"You're amongst the best I've ever come across." Inspector's top praise for endoscopy teams


Our endoscopy teams are celebrating after a hugely successful  decontamination audit.

 Both HRI and CRH units have undergone it as part of their application for JAG accreditation. JAG is the Joint Advisory Group for Endoscopy and is an accreditation to demonstrate the units are running to very high standards and providing excellent patient care. 

This recent decontamination audit goes towards the final JAG assessment in November.

Over the last 18 months - since the fire at CRH - both decontamination units have undergone a large refurbishment programme.

Endoscopy manager, Tracy Burland, said: " In recent times, staff  have been working above and beyond to keep the services running smoothly. This has been very difficult time in Endoscopy and to receive such positive feedback from the audit was a massive boost for  us all."

Included in his feedback, the inspector said: "  An excellent result and the departments are both operating at an extremely high standard and are amongst the best I have come across when auditing within the NHS. They are a credit to you and the rest of your team."

How we are assessed.

The decontamination audit looks at the process of the Endoscope from leaving the patient, cleaning then storage ready for the next patient. It is very important that this process is done to a very high standard following national and department protocols to ensure patient safety at all times. The inspectors look at how staff work and watch to see if they are following correct guidelines.

How important is evidence?.

Evidence is shown to them to demonstrate that all the machines  and storage cabinets are maintained by regular services and validations. They also check that the scope traceability is maintained so this is who washed the scope manually, what machine it was processed in, to what drying cabinet the scope was stored in then finally what patient the scope was used on. All vital information that would be needed if there was ever then need to retrace. If there is no decontamination then there would be no Endoscopy because you can’t have one without the other.

How does the audit fit with JAG?

This audit is needed as part of JAG accreditation which is a much larger audit this will be carried out on the 21&22nd November across both sites. JAG (Joint Advisory Group for Endoscopy) was established in 1994 and the aim of JAG is to ensure the quality and safety of patient care by defining and maintaining the standards by which endoscopy is practiced. A JAG committee agrees on the standards practiced in endoscopy. It also advises suitable processes and frameworks to ensure quality assurance and that the unit maintains those standards. Having JAG reassures patients that the two units are working to very high standards therefore providing an excellent patient experience.


Our excellent HCAs and working together since the fire.

It is mainly HCAs who work in decontamination. They are excellent at what they do and over the past 18 months have gone above and beyond at times by offering to work late or start early to ensure the lists have kept running and patients were not cancelled. It has been a difficult 18 months for the decontamination facilities: it started with a fire at CRH which saw the HRI site processing all the scopes for both sites. Then the refurbishment of both facilities commenced, this was a planned project which involved lots of organising but put huge pressure on decontamination services because for most of that time they were running on only half the capacity they needed. Scopes were travelling up and down the bypass which has its own challenges. Everyone within the Endoscopy unit pulled together -  staff nurses, Endoscopists and HCAs worked hard.