Management of Used and Infected Linen · PDF fileManagement of Used and Infected Linen Policy ... SH NCP 50 Management of Used and Infected ... of this policy supports the prevention

1 Management of Used and Infected Linen Policy Version: 2 February 2016

SH NCP 50

Management of Used and Infected

Linen Policy

Version: 2

Summary: This policy sets out the requirements for the management of linen within

Southern Health NHS Foundation Trust, it takes into account initiatives such as (but not limited to) The Hygiene Code & The Choice Framework for local Policy and Procedures 01-04 – Decontamination of linen for health & social care. The Trust aims to ensure that an appropriate contract is in place at all times to manage used & infected linen within the Trust and follow the actions contained in this policy to ensure the safety of the service users healthcare staff. The purpose of this policy supports the prevention of infection or injury in

service users and healthcare staff involved in the use, handling or laundering of

healthcare linen, which requires that effective systems are in place to protect

service users and staff from the risk of acquiring healthcare associated

infection.

Keywords: Linen, laundry, sheet(s), duvet, duvet cover(s), towel(s), mop(s)

Target Audience: All Trust Staff, Executive & Non-Executive Directors, All patients, service users, carers & their families.

Next Review Date: February 2019

Approved &

Ratified by:

Health & Safety Forum Date of meeting: 25th January 2016

Date issued: February 2016

Author: Tracy England, Senior Contracts and PFI/LIFT Manager

Bob Beeching, Contracts and Project Manager

Director: Scott Jones – Head of Facilities and Environment


Version Control

Change Record

Date Author Version

Page Reason for Change

21.9.2015 Tracy England/

Bob Beeching

V2 All

5

6

8

19

Facilities and Environment changed to Estates Services

4.6 change of title

4.11 The Housekeeping staff are now contracted to external providers

8.15 EBOLA paragraph included

Appendix 1 updated to reflect appropriate audit requirements

21.1.2016 Tracy England/

Bob Beeching

V2 11

14

Updated to reflect Infection Control management within laundry

environments

New process introduced to manage specialised items for laundering

Reviewers/contributors

Name Position Version Reviewed & Date

Sandra Grimes Commercial Contract Manager & Project Manager V1/August 2014

Toni Scammell Modern Matron V1/August 2014

Theresa Lewis Lead Nurse Infection Prevention and Control V1/August 2014

Scott Jones Head of Facilities and Environment V1/August 2014

Tracy England Senior Contract and PFI/LIFT Manager V1/September 2014

Alison Edmundson Compliance Assurance Manager V1/October 2014

Ricki Somal Equality and Diversity Lead V1/October 2014

John Micklewright Counter Fraud Lead V1/October 2014

Bob Beeching Contract and Project Manager V2/September 2015

Tracy England Senior Contract and PFI/LIFT Manager V2/September 2015

Theresa Lewis Lead Nurse Infection Prevention and Control V2/January 2016


Quick Reference Guide For quick reference, this page summarises the actions required by this policy. This does not negate the need to be aware of and to follow the further detail provided in this policy.

1. All Trust employees have a legal obligation to take necessary measures to prevent the risk of

infection in all linen storage, (both clean & dirty) distribution and for staff to understand the correct process of the use of clean linen, handling and storage of dirty linen to linen contractor or in house facilities to ensure good standards.

2. All Trust employees to report issues and failures in relation to linen to the Site/Local representative to manage all day-to-day operational issues, any contractual issues to be reported to the Authorised or Supervising Officer who will receive, investigate, and initiate appropriate action as part of the key performance indicators for the Trust’s Linen & Laundry Services specification.

3. All items purchased conform to current NHS fire retardant fabric recommendations and in line

with the Trust’s fire policy and that they can be identified as such and that the fire retardant properties are maintained through the life of the goods.

4. An internal audit of Trust site laundry processes will be undertaken annually by the site manager

and cleaning supervisor, or as appropriate, See Appendix 3 for audit form.


Contents

Section Title Page

1. Introduction

5

2. Who does this policy apply to?

5

3. Definitions

5

4. Duties and Responsibilities

6

5. Main Policy Content

7

6. Training Requirements

16

7. Monitoring Compliance

16

8.

Policy Review 17

9.

Associated Trust Documents 17

10.

Supporting References 17

11.

Training Needs Analysis 18

12.

Equality Impact Assessment Tool 19

1 2 3 4

Appendices Training Needs Analysis Equality Impact Assessment Site/Unit Laundry Audit Checklist Linen Segregation Guidance

18 19 20 21


Management of Used & Infected Linen Policy

1. Introduction

1.1 The purpose of this policy is the prevention of infection or injury in service users and health care staff involved in the use, handling or laundering of hospital linen.

1.2 This policy is based on The Choice Framework for local Policy and Procedures 01-04 –

Decontamination of linen for health & social care, Part 1 – 4 and should be read in conjunction with The Hygiene Code.

1.3 This policy aims to minimise the risk of contamination of injury and infection when handling linen. 2. Who does this policy apply to? 2.1 This policy applies to all directly and indirectly employed staff and staff working under contract

within the Trust.

2.2 This policy embraces all laundry related activities within the Trust and it is written into the service specifications with other Estates Services providers that they must adopt it as part of their terms and conditions.

3. Definitions

Clean Linen Linen items that are new, have been processed or are otherwise clean and have not yet been used

Condemned Linen Linen that is no longer functional, fit for purpose i.e. torn or stained

Emergency Supplies The stock of linen required to service the needs of a special incident

Fouled Linen Used Linen that has been fouled by body substances including but not limited to blood and faeces.

Linen

Articles and garments made form linen or similar textile, such as cotton or manmade fibres

Known, or Potentially, Infected/Infested Linen

All linen which is:

grossly contaminated with excreta, blood or body fluids, or

contaminated linen from an infectious service user patient who is known, or clinically suspected, to be infectious. For example salmonella, hepatitis A, B or C, open pulmonary tuberculosis, HIV. See SH CP 32: Isolation for In-patient Areas (Source & Protective) Procedure for used linen from highly infected patients, handling and disposal of this type of linen or seek advice from Infection Prevention Control team.

Linen and Laundry Services

Linen, laundry and sewing room services provided under the Trust Linen & Laundry Contract

Soiled Linen Used Linen not classified as Fouled Linen or Infected Linen.

Theatre Linen Linen for use in theatres (scrubs)

Used Linen

Linen which has been used but is not contaminated with blood or

body fluids. Used dry linen from non‐infected patients.


4. Duties and responsibilities

4.1 The Trust has a legal obligation to take necessary measures to prevent the risk of infection in all linen storage, (both clean & dirty), distribution and for staff to understand the correct process of the use of clean linen, handling and storage of dirty linen to linen contractor or in house facilities to ensure good standards.

4.2 The Health and Social Care Act 2008 – Code of Practice for the prevention and control of

infections sets out criteria by which NHS organisations must ensure the risk of Health Care Associated Infections is minimised and patients are cared for in a clean environment. Compliance with this code is a statutory requirement including the duty to adhere to policies and protocols applicable to infection prevention and control.

4.3 Trust Board

The Trust Board has a responsibility to ensure that the risk of infection to service users, patients, staff and visitors is minimised.

4.4 Chief Executive

The overall accountability for the safe and effective management of Trust’s premises and service users resides with the Chief Executive of the Trust as accountable officer to the Trust Board, ensuring processes & procedures are in place to minimise the risk of infection and to complying with legal and statutory requirements.

4.5 Chief Finance Officer

The Chief Finance Officer for the Trust will determine the available budget for the management & operation of the cleaning of dirty or infected linen:

Arrangements to ensure compliance with the Trust’s Standing Orders and Standing Financial Instructions

Ensuring that satisfactory arrangements are in place for the provision or procurement of the linen contract or in house processes.

4.6 Head of Estates Services

Head of Estates Services has responsibility to the Chief Finance Officer and Corporate Services for ensuring robust arrangements are in place for the management of used linen.

4.7 Directorate / Service Leads/ Service / Locality Manager

The manager for any service or premise is responsible for ensuring that procedures are disseminated and that staff are aware of their organisational responsibilities to maintain a safe environment. Managers must ensure staff are aware of, have access to and comply with this policy, taking appropriate action should any breach this policy.

4.8 Modern Matrons

Modern Matrons are responsible for:

Supporting the operational implementation of this policy;

Providing clinical leadership with the policy implementation;

Improving and spreading best practice.

4.9 Managers’ Responsibilities: It is the responsibility of managers to ensure that:

Staff are aware of, and have access to, this policy.

Staff comply with this policy.

Staff receive adequate training.

There is an adequate supply of appropriate protective clothing available.

There is an adequate supply of all other equipment mentioned in this policy available at all times.

Take action if any breach of this policy should occur.


All items purchased conform to current NHS fire retardant fabric recommendations and in line with the Trust’s fire policy and that they can be identified as such and that the fire retardant properties are maintained through the life of the goods.

4.10 Authorised Officers

The Trust will nominate an Authorised Officer to act as the representative of the Trust for all purposes specified in this Policy. The Trust’s nominated Authorised Officer is the Head of Estates Services. The Authorised Officer will nominate a deputy (the Supervising Officer) who will monitor the performance of the linen contractor to ensure that the Trust is receiving an effective service; all in house processes will be managed by the Site/Local representative. All failures must be reported to the Site/Local representative to manage all day-to-day operational issues, any contractual issues to be reported to the Authorised or Supervising Officer who will receive, investigate, and initiate appropriate action as part of the key performance indicators for the Trust’s Linen & Laundry Services specification. The Trust will ensure that there are sufficient resources, including appropriate training, for the role of Authorised/Supervising Officer to be effectively undertaken. The Supervising Officer will hold regular contract review meetings to identify any areas of concern.

4.11 All staff All employees are responsibility for their own safety and the safety of others due to their actions or inactions with respect to Health and Safety Law. Contracted Housekeeping staff must ensure they are aware of the procedures for the management of used linen.

5. Main Policy Content

Clean Linen – Linen items that are new, have been processed or are otherwise clean and have not yet been used

Used Linen – Linen which has been used but not contaminated by blood or body fluids. The linen must be placed in a white plastic bag for laundering.

Known, or Potentially, Infected/Infested Linen - Linen which has been used and contaminated by bodily fluids, excreta, blood or contaminated linen from an infectious service user patient, who is known, or clinically suspected, to be infectious. For example salmonella, hepatitis A, B or C, open pulmonary tuberculosis, HIV. Linen used by patients already subject to infectious precautions (isolation) must be placed into a red water-soluble bag and then into a white plastic bag. Linen contaminated with cytotoxic waste must be placed into a red water-soluble bag and then into a white plastic bag to go to the laundry.

See SH CP 32: Isolation for In-patient Areas (Source & Protective) Procedure for used linen from highly infected patients, handling, and disposal of this type of linen or seek advice from Infection Prevention Control team.

5.1 Frequency of Linen Change

Linen must be changed and laundered between patients and when visibly soiled. The frequency of change will depend on the individual case e.g. daily for patient’s isolation or immediately if fouled.


5.2 Handling and Storage of used Linen in Ward / Department Used linen must be handled with care to prevent environmental contamination with excretion or

secretions, skin scales or bacteria. Staff must wear gloves and linen must be bagged at the bedside, never shaken or allowed to touch the floor. No extraneous items must be placed in the laundry bags, especially sharp objects. This may contribute to a Health & Safety risk for staff. All linen bags must be placed in the correct colour bag, securely tied, labelled as appropriate and stored in a room or area designated for the purpose, which is safe and separate from service user areas. A laundry poster explaining the colour coding of laundry bags to be displayed in the laundry storage areas. Bags must be less than 2/3 full. Laundry bags holding used linen should not be left unsealed/tied for long periods i.e. longer than 24 hours. All trust owned items that are sent to the laundry must be appropriately marked including mattress overlays and patient clothing. Plastic aprons and gloves should be worn when handling used, soiled or infected linen. Hands must be washed after handling all used soiled or infected linen even though gloves have been worn. Linen should be held away from the body to prevent contamination of clothing. See Appendix 2 for segregation guidance.

5.3 Transporting used Linen from Ward / Department to Pick-up Point

Laundry bags must be securely tied. The pick-up point must be dry, secure, and separate from the clean linen area. All dirty/used linen should be removed from clinical areas as frequently as circumstances demand. Linen handlers must have heavy-duty rubber gloves available, guidance on hand washing technique and frequency must be given (see CP23 Hand Hygiene Policy). Refer to section 3.5 for transportation of Service User Handling Aids. Dirty linen and clean linen must not be transported in the same cage/receptacle/bag.

5.4 From Pick-up Point to the Laundry Frequency of collection will be dependent on the volume of laundry and the agreed schedule

between the Trust and laundry provider. The provider is responsible for the cleaning and disinfection of the container/vehicle in order to prevent contamination of clean linen. Clean articles of laundry shall be transported in containers and vehicles that have been appropriately cleaned by the Contractor before each occasion on which they are used.


Each linen storage roll cage must be appropriately covered. The interiors of vehicles used to transport clean articles shall be thoroughly cleaned and disinfected daily with the aid of high-pressure hot water. It follows that the interiors should have smooth, plain, impervious surfaces with as few interstices, which might harbour bacteria as possible. Soiled and clean articles must never be allowed to come into contact with each other at any time. In order to prevent such contact, soiled and clean articles shall not be carried on the same vehicle unless separated by a waterproof partition or barrier in addition to the bags in which the articles are contained. The provider must comply with all aspects of the Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004. The majority of laundry consignments are not classified as dangerous for transport. However, there may be occasions when soiled linen will need to be classed as dangerous for transport due to it containing pathogens which pose a significant risk of spreading disease and the load is heavily soiled to the extent that the potential for exposure and infection is high. In these instances linen should be classed as infectious (i.e. healthcare/clinical waste) or example - where a person has clostridium difficile and has heavily soiled linen or a person with a blood borne virus has contaminated the linen with heavy blood spillage. All linen identified as being classed as healthcare waste will be disposed of by the Trust, not the laundry provider.

5.5 Ebola For patients with a ‘HIGH POSSIBILITY’ VHF infection, the use of disposable linen should always be considered. This linen must be treated and disposed of as Category A waste (yellow bag). If re-usable linen is used, it must be disposed of in yellow waste bags and treated as Category A waste and sent for incineration.

5.6 Storage

Storage areas must remain closed and kept secure from unauthorised persons. All clean linen must be stored off the floor in a clean, closed cupboard and must be segregated from used/soiled linen. It must not be stored in a sluice room or bathroom. Linen cupboards must be kept closed to prevent airborne contamination.

5.7 Condemned Linen

When deciding if articles to be deemed Condemned Linen the following criteria will apply:

There will be no more than three patches in any 35cm square

No repairs or patches will be larger than 15cm square

There will be no more than 5 patches over the entire piece of Linen 5.8 Return of Clean Linen to the User

Contamination of clean linen must be prevented by:

a) ensuring roll cages are adequately covered and cleaned on a regular basis, with a waterproof cover (Linen Contractor responsibility).

b) storage in a clean, dry area or cage.


c) transport in a clean, dry container/vehicle which is cleaned and disinfected prior to loading with clean linen.

Linen which is (or thought to be) contaminated must be returned to the laundry for re-processing as a rejected item by completing the reject label and placed in the pink rejects bag. Fire access points must not be obstructed by returned linen.

5.9 Infection Control Issues in the Unit/Site Laundry

No person shall be permitted to handle articles of laundry while suffering from an infection or skin disease. Gloves and aprons must be worn when handling linen. After handling used linen Personal Protective clothing should be disposed of immediately and hand hygiene performed.

Disposable items must not be re-used.

A hand wash basin, complete with soap and paper towels, must be available close to the laundry areas. Staff must be aware of the possibility of extraneous items and sharps containers must be available. Staff must be aware of actions to take in the event of a sharps injury. All staff handling used linen must have access to the Occupational Health Service and receive Hepatitis B vaccination, tetanus and polio immunisation. Laundry processing will be in accordance with The Choice Framework for local Policy and Procedures 01-04 – Decontamination of linen for health & social care. Plastic disposable bags should be used for storage of dirty linen. An audit of Trust site laundry processes will be undertaken annually by the site manager and cleaning supervisor, or as appropriate, See Appendix 3 for audit form. Audit of external laundry contractor processes will be undertaken annually, by Infection Control, Trust lead and a representation from the Laundry Contract review group.

5.10 Laundering in Small Units (wards, launderettes etc.) Laundry should be processed off the ward unless there is a local agreement between the clinical

manager, facilities estates and infection control teams. The Infection Prevention & Control team must be involved in the planning and design of any new laundry rooms.

5.11 Environment The laundry area should be designed for that purpose only and no other activities carried out in the designated area. Laundry should not be placed in a sluice area where dirty activities take place. Walls & floors should be washable, sealed and the internal decoration must meet an acceptable standard. The area should have a dirty area that flows logically to clean.


Clean laundry items should be stored in clean laundry storage areas/cupboards. There should be hand hygiene basin with lever taps and no plug or overflow, liquid soap, paper towels and foot operated bins must be available at all times. A hand hygiene poster should be on display at all times. The hand wash basin should be dedicated for hand hygiene only. Food or drink must not be allowed in the laundry areas. Washing machines designated for patient laundry should only be used for patient laundry. The laundry area should be kept clean, tidy and uncluttered.

5.12 Washing Machines/Tumble Dryers Wherever possible service users’ personal clothing should be given to relatives/carers to be taken home for laundering. All such linen should be placed in plastic bags and relatives/carers informed of any soiling. In exceptional circumstances where it is not possible for relatives/carers to take these items home for washing the designated ward washing machine may be used

Ward based washing machines are permitted with the agreement of the Infection Control Team. Washing machines must be appropriately situated in a designated area so as to reduce risk of cross contamination. All washing machines and tumble dryers must be purchased & installed through the relevant Estates Department to ensure compliance with infection control & engineering requirements. All washing machines and driers are managed for repairs and maintenance via the appropriate Estates Department.

An industrial washing machine should ideally be used which is complete with a sluice facility, disinfection cycle and temperature indicator. The machines should be checked at regular intervals and any maintenance or repairs to be reported to the appropriate Estate Services.

Care of washing machines & tumble dryers – follow manufacturer’s instructions. Instructions for use should be visible and on display

Items which are grossly contaminated with blood or other body fluids or which are known, or thought, to be infected must not be laundered in the ward but must be sent to the laundry. Items must be washed at the highest temperature the fabric can withstand. All items must be dried as quickly as possible, using a tumble drier, and not left hanging for long periods of time. Clean items must not come into contact with contaminated items or surfaces. Clean items must be stored in suitable areas to prevent contamination prior to use. Storage areas should be off the floor and away from dirty laundry. Staff must wear single use gloves, plastic aprons and when handling soiled items and wash hands after removal of gloves and apron. Laundry products – Control of substances Hazardous to Health (COSHH) sheets and product data sheets should be referred to in order to ensure the safe management of solutions being used for laundering, manufacturer’s instructions should also be adhered too.


5.13 Spillage of Contaminated Linen

Wearing gloves, replace the linen in an appropriate bag. Wash the contaminated surface with detergent and water and dry. Wash hands thoroughly after removing gloves.

5.14 Service Users Own Clothing

When dealing with patients’ own ‘soiled ‘clothing i.e., covered in urine, vomit or faeces, linen should be placed in a water soluble red alginate bag and then a green patient property bag. Hand the bag of clothing to the patients’ relative or carer with clear instructions to put the red water soluble bag and contents in their domestic washing machine. Relatives/carers should be advised to set the washing machine at the temperature required to dissolve the bag (60 degrees) and that failure to do so could damage the machine. Staff may also consider disposing of heavily soiled linen after discussion with the patient and their relative/ carer to gain their consent. This must be documented by staff. Procedure for sending soiled service users clothing to laundry see 5.18 below. If service users are responsible for laundering their own clothing / bedding, they should have

Individual baskets for both clean and dirty laundry which are clearly marked.

The laundry baskets should be cleanable.

Soiled laundry should be transported to the laundry area in ‘dirty/used’ laundry baskets and returned to the room using a clean basket.

Soiled linen should not pile up in laundry areas – if necessary service users should use a locally agreed rota system.

Clean laundry should not be left piled on work surfaces in the laundry, but returned to service users room

5.15 Marking of Linen, Uniforms and Patient Clothing

Clearly mark the bag PATIENTS CLOTHING, along with the name of the Hospital and Ward on a label and attach the label to the bag ensuring that it will not fall off in transit, as it cannot be returned to the correct ward or department if this is not done.

Placed soiled item in a water soluble bag.

Place dissolvable bag inside blue plastic bag.

Complete paperwork. If the items require marking then follow the procedure for Marking of Linen, Uniforms and Patient Clothing in Appendix 4.

5.16 Anti-embolic Stockings

Anti-Embolic Stockings are for single patient use only. Ensure stockings are changed every 2-3 days and washed according to the manufacturer instructions.

When another pair of stockings is required a new pair should be issued. If the patient requires continued use of the stockings on discharge they must be supplied with the manufacturers’ guidance to enable correct washing at home.

5.17 Pillows, Duvets, Mattress Overlays

These must be protected by heat-sealed, waterproof covers which are cleaned with detergent and water between service users, duvets or pillows must be laundered between service users if


waterproof covers are not suitable. If clostridium difficile is present, they should be wiped with a solution of chlorine based disinfectant (reference NSPA Cleaning manual). Alcohol wipes MUST NOT be used to clean these items as alcohol damages the cover which may allow fluid to pass through to the mattress foam. The life of the mattress and its ability to protect service users from cross infection is then reduced. If the cover is damaged or punctured, and the article itself is contaminated it must be condemned and disposed of as healthcare/clinical waste. Replacement covers can be purchased and may be used providing the mattress itself is not soiled stained or has an odour. In PICU areas a risk assessment must be carried out before any waterproof or plastic covers are used on an individual service user basis.

5.18 Staff Uniforms/Patients Own Clothing

There is no service for laundering of uniforms except laboratory coats, catering uniforms and theatre scrub suits. Aside from those items mentioned above, it is the responsibility of the member of staff to wash their uniform at home, (this includes nursing staff and Allied Health Professionals). Uniforms should be laundered at the hottest wash they will tolerate (usually 60°C) in a washing machine, as recommended for infection control. They should be tumble dried if possible and then pressed with a hot iron. They should be laundered separately from the family wash if possible. Heavily soiled uniforms should be washed separately. (see SH HR 36 Standards of Dress, Uniform & Personal Appearance Policy). If a uniform becomes very heavily contaminated with body fluids it is not advisable for the item to be washed at home by the member of staff. Instead it must be sent to the laundry contained in the appropriate coloured bag and labelled with the name of the individual, Trust, ward and hospital and complete local laundry provider documentation, following local laundry provider procedures to ensure it is returned. After washing, uniforms should be protected from contamination from dust during storage. A clean uniform is required for each shift for those members of staff having direct service user contact. Staff who are not issued with sufficient numbers of uniforms MUST take this up with the relevant manager to ensure an adequate number is supplied. Patients own clothing that is sent for laundering must be sent to the laundry contained in the appropriate coloured bag and labelled with the name of the individual, Trust, ward and hospital and complete local laundry provider documentation, following local laundry provider procedures to ensure it is returned.

5.19 Curtains & Soft Furnishings

Where ever possible curtains and soft furnishings should be purchased in compliance with NHS fire retardant fabric recommendations and in line with the Trust’s fire policy. When a fabric is designated as inherently fire retardant, permanently fire retardant, or durably fire retardant, the flame retardant will last for the life of the fabric. If curtains or soft furnishings are not purchased to these requirements a suitable fire retardant treatment to the items must carried out to ensure they meet the above standards. In the case of fabrics that are designated as fire retardant, that have been treated with chemicals, the flame retardant of the fabric will dissipate over time, particularly with repeated cleaning. The flame retardant properties of treated fabric will vary based on the number of times the fabric is laundered or dry-cleaned and the environmental conditions in the location in which the fabric is


used. It is recommended that treated fabric be re-tested for fire retardant on an annual basis and re-treated by a qualified professional as required. All curtains that require laundering must be put in the white plastic laundry bag then in the Orange fabric bag if due for routine clean. If curtains are deeply soiled put in the red alginate bag then in white plastic outer bag, then in Orange fabric bag. The bag must be clearly labelled with Trust, site name, ward and hospital and the local laundry provider documentation completed with all information including number, type, colour of curtains. Staff to follow local laundry provider procedures to ensure it is returned. All fabrics which need to be treated as infected and cannot be washed to high level thermal disinfectant temperature level (reaching 65 degrees), i.e. require dry cleaning, must be steam cleaned prior to dry cleaning. Curtains must be cleaned regularly in accordance to the standards as defined in the National Specifications for Cleanliness in the NHS April 2007. (published by NSPA). See table below:

5.20 Curtains/ Blinds clean, change, or replace

Risk Category Frequency

Very High 2 x Yearly Task

High 2 x Yearly Task

Significant 1 x Yearly Task

Low 1 x 2 Yearly Task

5.21 Service User Handling Aids – e.g. Slings, Slide Sheets

All handling aids must be individualised for each patient. This may be achieved by use of single patient disposable products, or washable fabric aids.

5.22 Mops

If mops are laundered by Trust linen contractor they must be placed in the appropriate coloured bag. A dedicated washing machine must be used for the laundering of mops on trust premises, this machine must have a sluice facility and temperature indicator. In the event of a machine failure another alternative may be used, this machine must be able to comply to high level thermal disinfection temperature levels (reaching 65 degrees), also after every mop wash, the machine should be run on a full wash cycle without a load.

5.23 Single User Disposable Products

On service user’s discharge or between service users, or after contamination with blood or other body fluids, single patient items must be disposed of in accordance with Waste Management Policy as healthcare (clinical) waste stream.

5.24 Washable Patient Aids

On service user’s discharge or between service users, or after contamination with blood or other body fluids, washable fabric items must be laundered at 60 degrees centigrade. Washable items must be placed in appropriate alginate red (water soluble) bags (see Linen & Laundry Contract Procedures for identification of colours) then an outer white plastic bag and separated from other infected linen. To ensure that items are returned to the appropriate ward/site they should be identified with Trust, ward or site name and complete local laundry provider documentation,


following Linen & Laundry Contract Procedures. It is recommended that new items are not put into use until suitable labelling has been carried out. NB. If a fabric sling contains plastic reinforcing struts these must be removed prior to the sling being sent for laundering. The strut must be wiped firstly with a detergent wipe and then an alcohol wipe before being replaced in the clean sling.

5.25 Colour Coding of Laundry Bags

Category Type Colour of bag

1. Used General items and personal clothing (labelled- name, ward, site or hospital)

White plastic laundry bag

Cleaning mops Clear plastic

Theatre scrubs Purple plastic outer bag

2. Known or potentially infected/infested

General items (labelled: name, ward, site or hospital)

Inner - dissolvable red bag (alginate) Outer - bag white, plastic

3. Known or potentially infected/infested Trust or patient own items

Bag labelled – patient name, ward and site or hospital

Inner - dissolvable bag red, plastic Blue plastic bag Outer - orange fabric bag

4. Curtains Routine clean unsoiled (labelled- ward and site or hospital)

Inner - white plastic laundry bag. Outer - orange fabric bag

Deep clean/soiled Inner - red alginate bag, place in white plastic laundry bag. Outer - orange fabric outer bag

5. Reject linen or returned items

Linen deemed not fit for purpose, heavily stained, torn, rough

Pink plastic bag/reject label

6. Condemned or unfit linen

When deciding if articles to be deemed Condemned Linen the following criteria will apply:

There will be no more than three patches in any 35cm square

No repairs or patches will be larger than 15cm square

There will be no more than 5 patches over the entire piece of Linen

White plastic bag - labelled “unfit for use” (this linen must NOT be placed in same bag as other linen)

7. Marking/labelling of linen

New or clean items of laundry Blue plastic, labelled with site/service/ward

8. Infected Scrub suits Inner - dissolvable red bag (alginate) Outer - bag blue plastic

9. Dirty Scrub suits Direct into blue plastic bags


5.26 Reject Linen

All items of rejected linen should be recorded on the order requirement documentation stating the reason for rejection. The top copy, along with the rejected items, should be placed in the appropriate bag (pink) identified by your laundry service provider. Bags must be clearly marked REJECTS and include the ward / department name and hospital. The bags of rejected linen should be returned with dirty linen.

5.27 Supplies of Bags

All outer plastic bags and water soluble bags will be purchased by the Trust and supplied to the clinical areas by local arrangement organised by site manager. The soluble bags come from NHS supplies and are ordered by nursing staff or can be ordered from laundry provider.

5.28 Laundry Contract & Queries

In the first instance all queries should be directed to the laundry provider. See Trust intranet for contact details. To contact the Supervising Officer for escalation of contract queries/issues contact by email: SHFT Soft FM Services - [email protected]

6. Training requirements

6.1 Managers to ensure staff are aware of their responsibilities with regard to training which includes:

Mandatory Infection Prevention & Control,

Use of Personal Protective Equipment

Mandatory Moving & Handling

Mandatory Health & Safety 7. Monitoring Compliance

Element to be monitored

Lead Tool Frequency Reporting arrangements

Compliance to the specification

Contract Manager

Email / Database Report

Weekly

A breakdown of service activity levels. e.g. collections/ deliveries - scheduled/ planned/ undertaken. Helpdesk report.

The contractors reports

Contract Manager

Email / Phone

Weekly/ Bi Monthly

Details of all requests received from the Contractor’s Helpdesk or other authorised source.

Regular review meetings with the contractor

Contract Manager, Infection Control Lead, Matrons, Solent NHS Trust

Meeting Bi Monthly A review of previous month’s quality assessments and the identification of repetitive short fall in service levels and trends, together with steps being taken to improve performance. Breakdown of quality inspections, i.e. test pieces inspected, number of rewash loads, finish quality, folding & packing quality, security of

mailto:[email protected]


Trust owned linen (items lost or misplaced)

The Authorised Officers annual audit of laundry premises

Contract Manager, Infection Control Lead, Matrons

Audit Annual Annual audit date and action plan in place with timescales agreed.

8. Policy Review

8.1 This policy will be reviewed by Estates Services team at three yearly intervals or earlier if

required to meet national guidance or statutory legislation. 9. Associated Trust Documents

9.1 This policy will also take account of other relevant Trust Policies such as (but not limited to):

SH CP 10 Infection Prevention & Control Policy - Version 3

SH HS 04 Health & Safety – Statement of Intent

SH CP 12 Hand Hygiene Policy

SH HS 05 Moving & Handling Policy

SH HS 06 Fire Safety Policy

SH CP 19 Standard Precaution Procedure

SH HR 36 Standards of Dress, Uniform & Personal Appearance Policy 10. Supporting References

Code of Practice on prevention & control of infections and related guidance.

Firecode – Fire safety in the NHS Health Technical Memorandum 05-03 Operational provisions Part C – Textiles & Furnishings

The Health & Social Care Act 2008

The Choice Framework for local Policy and Procedures 01-04

Decontamination of linen for health & social care

NSPA NHS Cleaning Standards 2007

Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004

Barrie, D (1994) “Infection Control in Practice: How hospital linen and laundry services are provided” Journal of Hospital Infection 27 pp 219-235


Appendix 1: Training Needs Analysis

If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality, Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on 02380 874091) before the policy goes through the Trust policy approval process.

Training Programme

Frequency Course Length Delivery Method Facilitators Recording Attendance Strategic & Operational

Responsibility

Title and Level (if

appropriate) of

your training

programme

How often will the target audience need to attend

this course?

How long will the programme run

(April – April?) and how long will each

course take (3 hours?)

How and where do you intend

delivering this programme (face to

face, e-learning, Essential Training

Days)?

Who will be delivering this programme if

delivery method is face to face?

Who do you anticipate recording attendance?

Who is accountable for this training strategically and

who is operationally accountable?

Directorate Service Target Audience

MH/LD/TQ21

Adult Mental Health

No formal training required.

Specialised Services


Learning Disabilities


TQtwentyone


ISD’s

Older Persons Mental

Health


ISD’s

Adults


ISD’s

Childrens Services


Corporate

All No formal training required.


Appendix 2: Equality Impact Assessment The Equality Analysis is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by the Equality Act 2010. Stage 1: Screening

Date of assessment: November 2015

Name of person completing the assessment:

Tracy England/Bob Beeching

Job title: Senior Contract PFI/LIFT Manager/Contract and Project Manager

Responsible department: Estates Services

Intended equality outcomes: No Adverse Impacts

Who was involved in the consultation of this document?

Tracy England Senior Contract PFI/LIFT Manager

Bob Beeching Contract Manager

Theresa Lewis Lead Nurse Infection Prevention and Control

Please describe the positive and any potential negative impact of the policy on service users or staff. In the case of negative impact, please indicate any measures planned to mitigate against this by completing stage 2. Supporting Information can be found be following the link: www.legislation.gov.uk/ukpga/2010/15/contents

Protected Characteristic Positive impact Negative impact

Age Not Applicable No adverse impacts

Disability Not Applicable No adverse impacts

Gender reassignment Not Applicable No adverse impacts

Marriage & civil partnership Not Applicable No adverse impacts

Pregnancy & maternity Risk Assessments are carried out as required

No adverse impacts

Race No adverse impacts

Religion No adverse impacts

Sex No adverse impacts

Sexual orientation No adverse impacts

Stage 2: Full impact assessment

What is the impact? Mitigating actions Monitoring of actions

http://www.legislation.gov.uk/ukpga/2010/15/contents


Appendix 3

Site/Unit Laundry Audit Checklist There will be systems in place for the audit of this policy. Audit should be carried out no less than annually.

Standard Statement Y N* N/A

1.

Ref 5.18 Uniforms contaminated with body fluids are sent to the laundry.

2.

Ref 5.2 There is a poster available explaining colour coding of laundry bags.

3.

Ref 5.2 Linen is bagged at the bedside.

4.

Ref 5.2 Linen is placed in correct bag (see Ref 5.25 Colour Coding of Laundry Bags).

5.

Ref 5.2 Linen bags are less than 2/3 full & labelled appropriately

6.

Ref 5.2 Linen bags are securely tied.

7.

Ref 5 Items which are contaminated with blood or other body fluids are sent to the laundry.

8.

Ref 5.12 Items washed on site are washed at the highest temperature the fabric can withstand.

9.

Ref 5.12 All items washed on site are dried using a tumble dryer unless unsuitable.

10. Ref 5.19/20 Any patient/curtain/site own laundry is correctly labelled before being sent to the laundry.

11. Ref 1 All staff are aware of this Policy.

12.

Ref 5.3/5.11 Laundry environment: clean laundry is managed and kept separate from dirty laundry. (Laundry is not placed in a sluice area where dirty activities take place)

Score: Y Y+N x 100 = %

*Action Plan Document below actions to be undertaken, with timescale, to achieve compliance with policy, following liaison with Infection Control Team. Review undertaken by: Date:


Appendix 4 Linen Segregation Guidance

USED LINEN should be placed directly into a white plastic laundry bag

SOILED LINEN should be placed in a red alginate bag then into a blue plastic bag

Alginate

Plastic

INFECTED SOILED LINEN should be placed in a red alginate bag and then into a white plastic bag

Alginate

INFECTED SOILED LINEN (patient own) should be placed in a red alginate bag and then into a blue plastic bag then to be placed in the orange outer bag clearly labelled with the laundry docket.

Alginate

Plastic

SPECIALISED ITEMS UN- SOILED Curtains and patient clothing to be placed in white plastic bag. Then to be placed in the orange outer bag clearly labelled with the laundry docket.

SPECIALISED ITEMS SOILED Curtains and patient clothing to be placed in red alginate bag, then white plastic bag and in orange outer bag with the laundry docket.

Alginate

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REJECT LINEN and SCRUB SUITS Reject linen should be placed into the pink reject bag identified by your linen service provider. See Section 27.

Please Note:

Slings and sliding sheets should be marked with site/hospital name, ward area and placed in clear plastic bags and taken to the linen room

Mop heads need to be placed separately in clear plastic bags. Ensure all extraneous material (service users teeth, books etc.) is removed prior to placing linen

in bags

Do not overfill bags – bags should be 2/3 full

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