Hotel Services Comment / Changes / Approval

Document Control Title Laundry Policy Author Manager Directorate Version Date Issued Status 1.0 1999 Final Approved Author s job title Manager Department Hotel Services Comment / Changes / Approval 2.0 2003 Final Approved 2.1 April 08 Revised Infection Control Committee 3.0 May 08 Final Clinical Services Executive Committee for approval 3.1 Jun 08 Revision Final amendments to ensure Corporate Identity requirements 3.2 Apr 2012 Revision One year review date extension approved by Infection Prevention and Control Committee on 3 rd April to allow updating 3.3 June 2014 Revision Bagging Policy and third party Contractor name update, harmonised with East 3.4 Aug 14 Final Approved by the Infection Control Committee 5 Aug 14 4.0 Sep 14 Final Published on Bob 5.0 May 16 Revision Appendix C Contingency plan contact details updated. 5.1 June 16 Revision Transferred to up to date template Main Contact Tel: Direct Dial - 01271 311821 Manager Department North Devon District Hospital Raleigh Park Barnstaple EX31 4JB Lead Director Director of Superseded Documents Trust Laundry Policy issued 2012 Issue Date June 2016 Review Date June 2018 Consulted with the following stakeholders: (list all) Matrons Charter Infection Control Group Infection Prevention Control Committee Review Cycle Two Years G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 1 of 20

Approval and Review Process Infection Prevention Control Committee Local Archive Reference Estates Local Path G:\FACILITIES ESTATES\\Hotel Services\LINEN\Policy\2016 Update Filename Laundry Policy V5.1 10.06.16 Policy categories for Trust s internal website (Bob) /Infection Control Tags for Trust s internal website (Bob) Linen, Laundry, Laundry Bagging, Soiled Linen, Rejected Linen, Curtains, Ski Sheets, Slide Sheets, Clothing G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 2 of 20

CONTENTS Document Control... 1 1. Purpose... 5 2. Responsibilities... 5 Role of the Director of... 5 Role of Author... 5 Role of Staff... 5 Role of Sodexo Linen Staff, Community Hotel Services Staff and Nurses... 5 Sodexo Porters and Community Hotel Services Staff... 6 Line Managers... 6 3. General Principles all types of Linen... 6 4. Normal/Used Linen... 7 5. Fouled/Infection Linen... 7 6. Theatre Linen... 8 7. Patient s Personal Clothing... 8 8. Return to Sender (RTS)... 9 9. Rejected Linen... 10 10. Uniforms... 10 Home Laundering of Uniforms... 11 11. Domestic Equipment... 11 12. Linen Use... 12 Sheets/Pillows/Blankets... 12 Towels... 12 Patient Gowns... 12 Slide Sheets... 12 Patient Hoist Slings... 12 Canvasses... 12 Scrub Suits... 13 Failure of Normal Service... 13 13. Monitoring Compliance with and the Effectiveness of the Policy... 13 Standards/ Key Performance Indicators... 13 Process for Implementation and Monitoring Compliance and Effectiveness... 13 14. Equality Impact Assessment... 13 15. References... 14 Appendix A... 15 Appendix B... 16 Appendix C - South West Laundry Consortium... 17 Contingency Plans... 17 SCENARIOS... 17 Berendsen Actions:... 17 Berendsen Actions:... 18 G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 3 of 20

Berendsen Actions:... 18 Trust Actions:... 18 Berendsen Actions:... 18 G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 4 of 20

1. Purpose 1.1. This document sets out Northern Devon Healthcare NHS Trust s system for the management of Laundry and Linen. It provides a robust framework to ensure a consistent approach across the whole organisation and covers the general principles of the handling and usage of linen together with a guide to when items of linen should be sent for laundering. 1.2. The purpose of this document is to ensure the linen and laundry service operates efficiently and effectively to reduce the risk of hospital acquired infections, to maintain patient and staff comfort and to manage the service within limited resources. 1.3. The fundamental requirements of this policy for the supply of a linen and laundry service are to comply with Health Guidance HSG (95) 18and BS EN 14065, Hospital Laundry Arrangements for used and infected linen. 1.4. The policy applies to all Trust staff. 2. Responsibilities Role of the Director of 2.1. The Director of Job Designation is responsible for: Overall compliance responsibility Role of Author 2.2. The Author is responsible for: Attending quarterly strategic meetings and Coordinator to attend monthly operational meetings with contractors and highlight any performance issues monitor compliance against this policy. Role of Staff 2.3. The staff are responsible for: Bagging used linen in the correct manner in line with this policy. Role of Sodexo Linen Staff, Community Hotel Services Staff and Nurses 2.4. The Sodexo linen staff, Community Hotel Services staff and Nurses are responsible for: Providing clean linen to all areas. G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 5 of 20

Sodexo Porters and Community Hotel Services Staff 2.5. The Sodexo Porters and Community Hotel Services Staff are responsible for: Collecting used linen from all areas, as long as it has been bagged and closed correctly. Line Managers 2.6. The Line Managers for Sodexo Linen staff, Community Hotel Services staff, Nurses, and Sodexo Porters are responsible for: Ensuring their staff are aware of and compliant with the Laundry Policy on appointment to the Trust. 3. General Principles all types of Linen 3.1. The storage of clean linen must be kept separate from clean supplies and used equipment. Linen must be stored in a separate cupboard or on a trolley just for linen that must be covered at all times. Only essential items of clean linen and no other items are to be placed on mobile trolleys. To reduce any potential contamination of unused items these must not be returned to cupboards/stores. 3.2. All used linen must be placed in an appropriate colour coded bag according to the colour coding chart displayed in every sluice, (please refer to appendix A) 3.3. Used linen must always be bagged at the bedside never carried through the ward to the sluice. 3.4. Skip bags must never be more than 2/3 full. 3.5. Used linen handling must conform to the specifications of Health Service Guidance (95) 18 and BS EN 14065 as outlined in this policy. 3.6. Staff must ensure they wear personal protective equipment when dealing with used linen. 3.7. Staff must always wash their hands after dealing with used linen and/ or after removing personal protective equipment. 3.8. Staff must ensure that items such as needles, syringes, instruments and other foreign objects are not placed in laundry bags. 3.9. No purchase of washing machines will take place without formal agreement by the Managers. 3.10. Regarding purchase of items requiring laundering, only items that withstand the intensive laundry process may be purchased, check with Coordinator if you are unsure G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 6 of 20

3.11. All Trust owned items must be sent to the external contractor for laundering except for Theatre and ICU slide sheets, shower curtains, handling equipment such as handling belts. Fire Evacuation ski sheets in the North are sent to Bideford Hospital and in the East are sent to Berendsen or local laundrette. 3.12. Fire Evacuation sheets should be changed between patients or if soiled. Shower curtains should be changed weekly or on discharge/if visibly soiled in single patient rooms. The internal laundrette at Bideford for the North is provided principally for patients clothing items. 3.13. Regarding labelling, all items, including curtains, must be clearly labelled with the ward/department and Hospital name. This must be carried out as part of the purchasing of equipment by the supplier. 3.14. Breaches to this policy must be recorded and communicated via the Incident Reporting process 4. Normal/Used Linen 4.1. Normal/ used linen must be placed in a white skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A). 4.2. Supplies of white skip bags will be available in all areas where linen is used. Further supplies may be obtained from the Linen Room, Sodexo Zone Coordinator or Community Hotel Services Coordinator. 4.3. Plastic aprons must be worn whilst handling normal/ used linen. 4.4. Hands must be washed after disposing of linen and after removing apron. 5. Fouled/Infection Linen 5.1. This is linen that has either been contaminated by blood or any other body fluids or linen from suspected or known infectious patients. If unsure, please seek advice from Infection Control. 5.2. Fouled/ infected linen must be placed in a water soluble bag, tied and placed in a white linen skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A). 5.3. Supplies of both water soluble bags and white skip bags will be available in all areas where linen is used. Further supplies may be obtained from the Linen Room, Sodexo Zone Coordinator or Community Hotel Services Coordinator. 5.4. Plastic aprons and gloves must be worn whilst handling fouled/ infected linen. 5.5. Hands must be washed after disposing of linen and after removing aprons and gloves. G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 7 of 20

6. Theatre Linen 6.1. Theatre drapes and gowns must be placed in a green skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A). 6.2. Pillowcases, sheets, blankets and scrub suits must be placed in white skip bags and secured. The bag must not be more than 2/3rds full, (please see appendix A). 6.3. Fouled/ infected pillowcases, sheets, blankets and scrub suits must be placed in a water soluble bag, tied and placed in a white linen skip and secured. The bag must not be filled to more than 2/3 full, (please see appendix A). 6.4. Canvasses are to be placed in white skip bags, but if they are fouled/ infected, they must be placed in a water soluble bag first then placed in a white skip bag. The bag must not be more than 2/3rds full. 6.5. Supplies of water soluble, green and white skip bags will be available in all Theatres. Further supplies can be obtained from the Linen Room, Sodexo Zone Coordinator or Community Hotel Services Coordinator 6.6. Plastic aprons and gloves must be worn whilst handling Theatre linen. 6.7. Hands must be washed after disposing of linen and after removing gloves and aprons. 7. Patient s Personal Clothing 7.1. The Trust offers a limited personal clothing service to those patients who do not have relatives, friends or carers to do their laundry for them. All staff responsible for admitting patients must emphasise this, including to patients from residential homes. 7.2. Patients personal clothing will not be sluiced or washed and dried at ward level. Nursing staff must remove large amounts of organic matter with a gloved hand. Once the organic matter has been removed, the item(s) must be secured in a water soluble bag and placed in a red bag and secured. (Red bags can be purchased via the web basket using code MVK037) 7.3. Staff must ensure that patient s personal clothing is not placed in the same skip bags as the flat linen. All patients personal clothing that the Trust agrees to launder is dealt with according to the principles set out in this section. 7.4. Items of clothing for hospital laundry must be checked by ward staff for suitability. Dry clean only or delicate garments must not be sent for laundering. 7.5. Where clothing is identified for laundering, these items must be labelled prior to laundering in the North that are being sent to Bideford Hospital. G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 8 of 20

7.6. Staff in the North should liaise with the Sewing Room at Bideford Hospital regarding all items that require labelling on patient admission and must be clean. Any items that are laundered prior to labelling are at risk of: (a) being lost; (b) delaying the laundry service provision. 7.7. Patients personal clothing to be laundered by the Trust at Bideford Hospital in the North or East sites who use a local laundrette Bubble-it or have local arrangements in place, must be placed in a red skip bag and secured. Fouled items should be placed in a water soluble bag in the first instance, tied and then placed in a red bag and secured. 7.8. Where relatives/ friends or carers are laundering soiled items of patient clothing, the items should be placed in a water soluble bag, tied and placed into another bag. It is very important that relatives are advised that the water soluble bag and clothing should be placed in the washing machine intact. 7.9. Staff must check there are no personal items, e.g. glasses or watches, left in pockets prior to these items being sent for laundering. 7.10. The bags should never be filled to more than 2/3 full. 7.11. Staff should ensure that patients personal clothing are not placed in the same skip bag as the flat linen. All patients personal clothing processed by the Healthcare service in the North are to be laundered at Bideford Hospital and in the East via the local laundrette. 7.12. Supplies of water soluble bags will be available in all appropriate areas. Further supplies can be obtained from the Linen Room, Zone Coordinators or Community Hotel Services Coordinator. Each ward is responsible for purchasing the red bags via procurement. 7.13. Aprons must be worn whilst handling normal/ used patients clothing and apron and gloves must be worn whilst handling fouled/ infected patients clothing. 7.14. Any items received that are unsuitable for machine washing should be returned immediately to the ward from which they were received. 7.15. Hands must be washed after disposing of patients clothing and after removing aprons and gloves. 7.16. Regarding Losses and Compensations, the Trust will take all due care and attention to ensure patients personal clothing is returned in a similar condition as it was received. G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 9 of 20

8. Return to Sender (RTS) 8.1. All RTS items are owned by the Trust and are not part of the general linen hire pool. Therefore, failure to identify these items before use may result in a delay or possible loss of items to your ward or department. 8.2. All Trust owned items to be sent to the external contractor for laundering in the first instance must be labelled prior to use. 8.3. Normal/ used items, except curtains, will be placed in a blue skip bag and secured. The bag must not be more than 2/3 full, (please see appendix A). 8.4. Fouled/ infected items will be placed in a water soluble bag, tied and placed inside a blue linen skip bag and secured. The bag should not be filled to more than 2/3 full. 8.5. Complete a Berendsen docket detailing information of items in the bag together with the amount (please see appendix B), retain 1 copy, 1 inside the bag and place the other docket inside the document wallet. Remove all of the backing from the document wallet and stick to bag. The bag must not be more than 2/3 full. 8.6. Curtains, normal/ used must be placed in a brown linen skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A) 8.7. Curtains that are fouled/ infected must be placed in a water soluble bag, tied and placed inside a brown linen skip bag and secured. The bag should not be more than 2/3 full. 8.8. A docket must also be completed for curtains as detailed above. 9. Rejected Linen 9.1. Linen that is not suitable for patient use, i.e. damaged, torn or stained, must be placed in pink skip bags and secured, (please see appendix A). 9.2. Supplies of pink skip bags will be available in all areas where linen is used. Further supplies may be obtained from the Linen Room, Sodexo Zone Coordinator or the Community Hotel Services Coordinator. 10. Uniforms 10.1. Staff uniforms to be sent to the external contractor for laundering must be labelled in the first instance. Any unmarked/ poorly marked uniforms are unlikely to be returned by the laundry contractor and could be lost; staff are responsible for ensuring their uniforms are labelled before they send to the contractor to be laundered (Berendsen Laundry). 10.2. Normal/ used uniforms must be placed in a blue skip bag and secured. The bag must not be filled to more than 2/3 full, (please see appendix A). G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 10 of 20

10.3. Fouled/ infected uniforms will be placed in a water soluble bag, tied and placed inside a blue linen skip bag and secured. The bag should not be filled to more than 2/3 full. 10.4. Complete a docket (as above) detailing information of items in bag together with the amount, retain 1 copy, 1 inside the bag and the other docket inside the document wallet. Remove all of the backing from the document wallet and stick to the bag. The bag must not be filled to more than 2/3 full, (please see appendix B). 10.5. Users of scrub suits provided by Berendsen Laundry follow steps 5 and 6 10.6. Uniforms other than scrub suits provided by Berendsen Laundry which have been visibly contaminated with any amount of blood or other body fluids must be changed immediately. Procedure for fouled/ infected uniforms (above) must be followed. 10.7. It is not mandatory for staff uniforms, except Berendsen Laundry s scrub suits, to be sent routinely to the external laundry contractor. For the majority of wards/ departments, it is acceptable for uniforms to be washed by staff at home. Exceptions to this include any uniform contaminated with any visible amount of blood or other body fluids. Home Laundering of Uniforms 10.8. It is recommended that uniforms are washed at 60 o C for 10 minutes or at the hottest temperature recommended for the fabric. 10.9. After washing, uniforms may be dried and ironed as normal. 11. Domestic Equipment 11.1. Hotel Services are responsible for bagging cloths and mops. 11.2. Used mop heads must be placed into net bags if microfibre, while normal mop heads are to be placed in clear plastic bags, tied and laundered on site. 11.3. Used microfibre cloths will be placed into net bags, tied and laundered on site. These must be laundered separately to mop heads. 11.4. Manufacturers laundering requirements must be followed. 11.5. The same applies to the Trust Community Hospitals but the net bag must be placed into the colour coded skip bag for your hospital and secured. 11.6. Tyrrell Hospital and Gables mops, cloths are sent to North Devon District Hospital Laundrette. All other North Community Hospitals send mops, cloths to Bideford Hospital. East Community Hospital mops are laundered at each locality with the exception of Crediton and Moretonhampstead who send their mops to Okehampton to be laundered. G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 11 of 20

12. Linen Use 12.1. The following section provides guidance for staff and indicates when linen should be sent for washing. Sheets/Pillows/Blankets 12.2. The above items must be changed when: A new patient is placed in a bed The linen is soiled/ wet Every day, i.e. the used top sheet is transferred to the mattress, on the following day the mattress sheet will be bagged (as per appendix A), therefore no sheet will be used for more than 2 days. Towels 12.3. The above item must be changed: Daily if used If soiled/ wet Patient Gowns 12.4. The above item must be changed: After each patient If soiled/ wet Slide Sheets 12.5. The above item must be changed: Between new patients When soiled/ wet Patient Hoist Slings 12.6. The above item must be changed: Between patient use When soiled/ wet Canvasses 12.7. The above item must be changed: After each patient G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 12 of 20

Scrub Suits 12.8. The above item must be changed: Daily When soiled/ wet Failure of Normal Service 12.9. Please refer to appendix C for contingency plans for: Failure of Berendsen Facility Adverse Weather Major Incident 13. Monitoring Compliance with and the Effectiveness of the Policy Standards/ Key Performance Indicators 13.1. Key performance indicators comprise: 100% target compliance in all areas with Berendsen audit, bags audited on a daily basis 100 % target compliance in all areas with staff complying with policy Process for Implementation and Monitoring Compliance and Effectiveness 13.2. Monitoring compliance with this policy will be the responsibility of the Manager. This will be carried out by regular audits by the Sodexo Zone Co-ordinator and Co-ordinator and Community Hotel Services Co-ordinators. 14. Equality Impact Assessment Table 1: Equality impact Assessment Group Age Disability Gender Gender Reassignment Human Rights (rights to privacy, dignity, liberty and non-degrading treatment), marriage and civil partnership Pregnancy Maternity and Positive Impact Negative Impact No Impact Comment G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 13 of 20

Breastfeeding Race (ethnic origin) Religion (or belief) Sexual Orientation 15. References Department of Health (2007) Uniforms and Work-wear, an Evidence Base for Developing Local Policy G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 14 of 20

V5.1 Appendix A NORTHERN DEVON HEALTHCARE TRUST LAUNDRY BAGGING POLICY Berendsen Laundry Soiled Linen Infected Soiled Linen Theatres Rejected Linen Return to Sender Return to Sender - Curtains Sheets/blankets/ Pillowcases etc (i.e flat linen) Fouled infected linen i.e scrubs, blankets, towels, sheets etc. Theatre Drapes & Gowns only. For torn, damaged & stained. NOT FOR SOILED LINEN. Yellow slide sheets, uniforms, white coats etc (hospital owned). Curtains only White Bag Inner Water Soluble Bag Outer White Bag Patients Personal Clothing / SCBU Baby Clothes For patients who do not have relatives, friends or carers who are able to launder their clothing. Green Bag Pink Bag Blue Bag (use inner water soluble if fouled / infected) Bideford Laundry (Northern sites only) Theatre / ICU Slide Sheets (not yellow) Hospital owned Theatre Slide Sheets only. Fire Evacuation Ski Sheets (red) Red Ski Sheets only. Brown Bag (use inner water soluble if fouled /infected) Blue / White Shower Curtains Blue / White shower curtains. Red Plastic Bag (Acute) Fabric Bags (North Community) USE WATER SOLUBLE INNER FOR INFECTED LINEN (label for Bideford Hospital & where it has come from/ needs returning) Red Plastic Bag (Acute) Fabric Bags (North Community) USE WATER SOLUBLE INNER FOR INFECTED LINEN (label for Bideford Hospital & where it has come from/ needs returning) Red Plastic Bag (Acute) Fabric Bags (North Community) USE WATER SOLUBLE INNER FOR INFECTED LINEN (label for Bideford Hospital & where it has come from/ needs returning) Red Plastic Bag (Acute) Fabric Bags (North Community) USE WATER SOLUBLE INNER FOR INFECTED LINEN (label for Bideford Hospital & where it has come from/ needs returning) G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx Page 15 of 20

V5.1 Appendix B Return to Sender Docket Procedure Please ensure the documentation provided is completed correctly 1. Place soiled item into BLUE plastic bag. 2. Infected heavily soiled items should be placed into a Water Soluble Bag prior to placing in Blue Bag. 3. Complete a Personal Laundry Parcel Service Docket as shown above. Failure to complete a docket will result in the item being lost or delayed in return. 4. White and blue copy of completed docket to be placed inside document wallet and stuck to Blue Bag. 5. Pink docket to be retained by person completing docket until item is returned from laundry. G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx

V5.1 Appendix C - South West Laundry Consortium Contingency Plans The following four scenarios have been identified as potential failures in the laundry service. The plans have been devised in partnership between members of The Laundry Consortium and Berendsen. Four potential scenarios are considered below, for easy reference a summary of contact numbers follows at the end. 1. FAILURE AT FACILITY 2. ADVERSE WEATHER 3. MAJOR INCIDENT 4. PANDEMIC FLU SCENARIOS 1. FAILURE AT BERENDSEN FACILITY. This relates to the potential risk of a key Berendsen facility being lost due to fire or failure of essential utilities. Berendsen Actions: Bonded stock available to continue supplies within 12 hours Use of other group laundry facilities, increase shifts, use of agency staff Consider deployment of staff to operational facilities If necessary consider purchasing additional stocks from Sunlight supplies If necessary, the Berendsen Commercial Division could be called to provide additional linen. Trust Actions: Nominated Trust linen reps to liaise to establish any immediate / foreseeable shortfalls. This may require an extra ordinary consortium meeting. If necessary, Trusts should consider sourcing disposable linen. Contact details: NHS Supply Chain: Normal working hours tel: 01773 724061 Out of hours tel: 01773 724000 Quote your hospital requisition point 32 NHS Supply Chain emergency response is 4 hours for a medical emergency NB. Trusts should consider: o o o the method of disposing of disposable linen i.e. clinical waste the collection of linen / segregation storage space Linen managers should notify their customers of the situation. Customers should be diligent in the use of all linen. If problems continue with supply, consider additional service from alternative suppliers: o RD&E Tel: 01392 411611 G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx

V5.1 o Synergy Tel: 01332 387100 2. ADVERSE WEATHER This relates to the risk of severe weather interrupting Berendsen transportation arrangements. Berendsen Actions: Consider alternative routes to hospital Depending on severity, liaise with emergency services to aid distribution Consider use of alternative plants if adverse weather is localised Trust Actions: The Trust may need to consider liaison with Local Authority Emergency Planning Teams for additional blankets and sheets The Trust may wish to consider (if necessary) the use of Trust owned washing machines to launder some items. Manage stocks carefully (approx 2 days stock at Trust), Trusts should check this buffer stock. Liaise with Berendsen with regard to stock levels. NB. Linen usage will reduce at Trusts if patients are unable to attend hospital. Customers should be diligent in the use of linen. 3. MAJOR INCIDENT This plan relates to a scenario whereby any one Trust is affected by a major incident with multiple casualties i.e. a major incident is declared. Berendsen Actions: On notification of major incident at any Trust, Berendsen, in consideration with individual Trusts, shall mobilise additional stocks. This could be via: o Other Berendsen o Bonded stock Dependent upon urgency, Berendsen should consider police assistance for transportation Trust Actions: Emergency contacts and telephone numbers for Berendsen are as follows: o Tel: C.R.M. - 07967623498 o Tel: Contract Director - 07734539078 o Tel: Newton Abbot G.M. 07825848271 Notify Berendsen of major incident and request additional laundry Consider requesting additional items from neighbouring Trusts 4. PANDEMIC FLU Once an outbreak has been confirmed at any single Trust or group of Trusts the following actions should be considered:- Berendsen Actions: Prepare to provide additional water soluble and red bags for affected Trusts If Berendsen have staff shortages they should consider: G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx

V5.1 1. Increase working hours of fit staff 2. Use of agency staff 3. Use of alternative facilities including commercial and work wear facilities if required. 4. Usage of bonded stock 5. Reduce movement of staff between facilities All staff in contact with infected linen should wear PPE as normal. Trust Actions: In the event of a confirmed outbreak the Trust s authorised Officer shall in liaison with Infection Control consider the following: o notify Berendsen C.R.M. (of the situation at the earliest possible opportunity. o Trusts may consider requesting additional water-soluble bags and red bags. o assume all linen from flu cohort areas is potentially infected and is bagged in line with Trust bagging policy (Appendix A o consider use of additional rental Curtains from Berendsen, if needed. Tel: C.R.M. 07967623498 o consider use of disposable curtains, if needed, via Sunlight Lisa Thomas at Rochialle 01443471300, Marshall Contracts 01217835777 or NHS Supply Chain 01773 724061 (contact your procurement department in the first instance) In the event of laundry shortages review linen usage and the following shall be considered: o o o o o Frequency of bed sheet changes Encourage patient to use own personal washing items and night wear Review stock levels at all sites and distribute essential linen to meet needs Review adequacy of dirty linen store areas Any changes to practice i.e. a requirement to go over to scrub suits it is up to the local Trust to advise Sunlight in advance due to the implications on linen/scrub stocks Summary of Contact Numbers Service Company Telephone Number Laundry (normal working hours) Berendsen Newton Abbott 01626 882992 Rental Curtains Berendsen C.R.M. 07967 623498 Linen Emergency Berendsen C.R.M. 07967623498 Alternative Linen Supplier Royal Devon & Exeter NHS Trust Contract Director 07734539078 Newton Abbot G.M. 07825848271 01392 411611 Synergy 01332 387100 G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx

V5.1 Disposable Linen NHS Supply Chain Normal hours 01773 724061 Disposable curtains Berendsen (Rochialle) Out of hours 01773 724000 01443 471300 Marshal Contracts 0121 7835777 G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\\Laundry Policy\Laundry Policy V5.1 10.06.16.docx