to live...

Patient
Let me go

Nurse
Go where?

Patient
Please, please

Nurse
Where do you want to go Ivy?

Patient
I'm dying to go

Nurse
Go where, where?

Patient
Heaven



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