THIS POLICY SUPERSEDES ALL PREVIOUS … and...soiled linen. 4.7 Housekeepers, Health Care Assistants, Nursing, other Clinical Staff Housekeepers, HCA’s, nursing and other clinical

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LINEN AND LAUNDRY POLICY

THIS POLICY SUPERSEDES ALL PREVIOUS POLICIES FOR LINEN AND LAUNDRY

January 2019

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Policy title Linen and Laundry Policy

Policy reference

EF14

Policy category Estates and Facilities

Relevant to All staff/contractors dealing with Linen and Laundry

Date published January 2019

Implementation date

January 2019

Date last reviewed

January 2019

Next review date

JAANVJ January 2022

Policy lead Helen Flynn, Head of Facilities Management

Contact details Email: [email protected] Telephone: 0203 317 6773

Accountable director

David Wragg, Director of Finance

Approved by

Health, Safety and Fire Committee

January 2019

Document history

Date Version Summary of Amendments

Feb 2014 1 First draft after consultation

March 2016 B Review – Minor changes

January 2019 C

Routine review-replaced reference to Engie with ISS

Membership of the policy development/ review team

Helen Flynn, Head of Facilities Management

Consultation

Thomasia Knox-Goba, Soft Services Manager (ISS), Cleaning Staff, Housekeepers, Brid Fitzgerald, Infection Control Lead

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Contents Page

1. Introduction 5

2. Aims and Objectives 5

3. Scope of the Policy 6

4. Roles and Responsibilities 6 4.1 Chief Executive 4.2 Nominated Director- Associate Director of Estates 4.3 Head of Facilities Management 4.4 Estates and Facilities Contract Manager 4.5 Modern Matrons/Service Managers 4.6 Local Managers/Ward Managers 4.7 Housekeepers, Health Care Assistants, Nursing, other Clinical Staff 4.8 Cleaning Staff 4.9 The infection Control Team 4.9 Capital Programme Manager

5. Storage of Clean Linen 8

6. Used Linen Within the Healthcare Environment –Categories 8

7. General Guidelines for Handling Linen 9

8. Infected linen Within the Healthcare Environment 9

9. Items Unsuitable for Laundering 10

10. Curtains/Upholstery 10

11. On Site Laundering 10

12. Legislation and Guidance 11

13. Dissemination and Implementation Arrangements 12

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14. Monitoring and Audit Arrangements 12

15. Review of the Policy 12

16. Appendices 13-15 ___________________________________________________________________ Appendices

Equality Impact Assessment Tool APPENDIX 1 Handling Arrangements for Infected Linen APPENDIX 2

Bagging Procedure for linen APPENDIX 3

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Guidelines for the Management of Linen and Laundry

1.0 INTRODUCTION It has been shown that used linen, within healthcare settings, in particular, can harbour large numbers of potentially pathogenic microorganisms. Therefore, it is important that the appropriate precautions are taken to ensure contamination to/from linen does not occur as this might then lead to transmission of microorganisms to people or to the environment potentially causing infection. Such important precautions apply to all stages of linen management: storage, handling, bagging, transporting, and laundering.

The provision and management of laundry and linen services is an important function to enable sustainable delivery of good care. By complying with this policy staff will facilitate the continued delivery of these services, minimising risks to health and safety, complying with infection control requirements and ensuring best value for the Trust.

“The NHS has an obligation under the Health and Safety at Work Act (1974) to take steps to prevent the risk of infection to staff handling and laundering linen” The Health Service Guidelines HSG (95) 18 has been recently superseded with the DH (2012) Choice Framework for Local Policy and Procedures (CFPP) 01-04 – Decontamination of Linen for Health and Social Care (policy updated March 2016) The Trust has a legal requirement to comply with the Health and Social Care Act (D2010). This states that all health care providers are required to have in place systems to ensure effective practice when handling, segregating, and laundering linen.

2.0 AIMS AND OBJECTIVES In summary the aim of the policy is to describe the standard of linen and laundry to be provided to service users and residents and how linen and laundry should be stored, handled and transported around the Trust to ensure statutory compliance. The aims of this policy are specifically:

To ensure the use of correct laundry and linen specifications to comply with the requirements of infection control and national guidance: DH (2012) Choice Framework for Local Policy and Procedures (CFPP) 01-04 – Decontamination of Linen for Health and Social Care.

To demonstrate continuous improvement in the management of laundry and linen to minimise the risks of cross infection infections by adopting proven washing technology.

To continuously strive to improve environmental standards using the most environmentally friendly technology and products possible.

To define and allocate the necessary resources to achieve consistently high quality standards of personal laundry provision for elderly residents.

To specify clear, well defined roles and responsibilities for staff within clinical and community settings.

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To provide the necessary information and visual guidance (via posters) to all relevant staff in relation to laundry and linen.

To closely monitor the performance of the commercial laundry, to ensure they comply with national guidance and with a view to further improve service provision.

To ensure that any failings with regards to the laundry are addressed promptly and that unsatisfactory items of laundry are rejected.

3.0 SCOPE OF THIS POLICY To promote guidance for health care workers on the correct hygiene measures for the laundering of linen. Highlight the risks of infection associated with handling dirty laundry, as well as keeping clean laundry free from the risk of contamination.

Identify appropriate prevention measures to reduce the risk and protect service users, residents, staff and the wider community. Provide staff with a broad outline of what to do, and whom to contact for more detailed advice in relation to the management of linen and laundry.

4.0 ROLES AND RESPONSIBILITIES

4.1 The Chief Executive The Chief Executive is ultimately responsible for linen and laundry provision and standards across The Foundation Trust. The Chief Executive will ensure that adequate resource is available to enable the provision of high quality laundry and linen service, via the TFM contract, which is sufficiently flexible to meet variable volume demands generated by the services and service users and that the organisational structure supports those responsible for overseeing the service throughout The Trust.

4.2 The Associate Director of Estates and Facilities

The Associate Director for Estates and Facilities has been delegated responsibility for ensuring that robust systems and processes are in place across the Trust and that sufficient resources are allocated to ensure the maintenance adequate levels of linen across the organisation. They also have the responsibility for overseeing the Service user Led-Assessment of the Clinical Environment (PLACE) annual audits, which includes laundry storage in its monitoring.

4.3 Head of Facilities Management The Head of Facilities Management is responsible for drawing up an audit plan for monitoring of the quality of linen, the stock levels and appropriate storage at an agreed interval across the inpatient properties and for collecting the results and where standards are unsatisfactory, for

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agreeing action plans and rectification times and scheduling follow-up audits. The Head of Facilities Management is also responsible for organising the PLACE inspection visits and inputting the resulting scores relating to laundry/linen and comments and taking action where PLACE audits have identified failings within this area.

4.4 Estates and Facilities Contract Manager

The role of the Estates and Facilities Contract Manager is to monitor the standard of the linen and laundry service provided by the Total Facilities Manager (TFM) contractor and to calculate any financial deduction s where failings have been identified in any month. They will participate in audits, in conjunction with the infection control team.

4.5 Modern Matrons/Service Managers Service Managers and Modern Matrons have responsibility for ensuring that any on-going stock delivery or quality issues raised by their teams are fed to the Estates and Facilities Contract Manager, for their intervention.

4.6 Local Managers/Ward Managers Local Managers/Ward Managers are responsible for the tidiness of their areas, including linen stores. They are required to ensure that only clean and unstained bed linen and towels are used and that staff are aware of the process for rejecting unacceptable linen and dealing with used and soiled linen.

4.7 Housekeepers, Health Care Assistants, Nursing, other Clinical Staff Housekeepers, HCA’s, nursing and other clinical staff, managed directly at ward and department level may also come into contact with clean and used/soiled linen and they need to be aware of handling protocols.

4.8 Cleaning/Portering Staff

Cleaning staff on some sites are responsible for collecting laundry bags from storage areas, such as sluice rooms and moving them to designated collection points. They must ensure when dealing with clean and dirty linen that they are kept completely separate to avoid any risk of cross-contamination. Likewise when porters transport laundry only dedicated clean trollies may be used. Staff must be inducted to know that clean and dirty linen must never be stored or transported in the same trolley.

4.9 The Infection Control Team The Infection Control Team is responsible for offering support, advice and guidance on specific/specialist laundry technology to be used. Where there are concerns about the effectiveness of the laundry service, in microbiological terms, they may instigate microbiological tests or instigate specific audits.

4.10 Capital Programme Manager

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The Capital Programme manager is responsible for ensuring that when refurbishments are planned or new developments approved consideration is given to the any linen storage area required and to the materials to be used in terms of flooring and wall surfaces to ensure ease of cleaning. They must also ensure any washing machines to be installed as a result of refurbishments or new capital works meet agreed Trust specifications.

5.0 STORAGE OF CLEAN LINEN/LAUNDRY Clean laundry must be handled in such a way that contamination is avoided including during transport and storage. Clean linen should always be stored in a clean, dry designated area, preferably in a purpose built cupboard. Clean laundry should be stored above floor level and kept tidy to prevent contamination with dust and/or aerosols. If a linen trolley is used for the storage of linen it should be enclosed. Linen and/or the linen trolley must not be stored in bathrooms, sluices, laundry rooms or staff changing room.

Ideally, linen should not be decanted onto different trolleys, or stored in corridors when delivered, as this may result in contamination.

Clean linen must be monitored to ensure it is in a good state of repair, as tearing or roughness can damage skin. Staff with exposed skin lesions should ensure they are covered when handling clean laundry.

6.0 USED LINEN WITHIN THE HEALTHCARE ENVIRONMENT It is the responsibility of the person disposing of the linen to ensure that it is segregated properly. There are three categories of used linen:

Bags for used linen should be securely fastened when ¾ full.

They should be stored in a secure area whilst awaiting collection.

Bags should not block access to walkways, fire doors, or hand washing sinks. There are three categories of used linen:

6.1 Soiled and Foul linen This is all used linen, irrespective of condition, which may be contaminated by body fluids, except linen from a known or infectious person.

6.2 Infected linen

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This is linen from patients/service users/residents with either a confirmed diagnosis of or suspected to be suffering from enteric fever, and other Salmonella infections, Dysentery, H.I.V, open pulmonary T.B. Hepatitis A, Hepatitis B and Hepatitis C. In addition, any notifiable disease or infection in hazard group 3 COSHH Approved List of Biological Agents and any other infection as specified by the Control of Infection team, as hazardous to staff. Linen from patients infected with Hazard Group 4 organisms, such as Lassa fever, also fall into the category of infected linen but have a specific treatment regime (steam sterilising before autoclaving). In any of the above cases the Infection Control Team should be notified and their advice sought-this may ultimately mean the destruction of some items of linen, where satisfactory decontamination cannot be assured.

6.3 Heat Labile Items These are fabrics damaged by thermal disinfection e.g. wool, synthetics, etc.

7.0 GENERAL GUIDELINES FOR HANDLING LINEN

All staff that deal with laundry (clean or used) must adhere to the Trust’s guidelines on linen and laundry. Exposure to infected agents will be averted with responsible handling of linen, separation of clean and dirty linen and performing effective hand hygiene. Staff should be vigilant for any discarded items that may pose a risk or injury. Such items should be disposed of correctly (e.g. in accordance with the policies on Disposal of Clinical Waste and Sharps). Appropriate personal protective equipment PPE should be worn when handling when handling/ disposing of linen. Laundry bags should always be used when clearing away used linen from bed areas and the used linen carefully removed, avoiding any unnecessary agitation, and directly placed into the appropriate bag. Staff must not hand carry loose used linen, or leave items of linen on the floor, in order to minimise environmental and personal contamination. All staff must ensure that no extraneous items are disposed of with used linen, such as dentures, spectacles, sharps, incontinence pads, and tissues as they may harm the laundry operators at the commercial laundry or cause damage to machinery. The laundry bag should not be overfilled and should be securely closed when ¾ full Staff should wear aprons and gloves when handling linen especially from infected patients or whenever handling linen contaminated with bodily fluids. The linen bags should be used for linen only and never for clinical waste. Staff must wash or alcohol gel their hands after handling used linen, and after removing gloves and aprons.

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Sheets, towels or other items of linen should never be used to mop up or contain spills of any liquid.

8.0 INFECTED LINEN WITHIN THE HEALTHCARE ENVIRONMENT

The infected linen must be placed in a red water – soluble bag, tied when ⅔ full and placed in a white plastic bag.

Linen that has been taken into room where a patient has been barrier/isolation nursed and then not used must be removed and sent to the laundry, this must not be used for another patient/resident/service user. All infected linen is to be stored in a secure external area for collection by the porter/ laundry

contractor.

9.0 ITEMS UNSUITABLE FOR LAUNDERING Pillows must be covered with a washable cover and should be wiped clean with a disposable detergent wipe between each patient/service user occupant and/or if soiled/damaged. Torn or badly stained pillows must be thrown away/placed into an orange clinical waste bag (hospital and healthcare premises), placed into a plastic bag and lead manager/person in charge advised accordingly.

DO NOT SEND PILLOWS TO THE LAUNDRY

Note: Cotton covered pillows are only to be designated for single patient use.

10.0 CURTAINS/UPHOLSTERY Window and bedroom curtains should be changed every six months as a minimum. Domestic Supervisors must ensure that they are regularly subject to audit and inspection and where necessary the curtains must be changed whenever they are visibly soiled, during terminal cleaning after the discharge of an infected patient or following episodes of an outbreak of infection. Shower curtains must be changed regularly, and where necessary shower curtains must be changed whenever they are visibly soiled, during terminal cleaning after the discharge of an infected patient or following episodes of an outbreak of infection. Any curtains purchased for clinical areas must be machine washable and fire retardant to Crib 5 standard. Soft furnishings such as chairs must have fluid repellent upholstery and must be wipeable. Chairs should be cleaned and inspected regularly. Stained and /or soiled chairs must be decontaminated or removed from use. Advice must be sought from the Senior Infection Control Nurse when purchasing furnishings for clinical areas to ensure compliance with infection control requirements.

11.0 ON SITE LAUNDERING- service users/residents own private clothing

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The laundry room on the ward is for the use of service users to wash their own private clothing. However, it is the ward staff’s responsibility to ensure that the room and the equipment therein are kept to a satisfactory hygienic standard. The laundry room should be located away from clinical or food preparation areas. The washing machines should be in good working order and kept clean. If not functioning correctly the Estates and Facilities Department should be called to arrange for an engineer to visit. The work tops should be kept clean and free from visible contamination by the use of detergent and water. Dirty laundry should be placed directly into the machine and not sorted out on the worktops. Hands should be washed after dealing with dirty laundry. No manual rinsing of soiled laundry by staff is allowed. Faecal solid bulk may be disposed of in the toilet and the laundry put on pre-wash to remove stains. Laundry from service users containing body fluids or who are suffering from an infection must put into a soluble alginate bag and be washed on the highest temperature that the fabric will tolerate and then the washing machine must be set to run empty through a cycle on the hottest washing setting to complete a heat disinfection (thermal disinfection) cycle, where the temperature should be maintained at 65 degrees, not less than 10 minutes or preferably 71 degrees for not less than 3 minutes. Ward staff should ensure that service users who are allowed to use the laundry room abide by the good practice recommended in this policy. Ward Washing Machines and Dryers Domestic machines must not be used in health care areas. Industrial machines must be used and be maintained and serviced according to the manufacturer’s instructions. There are a couple of specific models that may be leased that meet Infection Control standards-the procurement department should be consulted before entering into any arrangement to lease a washing machine or dryer. Protective clothing i.e. gloves and aprons must be used and hands washed, after the removal of protective clothing, in a hand wash sink in the laundry room. There must be clear work flow so contaminated and clean linen cannot come into contact.

Clean gloves and apron must be used for each load, dirty and clean. The washed linen must be dried straight away in an industrial dryer, this must be vented externally and filters checked and changed as recommended. Clean linen must not be stored in the laundry room, where there are washing machines, to avoid the risk of cross contamination. The room must be kept clear, clean and dust free.

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Washing processes for both used and infected linen should include a heat disinfection (thermal disinfection) cycle, where the temperature should be maintained at 65 degrees, not less than 10 minutes or preferably 71 degrees for not less than 3 minutes. Washing machines must be checked on a regular basis to ensure these temperatures are maintained.

12.0 LEGISLATION AND GUIDANCE

The Health and Safety at Work etc. Act (1974) places a number of duties on employers and employees concerning the requirements of safe work practices. The Management of Health and Safety at Work Regulations (1999) places a statutory duty of co-operation between employers and employees to provide each other with clear communication in health and safety matters including any hazards associated with their activities e.g. potential contamination, transfer of infection etc. In addition, the Control of Substances Hazardous to Health (COSHH) Regulations (2002) are applicable to both chemical hazards and biohazards. The Controls Assurance Standards programme was established in 1999 to ensure that Trust Boards trusts and other NHS bodies have systems in place to ensure that risks are assessed and properly managed. Of the published Controls Assurance Standards a number are relevant to this area, in particular, infection control and environmental management.

DH (2012) Choice Framework for Local Policy and Procedures (CFPP) 01-04 – Decontamination

of Linen for Health and Social Care.

13.0. DISSEMINATION AND IMPLEMENTATION ARRANGEMENTS

This policy will be available to staff on the Trust intranet. It will also be made available to the

Trust’s TFM contractor.

14. MONITORING AND AUDIT ARRANGEMENTS

Compliance to the guidance in this policy will be undertaken by Estates and Facilities Managers during regular audits, the Infection Control Team and the TFM service provider.

15. REVIEW OF POLICY

The policy will be reviewed every 3 years or whenever there is a new piece of legislation or good

practice which should be adopted by the Trust.

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16.0 APPENDICES

Appendix 1

Equality Impact Assessment Tool

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers)

No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A

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APPENDIX 2

Handling Arrangements for Infected Linen (Outbreaks or isolation rooms) · Carefully remove dirty bed linen from bed. · Bagging of linen should be carried out immediately on removal from the bed. · Dirty linen should be carefully handled and not shaken prior to bagging. · Carefully place infected linen into a red water soluble bag. · The bag should then be sealed using the white/clear plastic bag and taken to the holding area. · The RED colour- coded bag shall be securely fastened when it is two-thirds full.

Infected Linen Storage Area · Trust will identify a dedicated infected linen storage area that has the necessary accommodation to enable loaded trolleys to be stored awaiting collection by the laundry vehicle. · Storage areas should be protected from the elements; vermin proof and have washable surfaces.

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APPENDIX 3

Bagging Procedure for Linen

Used Linen Bagging Procedure

CATEGORY

DESCRIPTION

SPECIAL NOTES

COLOUR

PICTURE

A

Used linen

All used linen including synergy patient nightwear for example nightwear, patient gowns etc.

Place into a white polythene bag; Do not place linen soiled with blood or body fluids in white bags

White Polythene

Bags

B

Soiled/ Foul/Infected linen

All used and linen soiled with blood or body fluids including linen from patients with known infections or suspected infectious e.g. MRSA.

Put linen that is soiled with blood, faeces, vomit and urine in to a red soluble (alginate) bag and tie, then into a WHITE polythene bag. The outer bag must be tied

Red Soluble

Bag Inside a White

Polythene Bag

C

Return to Sender items *(RTS)

Items owned by the Trust / Hospital / Ward, for example hoist slings, glide sheets, curtains etc.

*All items must be individually labeled, with Service and Hospital/Site. Any items sent not labeled may not be returned. If you have any Return to Sender items that are infected, follow instruction in section B

Navy Blue Polythene

Bag

D

Rejected clean linen (UNUSED)

Any clean linen which is found to be unusable (i.e. torn, stained, etc. not fit for purpose)

All rejected linen must be placed in a green polythene bag for returned through the specific process agreed with the Trust.

Green Polythene

Bag

Important Notes Before fastening any bag, make sure it is no more than three quarters full, (bags that are too heavy may not be collected and could cause manual handling issues) Dirty linen may not be collected if any of the above procedures are breached. Do not send any other items such as pillows, patient belongings etc. within the soiled linen. *A completed “Return to Sender” form must be completed and sent with items