Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Laundry Policy NTW(O)15 James Duncan Deputy Chief Executive / Executive Director of Finance Martin Laing Facilities Manager Business Delivery Group Date ratified August 2016 Implementation Date August 2016 Date of full implementation December 2016 Review Date August 2019 Version number V03.1 Review and Amendment Log Version Type of change Date Description of change V03 Review August 16 Review Policy Documentation and addition of Appendix 2 V03.1 Update Sep 17 Update due to clinical transition This Policy supersedes the following documents which must now be destroyed: Reference Number Title NTW(O)15 V03 Laundry Policy
Laundry Policy Section Contents Page No. 1 Introduction 1 2 Purpose 2 3 Duties, Accountability and Responsbilities 2 4 Definitions of Terms Used 3 5 Assessment of Laundry and Business Risks 4 6 Central Laundry Arrangements 4 7 Linen Audits 5 8 Identification of Stakeholders 5 9 Training 6 10 Equality Impact Assessment 6 11 Implementation 6 12 Monitoring compliance and Effectiveness 7 13 Standards / Key Performance Indicators 7 14 Fair Blame 7 15 Fraud, Bribery and Corruption 7 16 Associated Documentation 7 17 References 7 Standard Appendices attached to Policy A Equality Analysis Screening Toolkit 9 B Training Check List and Training Needs Analysis 11 C Monitoring Tool 13 D Policy Notification Record Sheet - click here
Appendices listed separate to the Policy Appendix No: Description Issue No: Issue Date Review Date 1a Curtain Washing Procedure 1 May 16 May 19 1b Curtain Washing Form 1 May 16 May 19 2 Cleaning Frequencies for Washing Curtains 1 May 16 May 19 See also NTW(C)23 Infection, Prevention and Control Policy, Practice Guidance Note IPC-PGN-12 - Used Laundry
1 Introduction 1.1 The provision of good laundry services is a fundamental requirement of direct patient care. Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/NTW) has a legal responsibility to provide safe and adequate Laundry Services for its patients and service users. The Department of Health Guideline Hospital Laundry Arrangements for Used and Infected Linen HSG(95)18, sets out the recommended procedures to ensure this commitment as does the Health Technical Memorandum 01-04: Decontamination of linen for health and social care: Management and provision (March, 2016). These cover the safe handling and laundering of linen, the importance of securing the disinfection of used and infected linen and basic principles of infection control within the laundry system. 1.1.1 The Laundry Policy reflects the guidelines within HSG(95)18, and aims to promote practices which will reduce the risk of infection to staff handling and laundering linen and prevent damage to equipment/linen. There is also a need to ensure the protection of staff, and damage to equipment/ linen, from the failure to separate sharps from linen before placing into laundry bags. 1.1.2 The Policy reflects standards and guidance within the Best Practice Guide for Linen Services document. Advice on home laundering of uniforms is gained from the Department of Health document Uniform and Workwear an evidence base for developing local policy and in the Trust s Uniform and Dress Code Policy - NTW(O)48. 1.3 Pool linen will be purchased in line with HTM Fire Code 05-03 Part C Textiles Recommendations. Individual wards purchasing linen items can contact the Fire Officer or Linen Services for advice. For patients wanting to purchase their own bedding an individual Risk Assessment will need to be carried out and the above guidelines followed. All Trust Policies must be complied with. 1.4 The Trust wholly accepts its legal duty to follow guidance HSG(95)18 and legislation. All suppliers of linen and chemicals for Laundry Services must comply with this legislation. 1.5 Trust staff are required to follow this Policy and all procedures laid down by the management. 1.6 This document should be read in conjunction with Trust Policy, NTW(C)23, Practice Guidance Note - IPC PGN-12 Management of used Hospital Laundry. 1.7 Provision of Laundry Services 1.7.1 The Trust operates its in-house laundry at Northgate Hospital site for the provision of the Trust s main sites linen and patient s clothing. Community areas and wards will have onsite washing machines for local laundry needs. Procedures for community areas and wards must be of a similar level and follow the same legal requirements as the main Laundry Department. 1
2 Purpose 2.1 The purpose of this Policy is to set Trust-wide standards ensuring full compliance with laundry industry guidance and codes of practice. Setting out to make staff fully aware of their roles including levels of competency required. 3 Duties, Accountability and Responsibilities 3.1 Facilities Organisation Director of Estates and Facilities Head of Estates and Facilities Facilities Manager (North) Facilities Manager (South) Laundry Services Manager Service Supervisors Service Supervisors Key Indicates Managerial Responsibility Indicates Professional and Technical Responsibility 3.2 Final accountability for all aspects of Laundry Services lie with the Chief Executive and the Board of Directors, the designated Board Member is the Executive Director of Finance. They have responsibility for ensuring the contents of this Policy are adhered to by all appropriate staff. 3.3 Responsibilities of the Facilities Managers 3.3.1 Has responsibility for the implementation, control, monitoring and review of this Policy. 3.3.2 To make available sufficient suitable resources to ensure that the Policy can be implemented and operated within the Trust. 3.3.3 To ensure that the Policy and workplace standards are monitored. 3.3.4 To ensure robust Service Level Agreements (SLAs) are in place with other purchasers of service and suppliers. 2
3.3.5 Will ensure a competent person monitors and maintains records within the Laundry Department. 3.3.6 Will ensure that all staff have suitable laundry qualifications/training appropriate to the department. 3.3.7 The Manager will ensure that recommendations from visiting enforcement officers are acted upon. 3.4 Responsibility of Linen Services Manager 3.4.1 Day-to-day responsibility for all laundry safety. 3.4.2 Ensuring all laundry is processed in a safe and hygienic manner, preventing contamination as far as possible. 3.4.3 Ensuring staff follow factory rules and procedures. 3.4.4 Ensure all work areas are kept clean and report any infestation to Departmental Manager. 3.4.5 Maintain daily records of laundry distribution. 3.4.6 Keep up-to-date with relevant laundry legislations. 4 Definitions of Terms Used Linen All articles requiring laundering process Soiled linen used linen other than foul or infected which remains dry from a non-infected patient Fouled linen and Infected linen used linen which is contaminated with blood, body fluids and/or remains wet, or linen used, by patients known or suspected to be suffering from a notifiable disease, MRSA or ACDP Hazard Group 3 pathogens 4.1 Examples of infected linen would include: Infective diarrhoea Salmonella, Shigella, Campylobacter, E. coli O157, C. difficile, Rotavirus Blood borne or Hepatitis viruses HIV, Hepatitis A,B,C,D,E,G Mycobacteria M. Tuberculosis Transmissible Spongiform Encephalopathies Creutzfeld Jakob Disease 3
5 Assessment of Laundry and Business Risks 5.1 Risk Assessments will be carried out annually by Facilities Managers for central laundry functions and Ward Managers for clinical areas. 6 Central Laundry Arrangements 6.1 Laundry equipment, materials and linen, will be purchased from NHS approved suppliers. 6.2 Handling and Segregation Categories for Processing 6.2.1 Soiled Linen 6.2.2 Foul Linen 6.2.3 Infected Linen 6.2.4 Infested Linen 6.2.5 Curtains Place this linen in a WHITE outer laundry bag. Bags must be secured using either buckles or press studs on linen bag before leaving in storage area for collection by Portering Staff. (Care must be taken to ensure only linen is placed in these bags) Place this linen in an inner soluble seam bag (obtained from NHS logistics) and RED outer laundry bag and secure Place this linen in an inner soluble seam bag (obtained from NHS logistics) and RED outer laundry bag and secure. Complete identification linen tags to identify ward of origin (available from Laundry) Treat as infected linen The Trust follows recommendations set out in The National specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes April 2007. Appendix 2 of this document states the cleaning frequencies of curtains depending on the category of risk. There are 4 categories: Very high risk, High risk, Significant risk and Low risk. It is up to the ward to discuss with their IPC Modern Matron to determine which category their area comes under If curtains are sent to be laundered it is the ward s responsibility to ensure the dignity and privacy of patients is still maintained. Spare curtains need to be available and may need to be purchased to adhere to this 4
6.2.6 Net Bags 6.2.7 Uniforms For the processing of high value curtains contact the laundry and complete relevant Curtain Documentation Form (refer to Appendix 1a and 1b of this Policy). The form and guidance are also available on the Trust s Intranet These are available for items such as socks, underwear and mops, which require a return to sender service Place in a separate white bag and seal. Record in book obtained from laundry. The laundry will process staff uniforms after agreement has been made with each individual Department Managers 6.2.8 Patients Clothing Wards must ensure all clothing is marked at St George s Park before laundering. The clothing that is sent for marking must be clean, dirty clothing will not be accepted. Purchases of textiles which can withstand industrial processes are recommended (avoiding 100% woollens, for example) 6.3 Care must be taken to ensure extravenous items such as sharps are not placed in laundry bags. 6.4 When considering the purchase of new textile items for wards ensure samples are obtained and sent to the Laundry for test laundering. 7 Linen Audits 7.1 These must be carried out twice per year in order to establish adequate stock levels. 8 Identification of Stakeholders 8.1 This is an existing Policy with additional/changed content that relates to operational and/or clinical practice and was therefore circulated to the following for a two week consultation period to the following: North Locality Care Group Central Locality Care Group South Locality Care Group Corporate Decision Team Business Delivery Group Safer Care Group Communications, Finance, IM&T 5
Commissioning and Quality Assurance Workforce and Organisational Development NTW Solutions Local Negotiating Committee Medical Directorate Staff Side Internal Audit 9 Training 9.1 All Facilities and Ward Managers are responsible for ensuring staff adhere to this Policy and local training, if required, is carried out and recorded. Please see Appendix B. 10 Equality Impact Assessment 10.1 In conjunction with the Trust s Equality and Diversity Lead this Policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. Please see Appendix A. 11 Implementation 11.1 Taking into consideration all the implications associated with this Policy, it is considered that a target date of December, 2016 is achievable for the contents to be fully implemented within the organisation. 11.2 This will be monitored by the Quality and Performance Committee during the review process. If at any stage there is an indication that the target date cannot be met, then the Quality and Performance Committee will consider the implementation of an action plan. 12 Monitoring Compliance Review Reports/Audit Records from Chemical Suppliers Review Customer Satisfaction Surveys Review Infection Control Audits Review PLACE Audits 6
13 Standards/Key Performance Indicators 13.1 The standards outlined in this Policy reflect what is required to comply with current legislation and best practice. Should these change, this Policy will be reviewed and appropriate amendments will take place. 14 Fair Blame 14.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken. 15 Fraud, Bribery and Corruption 15.1 Under no circumstances must any form of linen be disposed of inappropriately or sold to non-ntw approved organisations / companies. This includes heavily stained or badly damaged linen etc. Any disposal must be arranged by an authorised officer. Advice can be sought from the Laundry Department. 16 Associated Documentation NTW(0)01 - Development and Management of Procedural Documents NTW(C)23 Infection, Prevention and Control Policy IP-PGN 4.1 Hand Hygiene and the use of Alcohol Rub NTW(C)23 Infection, Prevention and Control Policy IPC PGN 12 - Management of Used Hospital Laundry NTW(O)48 - Uniform and Dress Code Policy 17 REFERENCES Best Practice Guide for Linen Services 2008 HSG 95 18 Hospital Laundry Arrangements for Used and Infected Linen Uniforms and Workwear an evidence base for developing local policy The Management of Used Hospital Laundry Fire Code HTM 05-03 Part C Textiles and Soft Furnishings Health Technical Memorandum 01-04: Decontamination of linen for health and social care: Management and provision (March, 2016) 7
The National specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes April 2007 8
Appendix A Equality Analysis Screening Toolkit Names of Individuals Date of Initial Review Date Service Area / Locality involved in Review Screening Christopher Rowlands July 2016 July 2019 Trust-wide Policy to be analysed NTW(O)15 Laundry Policy Is this policy new or existing? Existing What are the intended outcomes of this work? Include outline of objectives and function aims The provision of adequate Laundry Services is a fundamental requirement of direct patient care. has a legal responsibility to provide safe and adequate laundry services for its patients and service users. The Department of Health guideline Hospital Laundry Arrangements for Used and Infected Linen HSG(95)18, sets out the recommended procedures to ensure this commitment. It covers the safe handling and laundering of linen, the importance of securing the disinfection of used and infected linen and basic principles of infection control within the laundry system. To ensure appropriate segregation of laundry items as per this policy ward managers should be aware of any staff on their wards who may be colour blind. In these circumstances a risk assessment should be carried out and appropriate precautions taken to avoid any control of infection and safety issues for ward staff, porters and laundry staff who all handle / process laundry items. Who will be affected? e.g. staff, service users, carers, wider public etc. Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them Disability Sex Race Age Gender reassignment (including transgender) Sexual orientation. 9
Religion or belief Marriage and Civil Partnership Pregnancy and maternity Carers Other identified groups How have you engaged stakeholders in gathering evidence or testing the evidence available? Through standard Policy Process Procedures How have you engaged stakeholders in testing the policy or programme proposals? Through standard Policy Process Procedures For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: Through standard Policy Process Procedures Summary of Analysis No impact Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic Eliminate discrimination, harassment and victimisation Advance equality of opportunity Promote good relations between groups What is the overall impact? Addressing the impact on equalities From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? NO If yes, has a Full Impact Assessment been recommended? If not, why not? Manager s signature: Christopher Rowlands Date: July, 2016 10
Appendix B Communication and Training Check list for policies Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc. Please identify the risks if training does not occur. Change to existing Policy Awareness Training for nursing staff and managers Operational instructions for Laundry and Facilities staff Legislation listed in paragraph 2 See training needs analysis Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session, E Learning Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. See training needs analysis Ward Based Staff Laundry Staff Basic areas of policy bagging L & S training Management level training by laundry management for laundry staff Local induction Team brief cascade for general awareness Training courses E-learning training Martin Laing - Facilities Manager Ken Tait Laundry Manager 11
Appendix B continued Training Needs Analysis Staff/Professional Group Type of training Duration of Training Frequency of Training Laundry Department Staff Refresher training as required One hour As required Laundry Department Managers / Supervisors Refresher training as required One hour As required Trust wide Staff who handle laundry Awareness to be determined locally depending on role To be determined locally As required, e.g. change in guidance or risk assessment review Copy of completed form to be sent to: Training and Development Department, St. Nicholas Hospital Should any advice be required, please contact:- 0191 245 6777 (internal 56777) 12
Monitoring Tool Appendix C Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, Policy Authors are required to include how monitoring of this Policy is linked to Auditable Standards / Key Performance Indicators will be undertaken using this framework. NTW(O)15 Laundry Policy - Monitoring Framework Auditable Standard / Key Performance Indicators Frequency / Method / Person Responsible Where Results and Any Associate Action Plan Will Be Reported To and Monitored; (this will usually be via the relevant Governance Group). 1. Review training records of Laundry Staff and ward-based staff to ensure received appropriate training 2. Review chemical supplier reports Annually, checking personal records and the Dashboard. Carried out by the Laundry Manager Annually from reports received. Carried out by the Laundry Manager Safer Care Group Safer Care Group 3. Review PLACE documentation Once a year after annual audits have been completed. Carried out by the Laundry Manager Exceptions to the Facilities Management Group The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out. 13