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Linen and Laundry Policy
V3.0
February 2017
Linen and Laundry Policy
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Summary
Linen and Laundry Policy
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Table of Contents
Summary ............................................................................................................................. 2
1. Introduction ................................................................................................................... 4
2. Purpose of this Policy/Procedure .................................................................................. 4
3. Scope ........................................................................................................................... 5
4. Definitions / Glossary .................................................................................................... 5
5. Ownership and Responsibilities .................................................................................... 6
5.1. Role of the Chief Executive Officer ........................................................................ 6
5.2. Role of the Director of Nursing .............................................................................. 6
5.3. Role of Joint Director Infection Prevention and Control (DIPC) ............................. 6
5.4. Role of the Divisional Nurses and Matrons ............................................................ 6
5.5. Role of Infection Prevention and Control ............................................................... 6
5.6. Role of the Managers ............................................................................................ 7
5.7. Role of Individual Staff ........................................................................................... 7
5.8. Role of the Soft Facilities Management Contractors (Mitie) ................................... 7
5.9. Accountable Officer and Contract Monitoring Officers ........................................... 8
6. Standards and Practice ................................................................................................ 9
6.1. Management of Linen and Laundry Services ........................................................ 9
6.2. Linen Usage for Making Beds................................................................................ 9
6.3. Rejecting or Condemning Linen ............................................................................ 9
6.4. Mini Laundry .......................................................................................................... 9
6.5. Segregation of Linen ........................................................................................... 10
6.6. Out of hours Linen Service .................................................................................. 10
6.7. Patients Taking Home Linen ............................................................................... 10
6.8. Trust owned washing machines .......................................................................... 11
7. Dissemination and Implementation ............................................................................. 12
8. Monitoring compliance and effectiveness ................................................................... 12
9. Updating and Review .................................................................................................. 12
10. Equality and Diversity .............................................................................................. 12
10.2. Equality Impact Assessment ............................................................................ 12
Appendix 1. Governance Information ................................................................................ 13
Appendix 2. Initial Equality Impact Assessment Form ....................................................... 15
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1. Introduction The supply of clean linen for patients, staff and visitors is an integral part of safe, effective and efficient healthcare.
1.1.1. Clean, well maintained bed linen enhances aesthetic appeal, providing confidence and reassurance to all service users.
1.1.2. NHS organisations must ensure that they have effective systems in place to prevent and minimise the risk of healthcare associated infections. Linen used by patients and staff can pose a potential infection risk to staff handling it within any health care environment and during transport. Although acquiring an infection from laundry is low risk even when contaminated with blood and body fluid, high standards of the management of linen must be maintained.
1.1.3. Royal Cornwall Hospitals NHS Trust (RCHT) has a duty of care to ensure the safety of all staff, patients and visitors when processing linen and laundry items.
1.1.4. The processing and management of linen and laundry at the Royal Cornwall Hospitals NHS Trust is managed by the Soft Facilities Management Contractor (Mitie Clean Environments).
1.1.5. Ensuring that standards are in place for infection control to enable patient well-being.
1.1.6. This policy has been written in line with the following guidance and legislation:
Heath Technical Memorandum 01-04 Decontamination of linen for health and social care: Management and provision (Department of Health), Updated June 20161
Health & Safety at Work etc. Act 1974
1.1.7. This policy should be read in conjunction with the Health & Safety General Policy, and the Infection Prevention & Control Policies.
1.1.8. This version supersedes any previous versions of this document.
2. Purpose of this Policy/Procedure 2.1.1. This policy will ensure that:
There are clear and well defined roles and responsibilities across the entire spectrum of employees, wards and departments across Royal Cornwall Hospitals NHS Trust in relation to Linen & Laundry.
The Trust allocates the necessary resources to achieve consistently high quality standards of linen across the Trust.
1 https://www.gov.uk/government/publications/decontamination-of-linen-for-health-and-social-care
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Responsibility for the safe and prudent use of linen is embedded at all levels of the organisation.
Linen and Laundry performance and processes will be closely monitored to ensure compliance with national guidance and with a view to further improve the service.
Any persistent failings with regards to hospital linen are addressed at the most senior level and rectified at the earliest opportunity.
3. Scope 3.1.1. This policy applies to all staff and contractors who use, manage or are in contact with laundry and linen
3.1.2. The policy covers both the linen provided by off-site and on-site laundry facilities.
4. Definitions / Glossary 4.1.1. For the purposes of this policy the following terms are used:
The Trust is The Royal Cornwall Hospitals NHS Trust
Mitie (Mitie Clean Environments) is the Soft Facilities Management Contractor responsible for the management and provision of linen across the Trust.
Linen is any reusable cloth/material items such as:
o Sheets o Pillowcases o Towels o Gowns o Curtains o Slide Sheets o Mops o Slings o Scrubs
Clean Linen is linen that has been decontaminated through the process of washing and temperature; is visibly clean; free from infection, dirt or staining; is not damaged, ripped or missing fastenings; has been folded, delivered and stored in a designated linen cupboard.
Infected Linen is linen that has been used for or come into contact with patients with or suspected to have specific infections, or is contaminated with blood or other bodily fluids. Infections can include enteric infections, open pulmonary tuberculosis, Hepatitis A, and other infections as defined by the Trusts isolation Policy.
Used (soiled and fouled) This definition applies to all used linen, irrespective of state, but on occasions contaminated by body fluids or blood. It does not apply to:
o linen from infectious patients;
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o those suspected of being infectious; and
o other linen covered by the following paragraph on “infectious linen”.
Condemned Linen is linen that has been rejected by a Ward Sister/Charge Nurse as no longer fit for purpose.
5. Ownership and Responsibilities
5.1. Role of the Chief Executive Officer
The CEO has overall responsibility on behalf of the Trust to ensure that the linen and laundry are managed in line with legislation and relevant guidance.
5.2. Role of the Director of Nursing
The Director of Nursing is responsible for ensuring that Infection Prevention and Control is maintained in relation to linen provision for the Trust.
5.3. Role of Joint Director Infection Prevention and Control (DIPC)
Has responsibility for ensuring that the policies and procedures in relation to Infection Prevention and Control are followed and suitably managed.
5.4. Role of the Authorised Person (Decontamination)
The Authorised Person (Decontamination) does not have direct input into the decontamination of linen, but should be consulted where advice on the standards required for the mini laundry and general advice on decontamination.
5.5. Role of the Divisional Nurses and Matrons
The Divisional Nurses and Matrons are responsible for ensuring:
This policy forms the basis of good practice and for leading and driving a culture for the safe and prudent use of linen all levels of the organisation.
The appropriate resources are allocated to adequately control risks associated with soiled and infected linen that are identified through the risk assessment process, including the provision of suitable information, instruction, training and supervision of staff
Appropriate support arrangements continue to be available for those who are involved in or affected by such incidents.
Members of staff attend the Infection Prevention and Control training.
5.6. Role of Infection Prevention and Control
Infection Prevention and Control (IPAC) team are responsible for offering support, advice and guidance on specific / specialist linen requirements and training staff on hygiene and best practice in relation to linen.
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5.7. Role of the Managers
Ward Sisters/Charge Nurses and Department Managers are responsible for the correct and prudent use of linen within their area; this includes rejecting linen correctly and managing its use.
5.8. Role of Individual Staff
All employees have a general duty to take reasonable care of their own safety and that of others who may be affected by their actions, which includes the prevention of risk of the transmission of infections to patients and other staff. All employees must further ensure that they will: Ensure that all linen to be used meets the definition of Clean Linen.
Ensure that all soiled or infected linen is securely and correctly stored for decontamination or incineration.
Notify the Mitie Helpdesk of any items of linen that do not meet the definition of Clean Linen.
Report any potential risk of infection using the Trust incident management system (Datix).
Use all linen in a professional and prudent manner to avoid excessive use increasing the costs to the Trust.
5.9. Role of the Soft Facilities Management Contractors (Mitie) and Designated Person
5.9.1. Mitie are responsible for overseeing the development of the linen & laundry service within the Trust. This role also offers representation at the Hospital Infection Control Committee (HICC). In addition, they will offer strategic direction with regard to Government initiatives.
5.9.2. Mitie is contracted to manage Linen Contract on behalf of the Trust to ensure there is sufficient clean linen at all times and that dirty and infected linen is collected, removed, laundered and returned according to the contract specification.
5.9.3. Mitie oversee the operational control and staff management of the linen & laundry service.
5.9.4. Mitie will appoint a Designated Person as defined in HTM 01-04 to act as the interface role between the linen processor and the Mitie.
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5.10. Accountable Officer and Contract Monitoring Officers
The Accountable Officer and Contract Monitoring Officers are responsible for ensuring that Mitie meet their obligations in terms of Linen and Laundry management as detailed in the Specification and Contract for the provision of Soft Facilities Management (FM) Services.2
2
http://www.rcht.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Websites/Internet/OurOrganisation/FreedomOfInformation/Contracts/2014/01PublicationHotelServicesTenderDocumentsAndAwardOfContractTheContract.pdf
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6. Standards and Practice
6.1. Management of Linen and Laundry Services
Mitie are contracted by the Trust to manage the Linen and Laundry services. This includes the provision of clean linen, collection of dirty/soiled and infected linen, the management of the laundry contracts, and mini-laundry services.
6.2. Linen Usage for Making Beds
6.2.1. Clean linen will be used for the making of beds. Beds will be made with 2 sheets, sufficient pillow cases for the number of pillows and where necessary a blanket.
6.2.2. If practicable, sheets can be top and tailed, rather than changed. Ward staff to assess bed and decide if changing bed sheets is necessary.
6.2.3. Bed linen MUST ALWAYS be changed when a patient has been discharged and in preparation for a new patient to be admitted. This should follow procedures for cleaning bed spaces.
6.3. Rejecting or Condemning Linen
6.3.1. Clean linen will be rejected if it is deemed unsuitable to use. Purple reject linen bags are available to every ward/department and reject linen to be placed in these bags and left in the dirty linen cupboard or cage for collection by Mitie Linen staff.
6.3.2. Rejected linen will be returned to the Laundry Contractor.
6.4. Mini Laundry
6.4.1. The Mini Laundry is available at Royal Cornwall Hospital and is used for laundering the following items3:
Slide sheets Slings Mermaid Capes Mops Cloths
6.4.2. Items for the Mini Laundry will need to be placed in a green bag and left in a green Mini Laundry container, found in the following locations:
PAMW – Waste cupboard 1st floor Tower – General Theatre Lobby Tower – Basement Trelawney – Waste cupboard by South Crofty 2nd floor Trelawney – Outside Linen room 1st floor Trelawney – Outside Newlyn Theatre – Ground floor
3 Note: clothing and linen from the Neo-Natal Unit will be processed at the mini-laundry from April 2017.
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6.4.3. The Mini Laundry including equipment must meet or exceed the minimum appropriate standards (Essential Quality Standards) as detailed in HTM 01-04 Decontamination of linen for health and social care, Engineering, equipment and validation. Department of Health
6.5. Segregation of Linen
6.5.1. Only clean linen should be stored in the Clean Linen Cupboard on or near the ward. No other items should be stored in the Clean Linen Cupboards.
6.5.2. Soiled/fouled linen should be placed in a white impermeable bag and stored in the appropriate storage facility outside the ward for removal by Mitie.
6.5.3. All linen identified as infectious should be placed in a red water-soluble bag which should then be placed inside a white impermeable bag which is identified as ‘infectious linen’
6.6. Out of hours Linen Service
6.6.1. Linen levels for all wards and departments are agreed between ward/department and Hotel Services. Linen should be managed prudently. If additional linen is required out of hours, the ward or department will contact the Mitie Helpdesk.
6.6.2. If it is found that linen stocks are running low, this should be escalated to the Mitie On-Call Manager and Clinical Site Co-Ordinators.
6.7. Patients Taking Home Linen
6.7.1. Patients should not be given linen to take home.
6.7.2. Patient’s used clothing should be taken home by relatives for laundering. The used clothing should be place into a patient property bag awaiting collection.
Guidance for relatives - Dirty laundry should be washed at the highest temperature that the fabric will allow. If it is contaminated it should be washed separately from other clothes, remembering to wash hands with soap and water after handling dirty laundry.
6.7.3. Permission should be sought from the patients or relatives to dispose of heavily soiled linen by disposing into clinical waste.
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6.8. Trust owned washing machines
6.8.1. Washing machines owned by the Trust are available in:
Daisy Suite (for parents use only) Residencies (for use by staff/visitors using the residencies)
6.8.2. The washing machines in these areas must not be used for washing patient clothing or linen.
6.8.3. There will be no other Trust owned washing machines available or purchased for use.
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7. Dissemination and Implementation 7.1.1. This document will be available through the Documents Library.
8. Monitoring compliance and effectiveness
Element to be monitored
Delivery of Linen Contract
Lead Contract Monitoring Officers
Tool Reporting arrangements against the Mitie Contract Specification for Linen and Laundry
Frequency Monthly reports will be received by the Contract Monitoring Officers and this will be supported by audits and reviews of the service
provision.
Reporting arrangements
The reports will form part of the Soft Facilities Management Contract performance management meetings.
Acting on recommendations and Lead(s)
The Accountable Officer and the relevant representative from the contractor
Change in practice and lessons to be shared
Through action plans and responses in the contract management processes.
9. Updating and Review 9.1.1. This policy will be reviewed where there are changes to legislation and guidance or every three years.
9.1.2. Any revision activity is to be recorded in the Version Control Table as part of the document control process.
10. Equality and Diversity 10.1.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.
10.2. Equality Impact Assessment
10.2.1. All public bodies have a statutory obligation to undertake Equality Impact Assessments on all policy documents. This must be undertaken by the author using the agreed Equality Impact Assessment Template. The completed assessment is to be added to the end of the policy document as an appendix prior to it being ratified.
10.2.2. The Initial Equality Impact Assessment Screening Form is at Appendix 2.
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Appendix 1. Governance Information
Document Title Linen & Laundry Policy
Date Issued/Approved: Date signed
Date Valid From: March 2017
Date Valid To: March 2020
Directorate / Department responsible (author/owner):
Phil Bond, Governance Lead, Estates & Facilities
Contact details: 01872 253249
Brief summary of contents
NHS organisations must ensure that they have effective systems in place to prevent and minimise the risk of healthcare associated infections. Linen used by patients and staff can pose a potential infection risk to staff handling it within any health care environment and during transport. Although acquiring an infection from laundry is low risk even when contaminated with blood and body fluid, high standards of the management of linen must be maintained.
Suggested Keywords: Linen, Laundry, Health and Safety, Infection Prevention and Control
Target Audience RCHT CFT KCCG
Executive Director responsible for Policy:
Chief Operating Officer
Date revised: February 2017
This document replaces (exact title of previous version):
RCHT Linen & Laundry Policy V2.1
Approval route (names of committees)/consultation:
Health & Safety Committee
Divisional Manager confirming approval processes
Director of Estates
Name and Post Title of additional signatories
Not Required
Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings
{Original Copy Signed}
Name: Phil Bond
Signature of Executive Director giving approval
{Original Copy Signed}
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Publication Location (refer to Policy on Policies – Approvals and Ratification):
Internet & Intranet Intranet Only
Document Library Folder/Sub Folder
Chief Operating Officer / Hotel Services
Links to key external standards HASAWA 1974 HTM 01-04
Related Documents: Health & Safety General Policy Infection Prevention and Control Policy
Training Need Identified? Yes
Version Control Table
Date Version
No Summary of Changes
Changes Made by (Name and Job Title)
1 Jul 09 V1.0 Initial Issue Not Known
25 Oct 12 V2.0 Complete review and rewrite of all content. Nathan Harrow Hotel Services Manager
30 Nov 12 V2.1 Reviewed again following comments from IPAC
Nathan Harrow Hotel Services Manager
01 Feb 17 V3.0 Full review in line with contracting out of Soft Facilities Management
Phil Bond, Governance Lead Estates
All or part of this document can be released under the Freedom of Information Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
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Appendix 2. Initial Equality Impact Assessment Form
Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age X
Sex (male, female, trans-
gender / gender reassignment)
X
Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description):
Directorate and service area: Estates Is this a new or existing Policy? Existing
Name of individual completing assessment: Phil Bond
Telephone: 01872 253249
1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?
All staff responsible for linen, and the contractors
2. Policy Objectives* To ensure that linen is clean and free from contamination
3. Policy – intended Outcomes*
Patient, staff and visitor safety
4. *How will you measure the outcome?
Through Hospital Infection Control Committee ensuring that there have been no infections due to soiled, dirty or infected linen.
5. Who is intended to benefit from the policy?
Patients
6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure.
No
7. The Impact Please complete the following table.
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Race / Ethnic communities /groups
X
Disability - Learning disability, physical disability, sensory impairment and mental health problems
X
Religion / other beliefs
X
Marriage and civil partnership
X
Pregnancy and maternity X
Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian
X
You will need to continue to a full Equality Impact Assessment if the following have been highlighted:
You have ticked “Yes” in any column above and
No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or
Major service redesign or development
8. Please indicate if a full equality analysis is recommended. No
9. If you are not recommending a Full Impact assessment please explain why.
N/A
Signature of policy developer / lead manager / director Phil Bond
Date of completion and submission 1st July 2016
Names and signatures of members carrying out the Screening Assessment
1. 2.
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust’s web site. Signed _______________ Date ________________