Colour Coding of Cleaning Materials and Equipment Policy Document Summary To ensure the Trust meets its legal duty to comply with the Food Safety Act 1990 and all subordinate legislation. DOCUMENT NUMBER POL/002/056 DATE RATIFIED 20 th May 2016 DATE IMPLEMENTED May 2016 NEXT REVIEW DATE May 2018 ACCOUNTABLE DIRECTOR POLICY AUTHOR Director of Strategy and Support Services Head of Facilities Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and, as such, may not necessarily contain the latest updates and amendments.
Contents SCOPE... 2 INTRODUCTION... 2 STATEMENT OF INTENT... 2 DEFINITIONS... 3 Accountable Director... 3 Policy File Holder... 3 Policy Author... 3 PLACE... 3 RESPONSIBILITIES... 3 Director of Strategy and Support Services... 3 Head of Facilities... 3 Facilities Coordinator... 3 Ward/Department Manager and Sister... 4 Domestic/Housekeeping Supervisor... 4 Domestic Assistant/Housekeepers... 4 General Staff... 4 POLICY CONTENT... 5 General Guidelines... 5 Training... 6 MONITORING COMPLIANCE WITH THIS POLICY... 6 REFERENCES/BIBLIOGRAPHY... 7 RELATED TRUST POLICY/PROCEDURES... 7 1 P a g e
SCOPE This policy applies to all staff, whether they are directly employed by Cumbria Partnership NHS Foundation Trust or are under contract to the Trust. This policy will also take account of other relevant Trust policies such as Infection Prevention and Control, and Health & Safety and will also reflect National Standards, for example Standards for Better Health, PLACE, the Code of Practice for the Prevention and Control of Healthcare Associated Infections, and the Matrons Charter. INTRODUCTION Colour coding of Trust cleaning materials and equipment ensures that these items are not used in multiple areas, therefore reducing the risk of cross infection. This policy follows a recommendation from the National Patient Safety Agency to improve the safety of hospital and healthcare premise cleaning, ensure consistency and provide clarity to staff. The majority of hospitals and healthcare premises already have colour coding schemes for materials and equipment in place, most of which revolve around the same core colours. However, this presents a potential risk when domestic staff move from organisation to organisation or even in some cases from site to site. Due to the inconsistency this causes throughout the NHS, the NPSA developed a standardised code to be used by all NHS organisations providing in-patient services in England and Wales. The National colour coding scheme is designed to standardise and streamline existing schemes. STATEMENT OF INTENT The aim of the colour coding system is to work alongside standard cleaning procedures to:- Ensure that a standardised colour coding system is adhered to by all staff employed by Cumbria Partnership NHS Foundation Trust and external agency/contract staff working within Cumbria Partnership NHS Foundation Trust properties. Help maintain a clean, comfortable and safe environment for patients, clients, visitors and members of the general public. Increase patient confidence in relation to environmental hygiene and the organisational commitment to reduce the incidence of healthcare associated infection. 2 P a g e
DEFINITIONS Accountable Director The Director accountable for the policies within a specific area of responsibility. Also the person responsible for the process or production of specific policies. Policy File Holder Person in charge of the administration systems for policies and procedures in a particular service location. Policy Author The person nominated by the Accountable Director to prepare the draft of a specific policy. PLACE Patient Led Assessment of the Care Environment. RESPONSIBILITIES Director of Strategy and Support Services The Director of Strategy and Support Services is the accountable director for this policy. Head of Facilities It is the responsibility of the Head of Facilities to: Take the operational lead for colour coding of cleaning materials and equipment throughout the Trust. Ensure a Colour Coding Policy is in place and kept updated of significant changes. Ensure the Trust complies with national cleaning, specifically the colour coding requirements. Ensure effective quality standard monitoring and feedback arrangements are in place and that any remedial information relating to colour coding is passed on to the Ward/Dept managers/sisters for them to action. Ensure that SLAs and service specifications/contracts are in place, that they include colour coding requirements, and that all cleaning providers adhere to them. Facilities Coordinator It is the responsibility of the Facilities Coordinator to: Promote the colour coding of cleaning equipment and material requirements to all staff. Set and monitor standards in conjunction with Facilities Management and Infection Prevention and Control teams. 3 P a g e
Ward/Department Manager and Sister It is the responsibility of all Ward/Department Managers and Sisters to: Allow access for quality Monitoring, and support the Facilities Department to implement the colour coding policy within the ward/department Ensure that the colour coding poster is placed in all required areas Ensure the Estates Department is notified of any known remedial action required to support the colour coding policy He/she will ensure that staff receive training on the colour coding policy within their local induction. He/she will ensure that all recommendations from quality monitoring audits in relation to colour coding are acted upon. He/she has the day to day responsibility for supervising and ensuring the ward staff are compliant in completing their responsibilities as laid out by this policy. Domestic/Housekeeping Supervisor It is the responsibility of domestic/housekeeping supervisor to: Maintain appropriate records e.g. quality monitoring, training Ensure all staff are appropriately trained and that it is regularly updated as required Ensure adequate equipment and materials are available Maintain and adhere to National Specifications for Cleanliness in the NHS, as set out in the Trust Cleaning Manual Ensure staff are aware of and understand the importance of keeping a Colour Coding system Monitor standards of cleanliness on a regular basis. Domestic Assistant/Housekeepers It is the responsibility of all housekeepers to: Ensure that all equipment is correctly Colour Coded Comply with all training policies and procedures Carry out their duties in a manner which prevents the spread of infection Report any untoward occurrences, in line with Trust policy General Staff It is the responsibility of all staff to: Ensure that their training for this policy is kept up to date Follow the guidelines stipulated in this policy. 4 P a g e
POLICY CONTENT General Guidelines All Trust premises should be cleaned using the following colour code system:- BLUE General Use BLUE (Wards, departments, offices, clinical rooms etc.) GREEN Kitchens - GREEN (In wards or departments) RED Washrooms Disposable - RED (Bathrooms, washrooms, showers, toilets, urinals and washroom floors) YELLOW Isolation Areas - YELLOW (MRSA etc.) All cleaning materials and equipment for example, cloths, mops, buckets aprons and gloves should be colour coded. The method used to colour code items should be clear and permanent The colour coding system should form part of any employee induction or continuous training programme. N.B. In doing this, it must be noted that a minority of people are colour- blind in one or more colours. Some individuals may not know this and therefore colour identification testing should form part of any induction programme. Where someone is identified as colour blind, amendments to the labelling of materials and equipment would be introduced. In addition to the colour coding of these, colours would also be attached in a written format. Adherence to the colour coding system should form part of any domestic service quality monitoring procedure. 5 P a g e
Training Training required to fulfil this policy will be provided by the Ward Manager/Matron during local induction. The management of training will be in accordance with the Trusts Learning and Development Policy. The Trust Cleaning Manual is the supporting reference guide to this training, based on the National Specifications for Cleanliness in the NHS and available for all staff to use at ward/departmental level It is recognised that on the job training is a continuous process necessitating a constant review of methods/procedures and monitoring of the individual s general performance. MONITORING COMPLIANCE WITH THIS POLICY The table below outlines the Trusts monitoring arrangements for this policy/document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored Monitoring method Individual responsible for the monitoring Frequency of the monitoring activity Group / committee which will receive the findings / monitoring report Group / committee / individual responsible for ensuring that the actions are completed Colour coding notices are displayed in all relevant areas as laid out in this policy Cleanliness Audit Facilities Coordinator Monthly IC Link Nurse Meeting Network meetings ICC Meeting Ward/ Department Manager and Sister Facilities Mgmt meeting Supervision The colour coding system and the requirements as set out in this policy, is being used across the Trust Cleanliness Audit Facilities Coordinator Monthly IC Link Nurse Meeting Network meetings ICC Meeting Facilities Mgmt meeting Ward/ Department Manager and Sister Supervision 6 P a g e
REFERENCES/BIBLIOGRAPHY National Patient Safety Agency National Colour Coding Scheme National Standards for Cleanliness (April 2007) Patient Environment Action Teams Cumbria Partnership Colour Coding Policy (2009) BSi Specification for the Planning, Application and Measurement of Cleanliness Services in Hospitals (PAS5748-2011) Code of Practice for the Prevention and Control Of Healthcare Associated Infections (Health Act 2006) Care Quality Commission Guidance (March 2010) Matrons Charter (October 2004) BS EN ISO 9001:2000 Quality Assurance Standard Revised Guidance on Contracting for Cleaning (December 2004) NHS Standards for Cleanliness (2001) The NHS Plan (July 2000) RELATED TRUST POLICY/PROCEDURES Cleaning Policy Cleaning Manual Infection Prevention and Control 7 P a g e
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