TRUST STRATEGIC CLEANING PLAN

TRUST STRATEGIC CLEANING PLAN FINAL: August 2009 BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 1 of 55

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 7 5.1 Cleaning Standards 7 5.2 Cleaning Schedules 8 5.3 Cleaning in Rehabilitation Units 8 5.4 Deep Cleaning 9 5.5 Reactive Cleaning 10 5.5.1 Bodily spillages/deposits (Wards and Outpatient Clinics) 10 5.5.2 Bodily spillages/deposits (Non-patient Departments, Offices and Public Areas) 10 5.5.3 Floods 11 5.5.4 Out of Hours Arrangements 11 5.6 Change of Occupancy Cleaning 11 5.7 Management of Infection 11 5.7.1 Cleaning During an Infection 11 5.7.2 Post-Infection Cleaning 11 5.7.3 Post-Infection Deep Cleaning 12 5.7.4 Provision of Designated Disinfectants 12 5.7.5 Provision of Cleaning Equipment and Materials 12 5.7.6 Monitoring, Recording and Reporting of Cleaning During Infections and Post Infections 12 5.7.7 Infection Control Training 13 5.7.8 The NHS Colour Coding Scheme 13 5.8 Application of Trust s (NHS) Cleanliness Standards when Acquiring Properties 14 5.9 Commissioning and Decommissioning of Buildings 15 5.9.1 Commissioning of Buildings 15 5.9.2 Decommissioning of Buildings 15 6. Hand Hygiene and Access to Hand Washing Facilities 15 7. Arrangements for Decontamination of Instruments and Other Equipment 16 8. Waste Management 16 9. Provision of Linen and Laundry Supplies 17 10. Cleanliness of Work-wear 18 11. Monitoring, Audit, and Rectification and Reporting 18 11.1 Internal Monitoring 18 BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 2 of 55

11.2 External Monitoring/Audit 19 11.3 Rectification 19 11.4 Estates & Facilities Reports to the Infection Control and Decontamination Operational Group (ICDOG) 19 11.5. Supporting Modern Matrons Quarterly Reports to the Trust Board 19 12. PEAT Arrangements 20 13. Domestic Services Software 21 14. Domestic Staff Training 21 15. Action Plan 23 16. Implementation and Monitoring of the Strategic Cleaning Plan 24 17. Review Arrangements 24 18. 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 01.08.09- /Page 3 of 55

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 01.08.09- /Page 4 of 55

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 01.08.09- /Page 5 of 55

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 01.08.09- /Page 6 of 55

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 01.08.09- /Page 7 of 55

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 01.08.09- /Page 8 of 55

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 2007-8 and to complete this by 31 March 2008. 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 01.08.09- /Page 9 of 55

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 5.5.1 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. 5.5.2 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 01.08.09- /Page 10 of 55

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. 5.5.4 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 5.7.3 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 5.7.1 5.7.3 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. 5.7.1 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. 5.7.2 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 01.08.09- /Page 11 of 55

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). 5.7.3 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). 5.7.4 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. 5.7.5 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.. 5.7.6 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 01.08.09- /Page 12 of 55

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. 5.7.8 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 2008. 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 01.08.09- /Page 13 of 55

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 2008. 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 01.08.09- /Page 14 of 55

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 8. 5.9 Commissioning and Decommissioning of Buildings 5.9.1 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). 5.9.2 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 01.08.09- /Page 15 of 55

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 9. 8. 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 01.08.09- /Page 16 of 55

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 01.08.09- /Page 17 of 55

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. 11.1 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 01.08.09- /Page 18 of 55

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. 11.2. 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. 11.3. 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. 11.4 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). 11.5. 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 01.08.09- /Page 19 of 55

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 01.08.09- /Page 20 of 55

3 Acceptable Standards usually meet expectations though there is room for improvement in some areas. 2 Poor Standards regularly fail to meet expectations and there is significant room for improvement. 1 Unacceptable Standards fail to meet expectations in most areas and improvements are required urgently. 0 Not Applicable The PEAT Assessment for each in-patient unit is also required to incorporate the Cleanliness Scores for the same area for the previous 12 months. BSMHFT s Estates & Facilities Department s internal monitoring of cleanliness standards (set out in Section 10), facilitates this process and provides the scores. The Trust PEAT Lead ensures each Self Assessment Form is also accompanied by a summary of the Assessment. These are submitted to the Head of Estates & Facilities for inspection and who then presents these to the nominated Trust Board Representative (The Trust Executive Director of Nursing) to sign each assessment off. Assessments signed off by the Trust Board Nominee are then input by the Trust PEAT Lead into the NPSA PEAT Database, within the timescales set by the NPSA. The Trust PEAT Lead writes to each in-patient unit providing a summary of the assessment, pending and subject to the issue of the formal scores from the NPSA. 13. Domestic Services Software The Trust Estates & Facilities Department operates a Domestic Services Software package. The details and floor area of each ward and department are input into the software with the appropriate cleaning tasks, frequencies and access times. The software calculates recommended cleaning times for a range of designated performance levels - from which rosters are produced and cleaning costs are calculated. The outcome is sense checked by a comparison with the manual assessment made by the Trust Domestic and Facilities & Hotel Services Managers, based on their experience. The software is used to ensure that the number of cleaning hours allocated to each area are the most cost effective level to ensure the tasks and frequencies required are undertaken. The software is also used to provide an accurate assessment of cleaning costs associated with any required changes to cleaning tasks and frequencies and for business cases for new developments and changes to the Trust estate. 14. Domestic Staff Training A comprehensive training programme for Domestic Staff and Supervisors is essential to ensure the Domestic Service performs to the highest standards and levels of productivity. The Domestic Staff and Supervisors Training Programmes are summarised in Table 3 below. BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 21 of 55

Table 3 - DOMESTIC SERVICES TRAINING Domestic Staff Training Correct use of cleaning equipment Correct use of cleaning materials COSHH Correct cleaning procedures, tasks and frequencies Cleaning work schedules Reactive cleaning Safe working practices Infection Control Hand Hygiene Colour Coding Scheme for cleaning materials and equipment Cleaning procedures during an infection Post-infection cleaning Deep Cleaning NVQ Level 1 & 2 BICS (British Institute of Cleaning Science)Training Domestic Supervisors Training Correct use of cleaning equipment Correct use of cleaning materials COSHH Correct cleaning procedures, tasks and frequencies Cleaning work schedules Reactive cleaning Safe working practices When Provided Induction and Annual Refresher Training Within 1 st year in post When Provided Induction and Annual Refresher Training Infection Control Hand Hygiene Colour Coding Scheme for cleaning materials and equipment Cleaning procedures during an infection Post-infection cleaning Deep Cleaning Monitoring, assessing and maintaining cleanliness standards Supervision and 1 st Line management training (in-house) City & Guilds Cleaning Science Parts 1 & 2 NVQ Level 3 BICS Assessor Training Within 1 st year in post BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 22 of 55

15. Action Plan No ACTION STRATEGIC CLEANING PLAN REFERENCE 1. Introduce and implement this Strategic Cleaning Plan through an awareness programme Appendix 11 Page 53 2. Formalise Liaison arrangements between ICT and Estates & Facilities Department in respect of; i. Monthly Estates & Facilities Team Meetings ii. Capital & Revenue Developments/Projects Teams/Groups 3. Cleaning standards, tasks and frequencies to be regularly updated to ensure compliance with current (and any revisions to) NHS Cleaning Standards & Frequencies 4. Ensure the Estates & Facilities Department has dedicated sealed or lockable notice boards in all wards and departments and public areas for the display of cleaning standards and cleaning schedules. 5. Cleaning tasks that are undertaken at a designated frequency less than daily to be allocated a specified day of the week or date to be shown in cleaning schedules. 6. i. All Rehabilitation Units to adopt the compliance clean provided by the Trust Estates & Facilities Department/PFI Provider. ii. Cleaning activities by service users to be undertaken in addition to (not instead of) the compliance clean. iii. Service users to be provided with dedicated cleaning materials and equipment that is safe to use, following a risk assessment, and that is maintained in safe condition. Section 4 Page 6 Section 5.1 Page 7 Sections 5.1 & 5.2 Pages 7 & 8 Section 5.2 Page 8 Section 5.3 Page 8 7. Implement and monitor the rolling Deep Cleaning Programme Section 5.4 Page 9 8. Review out of hours arrangements for reactive cleaning. Section 5.5.4 Page 11 9. Review Infection Control Training for Trust and PFI Provider s Domestic Staff, Supervisors and Managers Section 5.7.7 Page 13 10. i. Formalise involvement of Infection Control Team in procedures for acquiring properties. ii. Review of cleaning arrangements in premises where cleaning is provided by the landlord. iii. Introduction of Trust managed cleaning services in premises where cleaning has been provided by the landlord (where this is cost effective, affordable and feasible). iv. Implementation of Trust (NHS) Cleaning Standards, Tasks and Frequencies to premises where cleaning is provided by the landlord (where it has not been possible to introduce a Trust managed cleaning service). 11. Review cleaning arrangements for properties not cleaned by the Estates & Facilities Department or the Trust s PFI Provider. Produce costed proposals to adopt the Trust s cleaning standards and schedules in these properties. Section 5.8 Page 14 Section 5.8 Page 14 BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 23 of 55

12. Formalise involvement of Infection Control Team in commissioning and decommissioning plans and programmes. 13. Formalise responsibilities for cleaning of equipment in the patient environment by provision of schedules and training. 14. Review Domestic Services Software and consider replacement to ensure continued functionality and compatibility with current Trust IT Infrastructure. Section 5.9 Page 15 Section 7 Page 16 Section 13 Page 21 16. Implementation and Monitoring of the Strategic Cleaning Plan This Strategic Cleaning Plan will be introduced through an awareness campaign to be managed by representatives of the Estates & Facilities Department and the Infection Control Team. The Implementation Plan is at Appendix 11. The same representatives will monitor the Trust s compliance with the Plan. 17. Review Arrangements This Strategic Cleaning Plan will be reviewed annually and as required in response to new DOH Guidance. Reviews will be undertaken by the Estates & Facilities Managers designated with responsibility for this Strategic Cleaning Plan in conjunction with the Trust Infection Control Team. The outcomes of each review and associated draft amendments will be submitted to the Trust Infection Control and Decontamination Operational Group in the first instance. 18. Reference Documents i. 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). ii. The NHS National Healthcare Standards, Standards for Better Health in iii. relation to Cleanliness. The National Specification for Cleanliness in the NHS (National Patient Safety Agency, 2007) iv. Clean, safe care Reducing Infections and saving lives (DOH 2008). v. Improving Cleanliness and Infection Control (DOH 2007). vi. Essence of Care Benchmarks for the Care Environment (DOH 2007). vii. A Matron s Charter: An Action Plan for Cleaner Hospitals (NHS Estates 2004). viii. Healthcare Commission Inspection guide for hygiene code (2007). ix. From Deep Clean to Keep Clean Learning from the Deep Clean Programme October 2008 (DOH 2008). x. NPSA Safer Practice Notice 15 Colour coding hospital cleaning materials and equipment (10 January 2007). xi. Trust Infection Prevention and Control Policy Infection Control Supplementary Procedure Annexe E Decontamination. xii. BSMHFT Infection Prevention and Control Policy (March 2006) BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 24 of 55

xiii. BSMHFT Waste Disposal Policy (December 2008). xiv. The BSMHFT s Laundry and Linen Policy (DRAFT 2009). xv. BSMHFT Decontamination Policy (DRAFT 2009). Authors Di Franklin, Facilities & Hotel Services Manager Sharon Duffy, Senior Nurse for Infection Control Rosemary Brown, Assistant Head of Estates & Facilities Management With Support and Input from; Amie Marsh, Decontamination Officer Neil Cross, Energy and Environment Manager BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 25 of 55

TRUST STRATEGIC CLEANING PLAN TRUST STRUCTURE SHOWING ROLES AND RESPONSIBILITIES FOR CLEANING AND DECONTAMINATION APPENDIX 1 (Page 1 of 2) Head of Estates & Facilities Management In-House Cleaning Services PFI/Contracted Cleaning Service Decontamination Services Senior Facilities & Hotel Services Manager Assistant Head of Estates & Facilities Management Energy & Environment Manager Facilities & Hotel Services Manager Ward Managers Ward Housekeepers Contract Monitoring Manager + Trustwide Cleaning Inspections Facilities & Hotel Services Manager Decontamination Officer Domestic Manager PFI Project Co John Laing Investments Ltd Domestic Supervisors Domestic Assistants (Departments) Domestic Assistants (Wards) FM Provider Amey Built Environment Ltd (Structure attached) BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 26 of 55

APPENDIX 1 (Page 2 of 2) BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 27 of 55

APPENDIX 2 REQUIRED CLEANLINESS STANDARDS (AS SET OUT IN THE DOMESTIC SERVICES OUTPUT SPECIFICATION) SERVICE ELEMENT ALL AREAS Sanitary Appliances Fixtures and Fittings Supplies Floors (Hard, Soft and Mats) Furniture, Equipment, Objects, Fixtures and Fittings (including Wall Tiles and Mirrors) Walls, Ceilings, Ledges, Rails, Door Frames, Window Frames Windows and Glass/Perspex Panels Curtains (Bed, Screen, Window, Shower) and Blinds Waste Disposal Pest Control Washing up Cleaning and Maintenance of Kitchen, Vending and Dining Areas SPECIFICATION Free from dust, deposits, stains (removable), foreign matter, residue, scale and odour. Chrome accessories smear-free and shining. Plentiful supplies of hand soap, paper hand towels, paper rolls and toilet tissues/rolls in dispensers. Free from litter, dust, fluff, debris, residue, deposits, soil, stains (removable), spillages, build-up, smears and odour. Uniform matt finish including beneath and behind movable objects. Free from litter, dust, fluff, debris, residue, deposits, soil, stains (removable), spillages, build-up, smears and odour. Waste bins have correct coloured liners (in accordance with Trust Waste Disposal Policy). Free from build-up of dust, grease, grime, stains (removable) and smears. Free from build-up of dust, grease, grime, stains (removable) and smears. Free from soiling, deposits, residue and spillages and build-up of dust, grime and stains (removable). Fully hung and secured. Refuse correctly bagged and removed to collection point. Absence of pest activity or evidence of pest monitoring/treatment. The Service Provider will be responsible for washing up promptly after completion of each meal and beverage service in all wards, day hospitals and the staff vending area and hospitality functions. The Service Provider will ensure that kitchens and food preparation, storage and display areas and dining and vending rooms and contents are maintained to the highest standards of cleanliness as specified. The Service Provider will ensure - floors and walls are free from dust, grease, debris, spillages, litter, grime, smears, removable stains, build up including underneath and behind movable objects and fittings and free from mal odour. - Interior and exterior of all surfaces, cupboards, drawers, sinks, surrounds, ledges, furniture, fixtures and fittings, window frames, wash hand basins, radiators, pipes, skirtings, blinds, waste bins and other items are free from dust, grease, debris, spillages, litter, grime, smears, removable stains and scale. - interiors and exteriors of all kitchen and vending equipment are free from dust, grease, debris, spillages, litter, grime, smears, removable stains and scale. - windows, ceilings, light fittings, vents and curtains are free from build up of dust, grease, grime, removable stains and smears. - refrigerators, freezers and chill cabinets are free from ice build up. The Service Provider will ensure - adequate supplies of disposable paper towels, paper towel rolls and hand soap in dispensers at wash hand basins and in kitchens and dining/vending areas. - kitchen and vending equipment is maintained in full working order. - dishwasher detergent and rinse dispensers are adequately filled and working. The Service Provider will ensure - waste food is disposed of in Waste Disposal Unit after each meal service. - other waste is bagged correctly and removed to collection point after each meal service and clean liner placed in bin. BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 28 of 55

APPENDIX 3 BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST CLEANING SCHEDULE IN-PATIENT UNITS THE FOLLOWING CLEANING DUTIES CARRIED OUT IN THESE PREMISES DAILY DOMESTIC STAFF SHIFT 9AM TO 7.00PM 7 DAYS PER WEEK Regeneration Kitchens, Pantry s and Beverage Bays 9am to 10am and then 1pm to 1.30 pm 5.45-7.00pm Bins emptied Damp wiping of all surfaces, equipment, sinks, windowsills, skirting boards and pipe work Damp mopping of floors Replenishing of soap, hand towels & toilet rolls Toilets, Bathrooms, Showers, Washrooms and En - suites 9am to 12.30pm & 2pm 5.45pm Bins emptied Sinks / baths / showers and toilets cleaned. Walls and tiles damp wiped, window sills, skirting boards and pipe work damp wiped. Floors damp mopped. All soap, hand towels and toilet roll dispensers replenished. Dining Rooms 9.45am to 11am, 12.30pm to 1.30pm & 5.45 7.00pm Bins emptied Tables and chairs damp wiped. Skirting boards, windowsills and pipe work damp wiped. Floors vacuumed and damp mopped (Buffed weekly ). Bedrooms 9am 5.45pm Bins emptied All surfaces damp wiped, furniture damp wiped windowsills, skirting boards and pipe work damp wiped. Floors vacuumed and damp mopped. (Buffed weekly for vinyl, carpets shampooed when required). Beds pulled out 3 times a week Lounges, Dayrooms, Quiet Rooms and T.V rooms 9am to 5.45pm Bins emptied. Damp wiping of all surfaces and furniture. Windowsills, skirting boards and pipe work Floors vacuumed and damp mopped. (Buffed weekly for vinyl, carpets shampooed when required). Offices, Corridors and General Area s 9am to 5.45pm Bins emptied. Floors vacuumed and damp mopped daily (Buffed weekly). All surfaces damp wiped, furniture, shelves, skirting boards, windowsills and pipework damp wiped. ADDITIONAL WEEKLY DUTIES (All Areas) Dust Control High Dusting Steam cleaning of en-suites and kitchen areas Once a week once a fortnight BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 29 of 55

APPENDIX 4 INFECTION OUTBREAK WARD To be completed by Nursing Staff Infection/Incident: Cidiff Domestic Supervisor name and contact :- MRSA Date Reported : Diarrhoea/Vomiting Who was effected: Infestation Staff/Patient/Visitor: Other Infected Areas: Bedroom Single Dormitory Dining Room Bathroom Clinic Quiet Room Kitchen TV Toilet Office Communal Areas Rest Room Cleaning Procedure To be completed by Domestic Supervisor Standard Clean Precaution Clean Deep Clean Mattress/Pillows Clean Deep Clean under taken by Domestic Supervisor:. Mattress and Pillows cleaned by Nursing Staff : BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 30 of 55

ENVIRONMENTAL CLEANING RECORD Infection: Antibacterial D/V MRSA/Cideff Diarrhoea, Vomiting Other Detail Clean: Bedroom Single Dormitory Dining Room Bathroom Clinic Quiet Room Kitchen TV Toilet Office Communal Areas Rest Room Duration: Less than one day One to two days Three to four days Five to nine days Ten to nineteen days Twenty days or more Nursing Staff - Monitoring Infection/Detailed Cleaning Day Night 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. Completed by Date.. BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 31 of 55

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APPENDIX 6 BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS TRUST MEMORANDUM To: From: See below Sharon Duffy, Senior Nurse for Infection Control Rosemary Brown, Assistant Head of Estates & Facilities Management Di Franklin, Facilities & Hotel Services Manager Julie Keith, Service Manager, Solihull Date: 28 th January 2008 NEW COLOURS FOR CLEANING! RE: THE NHS NEW NATIONAL NEW COLOUR CODING SCHEME FOR CLEANING MATERIALS AND EQUIPMENT Please find attached Notice (2 pages) giving details of the NHS New National Colour Coding Scheme for cleaning materials and equipment (cloths, mops, buckets, aprons and gloves) that is being implemented in BSMHT with effect from 18 th February 2008. Please also note the following; 1. The Additional Information section regarding; Catering Departments and Main Production Kitchens Yellow Colour Coded Cleaning Equipment Cleaning and Disinfection of Bodily Spillages Use of Cleaning Equipment and Materials by Nursing Staff. 2. Arrangements for supply of colour coded cleaning materials and equipment. 3. Arrangements for provision and display of the new Colour Coding Scheme Posters in wards, departments and centres. 4. Colour Coding Awareness Week 11 17 February 2008 (activities). 5. Arrangements for the Audit of the new Colour Coding Scheme. Could you please ensure that this memo and the attached notice are brought to the attention of all staff in your ward/department. If you have any queries, please do not hesitate to contact a member of the Colour Coding Working Group (names on page 2 of the notice attached). Thank you for your attention and action. Regards Sharon Duffy Rosemary Brown Di Franklin Julie Keith Senior Nurse for Infection Control Assistant Head of Estates & Facilities Management Facilities & Hotel Services Manager Service Manager, Solihull BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 36 of 55

To: Modern Matrons Ward and Department Managers Centre Managers Dawn Dugan, B1 Patrick Mckeown, Uffculme and B1 Cfi: Executive Directors and Directors Service Directors Service Managers Clinical Managers Neil Hathaway, Head of Estates & Facilities Management All Managers, Supervisors and Staff, Estates & Facilities Department Ewan Robinson, General Manager, Healthcare Support (Erdington) Limited Mark Woodcock, Interim Contract Manager, Amey Business Services Limited Colour Coding Working Group BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 37 of 55

NEW COLOURS FOR CLEANING! New national standards for colour coding cleaning materials and equipment are being introduced to BSMHT from 18 February 2008. Cloths, mops, buckets, aprons and gloves must all be colour coded under the new NHS National Patient Safety Agency (NPSA) standards. 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. Implementation of the new National Colour Coding Scheme will be launched by Colour Coding Awareness Week, 11 17 February 2008. THE NEW NATIONAL COLOUR CODING SCHEME Posters will be provided for display in all wards & departments Main Notice Board Kitchens Clinics/Treatment Rooms Utility/Sluice Rooms. BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 38 of 55

PLEASE NOTE - ADDITIONAL INFORMATION In the Catering Departments and Main Catering Production Kitchens (QEPH, Reaside, Ardenleigh, Uffculme, B1) Green colour coded materials and equipment will be used for general background cleaning. However, this will not replace the essential practice of using different coloured materials eg cloths in raw food areas and cooked food areas. This essential practice will continue. Yellow Colour Coded Cleaning Equipment and Materials Yellow colour coded cleaning materials eg cloths, mop heads, gloves and aprons will be disposable and disposed of after use. Yellow colour coded cleaning equipment eg buckets will be disinfected using Chloroclean. Bodily spillages (eg; urine, blood, sputum, vomit, faeces) occurring in areas other than toilets will be cleaned up and disinfected using Yellow colour coded cleaning materials and equipment and Chloroclean (as these spillages may be infected). 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. 2. WHO WILL SUPPLY COLOUR CODED CLEANING EQUIPMENT & MATERIALS? (Cloths, Mops, Buckets, Aprons and Gloves) At South (QEPH, Reaside and South Community Units) and Ardenleigh, the Domestic Department will continue to supply these units. In the former North, Amey will supply the Trust Units and New PFI Units. Solihull - BSMHT s premises, centre staff will order these items by stock requisition (stock codes and details have been provided to centre staff by Julie Keith, Service Manager, Solihull Directorate. Solihull Hospital BSMHT units, the hospital Domestic Service provider will supply. 3. WHO WILL SUPPLY THE NEW COLOUR CODING SCHEME POSTERS? (The same arrangements as for 2. above). 4. COLOUR CODING AWARENESS WEEK 11 17 FEBRUARY 2008 Posters and cleaning materials and equipment supplies will be provided to all wards/departments. The Colour Coding Working Group will visit wards and departments to launch. Enter THE COLOUR CODING MYSTERY QUIZ (watch the Intranet & post). 5. AUDIT The Colour Coding Working Group will audit the new Scheme in wards & departments and report to the Trust Infection Control Committee in May 2008. 6. Any Questions? Please contact; Sharon Duffy Senior Nurse Infection Control Ext 1056 Rosemary Brown Assistant Head of Estates & Facilities Management Ext 5133 Di Franklin Facilities & Hotel Services Manager Ext 2051 Huw Price Facilities & Hotel Services Manager Ext 5137 Steve Clinton Contract Monitoring Manager Ext 5134 Julie Keith Service Manager, Solihull Directorate 712 8344 BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 39 of 55

APPENDIX 7 COLOUR CODING AUDIT RECORD (WARDS, DEPARTMENTS, UNITS, CENTRES) UNIT: Date of Audit Colour Coding Poster is Displayed Colour Coding Equipment & Materials are Available to and Accessible by Domestic and Nursing Staff Staff know how Colour Coding Equipment & Materials are supplied Memo and Notice received and displayed Comments and Action Taken Main Notice Board Clinics & Treatment Rooms Kitchens Utility & Sluice Rooms Cleaning Cupboards Mops Buckets Cloths Gloves Aprons Domestic Nurses/Other Clinical Staff Signature: Print: Title: (Auditor) Signature: Print: Title: (Ward/Dept Representative) BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 40 of 55

COLOUR CODING AUDIT RECORD (MAIN & PRODUCTION & REHAB KITCHENS) UNIT/KITCHEN: Date of Audit Colour Coding Poster is Displayed Colour Coding Equipment & Materials are Available to and Accessible by Catering and Other Staff Staff know how Colour Coding Equipment & Materials are supplied Memo and Notice received and displayed Comments and Action Taken Main Notice Board Main Kitchen Dining Rooms Sluice Rooms Cleaning Cupboards Mops Buckets Cloths Gloves Aprons Domestic Other Print: Signature: Title: (Auditor) Signature: Print: Title: (Ward/Dept Representative) Kitchens include; QEPH Main Kitchen Main House Centre Kitchen Uffculme Centre Kitchen Reaside Main Kitchen Grove Avenue Centre Kitchen B1 Kitchen Hillis Lodge Centre Kitchen Ross House centre Kitchen Phoenix Centre Kitchen Holly Hill Centre Kitchen Ardenleigh Main Kitchen Hopkins Day Centre Kitchen (Soho Hill) Howard Court Kitchen BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 41 of 55

APPENDIX 8 STRATEGIC CLEANING PLAN SCHEDULE OF CLEANING ARRANGEMENTS FOR ALL PROPERTIES OWNED OR OCCUPIED BY BSMHFT Property Address Tenure Landlord Domestic Service Provider Domestic Service Supervised/ Managed By 1 Ardenleigh Kingsbury Road Erdington, B24 9SA Freehold in - house Ian Poole Domestic Service Monitored By CMM/Huw Price 2 Azaadi 294-296 Washwood Heath Rd, B8 2UL Freehold AMEY AMEY CMM 3 Dan Mooney House 1 Woodside, Downing Close, Knowle, Solihull, B93 0QA Freehold In House Ward CMM 4 David Bromley House 2-4 Woodside Crescent, Downing Close, Knowle, Solihull, B93 0QA Freehold In House Ward CMM 5 Dennis Shilston House Mindelsohn Way, Edbaston, B15 2QZ Freehold in - house BSMHFT BSMHFT 6 Doctors Mess Fentham Road Erdington Birmingham B23 6AL Freehold AMEY AMEY CMM 7 Eden Unit 355 Slade Rd Erdington, B23 6AL Freehold AMEY AMEY CMM 8 Elm House Highcroft Site, Erdngton, B23 6AL Freehold MOTHBALLED 9 Fentham Road 71 Fentham Road, Erdington, B23 6AL Freehold MOTHBALLED 10 Gardener's Department North Fentham Road, Erdington, B23 6AL Freehold AMEY AMEY CMM 11 Gardener's Department South 2 Robinsfield Drive, West Heath, B31 4TU Freehold 12 George Ward 355 Slade Rd, Erdington, B23 6AL Freehold AMEY AMEY CMM 13 Hertford House 29 Old Warwick Road, Olton, Solihull, B92 7JQ Freehold IN HOUSE WARD CMM 14 Hillis Lodge Hollymoor Way, Northfield, B31 9AY Freehold in - house BSMHFT BSMHFT 15 Hollyhill Rubery Lane, Rubery, B45 9AY Freehold in - house BSMHFT BSMHFT 16 Howard Court 2 Montague Rd Edgbaston, B16 9HR Freehold AMEY AMEY CMM 17 John Black Day Hospital 4 Maple Leaf Drive, Marston Green B37 7JB Freehold IN HOUSE WARD CMM 18 Ladywood Health Centre 395 Ladywood Middleway Ladywood B1 2TJ Freehold AMEY AMEY CMM 19 Little Bromwich Centre Hobmoor Rd, Small Heath, B10 9JH Freehold AMEY AMEY CMM Longbridge Health & Community Centre 10 Park Way, Birmingham Great Park, Rubery, B45 9PL Freehold in - house BSMHFT BSMHFT 20 21 Lyndon Resource Centre Hobs Meadow, Solihull, B92 8PW Freehold IN HOUSE WARD CMM 22 Main House 201 Hollymoor Way, Northfield, B31 5HE Freehold BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 42 of 55

23 Maple Leaf Drive 2 Maple Leaf Drive, Marston Green B37 7JB Freehold IN HOUSE WARD CMM 24 Marsh Lane Centre 79 Marsh Lane Erdington B23 6HY Freehold AMEY AMEY CMM 25 Mary Street Centre 213 Mary Street, Balsall Heath B12 9RN Freehold AMEY AMEY CMM 26 Monyhull Road 208 Monyhull Hall Road, Kings Norton, B30 3QJ Freehold 27 Newbridge House Hobmoor Rd, Small Heath, B10 9JH Freehold AMEY AMEY CMM 28 Newington Resource Centre Newington Road, Hamar Way, Marston Green, B37 7RW Freehold IN HOUSE WARD CMM 29 Nightingale House Hobmoor Rd B10 9JH Freehold AMEY AMEY CMM 30 Northcroft 190 Reservoir Rd, Erdington B23 6DJ Freehold AMEY AMEY CMM 31 Poplar View Highcroft Site Erdington B23 6AL Freehold AMEY AMEY CMM Birmingham Great Park, Bristol Road South, Rubery, B45 32 Reaside 9BE Freehold 33 Redwoods properties 107 Loynells Road, Rubery, B45 9NT Freehold 34 Residential Flats, Highcroft Highcroft Site Erdington B23 6AL Freehold AMEY AMEY CMM 35 Ross House Sheldon Drive, Northfield, B31 5EJ Freehold in - house BSMHFT BSMHFT 36 Slade Road Centre 411 Slade Rd Erdington B23 7JA Freehold AMEY AMEY CMM 37 Small Heath Health Centre 42 Chapman Rd Small Heath B10 0PG Freehold AMEY AMEY CMM 38 Soho Hill Centre 176 Soho Hill Handsworth B19 1AG Freehold AMEY AMEY CMM 39 Soho House 362-364 Soho Rd B21 9QL Freehold AMEY AMEY CMM 40 Stockland Clinic Slade Road Erdington B23 7JA Freehold AMEY AMEY AMEY 41 Stratford Road Day Centre 570-576 Startford Road, Sparkhill, B11 4AN Freehold in - house Patrick Patrick 42 Tall Trees 80 Queensbridge Road, Moseley, B13 8QY Freehold in - house Patrick Patrick 43 Uffculme Centre 52 Queensbridge Road, Moseley, B13 8QY Freehold in - house BSMHFT BSMHFT 44 Venture House Fentham Rd Erdington B23 6AL Freehold AMEY AMEY CMM 45 Warstock Lane Warstock Lane, Billesley, B14 4AP Freehold in - house BSMHFT BSMHFT 46 Yardley Fields Road 7 Yardley Fields Rd Yardley B33 8TY Freehold MOTHBALLED 47 Shenley Fields 15 Shenley Fields Drive, Northfield, B31 1XH Freehold in - house BSMHFT BSMHFT PFI 1 Ashcroft Unit Lodge Rd Winson Green, B18 5SJ PFI AMEY AMEY CMM 2 Reservoir Court 220 Reservoir Rd Erdington, B23 6DJ PFI AMEY AMEY CMM 3 Mary Seacole House Lodge Rd, Winson Green, B18 5SD PFI AMEY AMEY CMM 4 Endeavour Court 210 Reservoir Rd Erdington, B23 6DJ PFI AMEY AMEY CMM 5 Endeavour House 202 Reservoir Road Erdington, B23 6DJ PFI AMEY AMEY CMM 6 Forward House Slade Road, Erdington, B23 7JQ PFI AMEY AMEY CMM 7 The Barberry 25 Vincent Drive, Edgbaston, B15 2FG PFI in - house BSMHFT BSMHFT BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 43 of 55

8 The Zinnia Centre 100 Showell Green Lane, B11 4HL PFI in - house BSMHFT BSMHFT 9 The Oleaster 6 Mindelsohn Crescent, Edgbaston, B15 2SY PFI in - house BSMHFT BSMHFT Leasehold 1 Adams Hill 190 Adams Hill, Bartley Green, B32 3JP Leasehold BCC in - house BSMHFT BSMHFT 2 B1 Unit 1 B1, 50 Summer Hill Road, B1 3RB Leasehold BAA Pension Trustees Ltd PREMIER GROUP SERVICES D. DOUGAN CMM 3 Bridge House 509 Aldridge Rd, Great Barr Birmingham, B44 8NA Leasehold Derek Blake (private individual) AMEY AMEY CMM 4 Bridger House 22 Summer Road, Acocks Green, B27 7UT Leasehold Birmingham Health, Safety & Environment Association in - house BSMHFT BSMHFT 5 Callum Lodge Lodge Rd, Winson Green, B18 5SJ Leasehold BCC AMEY AMEY CMM 6 Caynham Road 22 Caynham Road, Bartley Green, B32 4HA Leasehold BCC in - house BSMHFT BSMHFT 7 Devon House 201 Dogpool Lane, Stirchley, B30 2XH Leasehold Westowe Properties Limited in - house BSMHFT BSMHFT 8 Express Signs 2 Vulcan House, Vulcan Road, Solihull, B91 2JY Leasehold Solihull Council 9 Greenbank 1025 Stratford Road, Hall Green, B28 8BG Leasehold Aamir B Sayid and others in - house BSMHFT BSMHFT Trident Charitable Housing Association Ltd in - house BSMHFT BSMHFT 10 Grove Avenue 32 Grove Avenue, Moseley, B13 9RY Leasehold 11 Harry Watton House 97 Church Lane Aston B6 5UG Leasehold BCC AMEY AMEY CMM 12 Heathway Centre 70 Reddicap Heath Road, Sutton Coldfield, B75 7EW Leasehold BCC LANDLORD 13 Ladywood Day Centre Vincent Street West, Ladywood, B16 8RR Leasehold BCC AMEY AMEY CMM 14 Matthews Centre Duddeston Manor Road, Duddleston, B7 4LZ Leasehold Aquarius A-Kleen Services Unit CCM 15 Miller Street 1 Miller Street, Newtown, B6 4NF Leasehold Lowerland (2004) Limited PREMIER GROUP SERVICES CMM 16 Morcom House Ledsam Street, Ladywood, B16 8EE Leasehold Alan Silverwood Limited AMEY AMEY CMM 17 Orsborn House 55 Terrace Road, Handsworth, Birmingham, B19 1BP Leasehold Sovereign Property Holdings Ltd LANDLORD PREMIER CMM 18 Patrick House 5 Maney Corner Sutton Codlfield B72 1QL Leasehold K B Jackson And Son (Midlands) Ltd AMEY AMEY CMM 19 Phoenix Day Centre Harrison Road Erdington B24 9AB Leasehold BCC AMEY AMEY CMM 20 Riverside Park Units 1 & 3 2 & 14 Riverside Park, Albert Road, Stechford, B33 9BD Leasehold O'Donnell Developments Ltd AMEY AMEY CMM 21 Scarborough House 35 Auckland Road, Sparkbrook, B11 1RH Leasehold Lafarge Plasterboard Ltd in - house BSMHFT BSMHFT 22 Selly Oak Hospital E Block E Block, Selly Oak Hospital, B29 6JD Leasehold University Hospital Birmingham in - house BSMHFT BSMHFT 23 Park Lane Garden Centre Park Lane Aston B6 5DL Leasehold BCC AMEY AMEY CMM 24 Spring Road Centre 258 Spring Road, Fox Hollies, B11 3DW Leasehold Birmingham Health, Safety & Environment Association in - house BSMHFT BSMHFT BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 44 of 55

25 Ten Acres 201 Dogpool Lane, Stirchley, B30 2XH Leasehold Westowe Properties Limited in - house BSMHFT BSMHFT 26 The Custard Factory Unit 1-317, Gibb Street, Digbeth, B9 4AA Leasehold Sven Bennie Gray 27 The Old Fire Station 288 Bordesley Green Rd B9 5NA Leasehold Thomas Joyce MOTHBALLED 28 Yewcroft Court Oak Road, Harborne, B17 9AB Leasehold BCC in - house BSMHFT BSMHFT Licence and SLA 1 Bridge House Annex 509 Aldridge Rd, Great Barr B44 8NA Licence North PCT AMEY AMEY CMM 2 Cartland House 2251 Coventry Rd Sheldon, B26 3NX Licence Heart of Birmingham Teaching PCT 3 Grove Road 51 Grove Road, Solihull, B91 2AQ Licence 4 HMP Winson Green Winson Green Road, B18 4AS Licence HM Prison Services Kings Norton Business Centre, Pershore Road South, 5 Imperial Court Kings Norton, B30 3HN Licence South PCT 6 Middlewood House 15 Larch Croft, Chelmsley Wood, B37 7UR Licence Solihull Care Trust 7 Poplar Road Poplar Road, Solihull Licence Solihull Care Trust 8 Radclyff House Radclyff House, 68-68 Hagley Road, B16 8PF Licence Edgbaston Business Centre Ltd 9 Saheli House (Womens Day Centre) 59 Prince Albert Street, Bordsely Green, B9 5AG Licence BCC Heart of England NHS Foundation 10 Solihull Hospital Lode Lane, Solihull, B91 2JL Licence Trust IN HOUSE WARD CMM 11 Sparkhill Neighbourhood Office 641 Stratford Road, Sparkhill, B11 4DY Licence BCC 12 Summerhill Terrace 23 Summerhill Terrace Ladywood, B1 3RA Licence Heart of Birmingham Teaching PCT 13 The Bridge 15 Larch Croft, Chelmsley Wood, B37 7UR Licence Solihull Care Trust 14 Underwood Centre Underwood Close Marsh Hill Erdington B23 7EZ Licence BCC 15 Union Road 20 Union Road, Solihull, B91 3EF Licence Solihull Care Trust 16 Weatherdale 31 Weatheroaks, Harborne, B17 9DD Licence BCC 17 Weatheroak Day Centre 24 Pershore Road South, Cotteridge, B30 3AS Licence Cotteridge Church 18 Hilldale & Edendale Bushmere house, 137 Edenbridge Road, Hall Green, B28 8PN SLA BCC 19 Main Street 86 Main Street, Sparkbrook, B11 1RS SLA BCC 20 Charlotte Road Centre 45 Charlotte Road, Stirchley, Birmingham, B30 2BT Licence B'ham Specialist Community Health NHS Trust 21 Ladywood Day Centre Vincent Street West, Ladywood, B16 8RR Licence BCC AMEY AMEY CMM CMM - Denotes Contract Monitoring Manager BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 45 of 55

Total Cleaning Responsibility Framework (incorporating cleaning not covered by Domestic Services) This document has been produced in line with The National Specifications for Cleaning in the NHS April 2007 Appendices 5 and 6. Items Frequency Method Ward Patient Equipment (medical) Staff group responsible Comments APPENDIX 9 IV Stand Weekly Detergent wipes Clinical Staff Include wheels IV Pumps/Syringe drivers Weekly Detergent wipes Clinical Staff Cleaned by med phys after repair Cardiac Monitors One full clean daily and clean after use Detergent wipes Clinical Staff Cleaned by med phys after repair Blood gas machine Weekly Alcohol wipes Clinical Staff Cleaned by med phys after repair Dressing trolleys One full clean daily and clean after use Detergent wipes Clinical Staff Include wheels Notes Trolleys Weekly Detergent wipes Clinical Staff Include wheels Drugs Trolleys Weekly Detergent wipes Clinical Staff Include wheels Sharps bin trolleys One full clean weekly and clean after use Detergent wipes Clinical Staff Include wheels Blood pressure cuffs One full clean daily and clean after use Detergent Wipes Clinical Staff Det/water/bowl/disposable Pillows Between patients and when soiled cloths Clinical Staff Mattresses Cotsides Wheelchairs Linen Trolleys Tea Trolleys Between patients and when soiled After Use Weekly One full clean weekly and clean after use One full clean weekly and clean after use Det/water/bowl/disposable cloths Clinical Staff Det/water/bowl/disposable cloths Clinical Staff Det/water/bowl/disposable cloths Clinical Staff Domestic / House Detergent wipes keeper Domestic / House Detergent wipes keeper Cleaned by med phys after repair (Bed frames cleaned by Domestic Staff - see Page 50) Include wheels Include wheels BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 46 of 55

Items Frequency Method Staff group responsible Comments Commodes One full clean daily and clean after use Det/water/bowl/disposable cloths Clinical Staff Cushions After Use Detergent wipes Clinical Staff Oxygen sat probes After Use Detergent wipes Clinical Staff Cleaned by med phys after repair Wash bowls After Use Det/water/bowl/disposable cloths Clinical Staff Invert to dry Det/water/bowl/disposable cloths Clinical Staff/or supplier when specialist clean required. Pressure relieving mattress CVRS After Use Hoists After Use Detergent Wipes Clinical Staff Pat Slides After Use Detergent Wipes Clinical Staff Det/water/bowl/disposable Easy slides After Use cloths Clinical Staff Consider laundry Hoist slings After Use Detergent wipes Clinical Staff Consider laundry Det/water/bowl/disposable Stands aids Daily cloths Clinical Staff Handling Belts After Use Detergent wipes Clinical Staff Consider laundry Detergent wipesd/w/b Resuscitation trolleys Dailly disposable cloths Clinical Staff Include wheels Larying handles One full clean daily and clean after use Detergent wipes Clinical Staff Medical physics Cleaned by med phys Oxygen/Suction equipment One full clean daily and clean after use Detergent wipes Clinical Staff after repair Oxygen/Suction equipment portable Weekly Detergent wipes Clinical Staff Wall humidifiers After Use Detergent wipes Clinical Staff Cleaned by med phys after repair Cleaned by med phys after repair Portable nebulisers One full clean weekly and clean after use Detergent wipes Clinical Staff Cleaned by med phys after repair BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 47 of 55

Items Frequency Method Staff group responsible Ventilator equipment One full clean daily and clean after use Detergent wipes Clinical Staff One full clean weekly and clean after Catheter Stands use Washer disinfector Clinical Staff Bed pans/holders After Use Washer disinfector Clinical Staff Slipper pans After Use Washer disinfector Clinical Staff Urine bottles After Use Washer disinfector Clinical Staff Urine jugs After Use Washer disinfector Clinical Staff One full clean weekly and clean after Det/water/bowl/disposable Scales use cloths Clinical Staff Gas cylinder holders After Use Detergent wipes Clinical Staff Weights After Use Detergent wipes Clinical Staff Weighing Scales One full clean daily and clean after use Detergent Wipes Clinical Staff Det/water/bowl/disposable Physio Equipment Manual Handling Equipment Other Medical equipment e.g. intravenous pumps, pulse oximeters etc. NOT CONNECTED TO PATIENT After Use After Use cloths Clinical Staff Det/water/bowl/disposable cloths Clinical Staff One full clean daily and clean after each patient use Detergent Wipes Clinical Staff Other Medical equipment e.g. intravenous pumps, pulse oximeters etc. CONNECTED TO PATIENT One full clean daily and clean after each patient use Alcohol wipes Clinical Staff Raised toilet seats Daily Det/water/bowl/disposable cloths Domestic Comments Cleaned by med phys after repair BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 48 of 55

Items Frequency Method Ward Media Equipment Staff group responsible Comments All other Telephones Daily Detergent wipes User Computers/keyboards Weekly Detergent wipes User Printers Weekly Detergent wipes User Fax Weekly Detergent wipes User Audio/Visual Systems Daily Detergent wipes User Photo-copiers Monthly Detergent wipes User Screens Weekly Detergent wipes User OHPs Monthly Detergent wipes User Flip Charts Monthly Detergent wipes User Accessories, i.e. staplers, in-trays, etc Monthly Detergent wipes User CCTV Equipment Monthly Detergent wipes Estates Loan equip i.e. heaters After Use Detergent wipes Estates TVs Det/water/bowl/disposable Weekly cloths Domestic Hi-Fis Weekly Detergent wipes Domestic Pay Telephones Daily Detergent wipes Domestic BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 49 of 55

Items Frequency Method Staff group responsible Comments Ward General Equipment Drugs Cupboards Weekly Detergent wipes Clinical Staff Drugs Fridges Weekly Det/water/bowl/disposablecloths Clinical Staff Isolation Trolleys Daily Alcohol wipes Clinical Staff Include wheels Kettles Weekly Detergent wipes User Also descale Dust Monthly Dry Cloth Ceilings Wash Yearly Det/water/bowl/disposablecloths Estates High deep cleaning Twice weekly Det/water/bowl/disposablecloths Estates Ventilation grilles extract and inlets One full clean monthly Det/water/bowl/disposablecloths Estates Water coolers Weekly Det/water/bowl/disposablecloths Supplier Pest Control devices Weekly Detergent wipes Pest Contractor External waste receptacles Varies by site As per contractors specifications Contractor All external glazing 3 times per year Det/water/bowl/disposablecloths Contractor Recycling bins Weekly Detergent wipes Waste Contractor Re-gen Trolleys Daily Det/water/bowl/disposablecloths Domestic Cookers (ADL Kitchens) After use Weekly Full Clean Det/water/bowl/disposablecloths Det/water/bowl/disposablecloths User/ADL Clinical Staff Domestic Refer to cleaning manual Microwaves Daily Check Clean Weekly Full Clean Det/water/bowl/disposablecloths Det/water/bowl/disposablecloths Housekeeper/Domestic Domestic Refer to cleaning manual Toasters Weekly Detergent wipes Domestic Kitchen Cupboards Daily Det/water/bowl/disposablecloths Domestic Refer to cleaning manual Chill Cabinets & Milk Fridges Daily Check Clean Weekly Full Clean Det/water/bowl/disposablecloths Det/water/bowl/disposablecloths Housekeeper/Domestic Domestic Dishwashers Weekly Det/water/bowl/disposablecloths Domestic Switches, Sockets and Datapoints Daily Detergent wipes Domestic All Doors Daily Det/water/bowl/disposablecloths Domestic All internal glazing including partitions Weekly Det/water/bowl/disposablecloths Domestic Mirrors Daily Detergent wipes Domestic Surface clean daily Det/water/bowl/disposablecloths Domestic Radiators One full clean monthly Det/water/bowl/disposablecloths Estates Dust removal once daily Dry Cloth Domestic Wet mop once daily Det/Water/Mop/bucket Domestic Floor polished Machine clean weekly Use appropriate machine Domestic BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 50 of 55

Items Frequency Method Staff group responsible Dust removal once daily Dry Cloth Domestic Wet mop once daily Det/Water/Mop/bucket Domestic Floor non slip Machine clean weekly Use appropriate machine Domestic Full clean daily Vaccuum Domestic Carpet shampooer or steam Soft Floor Shampoo six-monthly clean Domestic Cleaning Equipment After Use Detergent wipes Domestic Low Surfaces Once Daily Det/water/bowl/disposablecloths Domestic High Dusting Once Monthly Det/water/bowl/disposablecloths Domestic Chairs Daily Det/water/bowl/disposablecloths Domestic Lockers Daily Det/water/bowl/disposablecloths Domestic Bed Frames Daily Det/water/bowl/disposablecloths Domestic Tables general Daily Det/water/bowl/disposablecloths Domestic Dining Tables After Use Hand wash containers/dispensers Daily Detergent wipes Domestic Office bins Weekly Det/water/bowl/disposablecloths Domestic Internal waste receptacles Weekly Det/water/bowl/disposablecloths Domestic Sent to laundry or washed on Clean, change or replace yearly site Sent to laundry or washed on Curtains and Blinds Bed curtains three times per month site Domestic Showers Daily Det/water/bowl/disposablecloths Domestic Toilets and bidets Two full cleans daily Det/water/bowl/disposablecloths Domestic Replenishment Two times daily n/a Domestic Sinks Two full cleans daily Det/water/bowl/disposablecloths Domestic Baths Daily Det/water/bowl/disposablecloths Domestic Crockery After Use Dishwasher Domestic / Catering Cutlery After Use Dishwasher Domestic / Catering Macerators Weekly Det/water/bowl/disposablecloths Domestic / Contractor Linen Trolley Weekly Detergent wipes Domestic/Housekeeper Comments Fridges in Staff Rooms and Offices After use and weekly Det/water/bowl/disposablecloths Microwaves in Staff Rooms and Offices After use and weekly Det/water/bowl/disposablecloths Ward/Dept/Office Staff Users Ward/Dept/Office Staff Users BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 51 of 55

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IMPLEMENTATION PLAN for Strategic Cleaning Plan APPENDIX 11 Issues identified / Action to be taken Time-Scale Co-ordination of implementation How will the implementation plan be co-ordinated and by whom? Clear co-ordination is essential to monitor and sustain progress against the implementation plan and resolve any further issues that may arise. The implementation of this Strategic Cleaning Plan will be co-ordinated and managed by an Implementation Group of designated Estates & Facilities Managers and Infection Control Team and Modern Matron Representatives. Compliance with the Strategic Cleaning Plan will be monitored by the Implementation Group. The Strategic Cleaning Plan will be monitored to test effectiveness, compliance and performance. Initial Implementation & Annual Review & Additional Reviews as required. Engaging staff Who is affected directly or indirectly by the policy? Are the most influential staff involved in the implementation? Engaging staff and developing strong working relationships will provide a solid foundation for changes to be made. Involving service users and carers Is there a need to provide information to service users and carers regarding this policy? Are there service users, carers, representatives or local organisations who could contribute to the implementation? Involving service users and carers will ensure that any actions taken are in the best interest of services users and carers and that they are better informed about their care. Equality and Diversity Has a Diversity Impact Assessment been carried out? Could there be any differential and adverse impact on any group in terms of race, age, gender, disability, belief and faith and sexual orientation in the application of this policy? What actions are being taken to reduce or remove disadvantage? Diversity impact assessments are necessary to ensure the Trust meets its legal duties to ensure equality of opportunity. The Policy will have an impact on all service users, staff and visitors of BSMHFT. Colleagues within the Infection Control and Estates & Facilities Teams have supported the development of this Strategic Cleaning Plan. Awareness Campaign to be developed by the Implementation Group. Service User and Carer Representatives will be invited to be involved in the Implementation and Awareness Campaign and annual (and additional) reviews. Summary of the Strategic Cleaning Plan will be produced to be incorporated into Information Packs for service users, staff and visitors. The Equality Impact Assessment will be completed. Discussion with colleagues within Equality and Diversity will take place to help support the Strategic Cleaning Plan Initial Implementation & Annual Review & Additional Reviews as required. Initial Implementation & Annual Review & Additional Reviews as required. Initially & Annual Review & Additional Reviews as required. BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 53 of 55

Communicating What are the key messages to communicate to the different stakeholders? How will these messages be communicated? Effective communication will ensure that all those affected by the policy are kept informed thus smoothing the way for any changes. Promoting achievements can also provide encouragement to those involved. Training What are the training needs related to this policy? Are people available with the skills to deliver the training? All stakeholders need time to reflect on what the policy means to their current practice and key groups may need specific training to be able to deliver the policy. Resources Have the financial impacts of any changes been established? Is it possible to set up processes to re-invest any savings? Are other resources required to enable the implementation of the policy eg. Increased staffing, new documentation? Identification of resource impacts is essential at the start of the process to ensure action can be taken to address issues which may arise at a later stage. Securing and sustaining change Have the likely barriers to change and realistic ways to overcome them been identified? Who needs to change and how do you plan to approach them? Have arrangements been made with service managers to enable staff to attend briefing and training sessions? Are arrangements in place to ensure the induction of new staff reflects the policy? Initial barriers to implementation need to be addressed as well as those that may affect the on-going success of the policy. Issues identified / Action to be taken Communication will be very important. This Strategic Cleaning Plan will be the tool which will need to be effectively communicated. The messages of the Strategic Cleaning Plan will be communicated through an Awareness Campaign involving Estates & Facilities and Infection Control Teams, Programme Directors, Service Managers, Modern Matrons, Service users and Carers. This Strategic Cleaning Plan applies to ALL staff of BSMHFT. Divisions and Estates & Facilities will be responsible for ensuring that their staff received the required level of training. Copies of the Strategic Cleaning Plan and Awareness Campaign Notices will be provided to all wards & departments. Divisions and Estates & Facilities will be responsible for evaluating the levels or pay and non-pay resources required for training and compliance with the Strategic Cleaning Plan. Most documentation is currently in use, however some new documentation will be required. The emphasis on total cleaning involving clinical and non clinical staff will impact on staffing resources required (to be evaluated as above). This Strategic Cleaning Plan supports the Control of Infection Policy in securing long term change. Total cleaning involving different staff groups will present challenges. The greatest challenge will be to change the way staff working in BSMHFT accept and take ownership of key aspects, embracing a sustainable change in approaches to environmental cleanliness. The Strategic Cleaning Plan provides clarity of responsibilities for all aspects of environmental cleaning. This will be reinforced in the Awareness Campaign and Implementation. The Awareness and Implementation Plans will incorporate briefing sessions. It is proposed to incorporate the Strategic Cleaning Plan in the Trust Induction. Time-Scale Initial Implementation & Annual Review & Additional Reviews as required. Initial and Ongoing Initial and Ongoing Initial Implementation & Awareness Campaign & Annual Review & Additional Reviews as required. BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 54 of 55

Evaluating What are the main changes in practice that should be seen from the policy? How might these changes be evaluated? How will lessons learnt from the implementation of this policy be fed back into the organisation? Evaluating and demonstrating the benefits of new policy is essential to promote the achievements of those involved and justifying changes that have been made. Other considerations Issues identified / Action to be taken Total cleaning involving different staff groups. Emphasis on monitoring & audit. Post implementation review. Reviews and associated developments to the Strategic Cleaning Plan and in practice. Time-Scale Initial Implementation & Annual Review & Additional Reviews as required. BSMHFT/Strategic Cleaning Plan/Final 01.08.09- /Page 55 of 55