FOOD SAFETY POLICY Documentation Control

Transcription

1 FOOD SAFETY POLICY Documentation Control Reference HS/EI/020 Approving Body Directors Group Date Approved 22 Implementation Date 22 Summary of Changes from the Inclusion of Central Production Unit / Kitchen. Previous Version. Food Hygiene Rating System. Allergens. Supersedes April 2011 Consultation Undertaken Estates and Facilities Team, Trust Health and Safety Committee, Infection Prevention and Control Committee, Local Authority Environmental Health Officer, Nutritional Steering Committee, Patient Partnership Group, Organisation Risk Committee, Matrons Forum and Directors Group. Date of completion of the 25 th February 2014 Equality Impact Assessment Date of Environmental Impact 25 th February 2014 Assessment (if Applicable) Date of Completion of We Are 25 th February 2014 Here for You Assessment Legal and/or Accreditation Food Safety Act 1990 Implications Food Safety and Hygiene Regulations 2013 Chilled and frozen guidelines on cook chill and cook freeze catering systems 1989 Target Audience Catering Managers and Catering Staff Clinical Leads/Service Managers Matrons/All Trust Food Handlers, Trust Volunteers, Tenants and Contractors Review Date May 2016 Lead Executive Author / Lead Manager Further guidance/ Information. Director of Estates and Facilities David Preece. Head of Facilities Management (Catering & Linen/Laundry Services) Ext No Mark Fulford Food Safety and Compliance Officer: Ext No

2 CONTENTS Paragraph Title Page 1 Introduction 3 2 Executive Summary 3 3 Policy Statement 3 4 Definitions including glossary 4 5 Roles and Responsibilities 7 6 Policy and/or Procedural Requirements 16 7 Training, Implementation and Resources 24 8 Impact Assessments 26 9 Monitoring / Monitoring Matrix Relevant Legislation, National Guidance and Associated NUH Documents 31 Appendix (1) Equality Impact Assessment 33 Appendix (2) Environmental Impact Assessment 35 Appendix (3) Here For You Assessment 37 Appendix (4) Training Overview: Food Safety 39 Appendix (5) Food brought / bought in by patients. 40 Appendix (6) Certification Of Employee Awareness 41 2

3 1.0 Introduction 1.1 Good food hygiene is an essential element which underpins the achievement of the highest level of quality patient outcome thus supporting a high level of organisational performance and enhancement of the Trust s reputation. At its basic level, good food hygiene practices help to ensure that food contamination is prevented which could lead to illness/ harm to our patients, staff and visitor safety. The Food Safety Act 1990 and the Food Safety and Hygiene (England) Regulations 2013 (Sections 1 and 2) set out clear minimum requirements for food hygiene and safety with the fundamental objectives being the pursuit of the highest level of protection of human life and health. This policy therefore details the approach of Nottingham University Hospitals NHS Trust (NUH) to manage the risk from food hazards to protect all persons on our sites from physical contamination, chemical contamination, harmful bacterial contamination and food allergens leading to food poisoning, food-borne infection and allergic reactions. 2.0 Executive Summary 2.1 Outlines the key requirements to enable the Catering Providers, Nursing Directorates, Support teams, Volunteers and Food Handlers to manage food safely within NUH to ensure that the risk to patients, visitors and staff is minimal. 3.0 Policy Statement 3.1 The Trust will: Ensure that the management of food safety is at the highest level and a five rating is maintained as part of the food standards agency s Food hygiene Ratings. In addition NUH shall work towards having zero exceptions in the three main criteria of Hygiene, Structure and Confidence in Management. 3

4 NUH shall also aim to ensure a fair, consistent and economic approach to the at NUH. Food Safety is applicable to all staff employed by the catering provider and all NUH staff NUH, accepts its moral and legal responsibilities to set and maintain the highest levels of food safety and hygiene across NUH catering premises and providers. NUH acknowledges its responsibility to comply with all relevant legislation with respect to Food Safety. NUH accepts that it has a duty to ensure all risks associated with the storage, preparation, service and disposal of food are managed and comply with legislation. Experience has shown that the rules and procedures outlined in this Policy contribute a sound basis to ensure the highest standard of food hygiene and safety. 4 Definitions Ambient Temperature: The temperature of the surrounding environment; commonly used to mean room temperature. Bacteria: Single celled living organisms; some may spoil food and some may cause illness. Cleaning: The process of making something clean. Detergent - removes dirt and dust. Disinfection - reduce food poisoning bacteria down to a safe level. Contract Caterers: Businesses providing catering services under contract to NUH. CPK: Central Production Kitchen providing cook freeze meals to patients, restaurants and retail. The unit is based on City campus. 4

5 Cross-contamination: The transfer of a contaminant from one contaminated product such as raw meat to another previously uncontaminated product such as ready-to-eat food. Digitrack: Computer aided food temperature monitoring system. Due Diligence: A defence under section 21 of the Food Safety Act 1990 that every practicable measure was taken to avoid committing an offence under the act. Applications of the provisions of the act (d) section 21 (defence of due diligence); Food Hygiene (England) (no 2) Regulations EHO: Environmental Health Officer / Enforcement Officer. A person employed by a local authority who enforces food safety legislation. Environmental Hygiene: Those practices that are conducive to providing a healthy environment. For example: infection control, good ventilation, good sanitary facilities and natural lighting. Food: Any substance or product, whether processed, partially processed or unprocessed, intended to be or reasonably expected to be ingested by humans; includes drink and ice. Food-Borne infection: An infection caused by pathogens (food poisoning bacteria) that are carried by food but are not dependent on it. Food contamination: The presence in food or the process of transferring to food any unwanted material, object of substance. Food handler: Any person that handles wrapped or unwrapped food at any stage from delivery /production to disposal. 5

6 Food hygiene: All the processes involved in keeping food safe to eat. E.g. temperature control and recording, cleaning, exception reporting, good personal hygiene and food safety training. All the guidelines are contained within the Food Safety Management System (FSMS). Food Hazard: Microbiological, chemical or physical contaminant that might cause harm to the consumer Food Poisoning: Is any illness, caused by, or thought to be caused by, pathogens or toxins in food. The term is sometimes also used as a simple general term for all kinds of illness related to food. Food Safety: The protection of human health by preventing edible substances (defined by law) from becoming hazardous and by minimising the risks from those hazards. Also used to indicate the absence of harm to people from food. Food Safety Management System: FSMS. A system that incorporates HACCP, Monitoring, Standard Operating Procedures and training to ensure that food does not cause adverse human health effects. HACCP (Hazard Analysis and Critical Control Points): The system for identifying, assessing and controlling hazards and risks associated with food and drink. High risk food: A product intended for consumption, either cold or reheated but without further cooking. It is capable of supporting pathogenic, bacterial growth and, if contaminated, has a definite potential for causing food poisoning. Critical Control Point: CCP s. The point at which the exercise of control over one or more factors could eliminate a hazard or minimise the risk from it. (I.e. The point where control matters the most.) 6

7 Pathogenic micro organism: A micro-organism that can cause illness or harm. Personal hygiene: Hygiene practices performed by an individual which ensures food is protected against contamination. Providers: Third party catering business and suppliers to NUH. Sanitising: Application of heat and/or chemicals using (detergent and disinfectant) to reduce food poisoning bacteria to a safe level. Simulant Block: A plastic block that simulates a piece of food in a fridge or freezer. The block can be connected to probe thermometer or is directly linked to a computer monitoring system. STS: Supply Training & Services Consultancy for food safety matters and 6 monthly inspections. Tool Box Talks: A weekly meeting by catering managers to their teams to discuss timely topics. 5 Roles and Responsibilities 5.1 Committees The Trust Board is responsible for ensuring that arrangements are in place so that it can be assured about patient data quality and compliance with this policy. Estates and Facilities Operational Management Team (OMT) shall ensure that directorates shall comply with this policy through its monthly meetings The Trust Board has ratified this and is 7

8 accountable for the activities of food safety within NUH. The Trust Board will receive assurance that the requirements of current Food Safety Legislation are met through the annual report from the Nutrition Steering Committee to the Clinical Effectiveness Committee (CEC) and the annual declaration to the Care Quality Commission against its standards derived from the Health and Social Care Act The Trust Board delegates the responsibility for Food Safety to the Chief Executive. 5.2 Chief Executive The Chief Executive will, on behalf of the Board, be responsible for ensuring that all current Food Safety Legislation is complied with and that all stages of production, processing and distribution of food satisfies the relevant hygiene requirements and that there are effective arrangements for food safety within the Trust. The Chief Executive delegates the implementation of this Food Safety Policy to the Director of Estates and Facilities Management and Directorate Management teams for the food handlers under their direct control. 5.3 Director of Estates & Facilities Management The Director of Estates and Facilities Management has overall responsibility for ensuring that NUH catering services, catering contract providers, authorised outside caterers and voluntary sector partners comply with this. Third party catering providers shall adhere to the policy but monitored by their service provider. The Director of Estates & Facilities Management is responsible for ensuring that food safety issues within all catering services (Internal and External) are highlighted to the relevant NUH risk management committee. This responsibility will extend to proposed programmes of work relating to food safety risk management for consideration as part of 8

9 the annual business planning process which will be submitted to the Investment Governance Committee and Performance Management Team as appropriate. This will include the management of the food related components of the Trust s Capital Programme and future allocation of sufficient funding to ensure compliance with the Policy. At an operational level the Director of Estates & Facilities Management will; Ensure, through the Head of Facilities Management, that senior management and line managers within catering services develop, implement, maintain and monitor procedures related to HACCP principles. Ensure through senior management and line management structures full staff participation from catering staff in food safety training. Ensure that agreed programmes of investment in food safety are properly accounted for in the Trust s annual business plan. In line with delegated authority, the Director of Estates and Facilities Management has chosen to devolve the day to day duties to the Head of Facilities (Catering and Linen Laundry Service) who is responsible for food safety within catering service but accepts that he retains accountability as the Director of Estates and Facilities Management. 5.4 Head of Facilities Management Catering and Linen/Laundry Services The Head of Facilities Management will ensure: The senior managers within the Department implement and comply with this Policy by setting up food hygiene monitoring and management control systems following the principles of HACCP to ensure that food safety and hygiene is in accordance with relevant legislative requirements and auditing them on a not less than 6 month frequency. The Hazards (risks), controls, critical limits, monitoring and corrective actions along with the responsibilities are all set out in the NUH food safety management system (FSMS) and a copy is held by each NUH catering operation. 9

10 Compliance with food safety and hygiene is reported annually to the Nutrition Steering Committee and against the relevant assurance frameworks. That the Nutrition Steering Committee is informed of all outstanding actions on matters of Food Safety and the EHO reports, via the Menu, Diet and Food Service Work stream. That the EHO is kept informed and updated on all matters, both legal and best practice associated with food safety. The authorised outside caterers list is maintained and available on request, All catering / retail business operations, either NUH or third party occupiers will be registered with the local council and provide high levels of food safety in compliance within the regulations. That where necessary, food safety risks are reported on the Risk Register and to the appropriate risk management committee, The Central Production Kitchen (CPK) is operating to high standards (best practice) of food safety which meets the demand on the business. That all food handlers in co-operation with their line managers and the training department attend and attain food hygiene training foundation level 1 and subsequent 3 yearly refresher training. That all catering staff attend and attains food hygiene training foundation level 2 and subsequent yearly refresher training. That all catering managers and supervisors attend and attain food hygiene training foundation level 3 and subsequent yearly refresher training. That all catering managers attend and attain food hygiene training foundation level 4 and subsequent yearly refresher training. That all catering staff are trained in undertaking a new task to comply with the regulations and best practice. That all catering staff are trained on Food Allergens with yearly refresher training. That all 3 rd party providers of catering show evidence that food handlers working in their employment are trained commensurate to their work activities. That those responsible for the development, implementation, maintenance and monitoring of the defined processes and 10

11 procedures have received suitable and sufficient training in the application and principles of HACCP. That the nominated person audits all areas on not less than 6 month frequency. Link to Audit schedule. Patients are surveyed on matters relating to quality and safety on an annual basis. 5.5 Head of Estates (Operational Maintenance) The Head of Estates (Operational Maintenance) will ensure that the buildings and equipment are maintained in good order and in line with all relevant regulations. Sufficient resources will be provided by the Trust to ensure compliance and issues or gaps should be highlighted immediately to ensure funding can be sought to close the gaps. 5.6 Head of Capital Projects The Head of Capital Projects will ensure that all work which has implications for Food Safety on new and existing Trust buildings is carried out to a satisfactory technical standard and conforms to all prevailing statutory and mandatory Food Safety Legislation including the Control of Contractors Policy. 5.7 Assistant Head of Regulatory and Property Services. The Assistant Head of Property Services (Property and Land) will ensure that when letting contracts a clause is inserted to ensure that lessors conform to the Trust s. 5.8 Directorate Teams Each Directorate team (Clinical Director and by delegation clinical lead) will: Take responsibility for food hygiene in their areas and ensure all stages of production, processing and service of food under their control satisfy the requirements laid down in this Food Safety Policy. 11

12 Disseminate the policy details and allocate responsibility for implementation to local service managers and staff. Ensure that food hygiene and safety matters are included in management team briefings/meetings. Ensure all food handlers are aware of their specific responsibilities for food hygiene. Ensure that, where necessary, food hygiene risks are reported on the risk register. Ensure that all food handlers have completed mandatory food safety training with refresher every 3 years. 5.9 Ward Sisters / Charge Nurses. Matrons and Ward Managers will: Promote the highest standards of environmental and personal hygiene necessary to prevent food poisoning and potential contamination of food at a ward/department level. Ensure that staff and volunteers are competent to work safely and comply with this through food safety training and Nutrition Link Professionals. Ensure effective management of food hygiene within the ward areas and ward kitchens by ward sisters / charge nurses, which includes the implementation of this. Ensure that Nutritional Link Professionals have food safety responsibilities and are trained to foundation level 2 in food safety, updated yearly and promote good practice. Ensure by delegation that all foodstuffs are to be adequately stored and a rotational stock control practice followed. Ensure food brought in by patients and their relatives is managed in accordance with this policy Appendix 5 Food bought / brought in by patients. Drugs, samples or blood for transfusion shall not be stored in fridges or freezers used for patients food to avoid crosscontamination. All Ward staff have access to a copy and have read the `Food Safety at Ward level` document. Patients are surveyed on matters relating to quality and safety on an annual basis. The process to be overseen by Matrons. 12

13 5.10 Head of Catering. The Head of Catering will ensure that: Food providers and handlers are provided with suitable advice on all aspects of food safety and hygiene through the implementation and monitoring of appropriate management systems to ensure that all food is safe, wholesome and fit for human consumption. Establish Codes of Practice and key performance indicators which are monitored, reviewed and reported in accordance with the schedule. Establish standard operating procedures to ensure food safety is tracked from delivery and productionthrough to disposal in all NUH food businesses. All suppliers comply with this policy by including the requirement in all tender documents. For arranging supplier assessment visits by suitably qualified staff prior to contracts being placed. All food premises are registered with the Local Authority Environmental Health Department. All food outlets are audited by the local EHO`s. All risks associated with food preparation, distribution, delivery, handling and service are assessed and control measures introduced and, where necessary, reported to the relevant risk committee and departmental heads of service. All Food operatives within Catering Services are provided with information and training commensurate with their responsibilities. All matters relating to food safety are shared with trust teams and relayed to the Catering Teams through `Tool Box Talks` The, all relevant statutory requirements and other Trust policies are monitored and reviewed at least annually. Patients, visitors and staff are surveyed annually to comment on the safety and quality of food. That the EHO is kept informed and updated on all matters, both legal and best practice associated with food safety. That the Nutrition Steering Committee is informed of all outstanding actions on matters of Food Safety and the EHO reports, via the Menu, Diet and Food Service Work stream. 13

14 5.12 Central Production Kitchen Manager The Central Production Kitchen Manager and Assistant will: Ensure that the Trust s and Codes of Practice are implemented within all the catering sites including the CPK. Audit the catering premises as per schedule to ensure compliance and identify any specific training needs required. Ensure that all authorised outside caterers will be subject to an annual audit of their premises and food safety and hygiene systems either by EHO inspection reports, site visit by a member of the catering management team or the NUH supplies department. Report to the Head of Catering on matters of food safety. Ensure all matters of food safety are addressed and managed within the CPK 5.12 Retail Catering Services Manager The Retail Catering Services Manager and Assistant will: Ensure that the Trust s and Codes of Practice are implemented within all the catering outlets. Audit the catering premises as per schedule to ensure compliance and identify any specific training needs required. Ensure that all authorised outside caterers will be subject to an annual audit of their premises and food safety and hygiene systems either by EHO inspection reports, site visit by a member of the catering management team or the NUH supplies department. Report to the Head of Catering on matters of food safety Patients Food Services Manager The Patients Food Services Manager and Assistant will: Ensure that the Trust s and Codes of Practice are implemented within all patient food Service areas and ward kitchens. Audit the catering premises as per schedule to ensure compliance and identify any specific training needs required. 14

15 Report to the Head of Catering on matters of food safety Food Safety & Compliance Officer. The Food Safety & Compliance Officer will: Report to the Head of Facilities Management Catering and Linen/Laundry Services on matters of food safety. Report to the Head of Catering on matters of food safety. Liaise with the catering management team on matters of food safety. Report to the Food, nutrition and menu work stream on matters of food safety Liaise with the EHO on matters of food safety Liaise with STS on matters of food safety Act as the gate keeper for the food safety management system and provide updates in line with any legislation changes Ensure all monitoring on food safety is in line with the guidance set, inclusive of completion of action plans Ensure that the six monthly NUH multidisciplinary catering audit is delivered. Check for legislation updates through news, media, official publications and the food standards agency. Record, investigate and assist to resolve food safety matters in partnership with the catering teams Catering / Chef Supervisors Catering supervisors shall ensure that all matters relating to food safety are managed within their area of work. Also that all standard operating procedures are adhered to. Catering Supervisors will ensure that staff under their direct control Maintains the highest standards of hygiene and cleanliness in order to comply with this. Report on matters of food safety. Complete documents identified in the FSMS. Complete HACCP monitoring documentation. Comply with Standard Operating Procedures. 15

16 5.16 Volunteer Services Manager. The Volunteer Services Manager will ensure that all Volunteer food handlers at ward level comply with the Policy PPI (Patient & Public Involvement). The Patient Public Steering group (PPG) will be informed of the Policy and associated documents and updated via sharing of information with the head of Public Patient Involvement. Members of the Catering Management Team will attend the monthly meeting of the group PPI periodically and the PPG monthly Nutrition Steering Committee The Nutrition Steering Committee will ensure that there are written policies and procedures to support the provision and delivery of food and nutrition to hospital patients and actively promote the Trust-wide implementation of these. Information and actions shall be shared with the Clinical Effectiveness Committee Environmental Health Officer / Practitioner The EHO shall visit as scheduled from the official food hygiene rating guidance. Due to hospital patient food production and feeding being high risk this will be not less than annually. Retail, suppliers and third party catering providers shall be visited as per the official food hygiene rating guidance that has been agreed. The inspection reports shall be made available to the NUH when requested. Any breaches shall be escalated through the trust via the nutrition steering committee 6 Policy and/or Procedural Requirements. 6.1 Food Safety: 16

17 Food and Drink must be fit for human consumption. It is imperative that all food and drink is managed safely as not to put further risk on patients, visitors and staffs health. No food that is either past its use by or best before date shall be served to patients, visitors or staff. The Food Safety Management System (FSMS) is the main body of evidence to support the compliance with the food safety act and food safety regulations and to meet the requirements of the food safety policy. The policy can only highlight some of the main points and therefore the FSMS shall be read in conjunction with this policy. Food Hygiene Ratings (Food Standards Agency) The FSMS shall ensure that the 3 key requirements of the Food Standards Agency s food safety ratings are adhered to. These are. 1) Hygiene 2) Structure 3) Confidence in management. Key points. The key process at NUH food production is providing food for patients from the CPK using the cook freeze method. Frozen food is reheated at ward level using Burlodge Ovens. All NUH catering sites are subject to the standards laid out in the policy and the FSMS Catering Site Provision of frozen foods to NUH sites. CPK NUH Wards Queens Restaurant City Side Restaurant Coffee City Patient Hotel inc Hospitality Queens RDU All food provided shall meet the standards set in the FSMS in accordance with the food safety legislation. Best practice shall be the norm rather that exception. Temperature control is the key element to protect food from harmful hazards along with good standards, effective procedures, thorough cleaning, timely maintenance and well trained staff. 17

18 The key process steps that are identified in the food safety management system are. A Planning a Food Service K Sandwich production B Purchase L Cooking C Delivery M Cooling D Chilled Storage N Vacuum Packing E Frozen Storage O Portion / Packing F Dry Storage P Blast Freezing G Defrosting Q Holding Freezer H Decanting R Picking I Preparation S Dispatch / Transport J Repack HACCP is the legal system that is used in the FSMS. SOPs support all aspects of the safe management of food from its origin and supply, to delivery cooking and final consumption or disposal All Hazards shall be identified and managed safely throughout the system using temperature control, SOPS, monitoring, recording and reporting as part of the HACCP system. It is a legal and moral obligation that all staff shall not contaminate the food either by physical, chemical or biological contamination e.g. Staphylococcus aureus bacteria from human hands, nose etc. Considerations across all HACCP steps include: Recording & monitoring of temperatures and standards, safe management of food wastage, safe management of pest control and safe management of cleaning. 6.2 Temperature Control Summary. All probes used for testing temperatures of foods shall be calibrated in accordance to the guidelines set in the FSMS. All temperatures shall be recorded accurately; monitored and corrective action taken to ensure NUH has a strong case of Due Diligence. This shall be in accordance to the guidelines set in the FSMS. All foods shall be managed within the legal temperature parameters and be fit for human consumption. Ensure that all and any food issued to a patient has been kept at the 18

19 required safe temperature at all times including but not limited to storage prior to preparation, during cooking, during transfer and at point of service around the Facilities. Temperature Summary. Temperature Action. Delivery +1 c to +8 c Chilled foods. -15 c to -25 c Frozen foods Ambient Dry goods +63 c or above Hot foods All vehicles that transport hot foods shall utilise thermos containers to keep the food above +63 c during transportation. Foods moving around campus or campus to campus shall be transported under temperature control conditions. Storage +1 c to +4 c -18 c to -25 c Cool & Dry +1 c & +4 c Production +75 c +8 c -5 c Cold foods shall be kept at a minimum of +8 c but Ideally between +1 c to +4 c. Cook chill meals shall be stored at between +1 c to +3 c Frozen foods Dry goods Defrosting or tempering Cooking / Reheating foods minimum core temp. Hot food shall be chilled / blast chilled to below +8 c within 90 minutes of being handled from the production area and within 180 minutes of leaving the cooking vessel. Hot food shall be Blast Frozen to below -5 c within 90 minutes of being handled from the production area and within 180 minutes of leaving the cooking vessel. Where Halal, Kosher or Allergy foods / meals have been cooked / reheated, the temperature of another item of food (non Halal/Kosher/Allergy Food) will be taken to indicate a temperature for those specialist meals. 19

20 Service + 5 c to +63 c Any high risk food kept at ambient temperatures that aren t consumed after 4 hours shall be disposed of. Any high risk food shall only be and displayed for one period only outside temperature controlled conditions. +63 c and over Hot Holding. If the temperature drops below +63 c then the food shall be consumed within 2 hours. Hot food intended for patient consumption that has been reheated at ward level using a Burlodge Oven shall be served within 1 hour of being reheated and disposed of within 2 hours of being reheated. All Hot food shall be consumed within 2 hours of delivery from the catering department unless hot holding temperatures are recorded in accordance to HACCP guidelines. Any high risk food shall only be displayed for one period only outside temperature controlled conditions. 6.3 Allergens. It is important to consider how known allergens affect the safety of food when foods can become contaminated through cross contamination. Therefor all providers and handlers of food shall take the necessary steps to avoid any contamination. The 14 Allergens that must be tracked. 1) Cereals containing Gluten a. Wheat b. Oats c. Rye d. Barley e. Spelt f. Kamut 2) Crustaceans 3)Eggs 20

21 4) Fish 5) Peanuts 6) Soybeans 7) Milk 8) Nuts a. Almonds b.hazelnuts c. Walnuts d. Cashews e. Pecan f. Brazil nuts g. Pistachio h. Macadamia 9)Celery 10)Mustard 11)Sesame 12)Sulphur Dioxide/ Sulphites 13)Lupin 14)Molluscs Full list of allergens as requested, and the title of the national document is at the Allergen Toolkit for Healthcare Catering Foods shall be tracked from supply through to disposal and all the necessary practices and procedures are documented in the Food Safety Management System. All staff shall receive allergy awareness training commensurate with their job. Basic training must ensure as a minimum staff are aware of the procedures and policies for handling allergy-related requests for information. It is also important that staff preparing and serving foods know the risks of allergenic contamination during storage, preparation and display. All staff must know the emergency procedures for dealing with a customer who is having an allergic reaction to food. A quick response to incident could save a life. 21

22 6.3 Cleaning. All food areas, food rooms, kitchens, food service areas, transportation and equipment used for food shall be kept at a high standard of cleanliness inclusive of using detergents, disinfectant and sanitisers. All areas and equipment shall have a cleaning schedule to include daily, weekly, monthly and periodic cleaning. All areas shall have task list to supplement the cleaning schedules to include how to clean, what to clean with and the use of personal protective clothing. All areas shall have a sufficient deployment of staff to maintain a high standard of cleanliness for areas and equipment. Where catering staff cannot clean then the relevant manager shall employ the services of NUH cleaning services and/or a private cleaning contractor to facilitate the cleaning to the required standard. Staffing levels and budgets shall be made to the appropriate level to ensure effective cleaning is carried out and maintained. 6.4 Maintenance All areas and equipment shall be maintained to a high level which meets the standards set in the food safety regulations. Materials within food rooms shall be robust, non-porous and easy to clean. Areas or equipment requiring maintenance, if a food safety risk shall be reported on a priority 1 or 2 to the estates and facilities department, stating it s a food safety issue. The issue shall be dealt with in a timely manner. 6.5 Pest Control. The NUH pest control team shall monitor for the signs of pests, deal with any sightings or infestations. The catering staff, supervisors and managers shall ensure that any signs of pests or sightings shall be reported to the pest control team. The catering managers shall ensure that maintenance issues or poor housekeeping is addressed as not to entice any pests. NUH Pest Control Team to Liaise with the NUH Infection, Prevention and Control team where required. 22

23 6.5 Personal Hygiene Any person working in a food handling area is to maintain the highest level of personal cleanliness and is to wear suitable, clean and, where necessary, protective clothing. No person suffering from or being a carrier of a disease likely to be transmitted through food or afflicted for example with infected wounds, skin infections, sores or diarrhoea is to be permitted to handle food or enter any food handling area in any capacity if there is any likelihood of direct or indirect contamination. Any person so affected and employed in a food business and who is likely to come into contact with food is to report immediately to their line manager the illness or symptoms and if possible their cause. Staff shall be 72 hours symptom free before returning to work. Hand hygiene is one of the most effective action in preventing food poisoning and maintaining the highest standards of food hygiene. To facilitate effective hand hygiene, food handlers working in clinical environments must be bare below the elbow when undertaking food handling duties. Hands must be decontaminated. For further information refer to the Hand Hygiene Policy located on the NUH Policies and Procedures and Guidelines intranet site and in the Infection, Prevention and Control Manual. Oven gloves are used for heat protection and not hand hygiene. Blue water proof dressing shall be used for cuts and abrasions. Skin conditions will be assessed by the line manager and appropriate action taken for staff either cover of hands with protective disposable gloves or given non-food duties. 6.6 Monitoring / Recording / Reporting. The FSMS shall be the vehicle for monitoring, recording and reporting of food safety. Records shall be kept for a maximum of one calendar year. The policy shall be read in conjunction with the NUH Catering Service Specification inclusive of any contract Performance Payment Mechanism (PPM). The policy shall be read in conjunction with the NUH FSMS 23

24 6.7 E. coli It is recognised that NUH recognise the particular issues with this pathogenic food poisoning bacteria. Some of the key measures to control E.coli are: Identification of separate work areas, surfaces and equipment for raw and ready-to-eat food. Use of separate complex equipment, such as vacuum-packing machines, slicers, and mincers for raw and ready-to-eat food. Hand washing should be carried out using a recognised technique. Anti-bacterial gels must not be used instead of thorough hand washing. Disinfectants and sanitisers shall meet officially recognised standards and should be used as instructed by the manufacturer. All considerations shall be taken with reference to other pathogenic food poisoning bacteria which is issued specifically by the Food Standards Agency (FSA) E.G. Preventing Listeriosis in Hospitals & Nursing/Care Homes. This information shall be included in the FSMS as a SOP. 7 Training & Implementation 7 Training. No specific training required for the food safety policy, however catering teams, support teams and directorates shall ensure that staff that handle food are trained in aspects of food safety relating to their work which shall be inclusive of SOPS within the FSMS. In addition covering foundation level 1 and 2 in food safety where applicable. Induction Level Level 1 yr. 3 yr. 1 2 Refresher Refresher Catering staff Catering Supervisor Nursing Nutrition Link Nurse 24

25 Support teams Volunteers Induction Level Level 1 yr. 3 yr. 3 4 Refresher Refresher Catering Supervisors Catering Assistant Managers Catering Managers 3 rd parties Training commensurate to their work activities. 7.1 Implementation. Directorates awareness via the Trust Intranet and Trust Briefings. Catering management via catering and Linen Management meetings. Catering staff awareness via tool box talks 7.2 Resources. Training resources. Study leave form submitted or identified with staff appraisal Directorates training budget recharge to catering for foundation level 2 training for nursing and support staff. (Not including Volunteer Meal Time Assistants) Band 4 foundation training re charge to nursing level 2 - funding JIFF or equivalent. 25

26 8 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. All members of staff should be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a Trade Union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social and employment status, HIV status or gender re-assignment. This policy has been impact assessed (Appendix 2) and has been found to be neutral with regard to its impact upon specific equality groups and positive in its corporate impact to promoting valuing diversity and implementing equality of opportunity. Considerations have been made for the provision of specialist diets including food safety and any additional costs. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has indicated the need for additional considerations which have been duly incorporated. The Here for You standards have been introduced to ensure that employees are aware of the acceptable standards of behaviour that are expected and in doing so we have made a pledge to each other. We pledge that all day, every day we will all do our very best to ensure: You are appreciated, with a polite and respectful attitude, from kind and helpful colleagues, who value everyone who takes responsibility for doing a good job. You are supported to make the best use of your time, by simplifying processes, eliminating waste, and streamlining communication to ensure everyone can be focused on high quality care for patients. You are encouraged to improve the quality of our service to 26

27 patients, by listening to patients needs and through evidence-led improvement, team working, training and personal development. The examples of acceptable behaviour towards patients included within the Here for You standards will also apply to the way staff interact with each other. Staff have all undertaken training regarding NUH Values and Behaviours and a copy of the policy is issued to all staff. Any failures to adhere to the policy shall result in re training in NUH Values and Behaviours. Further failures could lead to disciplinary measures being taken. A here for you assessment has been undertaken and has not indicated that any additional considerations are necessary. 9 Policy Monitoring 9.1 Policy Monitoring All issues relating to food safety are reported and monitored by the Nutritional Steering Committee via the Nutrition Menu, Diet and Food Service work stream. The Nutrition Menu Diet and Food Service work stream is chaired by the Head of Facilities Management Catering and Linen/Laundry Services and meets quarterly. 9.2 An annual report on the Management of food safety shall be distributed to Nutrition Steering Committee (NSC) and any risk issues passed to the Clinical Effectiveness Committee (CEC) Under standard statement 5 of the standards for Nutrition; Food Services must have a HACCP process in place that complies with current Food Safety legislation. This process must be agreed with the local Environmental Health Officer and monitored through the FSMS. Appropriate training must be given to staff and monitored against the Trust Mandatory Training Policy and the FSMS via the Nutritional Steering Committee. 9.3 The NSC shall report matters of food safety to the CEC following each meeting. 27

28 9.4 The CEC is mandated by the Trust Board to oversee nutritional practice and care. The CEC shall report matters of food safety to the Organisation Risk Committee (ORC) 9.5 The CEC will agree annually with QRC those standards which it will report against. These will be described in the Trust Clinical Effectiveness Programme and Directorate Clinical Effectiveness Plans. Assurance against these standards will be reported to QRC bimonthly. 9.6 The Trust is required to meet national standards of best practice in relation to clinical effectiveness as set out by the Department of Health (DoH), Care Quality Commission (CQC), NHS Litigation Authority (NHSLA), National Institute for Health and Clinical Excellence (NICE) and the Clinical Negligence Scheme for Trusts (Maternity). 9.7 The FSMS shall provide the detailed information on the Hazards (risks), controls, critical limits, monitoring and corrective actions along with supporting documentation such as policies, procedures and guidance. The system incorporates HACCP, Cleaning systems and Food Safety training. The FSMS shall support the standards set in this policy and food safety legislation. Lead catering managers will feed back via the web based monitoring system. 9.8 An internal audit of the premises and the food safety management shall be conducted on a six monthly basis by a competent person/s and formally documented and issued to the Head of Facilities Mgt Catering and Linen/Laundry Services. 9.9 An external audit of the premises and the food safety management system shall be conducted on an annual basis by the EHO and formally documented and issued to the Head of Facilities Mgt Catering and Linen/Laundry Services An external audit of the premises and the food safety management system shall be conducted by an external contract company: Supply, Training and Services (STS) on a six monthly basis All relevant staff will receive suitable and sufficient training on food safety, to enable Nottingham University Hospitals NHS Trust to 28

29 comply with all relevant food safety regulations The monitoring arrangements will be reviewed on a six monthly basis by the Food Safety & Compliance Officer Review: This policy will be reviewed at least biannually or when there are changes to legislation which impacts on the policy s effectiveness. The and Food Safety Management Systems will be improved in line with any new legislation, best practice and team innovations. 29

30 9.1 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Responsible individual/ group/ committee Process for monitoring e.g. audit Frequency of monitoring Responsible individual/ group/ committee for review of results Responsible individual/ group/ committee for development of action plan Responsible individual/ group/ committee for monitoring of action plan Daily recording of critical temperatures. Catering Supervisors Chef Supervisors Monitoring of HACCP Daily Catering Management Catering Management Catering Management. FSMS Catering Managers and Assistants Catering Projects Manager Monitoring of FSMS Audits Monthly Catering Projects Manager Bi monthly: Menu, Diet & Food Service work stream Food Safety and Compliance Officer Food Safety and Compliance Officer Menu, Diet & Food Service work stream. 30

31 10 Relevant Legislation, National Guidance and Associated NUH Documents The United Kingdoms Legislative framework and its associated regulations are further underpinned by a number of NUH policies and procedures in support of this. These are set out below: Food Safety Act 1990 Food Safety and Hygiene Regulations 2013 DOH Chilled & Frozen guidelines on cook chill & cook freeze catering systems E.coli O157: An invisible threat to your business: FSA. Preventing Listeriosis in Hospitals FSA. Food labelling legislation:eu Consumers Regulation 1169/2011 Guidance for Management of Allergens (British Dietetic Association) Health and Social Care Act 2006 Health and Safety at Work Act (1974) Infection Prevention and Control Policy Waste Management Policy Mandatory Training Policy Uniform Policy Hand Hygiene Policy Pest Control Policy Legionella Policy Fire Policy Control of Substance Hazardous to Health Policy First Aid at Work Policy Food Hygiene at Ward Level Guidelines Duty of care act 1992 Standard of Business Conduct Policy Clinical Effectiveness Policy Nutrition Policy Risk Management Policy Food Safety Regulations: Regulation (EC) No. 852/2004 on the hygiene of foodstuffs, The Food Safety and Hygiene Regulations

32 These regulations set out the basic hygiene requirements for all aspects of our food service operations, from our premises and facilities to the personal hygiene of our staff. Food hygiene: A guide for business: Food Standards Agency Industry guide to good hygiene practice: Catering guide Food Handlers fitness to work Regulatory Guidance and best practice advice for food business operators (Food Standards Agency 2009) Good Practice Guide: Healthcare food and beverage service standards. A guide to ward level services Hospital Caterers Association. Care Quality Commission (CQC) Core Standard C15: A: Where food is provided, healthcare organisations have systems in place to ensure that Patients are provided with a choice and that it is prepared safely and provides a balanced diet. Core Standard C15: B: Where food is provided, healthcare organisations have systems in place to ensure that Patients individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day. Considerations for all core CQC standards with reference to food safety. 32

33 Appendix 1: Equality Impact Assessment Q1. Date of Assessment: 25 th February 2014 Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups experience? i.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: Race and Ethnicity Gender Age Religion Disability No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening Special menus / foods are available on request and cultural Foods can be supplied with adequate notice. c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality Sealed meals such as halal, Kosher and Allergy foods / meals are not probed for temperature control. However other foods in the same oven are and these shall be used as a guide for the safe temperature of these foods.. 33

34 Sexuality Pregnancy and Maternity Gender Reassignment Marriage and Civil Partnership Socio-Economic Factors (i.e. living in a poorer neighbourhood / social deprivation) No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified Q3. What consultation with protected characteristic groups Inc. patient groups have you carried out? Patient menus have been shared with the PPG group and amendments made from their feedback. Q4. What data or information did you use in support of this EQIA? Not Applicable Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? None Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups. None. What By Whom By When Resources required None Q7. Review date February

35 Appendix 2 Environmental Impact Assessment The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and materials Soil/Land Water. Is the policy encouraging using more materials/supplies? no Is the policy likely to increase the waste produced? no Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? no Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) no Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. Sealed containers, etc.) no Is the policy likely to result in an increase of water usage? (estimate quantities) no Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) no Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted Look for possible routes for waste food and bio digesters. 35