TRUST STRATEGIC CLEANING PLAN

Transcription

1 TRUST STRATEGIC CLEANING PLAN FINAL: August 2009 BSMHFT/Strategic Cleaning Plan/Final /Page 1 of 55

2 CONTENTS PAGE NO 1. Introduction 4 2. The Health and Social Care Act 2008 Code of Practice for the NHS on the Prevention and Control of Healthcare Associated Infections and Related Guidance (DOH January 2009) 5 3. Roles and Responsibilities 5 4. Liaison Arrangements between the Infection Control Team and Facilities Management 6 5. Cleaning Standards and Schedules Cleaning Standards Cleaning Schedules Cleaning in Rehabilitation Units Deep Cleaning Reactive Cleaning Bodily spillages/deposits (Wards and Outpatient Clinics) Bodily spillages/deposits (Non-patient Departments, Offices and Public Areas) Floods Out of Hours Arrangements Change of Occupancy Cleaning Management of Infection Cleaning During an Infection Post-Infection Cleaning Post-Infection Deep Cleaning Provision of Designated Disinfectants Provision of Cleaning Equipment and Materials Monitoring, Recording and Reporting of Cleaning During Infections and Post Infections Infection Control Training The NHS Colour Coding Scheme Application of Trust s (NHS) Cleanliness Standards when Acquiring Properties Commissioning and Decommissioning of Buildings Commissioning of Buildings Decommissioning of Buildings Hand Hygiene and Access to Hand Washing Facilities Arrangements for Decontamination of Instruments and Other Equipment Waste Management Provision of Linen and Laundry Supplies Cleanliness of Work-wear Monitoring, Audit, and Rectification and Reporting Internal Monitoring 18 BSMHFT/Strategic Cleaning Plan/Final /Page 2 of 55

3 11.2 External Monitoring/Audit Rectification Estates & Facilities Reports to the Infection Control and Decontamination Operational Group (ICDOG) Supporting Modern Matrons Quarterly Reports to the Trust Board PEAT Arrangements Domestic Services Software Domestic Staff Training Action Plan Implementation and Monitoring of the Strategic Cleaning Plan Review Arrangements Reference Documents 24 APPENDICES Appendix 1 Page 1 Trust Structure showing Roles and Responsibilities for Cleaning and Decontamination 26 Page 2 Amey (PFI Provider) showing Roles and Responsibilities for Cleaning and Decontamination 27 Appendix 2 BSMHFT Required Cleanliness Standards 28 Appendix 3 BSMHFT Cleaning Schedule for In-patient Units 29 Appendix 4 BSMHFT Infection/Post Infection Cleaning Check List 30 Appendix 5 NPSA Safer Practice Notice 15 Colour coding hospital cleaning materials and equipment (10 January 2007) 32 Appendix 6 New Colours for Cleaning BSMHT Memo and Notice The NHS New Colour Coding Scheme for Cleaning Materials and Equipment (28 January 2008) 36 Appendix 7 BSMHFT Colour Coding Audit Form 40 Appendix 8 Schedule of Cleaning Arrangements for all Properties Owned or Occupied by BSMHFT 42 Appendix 9 BSMHFT Total Cleaning Responsibility Framework (incorporating cleaning not covered by Domestic Services) 46 Appendix 10 BSMHFT Trust Inspection Form 52 Appendix 11 Implementation Plan 53 TABLES Table 1 Liaison Framework Between the ICT and Estates & Facilities Department 6 Table 2 PEAT Scoring Criteria Definitions 20 Table 3 Domestic Services Training 22 BSMHFT/Strategic Cleaning Plan/Final /Page 3 of 55

4 1. Introduction The NHS National Healthcare Standards, Standards for Better Health, Core Standard C21, Element 2, requires that Care is provided in clean environments, in accordance with the National Specification for Cleanliness in the NHS (National Patient Safety Agency, 2007) and the relevant requirements of The Health Act 2006 Code of Practice for the Prevention and Control of Healthcare Associated Infections (DOH 2006) (superseded by The Health and Social Care Act 2008 Code of Practice for the NHS on the Prevention and Control of Healthcare Associated Infections and Related Guidance (DOH January 2009)). Core Standard C21, Element 2, requires that Healthcare organisations should have: o A board approved strategic cleaning plan, including roles and responsibilities and provision for sufficient resources o An operational cleaning plan, which detail the standards of cleanliness required in each part of its premises, clear allocation of responsibility for cleaning all areas, and cleaning schedules and frequencies (where cleaning services are provided by an external contractor, these specifications should be written into the contract) o Consulted with the infection control team on the development of cleaning plans for both internal and contracted cleaning services. This document comprises the Trust s Strategic Cleaning Plan that also incorporates the Operational Cleaning Plans for all areas of the Trust. The document has been developed by senior representatives of the Estates & Facilities Management Team with the Senior Nurse for Infection Control. The Strategic Cleaning Plan focuses on the achievement of common and consistent compliant cleaning practices and cleanliness standards Trust-wide (whether delivered through the Trust s in-house or PFI/contracted cleaning service providers). The key objectives of the Strategic Cleaning Plan are; i. Setting and achieving common and consistent compliant cleaning practices and cleanliness standards Trust-wide (whether delivered through the Trust s in-house or PFI/contracted cleaning service providers). ii. iii. iv. Ensuring clear and designated responsibilities for the cleanliness of all aspects of the Trust environment and the elimination of grey areas and ambiguity. Integrated working between the Infection Control Team and Estates & Facilities Department, to ensure that all new developments, projects and property acquisitions are subject to the full involvement of, assessment by and approval of the ICT. To ensure the Domestic Service workforce is trained to the highest standards to enable Domestic Staff and Supervisors to perform to and achieve the highest standards of cleanliness and levels of productivity. BSMHFT/Strategic Cleaning Plan/Final /Page 4 of 55

5 2. The Health and Social Care Act 2008 Code of Practice for the NHS on the Prevention and Control of Healthcare Associated Infections and Related Guidance (DOH January 2009) This Strategic Cleaning Plan responds to the specific requirements of The Health and Social Care Act 2008 Code of Practice for the NHS on the Prevention and Control of Healthcare Associated Infections and Related Guidance (DOH January 2009), in particular as set out in Part 4 Guidance for implementation of compliance criterion 2 Provide and maintain a clean and appropriate environment which facilitates the prevention and control of HCAI. 3. Roles and Responsibilities Part 4 Guidance for implementation of compliance criterion 2 b. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; it designates lead managers for cleaning and decontamination of equipment used in treatment. The Trust Estates & Facilities Department (within the Commercial Services and Asset Management Directorate) is responsible for the management and delivery of cleaning services and compliant cleanliness standards as well as the maintenance of compliant procedures for decontamination of equipment used for treatment. The Head of Estates & Facilities Management takes the overall lead for cleanliness (and for decontamination of treatment equipment). The responsibility for delivering cleaning services and compliant cleanliness standards is delegated as set out in the Trust Structure showing Roles and Responsibilities for Cleaning and Decontamination at Appendix 1. The Job Descriptions for all of these posts specify the postholders responsibilities in respect of ensuring the cleanliness of the environment. Copies of job descriptions (Trust and PFI Providers) are held in the Estates & Facilities Department. Part 4 Guidance for implementation of compliance criterion 2 c. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; lead managers involve directors of nursing, matrons and the ICT (Infection Control Team) in all aspects of cleaning services from contract negotiation and service planning to delivery at ward level. The Estates & Facilities Departmental lead managers for cleaning will fully involve the Trust Executive Director of Nursing, and Matrons and the ICT in all aspects of cleaning services (in-house and contracted) including (but not limited to); o o o o o Development, agreement and implementation of Operational Cleaning Plans for all wards and departments (including standards, tasks, frequencies, time-spans and schedules as well as monitoring and audit arrangements). Production and reviews of Cleaning Specifications for existing services and new projects. Planning of cleaning services for new projects. Negotiation and agreement of any contracts for cleaning. Any proposed cleaning service reviews or changes. BSMHFT/Strategic Cleaning Plan/Final /Page 5 of 55

6 Part 4 Guidance for implementation of compliance criterion 2 d. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; matrons have personal responsibility and accountability for delivering a safe and clean care environment and that the nurse in charge of any patient area has direct responsibility for ensuring that cleanliness standards are maintained throughout that shift. The Estates & Facilities Departmental lead managers for cleaning will fully involve the Matrons in all aspects of cleaning services (in-house and contracted) as set out above. In particular, the Operational Cleaning Plans agreed with the Matrons will ensure that cleanliness standards are maintained throughout the operational periods of the wards and departments. The Estates & Facilities Departmental lead managers for cleaning will support the Matrons in all aspects of maintaining, monitoring, auditing and reporting on environmental cleanliness, including; o o Liasing with the Matrons in respect of all monitoring and audits of cleanliness standards undertaken by Domestic Supervisors and Contract Monitoring Manager. Providing information to support the Matrons Quarterly Reports to the Trust Board on Cleanliness and Infection Control. 4. Liaison Arrangements between the Infection Control Team and Facilities Management Part 4 Guidance for implementation of compliance criterion 2 a. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; it has policies for the environment that make provision for liaison between the members of the ICT (Infection Control Team) and the persons with overall responsibility for facilities management. There is a framework of liaison between the Trust Infection Control Team (ICT) and the Estates & Facilities Department. This is set out in Table 1 below; TABLE 1 LIAISON FRAMEWORK BETWEEN THE ICT AND ESTATES & FACILITIES DEPARTMENT LIAISON/FORUM PERSONS PURPOSE Quarterly Infection Control & Decontamination Committee (ICDC) Executive Director of Nursing Senior Nurse for Infection Control Head of Estates & Facilities Management Strategic overview and monitoring of Trust s compliance with current policies/legislation/guidance/ codes of practice relating to Infection Control. Approval of Policies and Procedures relating to Infection Control. Bi-monthly Infection Control and Decontamination Group (ICDOG) Senior Nurse for Infection Control Facilities & Hotel Services Manager Contract Monitoring Manager Operational monitoring of Trust s compliance with current policies/legislation/guidance/ codes of practice relating to Infection Control. Estates & Facilities BSMHFT/Strategic Cleaning Plan/Final /Page 6 of 55

7 Monthly Estates & Facilities Team Meetings Head of Estates & Facilities Management Estates & Facilities Management Team Senior Nurse for Infection Control Operational Infection Control Reports are submitted. First stage Approval of Policies and Procedures relating to Infection Control. To jointly review operational issues (including Infection Control). To agree operational action plans in response to current policies/legislation/guidance/ codes of practice relating to Infection Control. Capital & Revenue Developments/Projects Head of Estates & Facilities Management Assistant Head of Estates & Facilities Management Capital Development Manager Estates Managers Senior Nurse for Infection Control To ensure Infection Control is integral to all developments and refurbishments. To ensure all developments and refurbishments comply with current policies/legislation/guidance and codes of practice relating to Infection Control. Outbreaks Communication Flowchart shown in Trust Infection Prevention & Control Policy Appendix 2 5. Cleaning Standards and Schedules Part 4 Guidance for implementation of compliance criterion 2 e. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; all parts of the premises in which it provides healthcare are suitable for the purpose, kept clean and maintained in good physical repair and condition. Part 4 Guidance for implementation of compliance criterion 2 f. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; the cleaning arrangements detail the standards of cleanliness required in each part of its premises and that a schedule of cleaning frequencies is publicly available. Cleanliness and general tidiness of the environment needs to be in keeping with standards determined by DOH documents, these include (but are not exclusive to) Clean Safe Care, Essence of Care, and the National Patient Safety Agency NHS Cleanliness Standards (see Section 18. Reference Documents). 5.1 Cleaning Standards The Trust has established common Trust-wide output standards for all elements of environmental cleaning. These are shown at Appendix 2. These standards are applied (and monitored) consistently to the Trust s cleaning services whether delivered in-house or by PFI service providers. BSMHFT/Strategic Cleaning Plan/Final /Page 7 of 55

8 These cleaning standards are displayed on sealed/locked notice boards dedicated for this purpose in all wards and departments and public areas throughout the Trust. Copies are also displayed in all cleaners cupboards. The Estates & Facilities Department manages (and holds the keys to) these notice boards. These standards are incorporated as a requirement in all cleaning contracts and in-house cleaning policies. Copies of these cleaning standards are available from the Estates & Facilities Department and on the Trust Intranet. Compliance of the Trust s and PFI Provider s Domestic Services with these cleaning standards and the display of these standards in all wards and departments is monitored during the Estates & Facilities Department s monthly Monitoring and Trust Inspections (see Section 11). These cleaning standards are to be regularly updated to ensure compliance with the current (and any revisions to) NHS Cleaning Standards and Frequencies. 5.2 Cleaning Schedules The Trust has established cleaning schedules of tasks and frequencies for each ward and department in the Trust, to meet the Trust s cleaning output standards. Cleaning tasks that are designated to be undertaken at weekly, monthly or periodic frequencies (ie not daily), will be allocated a specified day of the week or date and this will be shown in the cleaning schedule. This is to ensure such tasks are allocated, and also covered when regular cleaning staff are on days off or annual leave and to facilitate monitoring and to provide assurance to service users and clinical staff. These cleaning schedules are displayed on sealed/locked notice boards dedicated for this purpose in all wards and departments and public areas throughout the Trust. Copies are also displayed in all cleaners cupboards. The Estates & Facilities Department manages (and holds the keys to) these notice boards. A sample cleaning schedule for in-patient units is shown at Appendix 3. Copies of all cleaning schedules are available from the Estates & Facilities Department and on the Trust Intranet. Compliance of the Trust s and PFI Provider s Domestic Services with these cleaning schedules and the display of these schedules in all wards and departments is monitored during the Estates & Facilities Department s monthly Monitoring and Trust Inspections (see Section 11). These cleaning schedules are to be regularly updated to ensure compliance with the current (and any revisions to) NHS Cleaning Standards and Frequencies. 5.3 Cleaning in Rehabilitation Units All aspects of this Strategic Cleaning Plan will apply to Rehabilitation Units in the same way as with all other in-patient units in the Trust. BSMHFT/Strategic Cleaning Plan/Final /Page 8 of 55

9 Cleanliness of the environment, (in compliance with the Trust s cleaning output standards and cleaning schedules) will be undertaken by the in-house or PFI Provider s Domestic Staff. This is the compliance clean. This is to ensure that the required cleanliness and infection control standards are maintained in compliance with NHS Standards. Where service users are encouraged, by clinical staff, to undertake any cleaning as part of their daily activities ie cleaning bath after bathing, cleaning kitchen after cooking, tidying their bedrooms, these activities will be in addition to (not instead of) the compliance clean. Service users will be provided with dedicated cleaning equipment and neutral harmless cleaning materials by clinical staff following a full risk assessment. Clinical staff will ensure that electrical equipment is approved (before purchase) and then PAT tested by the Estates & Facilities Department and is checked before each use and any faults are reported to the Maintenance Department. Cleaning materials must be used and disposed of in compliance with the manufacturers and COSHH instructions. 5.4 Deep Cleaning The NHS Deep Clean Initiative required all NHS Trusts to undertake a deep clean during and to complete this by 31 March This served to demonstrate a visible commitment to creating a clean environment. The Trust s Estates & Facilities Department completed the Deep Clean within this timescale. The NHS Publication From Deep Clean to Keep Clean Learning from the Deep Clean Programme (DOH October 2008), highlights that the deep clean initiative is not a one-off exercise. Trusts are expected to ensure that deep cleaning is an important component in their cleaning arrangements. Trusts are also expected to take into account the following factors when assessing deep clean requirements; o o o o o o Local patient and staff satisfaction surveys Environmental related complaints and incidents Items on the Risk Register PEAT Scores National Cleaning Specification Scores Trends in infection rates. In July 2008, the Trust allocated dedicated recurring funding to the Estates & Facilities Department to implement the following; i. 4 WTE in-house Rapid Response/Deep Cleaning Teams (2 Teams x 2 WTE) ii. Additional Deep Cleaning to be undertaken by the Trust s PFI Cleaning Service Provider. The in-house Rapid Response/Deep Cleaning Teams will undertake a rolling deep cleaning programme in accordance with the Trust s Deep Cleaning Specifications and will respond promptly to deep cleaning requirements following infection outbreaks. Copies of the Trust s Deep Clean Specifications are available from the Estates & Facilities Department. The PFI Domestic Services Provider is required to comply with the Cleaning Output Specification incorporated in the PFI Project Agreement. This requires the environment to be of a high standard of cleanliness at all times. In addition the PFI Domestic Service Provider is required to respond to floods and spillages and deep cleaning during and following infections and on changes of occupant of BSMHFT/Strategic Cleaning Plan/Final /Page 9 of 55

10 patient bedrooms. Therefore, the additional resource will be focused on areas of need identified as set out in the following paragraph. The Deep Clean Programme will be focused on areas of need identified by the Estates & Facilities Department from; o Satisfaction Surveys o Complaints and Incidents o Risk Assessments o PEAT Scores o Environmental Monitoring and Audits o Infection Control Audits o Food Hygiene Audits o Hygiene Audits o Environmental Health Officer (EHO) Reports o Infection Rates. The Estates & Facilities Department will ensure that a programme is in place for the regular Deep Cleaning of the Trust s Main Production Kitchens. These Deep Cleans will be undertaken by specialist sub contractors. 5.5 Reactive Cleaning Bodily spillages/deposits (Wards and Outpatient Clinics) To enable clinical staff to be aware of, and monitor incidents of, bodily spillages/deposits the following protocols will apply; Clinical staff will remove bodily spillages/deposits and decontaminate the site in accordance with the Trust Infection Prevention and Control Policy and Procedures. Domestic Staff will then undertake a follow up clean. Spillage kits/products used in dealing with the spillage or deposit will be segregated and disposed of in accordance with the Trust Waste Disposal Policy, immediately following use. Domestic Staff will clean up and decontaminate urine spillages in accordance with the Trust Infection Prevention and Control Policy and Procedures and report these to clinical staff. When Domestic Staff are not on duty, this will be undertaken by clinical staff. Spillage kits/products used in dealing with the spillage or deposit will be segregated and disposed of in accordance with the Trust Waste Disposal Policy, immediately following use Bodily spillages/deposits (Non-patient Departments, Offices and Public Areas) Patient Bodily Spillages/Deposits; Departmental Domestic Staff will remove bodily spillages/deposits and decontaminate the site in accordance with the Trust Infection Prevention and Control Policy and Procedures and will undertake a follow up clean. Spillage kits/products used in dealing with the spillage or deposit will be segregated and disposed of in accordance with the Trust Waste Disposal Policy, immediately following use. In the event of Staff Bodily Spillages (eg nose bleeds); The staff member concerned will clean up the spillage and contact the Domestic Department who will arrange for Domestic Staff to decontaminate the area in accordance with the Trust Infection Prevention and Control Policy and Procedures and undertake a follow up clean. Spillage kits/products used in dealing with the spillage or deposit will be segregated and disposed of in accordance with the Trust Waste Disposal Policy, immediately following use. BSMHFT/Strategic Cleaning Plan/Final /Page 10 of 55

11 5.5.3 Floods Immediate response to floods will be by the Domestic Staff in the near vicinity. The Rapid Response Team will also respond and take over to complete and undertake the full follow up clean. Flood should be reported to the on call Engineer to attend urgently Out of Hours Arrangements During out of hours periods when Domestic Staff are not on duty, any spillages/floods will be dealt with by clinical staff in wards. Spillages/floods in other areas will be reported as follows; o o o Amey Helpdesk (Northern Area of the Trust) BBW Helpdesk (Barberry, Oleaster and Zinnia Centres) Trust Estates & Facilities On-call Manager (via Reaside Switchboard) (inhouse managed Domestic Services). The Trust/PFI Provider s Domestic Services will ensure that cleaning equipment and materials are accessible in designated rooms in each ward and department for use by nursing/other staff at times when Domestic Staff are not on duty. 5.6 Change of Occupancy Cleaning When a service user vacates his/her bedroom, the bedroom and en-suite will be given a post-infection deep clean by the Trust/PFI Provider s Domestic Staff (see Section below), before a new service user moves in to commence using the room/ensuite. 5.7 Management of Infection All cleaning during and after infections (as referred to under Sections inclusive below) will be undertaken in consultation with the Trust Infection Control Team. Ward Managers are responsible for communicating to the Trust/PFI Provider s Domestic Management, Supervisors and Staff to arrange for cleaning during and after infections. Ward Managers should be aware in planning and arranging for such cleaning that cleaning undertaken during weekdays will be more resource efficient. However, where the cleaning is required urgently outside of weekday hours, the Domestic Service will attend to undertake this Cleaning During an Infection The Ward Manager is responsible for communicating to the Trust/PFI Provider s Domestic Management, Supervisors and Staff any changes in/additions to cleaning procedures, frequencies and arrangements as required during an infection. All cleaning tasks, procedures, frequencies and arrangements during an infection will be undertaken in accordance with the Trust Infection Prevention and Control Policy Post-Infection Cleaning The Ward Manager is responsible for communicating to the Trust/PFI Provider s Domestic Management, Supervisors and Staff, requirements for a full/deep clean following an infection. BSMHFT/Strategic Cleaning Plan/Final /Page 11 of 55

12 All cleaning tasks, procedures, frequencies and arrangements for a post-infection full/deep clean will be undertaken in accordance with the Trust Infection Prevention & Control Policy. Post-infection full/deep cleaning will be undertaken by the Trust/PFI Provider s Domestic Staff and will incorporate all elements of the patient environment (including for example; floors, walls, ceilings, ledges, fixtures, fittings, sanitary appliances, beds, mattresses and other furniture, curtains, blinds and shower curtains). Patient equipment such as hoists and commodes will be deep cleaned by nursing staff. (Also refer to Section 7. below) Post-Infection Deep Cleaning Deep Cleaning following an infection, will be undertaken by the Trust Rapid Response/Deep Cleaning Teams/PFI Provider s Domestic Staff. Post-infection Deep Cleaning will be undertaken in accordance with the Trust Infection Prevention & Control Policy and will incorporate all elements of the patient environment (including for example; floors, walls, ceilings, ledges, fixtures, fittings, sanitary appliances, beds, mattresses and other furniture, curtains, blinds and shower curtains). Steam cleaning will be used where applicable (for example, for curtains, blinds and shower curtains). Patient equipment such as hoists and commodes will be deep cleaned by nursing staff. (Also refer to Section 7. below) Provision of Designated Disinfectants The Trust Pharmacy is responsible for the purchasing and storage of disinfectants (and the containers with which to prepare and use these) as designated by the Trust Infection Control Team to be requisitioned and used by Wards and Departments and the Trust Estates & Facilities Department and the Trust s PFI Provider for the purpose of cleaning during an infection and postinfection cleaning and Deep Cleaning Provision of Cleaning Equipment and Materials The Trust/PFI Provider s Domestic Services will ensure that cleaning equipment and materials are accessible in designated rooms in each ward and department for use by nursing staff for the purpose of cleaning during an infection and postinfection cleaning Monitoring, Recording and Reporting of Cleaning During Infections and Post-Infections The Trust/PFI Provider s Domestic Managers are responsible for ensuring that each session of cleaning during infections and post-infections is checked to ensure it has been undertaken in accordance with the instructions given by the Ward Manager and in accordance with the Trust Infection Prevention & Control Policy and Procedures and that the resulting standards of cleanliness meet the required standards. The Trust/PFI Provider s Domestic Managers will document these checks and provide copies to the Ward Manager, Trust Domestic Manager and Trust Contract Monitoring Function. The form to be used to record these checks is shown at Appendix 4 attached and is provided by the Trust Estates & Facilities Department. All cleans undertaken during and following infections will be reported in the Estates & Facilities Department s Reports submitted to the Infection Control and Decontamination Operational Group (ICDOG). BSMHFT/Strategic Cleaning Plan/Final /Page 12 of 55

13 5.7.7 Infection Control Training All staff employed in undertaking cleaning duties (Trust staff and PFI Provider s staff) should undertake training as appropriate in accordance the requirements of their job descriptions/person specifications. All Trust Domestic Staff will attend the Trust Corporate Induction, which includes an Infection Control Session. All Trust Domestic Staff will then receive Infection Control Training updates through the Trust Statutory and Mandatory Training Programme. Domestic Staff Training Records and the Trust Training Database (for each Domestic Staff member) will be maintained up to date by the Trust Estates & Facilities Department (for Trust Domestic Staff). The Trust s PFI Provider will maintain training records for their staff who undertake cleaning duties. Evidence of training and Training Documentation will be made available by the Trust Estates & Facilities Department and Trust s PFI Provider for inspection by the Trust or any external body legitimately required to access and audit such documentation The NHS Colour Coding Scheme The new NHS National Patient Safety Agency (NPSA) National Colour Coding Scheme for hospital cleaning materials and equipment was introduced to BSMHT on 18 February The NPSA Notice is at Appendix 5 and the Trust s Notification to all wards and departments is at Appendix 6. The new Colour Coding Scheme was implemented through the Trust Colour Coding Working Group of representatives of Trust Estates & Facilities Managers and the Infection Control Team. Cloths, mops, buckets, aprons and gloves are all colour coded under the new National Colour Coding Scheme. Colour coding of hospital cleaning materials and equipment ensures that these items are not used in multiple areas, therefore reducing the risk of cross-infection. The new Colour Coding Scheme is set out in Appendix 6. Posters showing the new Colour Coding Scheme are displayed in all wards and departments in; o Main Notice Boards o Kitchens o Clinics/Treatments Rooms o Utility/Sluice Rooms. Additional Protocols (approved by the Trust Infection Control Team) o Catering Departments In the Main Catering Production Kitchens (QEPH, Reaside, Ardenleigh, Uffculme, B1) green colour coded materials and equipment are used for general background cleaning. However, this does not replace the essential practice of using different coloured materials eg cloths in raw food areas and cooked food areas. This essential practice continues. o Yellow Colour Coded Cleaning Equipment and Materials o Yellow colour coded cleaning materials eg cloths, mop heads, gloves and aprons are disposable and disposed of after use. Yellow colour coded cleaning equipment eg buckets are be disinfected using Chlorclean. BSMHFT/Strategic Cleaning Plan/Final /Page 13 of 55

14 o Bodily spillages (eg; urine, blood, sputum, vomit, faeces) occurring in areas other than toilets are cleaned up and disinfected using Yellow colour coded cleaning materials and equipment and Chlorclean (as these spillages may be infected). o Use of Cleaning Equipment and Materials by Nursing Staff In the event that Nursing Staff undertake any cleaning, they will use the designated colour coded equipment and materials applicable to the area. Supplying Colour Coded Cleaning Materials and Equipment Operational details are set out in the Trust Memorandum of 28 January 2008 (Appendix 6). Auditing Compliance with the new NHS Colour Coding Scheme o A post-implementation audit of compliance with the new Colour Coding Scheme was undertaken during April and early May The objective was to provide assurance that; o staff are complying with the new Colour Coding Scheme o Colour Coding Scheme posters are displayed in all designated areas o supply arrangements are in place for all Colour Coded cleaning materials and equipment o the Colour Coding scheme briefing pack is available in each ward/dept. o The Audit incorporated; i. all in-patient areas ii. all main kitchens and rehabilitation kitchens. o o o o Audit Proformas were designed to record the findings of the audit in each area within these two categories (see Appendix 7). The Post Implementation Audit provided assurance that all areas audited (inpatient areas and main and rehabilitation kitchens) were observed to be fully compliant with the new NHS Colour Coding Scheme for Cleaning Materials and Equipment. Ongoing monitoring and audit of compliance has been incorporated in the existing quality control, Trust Inspection, monitoring and audit procedures operated by the Trust Estates and Facilities Department and its PFI Domestic Services Provider (see Section 11 and Appendix 10). Findings of audits are reported in the Estates & Facilities Reports submitted to the Infection Control and Decontamination Operational Group (ICDOG). Reports of Colour Coding Compliance are incorporated in the Estates & Facilities Quarterly Performance Reports submitted to the Modern Matrons for their Quarterly Reports to the Trust Board on cleanliness and infection control. 5.8 Application of Trust s (NHS) Cleanliness Standards when Acquiring Properties The Trust s Cleaning Standards (see Section 5.1) will be strictly maintained in all properties in which the Trust operates. These same standards will be applied for; i. Property owned by the Trust ii. iii. Property owned by the Trust s PFI Partners, used by the Trust Property leased by the Trust in which the Trust provides the cleaning service BSMHFT/Strategic Cleaning Plan/Final /Page 14 of 55

15 iv. Property leased by the Trust in which the Landlord provides the cleaning service. When considering the acquisition of any new leased property, the Trust will ensure that its Cleaning Standards are incorporated into the business and associated resource plan for the running and maintenance of the property. The Trust Infection Control Team is to be fully involved in the assessment of the suitability of all potential properties being considered by the Trust. Acquisition of property should not proceed until the Infection Control Team has undertaken a full assessment of the property and signed off to agree its suitability and fitness for purpose. The Trust will, where possible ensure that it retains the responsibility for providing the cleaning service to all property that it leases. Where this is not possible, the landlord must be required to provide the cleaning service to meet the Trust s Cleaning Standards and to comply with the Trust Strategic Cleaning Plan and Trust Infection Prevention & Control Policy. A schedule of the properties from which the Trust operates (whether owned or leased by the Trust or occupied by the Trust under another arrangement) is set out in Appendix 8. Cleaning Services to most properties from which the Trust operates, are provided by the Estates & Facilities Department or its PFI Provider. The Estates & Facilities Department will work towards extending these consistent cleaning arrangements and the Trust s Cleaning Standards to all properties from which the Trust operates as set out in Appendix Commissioning and Decommissioning of Buildings Commissioning of Buildings All properties being commissioned for use by the Trust will be Deep Cleaned to the required standard to make the building safe and compliant to use and in consultation with the Trust Infection Control Team. Following Deep Cleaning and prior to use, a post Deep Clean Inspection will be undertaken by the Estates & Facilities Department and Infection Control Team and the findings of the Inspection will be documented on a Post Deep Clean Inspection Form (to be provided by the Estates & Facilities Department) Decommissioning of Buildings All properties being De-commissioned by the Trust will be Deep Cleaned to the required standard to make the building safe and compliant to be handed over and in consultation with the Trust Infection Control Team. Following Deep Cleaning and prior to handing over, a post Deep Clean Inspection will be undertaken by the Estates & Facilities Department and Infection Control Team and the findings of the Inspection will be documented on a Post Deep Clean Inspection Form (to be provided by the Estates & Facilities Department). 6. Hand Hygiene and Access to Hand Washing Facilities Part 4 Guidance for implementation of compliance criterion 2 g. of the Code of Practice, requires that A provider should normally, with a view to minimising the BSMHFT/Strategic Cleaning Plan/Final /Page 15 of 55

16 risk of HCAI, ensure that; there is adequate provision of suitable hand-washing facilities and antibacterial hand rubs. Hands will be decontaminated in line with the Trust Infection Prevention and Control Policy Infection Control Supplementary Procedure Annexe E Decontamination. The Trust will ensure that staff have access to hand-washing facilities (wash hand basins, hand soap dispensers and paper hand towel dispensers), to enable hand washing between tasks and at point of patient care, and that these are kept in good repair and maintained in clean condition and cleaned regularly in accordance with NHS Cleaning Standards and Frequencies. The Trust will ensure that staff have access to alcohol hand gels as appropriate. Hand Washing Instruction Guides should be located above each wash hand basin. This is the responsibility of Ward and Departmental Managers. Instruction Guides are available on the Trust Intranet and should be printed and laminated before being displayed above wash hand basins. Domestic Staff are responsible for ensuring that hand soap dispensers and hand towel dispensers are filled as required and that hand soap and paper hand towels are available at wash hand basins at all times. Ward and Departmental Clinical Staff are responsible for ensuring that alcohol hand gels are provided and available in their wards and departments as appropriate. Provision of hand wash facilities will be audited and reported on in Ward Manager s environmental audits. 7. Arrangements for Decontamination of Instruments and Other Equipment Part 4 Guidance for implementation of compliance criterion 2 h. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; that there are effective arrangements for the appropriate decontamination of instruments and other equipment these should be incorporated within appropriate disinfection and decontamination policies. Arrangements for the appropriate decontamination of instruments and other equipment used in providing healthcare for service users are set out in the Trust Decontamination Policy. The Trust has determined specific responsibilities for the cleaning of equipment in the patient environment. The matrix of responsibilities is shown at Appendix Waste Management Waste arisings as a result of cleaning activity will be disposed of in line with the Trust Waste Disposal Policy. Special attention needs to be given to the disposal of hazardous/potentially hazardous wastes including but not limited to; Body spillages/deposits/blood BSMHFT/Strategic Cleaning Plan/Final /Page 16 of 55

17 Cleaning Materials/Liquids Aerosols Electrical cleaning equipment. See BSMHFT Waste Disposal Policy (December 2008). 9. Provision of Linen and Laundry Supplies Part 4 Guidance for implementation of compliance criterion 2 i. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; the supply and provision of linen and laundry supplies reflect Health Service Guidance HSG (95) 18, Hospital Laundry Arrangements for Used and Infected Linen, as revised from time to time. The Trust has recently developed a new Laundry and Linen Policy which is out for consultation during November/December 2008 and will be submitted to the Clinical Governance Committee Meeting in January 2009 for ratification. This policy is written in compliance with the NHS Executive Guidance HSG(95) 18 Hospital Laundry Arrangements for Used and Infected Linen. Its overall objective is to provide Trust Staff and Service Providers with the relevant guidance so that they can protect themselves and patients from risks posed by handling used, soiled and infected linen. Correct categorisation, handling, transportation and processing of linen can help to reduce the risk of cross infection. The Policy and Procedures herein set out requirements for all Linen and Laundry activities from ward to laundry; including; Trust and Service Providers o Categorisation and segregation of linen o Handling and storage of clean (unused) linen o Dealing with used/soiled/fouled/infected/infested linen and sending to laundry o Laundering of patients clothing o Duvets and pillows Laundry Contractors o Categorisation and segregation of linen o Transportation of clean linen used/soiled/fouled/infected/infested linen o Handling, processing and storage of linen. The Policy s specific objectives are; i) To set out policy and procedures that all Trust Staff are required to comply with. ii) To set out policy and procedures that all Service Providers to the Trust (and any sub-contractors of these Service Providers) are required to comply with. iii) To establish standards that are required to be incorporated into all new capital and other developments for the Trust s In-patient Services. iv) To provide a framework and requirements for the auditing of compliance with this Policy and its Procedures. iv) To set out the roles and responsibilities of Trust Staff and its Service Providers and sub-contractors and any associated training required. vi) To set out provisions for review of this Policy and its Procedures. BSMHFT/Strategic Cleaning Plan/Final /Page 17 of 55

18 10. Cleanliness of Work-wear Part 4 Guidance for implementation of compliance criterion 2 j. of the Code of Practice, requires that A provider should normally, with a view to minimising the risk of HCAI, ensure that; uniform and workwear policies ensure that clothing worn by staff when carrying out their duties is clean and fit for purpose. Work-wear worn should be easily washable, clean from dirt and stains and not mal-odorous. All staff must comply with the Trust Work-wear Policy. Where staff wear uniform, they should take these home to launder (with the exception of Catering Whites which must be sent to the Trust s Laundry Contractor for laundering (in accordance with the agreed protocols). 11. Monitoring, Audit, and Rectification and Reporting The Estates & Facilities Department has introduced a system of monthly, quarterly and annual reporting of the performance of cleanliness standards in all areas of the Trust. This consolidates the physical monitoring inspections undertaken of in-house and PFI delivered Domestic Services Internal Monitoring In the North of the Trust, where services are delivered through a PFI arrangement, the Trust Contract Monitoring Team undertakes a number of Trust Inspections of cleanliness standards each month. Trust Inspections are a requirement under the North PFI Project Agreement and comprise inspections by the Trust of any aspect of Estates and Facilities Services in any area and are undertaken at random. These are led by the Trust Contract Monitoring Team and are also attended by the Service Provider, Modern Matron, Ward/Department Manager and Ward Housekeeper. Dates and times are arranged in advance, but the service and area to be inspected are not announced by the Trust Contract Monitoring Team until just prior to the Inspection. Failures to achieve the standards required by the Key Performance Indicators for each service (set out in the PFI Project Agreement) are recorded in the calculation of service failure points and any deductions from payments (under the Project Agreement). Trust Inspections are in addition to the PFI Provider s Self Monitoring. Trust Inspection Reports are summarised in the monthly Contract Monitoring Team s Reports of the PFI Providers performance. The findings of Trust Inspections are recorded on a Trust Inspection Form. Scores awarded are based on the NHS PEAT (Patient Environment Action Teams) scoring system (set out in Section 11. below). The outcomes of all Trust Inspections are translated into graphical form to provide a monthly report on those wards and departments inspected. This is stored for the production of quarterly and annual performance reports. In the South of the Trust, which has in-house staff, the Ausped computerised monitoring system is used. This produces reports giving a percentage mark to all areas inspected. The marking system is weighted so that more critical areas have a greater effect on the final mark than those not so critical. Monitoring comprises physical inspections by the Domestic Supervisors who input the results into the Ausped system. This system produces monthly, quarterly and annual reports. BSMHFT/Strategic Cleaning Plan/Final /Page 18 of 55

19 In Solihull, the Contract Monitoring Manager (from the Contract Monitoring Team) undertakes monthly Trust Inspections accompanied by the Ward/Department Managers and Ward Housekeeper. The findings are recorded on a Trust Inspection Form. Scores awarded are based on the NHS PEAT (Patient Environment Action Teams) scoring system. Under these arrangements, all patient areas are inspected quarterly and all other areas are inspected at least once a year. A copy of the Trust Inspection Form used is at Appendix 10. To provide a common reporting format, the Contract Monitoring Manager converts the percentage scores from the Ausped reports into PEAT scores. These are collated with the PEAT scores from the other Trust Inspections for the month and all scores are converted into graphical form from which a quarterly report of cleanliness standards Trust-wide is produced. These reports are provided to the Modern Matrons to incorporate into their Quarterly Cleanliness and Infection Control Reports to the Trust Board External Monitoring/Audit The Trust Inspections undertaken by the Trust Contract Monitoring Team of the PFI Provider s cleaning services, provide a form of external audit. The Estates & Facilities Department s strategy is to link up with other local Mental Health NHS Trusts to provide an external auditing facility on an exchange basis. This is in the development stage Rectification Any shortfalls in required cleanliness standards identified during Trust Inspections and monitoring of in-house services, are brought to the attention of the PFI Provider/in-house staff and rectification action and timescale is agreed. This is all documented. The affected area is then re-inspected within the same week and the process is repeated until the required standards are achieved and maintained Estates & Facilities Reports to the Infection Control and Decontamination Operational Group (ICDOG) Findings of internal and external monitoring and audits and all rectifications actions and re-inspections are reported in the Estates & Facilities Department s Reports submitted to the Infection Control and Decontamination Operational Group (ICDOG) Supporting Modern Matrons Quarterly Reports to the Trust Board The Estates & Facilities Department provides the following reports to support the Modern Matrons Quarterly Reports to the Trust Board on Cleanliness and Infection Control (as required by the DOH Letter Improving Cleanliness and Infection Control 1 st November 2007); i) Copies of Trust Inspection Reports and Ausped Reports (identifying any remedial actions where applicable) will be sent to the Ward Manager and Modern Matron for the relevant ward/department immediately following each inspection. BSMHFT/Strategic Cleaning Plan/Final /Page 19 of 55

20 ii) Copies of Quarterly Estates & Facilities Performance Reports of Cleanliness Standards and Trends and Remedial Actions will be sent to Modern Matrons in accordance with a programme of submission dates to be agreed with the Senior Nurse for Infection Control and the Modern Matrons Modern Matrons. 12. PEAT Arrangements Under the NHS PEAT (Patient Environment Action Teams) Annual Programme, set by the National Patient Safety Agency (NPSA), NHS Trusts are required to undertake self assessments of the patient Environment, focusing on standards of cleanliness, food and privacy and dignity. The NPSA PEAT Guidelines, requires each NHS Trust to have a nominated PEAT Lead. BSMHFT s nominated PEAT Lead is a senior member of the Estates & Facilities Management Team. BSMHFT undertakes annual PEAT Assessments in accordance with the NPSA PEAT Guidelines. The PEAT Assessments are required to be undertaken in each in-patient unit of 10 or more beds. In BSMHFT this includes all in-patient units. On each site, all wards must be assessed. This is to ensure annual PEAT Assessments are fully representative of standards in all areas. The Trust PEAT Team comprises; o Lead Facilities Manager o Lead Estates Manager o Lead Catering Manager o Infection Control Nurse o Hygiene Advisor o Trust PFI Provider s Domestic Service Manager o Service User o Modern Matron The same membership undertakes all PEAT Self Assessments Trust-wide to ensure consistency of approach and assessment. In-patient units are not given advance warning of the dates and times of assessments. This is a specific requirement laid down by the NPSA. Dates and times of assessments are provided to the NPSA in advance. This is to enable the NPSA to arrange for an external assessor to join the Trust PEAT Assessment Team for a number of assessments. The Trust PEAT Lead leads the self- assessments and ensures the PEAT Assessment Forms are completed immediately at the end of each assessment. The PEAT Scoring Criteria set by the NPSA is set out in Table 2 below. TABLE 2 - PEAT SCORING CRITERIA DEFINITIONS SCORE CRITERIA DEFINITION 5 Excellent Standards are consistently high, exceed expectations across all aspects of the element being measured. An occasional obviously temporary incident such as a single sweet wrapper can be overlooked if it is an isolated occurrence 4 Good Standards almost always meet expectations and often exceed them. BSMHFT/Strategic Cleaning Plan/Final /Page 20 of 55