CORPORATE CLEANING STANDARDS POLICY by 8DW4wo6

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									                           CORPORATE CLEANING STANDARDS POLICY

          POLICY NO                      SA16
          RATIFYING COMMITTEE            Corporate Document Review Group
          DATE RATIFIED                  19th June 2012
          NEXT REVIEW DATE               June 2013

POLICY STATEMENT:

The purpose of this Policy is to provide procedures that will ensure that the environment that all Service
Users’, Carers, Staff and visitors use is cleaned to a high standard, in accordance with NHS National
Standards and guidelines.

The Trust believes that all it’s premises should be cleaned and maintained to the highest possible
standard, not because the patients and public expect it, but because patients have the right to be cared
for in an environment that achieves the highest standard of cleanliness which determines a visible sign
of overall quality of care provided, minimises the risk of infection and ensures compliance with legislation
and standards.

ACCOUNTABLE
DIRECTOR:                     Director Facilities


POLICY AUTHOR:                Facilities Manager/PEAT Lead



                                           KEY POLICY ISSUES

       Duties
       Legislation and Guidance
       Decontamination of Equipment
       Operational Delivery
       Cleaning Equipment
       Cleaning Responsibility Framework
       Cleaning Schedules and Frequencies
       Housekeeping Cleaning/ Nursing Cleaning Duties




   This Policy and Procedure can be made available in a range of languages and formats on request.




Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                                             Contents


1.    Executive Summary

2.    Introduction
2.1   Rationale
2.2   Scope of Policy
2.3   Principles

3.    Policy
3.1   Duties
3.2   Legislation and Guidance

4.    Strategic Cleaning Plan

5.    Decontamination of the Environment
5.1   Operational Delivery
5.2   Cleaning Equipment

6.    Audit

7.    Other Trust Policies

8.    Development and Consultation

9.    Human Rights and Equality

10.   References/Bibliography

11.   Glossary of Terms

12.   Appendices

                  1.    Impact Assessment
                  2.    Specimen Cleaning Schedule
                  3.    Decontamination of Equipment and Medical Devices
                  4.    Policy Implementation




Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
1. Executive Summary:

        The Trust believes that all their managed premises should be cleaned and maintained to
        the highest possible standard. The Trust also believes that it is the right of every service
        user to be cared for in an environment that achieves these standards of cleanliness
        which determines a visible sign of overall quality of care being provided minimises the
        risk of infection and ensures compliance with legislation.

        The policy aims to provide detailed procedures and guidelines to ensure that all
        standards are adhered to.

        The policy applies to all clinical and non clinical staff, including permanent, seconded and
        temporary staff and those undergoing training and work experience.

        The policy applies to those premises that are managed by Mersey Care NHS Trust.

        This procedure should be read in conjunction with the following documents

               Care Quality Commission 2008: Essential Standards for Quality and Safety.

               DH, 2004, Towards Cleaner Hospitals and Lower Rates of Infection, A
               summary for Action.

               DH, 2006, Infection Control Guidance for Care Homes.

               DH, 2010 The Health and Social Care Act 2008; Code of Practice for health
               and adult social care on the prevention and control of infections and related
               guidance.

               HSC, 1974, Health and Safety at Work Act 1974.

               NHS, 2002, Infection Control in the Built Environment.

               NHS, 2004, Revised Guidance for Contract Cleaning.

               NHS, 2004, a Matrons Charter: An Action Plan for Cleaner Hospitals.




Version Control

   Version            Date            Author          Details       Ratifying body
   st
  1 Review          27 01 12         S Hulme        Passed to        Corporate
                                                     Infection       Document
                                                   Control Team     Review Group
  2nd Review        13 02 12         S Hulme


Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
2. Introduction

       Standards of cleanliness are often seen as a visible sign of overall quality of care provided. A key
       component of providing consistently high quality cleaning is evidence of a clear plan setting out
       all aspects of the Cleaning Services which define:

                 Clear specific roles and responsibilities for cleaning, portering and laundry
                 Clear agreed routines
                 Sufficient staff to keep the environment clean, and laundry and waste removed from the
                 clinical areas

       The responsibility for cleaning includes domestic/housekeeping services, nurses and healthcare
       workers, estates and maintenance staff and in some areas contractors and it is therefore
       essential that the Trust identifies who is responsible for cleaning each item or area.

       Working to the Care Quality Commission’s Regulations and Outcomes and the NHS National
       Specifications for Cleanliness and the Health and Social Care Act 2008, will ensure that patients
       are cared for in an environment where the premises, equipment, fixtures and fittings are kept
       clean to a standard that ensures that infection prevention and control risks are minimised, and
       that each part of the Trust has detailed arrangements which meet the cleanliness standards
       required for that area.

       The aims of this policy are to:

                 Inform and educate all healthcare workers of the public health function both in hospital
                 and community settings of the importance of standards of cleanliness and the early
                 detection and reporting of problems.

                 Explain the principles of prevention and control of infection, the purpose of cleaning and
                 decontamination, the importance of building design and purchase of fitments, furnishing
                 and flooring in cleanable materials.

2.1 Rationale

       The Trust believes that it’s premises should be cleaned and maintained to a high standard, not
       because the patients and public expect it, but because patients have a right to be cared for in an
       environment that achieves the standard of cleanliness which determines a visible sign of overall
       quality of care provided, minimises the risk of infection and ensures compliance with legislation
       and standards.

       Compliance with all legislation, required NHS standards and guidelines provides assurance to the
       Trust Board through monitoring and adherence with this Policy.

2.2 Scope of Policy

       This policy applies to all inpatient and outpatient areas. It relates to all permanent members of
       staff, Agency and additional staffing, volunteers, service users, their carers, visitors and all
       manner of contractors.

2.3 Principles

       The policy is devised from government legislation, local and national professional guidance.

       The Trust is determined to promote consistently high specifications for cleanliness which are
       embedded throughout the organisation.

       The Trust is committed to minimising the risk of cross infection and re-infection from contact with
       the environment. Furniture, fittings and floor coverings are chosen to facilitate ease of cleaning
       and decontamination to achieve the highest standards of cleanliness. There are defined roles
Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
       and responsibilities for cleanliness in the Trust and these are reflected through objectives and job
       descriptions from management through all levels of the service, and provide a culture for
       continuous improvement.

       The cleaning schedules and frequencies have been agreed by the Infection Prevention and
       Control Committee, meet the NHS Specifications for Cleanliness and guidance within the Health
       and Social Care Act 2008, Code of Practice on the prevention and control of infections and are
       available upon request.

       There are procedures for reporting accidental spillages, patients, visitors and staff are
       encouraged to use them.

3. Policy

       The Trust is committed to ensuring that all policies and procedures comply with the Human
       Rights principles of dignity, autonomy, respect, fairness and equality and as such this policy has
       been equality assessed to ensure compliance with these principles.

3.1 Duties
       Chief Executive
       The Chief Executive has a duty to provide and maintain a clean and appropriate environment for
       health care, the provision of a policy which is agreed by the Infection Prevention and Control
       Committee and for embedding cleanliness throughout the organisation. The Chief Executive has
       a duty to designate Lead Managers for cleaning and for decontamination of Medical Devices.

       Executive Director of High Secure Services and Nursing
       The Director of Infection Prevention and Control is responsible for ensuring that policies for
       maintaining a clean and appropriate environment to minimise Healthcare associated infection are
       fit for purpose and are compliant with current legislation and guidance.

       The Director of Infection Prevention and Control will ensure that any breaches of agreed
       standards, or inappropriate hygiene practices are challenged and where these may breach our
       compliance with the code of practice they should be brought to the attention of the Trust Board.

       Infection Prevention and Control Team
       The Infection Prevention and Control Team is responsible for policies related to The Prevention
       and Control of Infection and for ensuring they are compliant with national guidance
       and legislation.

       The Infection Prevention and Control Team have a duty to monitor standards of cleanliness by
       unannounced environmental hygiene audits at a minimum annually and report the outcomes to
       the Infection Prevention and Control Committee and in its annual report to the Trust Board.

       Local Services and Facilities Site Managers
       Local Services and Facilities Site Managers’ who are responsible for adhering to the standards of
       cleaning, have a duty to detail roles and responsibilities of service staff to ensure that the Trusts
       cleaning schedules and frequencies meet national guidance and local requirements. Schedules
       and frequencies of cleaning are agreed with and report compliance with standards to the
       Infection Prevention and Control Committee.

       Infection Prevention and Control Committee
       The Infection Control Committee has a duty to ensure that the schedules of cleaning and
       frequencies meet national and local requirements and monitor standards of cleanliness regularly.




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      Director Facilities
      Director Facilities involves directors of nursing, matrons and the Infection Prevention and Control
      team in all aspects of cleaning services from contract negotiation, service planning to delivery at
      ward level.

      Director Facilities has a duty to work with modern matrons to ensure that care is provided in
      environments that are suitable for purpose, maintained in good repair and kept clean.

      Director Facilities has a duty to ensure that design of new builds and refurbishments reflect
      Infection Prevention and Control advice and cleaning good practice.

      Estates Department
      The Estates department has a duty to provide the annual audit score through the Estates Returns
      and Information Collection process (ERIC).

      Clinical Business Unit Leads
      Clinical Business Unit Leads have a duty to include standards of hygiene in objectives of all
      managers and this is reflected through the line management.

      Clinical Business Unit Leads have a duty to ensure that areas of the Trust that they are
      responsible for reflect the Trusts policy of achieving the highest standards of cleanliness,
      minimise the risk of infection and ensure compliance.

      Modern Matrons
      The Modern Matrons have personal responsibility and accountability for delivering a safe clean
      care environment, which is suitable for purpose, kept clean and maintained in good physical
      repair and condition. They have a duty to establish a cleanliness culture across their units and
      work to the ten commitments of the Matrons Charter and an Action Plan for Cleaner Hospitals.

      The Nurse in charge of any patient area has direct responsibility for ensuring that cleanliness
      standards are maintained throughout that shift.

      Ward Managers and Clinical Managers
      The Ward Managers and Clinical Managers have a duty to ensure that the environment reflects
      the Trusts policy for cleanliness and minimising risk of infection and compliance, and
      immediately deal with any breaches of environmental hygiene in line with the cleaning schedule.

      Contracts Manager
      The Contracts Manager has a duty to ensure that Service Level Agreements and contracts meet
      the standards and frequencies of cleaning agreed by the Infection Prevention and Control
      committee and to monitor that these are being achieved.

      Procurement Manager
      The Procurement Manager has a duty to ensure that fitments, furnishings and flooring are agreed
      with Infection Prevention and Control and Facilities Services and can be cleaned and
      decontaminated easily.

      Complaints Manager
      The Complaints Manager has a duty to ensure that there is a process for patients and visitors to
      report breaches of hygiene and to monitor its success.

      Facilities Management - Domestic/Housekeeping Services
      The Domestic/Housekeeping Services have a duty to audit compliance with cleanliness with a
      technical audit tool, such as the ‘13 week review book’.

      All staff
      All Trust employees and contractors have a duty to comply with Trust policies on cleanliness and
      Infection Prevention and Control and ensure that this is embedded into everyday practice.

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      All Trust employees have a duty to complete Corporate Induction and Mandatory Training as
      required.

3.2 Legislation and Guidance:

      The Health and Social Care Act 2008: Code of Practice on the prevention and control of
      infections and related guidance

      This act requires that NHS Trusts declare their compliance against a set a criteria thus providing
      assurance that patients are cared for in a clean environment, where the risk of healthcare
      associated infections are kept as low as possible.

      Failure to comply with the criteria within the Health and Social Care Act may result in a range of
      sanctions being issued against the Trust by the Care Quality Commission, dependant on the
      extent and seriousness of any breach. Even where a breach of the regulations has not occurred
      the Care Quality Commission can make recommendations for improvement if they have concerns
      in specific areas.

      Health and Safety at Work Act 1974

      All employers have a legal obligation to ensure that all employees are appropriately trained in the
      procedures necessary for working safely.

      All employees have a legal duty to take care of themselves and others and to co operate with
      their employer and follow policies and guidelines so that they and others are not exposed to
      health and safety risks.

      Employers and Employees are accountable under this act to ensure that the workplace is free
      from hazards and it imposes specific obligations to ensure the microbiological safety of the Trust
      environment.

      NHS/ National Patient Safety Agency 2007; The National Specifications for Cleanliness in
      the NHS: A Framework for Setting and Measuring Performance Outcomes.

      This provides an assurance framework to support compliance to core standards of cleanliness
      within the Essential Standards of Quality and Safety (Outcome 8) and the Health and Social Care
      Act 2008, and is designed for the NHS Organisation whether services are provided in-house or
      should be written into contracts with service providers including Service Level Agreements.

      NHS 2007 Patient Environment Action Team Assessments and the National Specifications
      for Cleanliness.

      PEAT assessments will be calculated against these specifications.

      Care Quality Commission

      Care Quality Commission (CQC) Regulations and Outcomes include requirements in relation to
      cleanliness for which all Trusts must be able to demonstrate compliance.

      DH 2004; a Matrons’ Charter: An Action Plan for Cleaner Hospitals - 10 Commitments:

          1. Keeping the NHS clean is everybody’s responsibility.
          2. The patient environment will be well maintained, safe and clean.
          3. Matrons will establish a cleanliness culture across their units.
          4. Cleaning staff will be recognised for the important work they do. Matrons will make sure
             cleaning staff feel part of the Ward Team.
          5. Specific roles and responsibilities for cleaning will be clear.
          6. Cleaning routines will be clear, agreed and well publicised.
          7. Patients will have a part to play in monitoring and reporting on standards of cleanliness.
Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
          8. All staff working in healthcare will receive education in Infection Prevention and Control.
          9. Nurses and Infection Prevention and Control Teams will be involved in drawing up
              cleaning contracts and Matrons have the authority and power to withhold payment.
          10. Sufficient resources will be dedicated to keeping hospitals clean.

      NHS Estates- Infection Prevention and Control in the Built Environment

      If the burden of healthcare associated infection is to be reduced it is essential that architects,
      designers and builders be partners with healthcare staff and Infection Prevention and Control
      Teams when planning new facilities or renovating older buildings.

4. Strategic Cleaning Plan

      Introduction

      Good hospital care depends on getting the basics right and this includes ensuring that the
      hospital is clean. Patients / service users expect to receive care in clean, tidy and comfortable
      surroundings, and when they do not, they may lose confidence in the whole system.

      The cleaning of premises within the Trust is carried out by teams of cleaning staff who are
      managed by either the CBU, outside contractors or via SMS Facilities. These staffs play an
      important role in quality improvement, in the confidence the public has in hospitals and in
      reducing infection-related risks. This role is recognised and supported by management.

      This guidance sets out the Trust’s approach to maintaining and improving cleaning standards
      across all its hospital sites and premises in keeping with national specifications, government
      guidance and legislation.

       Board Level

      Whilst final accountability for all aspects of cleanliness lies with the Chief Executive and the Trust
      Board designated member, Executive Director of Service Development and Delivery who is
      responsible for the following;

             Keeping cleanliness high on the agenda.

             Ensuring year on year improvements in cleanliness.

             Reporting to the Trust Board.

             Ensuring proper systems and processes are in place to achieve high standards of
             cleanliness.

             Involve directors of nursing, matrons and the ICT in all aspects of cleaning services from
             contract negotiation and service planning to delivery at ward level.

             Ensuring that all parts of the premises in which the Trust provides healthcare are suitable
             for purpose, kept clean and maintained in good physical repair and condition.

       Patient/Service User involvement

      The patient / service user is central to all services we provide and the Trust is keen to work in
      partnership with service users and their representatives to ensure National Specifications of
      Cleanliness are achieved and maintained.

      The patient / service user or representative is involved in the following ways:



Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
             Their views are sought through patient / service user satisfaction surveys and feedback
             from these are reported back via patient / service user focus groups.

             Domestic/Housekeeping Services personnel attend patient / service user focus groups to
             ensure that patients / service users are satisfied with the service we provide.

             Patients / service users will be invited to attend PEAT visits. Where the nature of the
             patient / service user's illness does not allow for their involvement a representative will be
             sought for the visits for example PAL’s members, Advocacy or Carer representatives.

             Patient / service user’s comments on services will be monitored via formal and informal
             complaints and comments to PAL’s team.


      Staff awareness and understanding the Standards

      All cleaning staff, within 6 months of commencement, will have been trained and have an
      understanding of the cleaning manuals, so that they can ensure the delivery of these standards.

      Cleaning staff will also receive annual training from infection prevention and control.

      Cleaning services staff will be smart and professional, presenting themselves for work in a clean
      and tidy state and wearing the correct uniform.

      Staff will be kept updated on new developments as and when they arise, through local training
      sessions and team brief.

      Nursing staff are expected to keep up the cleaning standards when the designated
      domestic/housekeeping staffs are not on duty e.g. ‘out of hours’.

      Nurse in Charge

      Has direct responsibility for ensuring that cleanliness standards are maintained throughout that
      shift.

      Ward Manager Responsibilities

      Cleaning staff are responsible to their line management for day-to-day services and cleaning
      standards, with support from their Management Team to ensure that the highest standards
      possible are achieved.

      It is of particular importance that a degree of flexibility exists within the working day to allow for
      local requirements of the ward / department. The Domestic/Housekeeping Services team
      actively encourage Ward Managers to become involved in setting the standards on their wards
      and this includes participating in inspections and regular meetings.

      Modern Matrons

      Matrons have a personal responsibility and accountability for delivering a safe and clean care
      environment in conjunction with the Health and Social Care Act 2008.

      The Facilities Site Management Team will meet with individuals and groups of Modern Matrons at
      regular intervals to monitor performance on cleanliness and other issues and consider progress
      on action plans resulting from monitoring visits. The Modern Matrons are members of the PEAT
      team.




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      Infection Prevention and Control

      Infection Prevention and Control is high on the Trust agenda, the Facilities Site Services'
      Management Team works closely with the Trust’s Infection Prevention and Control Team.

      The following steps are taken to manage infection:

             The Cleaning Manual including cleaning schedules, cleaning method statements,
             equipment and materials used are agreed with the Infection Prevention and Control
             Team.

             The Infection Prevention and Control Team train cleaning staff in appropriate policies.

             Director Facilities is a member of the Trust’s Infection Prevention and Control Committee.

             A member of the Infection Prevention and Control Team participate in all the PEAT visits.

             In the event of an outbreak Cleaning staff work closely with the Infection Prevention and
             Control Team and ward team to manage the situation.

      Cleaning Standards Manual

      The Cleaning Standards Manual is a very detailed specification, which is available for all Ward
      Managers, Modern Matrons and Housekeeping/Domestic Services staff which details, work
      methods, frequencies etc. This can be found on the department of health website. It can also be
      obtained through the PEAT Team. Part of the Cleaning Standards Manual (the Cleaning Method
      Statement booklet) is given to each member of staff, managed by SMS Facilities upon
      commencement of employment and can be made available to all other cleaning staff or
      contractors via the PEAT Team. This document is also used as a basis for In-house induction
      training of cleaning staffs.

      Monitoring and Performance Indicators

      The Trust operates a robust monitoring system based on the National Specifications of
      Cleanliness. The overall performance target set for the Trust is between 92% - 95%. All areas
      are monitored on a regular basis and an action plan produced to correct any areas that fall below
      standard. The service is monitored on a day-to-day basis by the Housekeeping/Domestic
      Services.

      Reporting Problems

      Reporting arrangements are crucial to improve cleaning standards. These may include:

             Cleaning staff reporting problems or defects to their line management.

             Nursing staff reporting problems or             concerns     to   their   Cleaning    Team
             Leader/Supervisor/Senior Housekeeper.

             Patients / service users being encouraged to report problems or concerns to nursing staff
             or via focus groups or Advocacy and PAL’s and to the Cleaning Team Leader/
             Supervisor/Senior Housekeeper.

             Local information on how to report cleanliness issues should be readily available on all
             wards including who should be contacted, and how they can be contacted. To include ad
             hoc and ‘out of hours’ reporting mechanisms.

             Managers reporting damage to the trust estate, to facilities contractors must ensure that
             jobs are fully resolved, and check that work is carried out to a satisfactory standard; this

Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
             includes ‘making good’ resulting damage to areas and to ensure that the workmanship is
             acceptable.

      Staff Training

             Managers and Cleaning Team Leader/Supervisors/Senior Housekeepers will receive
             appropriate training and development.

             All new cleaning staff receive Trust induction, local Services Induction and on the job
             support. They will also have an annual Performance Appraisal and Development Review
             (PADR).

             All cleaning staff receive mandatory training in accordance with the Trust’s policy.

             All cleaning staff are encouraged to achieve the appropriate NVQ or equivalent
             qualification.

5. Decontamination of the Environment

 Good hygiene is an integral and important component of the Trust’s strategy for preventing hospital
 acquired infections, and all premises must be visibly clean, free from dust and dirt and acceptable to
 patients, visitors and staff.

      Walls, Ceilings, Floors and Doors

      Very small numbers of bacteria can be isolated from smooth, clean, intact wall surfaces, but this
      is not so with pitted plaster. Ceilings show an even smaller amount of bacteria. Plaster exposed
      through damage to the paint surface cannot be cleaned effectively and needs to be reported to
      ensure prompt repair.

      Floors are heavily contaminated by shoes bringing in organisms and from spillages especially
      body fluid spillages, general cleaning will remove soiling.

      Doors can be heavily contaminated and special attention should be paid to disinfecting areas
      where hands contact doors.

      Furniture and Fittings

      All surfaces should be kept clean and free from dust and finger marks. Neutral detergents are
      generally sufficient for routine cleaning, however if decontamination is required i.e. following
      exposure to known pathogens, clean with a high level disinfectant.

      Sinks and Toilets

      All hand wash basins should be cleaned at least daily and more frequently if soiled. Sinks should
      be cleaned with neutral detergent. If heavily stained sanitiser may be used. Always ensure that
      the sink is well rinsed after using sanitiser. Pay particular attention to cleaning the taps and the
      sides, underneath the sink and overflow where present

      Communal toilets must be cleaned at least twice a day and more often if used frequently. They
      should be checked in between cleaning and if necessary clean between scheduled cleans when
      accidents have occurred.

      Toilets should be cleaned with high level disinfectant. Pay particular attention to the handle,
      push/flush, seat, and lid and outside of the toilet as well as the inside. If heavily stained sanitiser
      may be used or lime scale cleanser.

      During an outbreak the frequency of cleaning toilets and sinks will be increased.

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      Bathrooms and Showers

      Showers must be run for 2 minutes twice a week to prevent build up of Legionella bacteria. Baths
      and showers and bath mats should be disinfected daily with a high level disinfectant and allowed
      to dry.

      Baths, showers and bath mats should be cleaned between use so cleaning products must be
      available for staff to use and their location indicated within the vicinity of the bath or shower.

      Carpets

      Carpets should be avoided in all clinical areas, but where they are in use, they must be
      vacuumed and cleaned regularly, be kept free from dust, dirt, stains and spillages and be
      maintained in good condition.

      The only exception will be during an outbreak of respiratory infection (i.e. Influenza/ Pandemic
      Flu) when vacuuming should be avoided (hepa-filtered devices may still be used) and cleaning
      and damp dusting will occur.

      Domestic Rooms and Equipment

      These rooms and the equipment used must be kept clean and in good condition. Time must be
      allowed on work rotas and cleaning schedules for cleaning equipment and domestic rooms.

      Storage/Adequate Space

      General storage – use of cupboards vs. shelves
      Wet/Dry – separation of clean/dirty and wet/dry
      Mop Racks – If mops are laundered, they need to be placed in racks
      Facilities – Hand wash basin – Utility Sink – Hopper Sink, there must be adequate space

      NHS Colour Coding for Cleaning

      This standard will be adhered to throughout the Trust and the colour coded poster should be
      displayed in the Housekeeping/domestic room.

      Body Fluid Spillages

      Disinfection is required for body fluid spillages.

      Staff must deal with body fluid spillages that occur in the area in which they work at the time of
      the spillage, unless the spillage covers a large area or is in connection with a sudden death.

      Any staff responsible for decontamination has a duty under the Health and Safety at Work Act to
      do so safely and correctly to ensure that the workplace is free from hazard. All areas should
      have spillage kits which are easily accessible to use.

      For splashes of body fluids on walls, and surfaces, these can be cleaned by using a high level
      disinfectant. Put on Personal Protective Equipment (PPE) and use disposable cloths or paper
      towels, spray walls and surfaces thoroughly, then wipe dry. Dispose of cloths or towels into a
      clinical waste bag or bin.

      For all body fluid spillages, follow the instructions contained within body fluid spillage kit. Dispose
      of used granules either down a toilet or sluice if nearby otherwise use the yellow clinical waste
      bag from the kit as per instructions.

      Large Blood Spillages, Dried Blood and Faecal Smearing (Dirty Protests).


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      This is a non-nursing/non housekeeping/domestic duty. Contractors may be brought in
      (subject to risk assessment)

      During office hours, the Nurse in Charge must contact the purchasing department to bring in
      contractors.

      Out of hours, the on call Manager is authorised to contact a specialist contractor who is equipped
      and competent at cleaning large body fluid spillages.

      Where possible isolate the contaminated area until it has been cleaned. If the spillage is in a
      passageway or day area that cannot be isolated please contact the Infection Prevention and
      Control Nurse for advice.

      Annual Deep Clean

      All clinical areas within the trust should ensure they arrange for an annual deep clean to be
      carried out.

      Decontamination of Equipment and Medical Devices

      Decontamination if not carried out correctly may increase the likelihood of micro organisms being
      transferred from patients to staff and the decontamination process makes equipment and medical
      devices safe for staff to handle and safe for use by patients.

      Decontamination Methods

             Cleaning

             This is the most basic form of decontamination, it is a process that physically removes
             contamination but does not necessarily kill the germs themselves.

             Disinfection

             This is the destruction of bacteria and viruses and it is achieved by using a high level
             disinfectant.

5.1 Operational Delivery

      Management responsible for those staff who carry out cleaning, work with the Infection
      Prevention and Control Nurses and cleaning staff to agree schedules and frequencies of
      cleaning, determine responsibility for items to be cleaned and products used.

      Infection Prevention and Control training is delivered to all employees and specific training is
      provided by Local Management regarding, cleaning tasks, risk assessments, COSHH and
      Personal Protective Equipment (PPE).

      At all inpatient sites, details of how staff can request ‘additional’ cleaning both urgently and
      routinely is on display and/or within the cleaning schedules.

      The Strategic Cleaning Plan details in full the accountability and involvement of all stakeholders
      whilst explaining staff awareness and understanding of the standards that are expected (see 4.
      Strategic Cleaning Plan).

5.2 Cleaning Equipment

      Equipment provided is regularly checked, is fit for purpose, chosen for ease of use, is kept clean
      and well maintained. The National Patient Safety Agency (NPSA) (now known as The Health and
      Social Care Information Centre), Colour Coding System is used and the colour posters are

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       displayed. Disposable cloths are used throughout the Trust where appropriate. Mops should be
       either laundered or disposed of daily.

       All equipment utilised should be risk assessed for suitability to the specific environment.

6. Audit

       Monitoring to the 50 elements of the quality standards occurs through the technical audit tool e.g.
       the 13 week review work book, the PEAT process and Infection Control Quality Improvement
       Audits, based on the Infection Prevention Society (IPS) Quality Improvement tools, occur
       annually and all are reported through the Infection Control Committee and to the Trust Board.

7. Other Trust Policies

       IC01:   Infection Prevention and Control Policy
       SA19:   Medical Devices and Decontamination Policy
       SA07:   Health, Safety and Welfare
       SA22:   Waste Management

8. Development and Consultation

       This policy was written by Facilities Management in conjunction with Infection Prevention and
       Control and widely distributed for consultation with:
       Modern Matrons
       Facilities Site Managers – Local Operational/Support Managers
       Infection Control Facilities Group
       Housekeeping/Domestic – Supervisors and Team Leaders

9. Human Rights & Equality

       ”Mersey Care NHS Trust recognises that all sections of society may experience prejudice and
       discrimination. This can be true in service delivery and employment. The Trust is committed to
       equality opportunity and anti-discriminatory practice both in the provision of services and in our
       role as a major employer.

       The Trust believes that all people have the right to be treated with dignity and respect. The Trust
       is working towards and is committed to the elimination of unfair and unlawful discriminatory
       practices. All employees have responsibility for the effective implementation of this policy. They
       will be made fully aware of this policy and without exception must adhere to its requirements.

       Mersey Care NHS Trust is also aware of its legal duties under the Human Rights Act 1998.

       All public authorities have a legal duty to uphold and promote human rights in everything they do.
       It is unlawful for a public authority to perform any act which constitutes discrimination.

       Mersey Care NHS Trust is committed to carrying out its functions and service delivery in line with
       Human Rights principles of dignity, autonomy, respect, fairness and equality”.

10. References/Bibliography

       DH, 2004, the NHS Healthcare Cleaning Manual.
       NHS Estates, 2000, Standards for Environmental Cleanliness in Hospitals.

11. Glossary of Terms

       CQC     Care Quality Commission
       DH      Department of Health
       ERIC    Estates Returns and Information Collection
       HSE     Health and Safety Executive
Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
      ICT    Infection Control Team
      IPS    Infection Prevention Society
      NHS    National Health Service
      NPSA   National Patients Safety Agency – (now known as The Health and Social Care Information Centre)
      PEAT   Patient Environment Action Team

12. Appendices

      1.     Impact Assessment
      2.     Domestic Service Level Agreement (Cleaning Schedule)
      3.     Decontamination of Equipment and Medical Devices
      4.     Policy Implementation Plan




Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
Appendix 1.

                                     Single Equality and Human Rights Screen

          Name of Document
          CORPORATE CLEANING STANDARDS POLICY


          Who does it relate to     Staff       √          Service          √          Carers         √
                                                           Users

          Area of Trust it covers
          Trust Wide


          Names of people completing screen (Minimum of 3)
          George Sullivan
          Collette Irving
          Andrew Hambley


            What is the purpose of policy / service change /strategy? what is your this document
                                                  trying to achieve
         The Trust believes that all it’s premises should be cleaned and maintained to the highest
         possible standard, not because the patients and public expect it, but because patients have the
         right to be cared for in an environment that achieves the highest standard of cleanliness which
         determines a visible sign of overall quality of care provided, minimises the risk of infection and
         ensures compliance with legislation and standards.

The screening of any document is completed to ensure that it does not have either a Direct or Indirect impact on
any members from particular protected Equality Groups.
          Equality Strand              Y    N       Reasoning
                                            x
          Age


          Disability                        x
          inc Learning Disability
                                            x
          Gender


          Race                              x
          Inc Gypsies and
          travellers and Asylum
          Seekers
                                            x
          Religion and Belief


                                            x
          Sexual Orientation


                                            x
          Transgender


                                            x       The policy is to inform staff about Dept of health and
          Cross cutting                             other national standards in relation to infection control
                                                    and cleanliness in hospitals. No issues have been

Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                                                    identified in the assessment.


          Total                       0      0

Accessibility

          Is it clear that this document is available in     Yes      No       comment
          other formats:                                     √

          Other comments noted from the assessment.

Any areas highlighted by the EIA assessors must be put into an action plan. This must record all areas noted even
when it can be rectified immediately. The document with the assessment, which includes the action plan, must be
available for scrutiny and be able to show:-

        What has been highlighted
        What has been done to rectify immediately
        What time frame has been agreed to rectify in the future
                                       HUMAN RIGHTS IMPACT ASSESSMENT
                            Right of freedom from inhuman and degrading treatment
                                                         (Article 3)
Does this policy ensure people are treated            No issues identified in discussions.
with dignity and respect                              However if staff do not follow the standards this could lead to
                                                      dignity and respect issues.
Could this policy lead to degrading or
inhuman treatment (e.g. lack of dignity in care,
excessive force in restraint)
How could this right be protected?
                                                        Right to life
                                                         (Article 2)
Does this policy help protect a persons right to As above.
life?
Does this policy have the potential to result in
a person’s loss of life?
How could this right be protected?
                                                    Right to a fair trial
                                                         (Article 6)
Does this policy support the right to a fair          N/A
trial?
Does this policy threaten the right to a fair
trial? (e.g. no appeals process)
How could this right be protected?
Right to liberty
                                                         (Article 5)
Does this policy support the right to liberty?        N/A
Does this policy restrict the right to liberty?
Is the restriction prescribed by law?
                                              Right to private and family life
                                                         (Article 8)
Does this policy support a persons right to           N/A
private and family life
Does this policy have the potential to restrict
the right to private and family life
How could this right be protected?
Is it prescribed by law?
Is it necessary?
Is it proportionate?
                                             Right to freedom of expression
                          Note: this does not include insulting language such as racism
                                                        (Article 10)
Does this policy support a persons ability to         N/A
express opinions and share information

Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
Does this policy interfere with a person’s
ability to express opinions and share
information?
Is it in pursuit of legitimate aim?
Is it prescribed by law?
Is it necessary?
Is it proportionate?
                                        Right of freedom of religion or belief
                                                      (Article 9)
Does this policy support a person’s right to        N/A
freedom of religion or belief?
Does this policy interfere with a person’s right
to freedom of religion or beliefs? (e.g.
prevention of a person practising their
religion)
Is it in pursuit of legitimate aim?
Is it prescribed by law?
Is it necessary?
Is it proportionate?

                                         Right freedom from discrimination
                                                       (Article 14)
If you have identified an impact, will this discriminate against anyone group in particular?

 N/A
Is the Document:-
        Compliant                                                  y/n
        Non compliant -                                             Yes
                                                                   y/n
        With actions immediately taken
        Action Plan completed                                      y/n
                                                                    N/A
       Full Impact Assessment Required                             y/n
                                                                    No
       Lead Assessor_____George Sullivan
       Date ___________10.01.2012_______




Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
Appendix 2.
                                                                             MERSEY CARE NHS TRUST

                                                                                    Cleaning Schedule

                                                               Schedule of Cleaning – Mental Health Ward – High Priority



 Area           Task                                                     Equipment / Instructions         Frequency                               Priority   Responsibility
 Linen Room     Floors (non-slip) to be dusted and mopped;               Blue mop, check / change head.   Dust brush and mop daily + 1            HIGH       Hospital Assistants
                Machine clean weekly.                                                                     check clean.
                                                                                                          Machine clean weekly

                Damp dust Low surfaces: sills and skirting               Blue cloths.                     1 full clean daily + one check clean.              Hospital Assistants

                Switches , sockets and radiators                         Blue cloths.                     1 full clean daily.                                Hospital Assistants

                Clean linen storage shelving weekly                      Blue cloths.                     1 full clean weekly                                Hospital Assistants

                Linen Trolley                                            Blue Cloths                      Contact point clean daily. Full clean              Hospital Assistants
                                                                                                          weekly

                High surfaces: pipe work etc                             Blue Cloths                      One full clean weekly                              Hospital Assistants

                Ventilation/extractor grills                             Mop/dust                         One clean weekly: deep clean by                    Hospital Assistants
                                                                                                          contractor as part of PPM

                Doors and frames                                         Blue Cloths                      One full clean daily                               Hospital Assistants

                Internal glazing of doors/windows/partitions             Blue Cloths                      One check clean daily                              Hospital Assistants

                Walls                                                    Blue Cloths                      One check clean daily                              Hospital Assistants
                                                                                                          One full dust weekly
                                                                                                                                                             N.B. This will form
                                                                                                                                                             part of FMA Linen
                                                                                                                                                             services role but
                                                                                                                                                             should be maintained
                                                                                                                                                             by Hospital Assistant
                                                                                                                                                             staff during A/L and
                                                                                                                                                             sickness

                                                                                                                                                             All Tasks: Ward Staff
                                                                                                                                                             between cleans.




        Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
Ward Managers   Floors (hard non-slip) to be brushed and mopped, deck      Blue mop, check / change head   Dust brush and mop daily + 1           HIGH   Hospital Assistants
Office          scrub to be used weekly                                                                    check clean.
                                                                                                           Deck scrub weekly

                Damp dust Low surfaces: sills and skirting and available   Blue cloths.                    1 full clean daily + one check clean          Hospital Assistants
                desk space                                                                                                                               (check clean Nursing
                                                                                                                                                         Staff)

                Switches, Sockets & Radiators                              Blue cloths.                    1 full clean daily.                           Hospital Assistants

                High surfaces: pipe work, picture frames, shelving etc     Blue cloths.                    One full clean weekly                         Hospital Assistants

                Internal glazing of doors/windows/partitions               Blue cloths.                    One check clean daily                         Hospital Assistants


                Empty and replace bin bags with appropriate coded bags     Blue cloths.                    1 full clean + 1 check clean daily.           Hospital Assistants
                and wash inside and out (inc. lid & foot pedal).                                           Deep clean weekly.                            (check clean Nursing
                                                                                                                                                         Staff)

                Ventilation/extractor grills                               Mop/dust                        One clean weekly: deep clean by               Hospital Assistants
                                                                                                           contractor as part of PPM

                Doors and frames                                           Blue Cloths                     One full clean daily                          Hospital Assistants

                Walls                                                      Blue Cloths                     One check clean daily                         Hospital Assistants
                                                                                                           One full dust weekly
                Chairs                                                     Blue Cloths/Hoover                                                            Hospital Assistants
                                                                                                           One full clean daily
                Ward media equipment:
                Telephones                                                 Detergent wipes                 Daily                                         Nursing Staff

                Computers/keyboards/printers/fax                           Detergent wipes                 Weekly                                        Nursing Staff

                                                                                                                                                         All Tasks: Ward Staff
                                                                                                                                                         between cleans.

Ward office     Floors (hard non-slip) to be brushed and mopped, deck      Blue mop, check / change head   Dust brush and mop daily + 1           HIGH   Hospital Assistants
                scrub to be used weekly                                                                    check clean.
                                                                                                           Deck scrub weekly

                Damp dust Low surfaces: sills and skirting and available   Blue cloths.                    1 full clean daily + one check clean          Hospital Assistants
                desk space                                                                                                                               (check clean Nursing
                                                                                                                                                         Staff)

                Switches, Sockets & Radiators                              Blue cloths.                    1 full clean daily.                           Hospital Assistants

                High surfaces: pipe work, picture frames, shelving etc     Blue cloths.                    One full clean weekly                         Hospital Assistants


       Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
              Internal glazing of doors/windows/partitions             Blue cloths.                     One check clean daily                          Hospital Assistants


              Empty and replace bin bags with appropriate coded bags   Blue cloths.                     1 full clean + 1 check clean daily.            Hospital Assistants
              and wash inside and out (inc. lid & foot pedal).                                          Deep clean weekly.                             (check clean Nursing
                                                                                                                                                       Staff)

              Ventilation/extractor grills                             Mop/dust                         One clean weekly: deep clean by                Hospital Assistants
                                                                                                        contractor as part of PPM

              Doors and frames                                         Blue Cloths                      One full clean daily                           Hospital Assistants

              Walls                                                    Blue Cloths                      One check clean daily                          Hospital Assistants
                                                                                                        One full dust weekly
                                                                                                                                                       Hospital Assistants
              Chairs                                                   Blue Cloths/Hoover               One full clean daily

              Ward media equipment:                                    Detergent wipes                  Daily                                          Nursing Staff
              Telephones
                                                                       Detergent wipes                  Weekly                                         Nursing Staff
              Computers/keyboards/printers/fax
                                                                                                                                                       All Tasks: Ward Staff
                                                                                                                                                       between cleans.

Sluice Room   Floors (hard non-slip) to be brushed and mopped, deck    Blue mop, check / change head.   Dust brush and mop daily + 1            HIGH   Hospital Assistants
              scrub to be used weekly                                                                   check clean.
                                                                                                        Deck scrub weekly

              Damp dust Low surfaces: sills and skirting               Blue cloths.                     1 full clean daily + one check clean.          Hospital Assistants

              Switches , sockets and radiators                         Blue cloths.                     1 full clean daily.                            Hospital Assistants

              High surfaces: pipe work etc                             Blue Cloths                      One full clean weekly                          Hospital Assistants

              Ventilation/extractor grills                             Mop/dust                         One clean weekly: deep clean by                Hospital Assistants
                                                                                                        contractor as part of PPM

              Doors and frames                                         Blue Cloths                      One full clean daily                           Hospital Assistants

              Internal glazing of doors/windows/partitions             Blue Cloths                      One check clean daily                          Hospital Assistants


              Walls                                                    Blue Cloths                      One check clean daily                          Hospital Assistants
                                                                                                        One full dust weekly

              Sinks                                                    Blue Cloths                      2 full cleans daily and one check              Hospital Assistants
                                                                                                        clean daily run taps twice weekly. (*          (check clean Nursing
                                                                                                        1)                                             Staff)

      Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                                                                                                                                                        All Tasks: Ward Staff
                                                                                                                                                        between cleans.

Bathroom /     Floors (hard non-slip) to be brushed and mopped, deck    Red mop, check / change head.    Dust brush and mop daily + 1            HIGH   Hospital Assistants
Toilets /      scrub to be used weekly                                  Red gloves.                      check clean.
Shower Rooms                                                                                             Deck scrub weekly

               Damp dust Low surfaces: sills and skirting               Red cloths.                      1 full clean daily + one check clean.          Hospital Assistants

               Switches , sockets and radiators                         Red Cloths                       1 full clean daily.                            Hospital Assistants

               High surfaces: pipe work etc                             Red cloths.                      One full clean weekly                          Hospital Assistants

               Ventilation/extractor grills                             Mop/dust                         One clean weekly: deep clean by                Hospital Assistants
                                                                                                         contractor as part of PPM

               Doors and frames                                         Red cloths.                      One full clean daily                           Hospital Assistants

               Internal glazing of doors/windows/partitions             Red cloths                       One check clean daily                          Hospital Assistants


               Walls                                                    Red cloths                       One check clean daily                          Hospital Assistants
                                                                                                         One dust clean weekly

               Mirrors                                                  Red Cloths                       One full clean daily                           Hospital Assistants

               All dispensers                                           Red Cloths                       1 full clean daily and one check               Hospital Assistants
                                                                                                         clean daily. Restock twice daily

               Empty and replace bin bags with appropriate coded bags   Red Cloths                       1 full clean daily and one check               Nursing Staff clinical
               and wash inside and out (inc. lid & foot pedal).                                          clean daily. Deep clean weekly                 waste bin / Hospital
                                                                                                                                                        Assistants white bin

               Showers and Baths                                        Red Cloths                       1 Full clean daily and 1 check clean           Hospital Assistants
                                                                                                         daily

               Toilets and Sinks (to be cleaned last)                   Red Cloths (dispose after use)   2 full cleans daily and 1 check                Hospital Assistants
                                                                                                         clean run taps twice weekly. (* 1)             (check clean Nursing
                                                                                                                                                        Staff)

               Commodes and bathroom hoists                             Detergent wipes                  After use, one full clean daily                Nursing staff

                                                                                                                                                        All Tasks: Ward Staff
                                                                                                                                                        between cleans.




     Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
Lounge           Floors (non-slip) to be dusted and mopped;                 Blue mop, check / change head     Dust brush and mop daily + 1           HIGH   Hospital Assistants
                 Machine clean weekly.                                                                        check clean.
                                                                                                              Machine Clean weekly

                 Damp dust Low surfaces: sills, skirting, sideboards,       Blue cloths.                      1 full clean daily + one check clean          Hospital Assistants
                 media units                                                                                                                                (check clean Nursing
                                                                                                                                                            Staff)

                 Switches, Sockets & Radiators                              Blue cloths.                      1 full clean daily.                           Hospital Assistants

                 High surfaces: pipe work, picture frames, shelving etc     Blue cloths.                      One full clean weekly                         Hospital Assistants

                 Internal glazing of doors/windows/partitions               Blue cloths.                      One check clean daily                         Hospital Assistants


                 Empty and replace bin bags with appropriate coded bags     Blue cloths.                      1 full clean + 1 check clean daily.           Hospital Assistants
                 and wash inside and out (inc. lid & foot pedal).                                             Deep clean weekly.                            (check clean Nursing
                                                                                                                                                            Staff)

                 Ventilation/extractor grills                               Mop/dust                          One clean weekly: deep clean by               Hospital Assistants
                                                                                                              contractor as part of PPM

                 Doors and frames                                           Blue Cloths                       One full clean daily                          Hospital Assistants

                 Walls                                                      Blue Cloths                       One check clean daily                         Hospital Assistants
                                                                                                              One dust clean weekly

                 Electrical equipment; TV, HI-FI, DVD player etc            Blue Cloths                       One clean daily(dust removal)                 Hospital Assistants
                                                                                                              One full clean monthly

                 Furniture: Tables and chairs                               Blue Cloths/Hoover for non-wipe   One full clean daily and one check            Hospital Assistants
                                                                            able                              clean daily
                                                                                                                                                            All Tasks: Ward Staff
                                                                                                                                                            between cleans.

Meeting Room     Floors (hard non-slip) to be brushed and mopped, deck      Blue mop, check / change head     Dust brush and mop daily + 1           HIGH   Hospital Assistants
                 scrub to be used weekly                                                                      check clean.
                                                                                                              Deck scrub weekly

                 Damp dust Low surfaces: sills and skirting and available   Blue cloths.                      1 full clean daily + one check clean          Hospital Assistants
                 desk space                                                                                                                                 (check clean Nursing
                                                                                                                                                            Staff)

                 Switches, Sockets & Radiators                              Blue cloths.                      1 full clean daily.                           Hospital Assistants

                 High surfaces: pipe work, picture frames, shelving etc     Blue cloths.                      One full clean weekly                         Hospital Assistants

                 Internal glazing of doors/windows/partitions               Blue cloths.                      One check clean daily                         Hospital Assistants

         Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
             Empty and replace bin bags with appropriate coded bags   Blue cloths.                      1 full clean + 1 check clean daily.           Hospital Assistants
             and wash inside and out (inc. lid & foot pedal).                                           Deep clean weekly.                            (check clean Nursing
                                                                                                                                                      Staff)

             Ventilation/extractor grills                             Mop/dust                          One clean weekly: deep clean by               Hospital Assistants
                                                                                                        contractor as part of PPM

             Doors and frames                                         Blue Cloths                       One full clean daily                          Hospital Assistants

             Walls                                                    Blue Cloths                       One check clean daily                         Hospital Assistants
                                                                                                        One dust clean weekly

             Furniture: Tables and chairs                             Blue Cloths/Hoover for non-wipe   One full clean daily and one check            Hospital Assistants
                                                                      able                              clean daily
             Ward media equipment:
             Telephones                                               Detergent wipes                   Daily                                         Nursing Staff

             Computers/keyboards/printers/fax                         Detergent wipes                   Weekly                                        Nursing Staff

                                                                                                                                                      All Tasks: Ward Staff
                                                                                                                                                      between cleans.

Bedroom      Floors (non-slip) to be dusted and mopped;               Blue mop, check / change head     Dust brush and mop daily + 1           HIGH   Hospital Assistants
             Machine clean weekly.                                                                      check clean.
                                                                                                        Machine clean weekly

             Damp dust Low surfaces: sills, skirting, sideboards,     Blue cloths.                      1 full clean daily + one check clean          Hospital Assistants
             media units                                                                                                                              (check clean Nursing
                                                                                                                                                      Staff)

             Switches, Sockets & Radiators                            Blue cloths.                      1 full clean daily.                           Hospital Assistants

             High surfaces: pipe work, picture frames, shelving,      Blue cloths.                      One full clean weekly                         Hospital Assistants
             wardrobes, curtain rails (if in dorm) etc

             Internal glazing of doors/windows/partitions             Blue cloths.                      One check clean daily                         Hospital Assistants


             Empty and replace bin bags with appropriate coded bags   Blue cloths.                      1 full clean + 1 check clean daily.           Hospital Assistants
             and wash inside and out (inc. lid & foot pedal).                                           Deep clean weekly.                            (check clean Nursing
                                                                                                                                                      Staff)

             Ventilation/extractor grills                             Mop/dust                          One clean weekly: deep clean by               Hospital Assistants
                                                                                                        contractor as part of PPM

             Doors and frames                                         Blue Cloths                       One full clean daily                          Hospital Assistants

     Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                    Walls                                                    Blue Cloths                       One check clean daily                         Hospital Assistants
                                                                                                               One dust clean weekly

                    All dispensers                                           Blue Cloths                       1 full clean daily. Restock daily.            Hospital Assistants

                    Furniture: Tables and chairs                             Blue Cloths/Hoover for non-wipe   One full clean daily and one check            Hospital Assistants
                                                                             able                              clean daily

                    Sinks (patient washbowls according to Standards)         Blue Cloths                       1 full clean daily and 1 check clean          Hospital Assistants
                                                                                                               daily run taps twice weekly. (* 1)            (check clean Nursing
                                                                                                                                                             Staff)
                    Patient personal items: cards, toiletries etc            Blue Cloths                       One full clean daily                          Hospital Assistants

                    Mirrors                                                  Blue Cloths                       One full clean daily                          Hospital Assistants

                    Beds                                                     Blue Cloth                        Frame Daily                                   Hospital Assistants
                                                                                                               Under weekly                                  Hospital Assistants
                                                                                                               Entire frame on discharge                     Nursing Staff

                    Pillows                                                  Disposable cloths                 After use                                     Nursing Staff

                    Mattresses                                               Disposable cloths                 After use                                     Nursing Staff

                                                                                                                                                             All Tasks: Ward Staff
                                                                                                                                                             between cleans.

Clinic/dispensary   Floors (non-slip) to be dusted and mopped;               Blue mop, check / change head     Dust brush and mop daily + 1           HIGH   Hospital Assistants
                    Machine clean weekly.                                                                      check clean.
                                                                                                               Machine Clean weekly

                    Damp dust Low surfaces: sills, skirting, sideboards,     Blue cloths.                      1 full clean daily + one check clean          Hospital Assistants
                    media units                                                                                                                              (check clean Nursing
                                                                                                                                                             Staff)

                    Switches, Sockets & Radiators                            Blue cloths.                      1 full clean daily.                           Hospital Assistants

                    High surfaces: pipe work, picture frames, shelving etc   Blue cloths.                      One full clean weekly                         Hospital Assistants

                    Internal glazing of doors/windows/partitions             Blue cloths.                      One check clean daily                         Hospital Assistants


                    Empty and replace bin bags with appropriate coded bags   Blue cloths.                      1 full clean + 1 check clean daily.           Hospital Assistants
                    and wash inside and out (inc. lid & foot pedal).                                           Deep clean weekly.                            (check clean Nursing
                                                                                                                                                             Staff)

                    Ventilation/extractor grills                             Mop/dust                          One clean weekly: deep clean by               Hospital Assistants
                                                                                                               contractor as part of PPM

       Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
              Doors and frames                                                 Blue Cloths                     One full clean daily                          Hospital Assistants

              Walls                                                            Blue Cloths                     One check clean daily                         Hospital Assistants
                                                                                                               One dust clean weekly

              Sink (same standard as patient washbowl due to non-              Blue Cloths                     1 full clean daily and 1 check clean          Hospital Assistants
              patient area)                                                                                    daily run taps twice weekly. (* 1)            (check clean Nursing
                                                                                                                                                             Staff)

              Drugs Trolley                                                    Blue Cloths                     Weekly                                        Nursing staff

              All medical equipment including blood pressure cuffs ,           Detergent /alcohol wipes        After use                                     Nursing staff
              scales etc
              (Note a full list of medical kit including their frequency for
              cleaning can be found in the cleaning standard policy and
              Medical Devices Policy)

              Medical gas equipment                                            Blue cloths                     One full clean daily                          Nursing staff

              Drugs Cupboards                                                  Detergent wipes                 Weekly                                        Nursing Staff

                                                                                                                                                             All Tasks: Ward Staff
                                                                                                                                                             between cleans.

Dining Room   Floors (non-slip) to be dusted and mopped;                       Blue mop, check / change head   Dust brush and mop daily after         HIGH   Hospital Assistants
              Machine clean weekly.                                                                            each meal.
                                                                                                               Machine Clean weekly

              Damp dust Low surfaces: sills, skirting, sideboards,             Blue cloths.                    1 full clean daily + one check clean          Hospital Assistants
              media units                                                                                                                                    (check clean Nursing
                                                                                                                                                             Staff)

              Switches, Sockets & Radiators                                    Blue cloths.                    1 full clean daily.                           Hospital Assistants

              High surfaces: pipe work, picture frames, shelving etc           Blue cloths.                    One full clean weekly                         Hospital Assistants

              Internal glazing of doors/windows/partitions                     Blue cloths.                    One check clean daily                         Hospital Assistants


              Empty and replace bin bags with appropriate coded bags           Blue cloths.                    1 full clean + 1 check clean daily.           Hospital Assistants
              and wash inside and out (inc. lid & foot pedal).                                                 Deep clean weekly.                            (check clean Nursing
                                                                                                                                                             Staff)

              Ventilation/extractor grills                                     Mop/dust                        One clean weekly: deep clean by               Hospital Assistants
                                                                                                               contractor as part of PPM

              Doors and frames                                                 Blue Cloths                     One full clean daily                          Hospital Assistants

      Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                  Walls                                                         Blue Cloths                       One check clean daily                           Hospital Assistants
                                                                                                                  One full dust weekly

                  Furniture: Tables, chairs                                     Blue Cloths/Hoover for non-wipe   One full clean daily after each meal            Hospital Assistants
                                                                                able                              (including underneath of table tops
                                                                                                                  and underside of chairs)
                                                                                                                                                                  All Tasks: Ward Staff
                                                                                                                                                                  between cleans.

Kitchen           Floors (hard non-slip) to be brushed and mopped, deck         Green mop, check / change         Brush and mop after each meal.           HIGH   Hospital Assistants
                  scrub to be used weekly                                       head. Green gloves.               Deck scrub weekly


                  Damp dust Low surfaces: sills, skirting, sideboards           Green cloths                      1 full clean daily + 1 check clean.             Hospital Assistants

                  Switches, Sockets & Radiators                                 Green cloths.                     1 full clean daily (check clean after           Hospital Assistants
                                                                                                                  use)

                  Fridge (no freezer) (temperature check to be logged)          Green cloths.                     3 check cleans daily + one full                 Hospital Assistants
                                                                                                                  clean weekly removing all content.

                  High surfaces: pipe work, picture frames, shelving, kitchen   Green cloths.                     One full clean weekly                           Hospital Assistants
                  cupboards etc

                  Clean sinks and kitchen surrounds.                            Green cloths.                     2 full cleans daily + 1 check clean.            Hospital Assistants

                  Wipe down any electrical equipment.                           Green cloths.                     1 full clean +2 check cleans daily.             Hospital Assistants

                  Microwave.                                                    Green cloths.                     1 full clean +2 check cleans daily.             Hospital Assistants

                  Dishwasher / Dishwasher Filter                                Green cloths.                     1 full clean daily + 2 clean checks.            Hospital Assistants
                                                                                                                  Clean Filter at the end of day.

                  Empty and replace bin bags with appropriate coded bags        Green cloths.                     1 full clean + 1 check clean daily.             Hospital Assistants
                  and wash inside and out (inc. lid & foot pedal).                                                Deep clean weekly.


                  Dispensers to be damp dusted and re-stocked                   Green cloths.                     1 full clean daily, restocked after             Hospital Assistants
                                                                                                                  each meal

                  Water coolers/water boilers                                   Green cloths                      1 full clean daily, check cleans after          Hospital Assistants
                                                                                                                  each meal. Water cooler tray to be
                                                                                                                  emptied and cleaned weekly.

                  Tea Trolleys                                                  Green cloths/detergent wipes      1 full clean after use including                Hospital Assistants
                                                                                                                  wheels


          Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                    Kitchen Cupboards                                             Green Cloths                1 full clean weekly                            Hospital Assistants

                    Walls                                                         Green Cloths                One check clean daily                          Hospital Assistants
                                                                                                              One full dust weekly

                    Internal glazing of doors/windows/partitions                  Green Cloths                One check clean daily                          Hospital Assistants


                    Doors and frames                                              Green Cloth                 One full clean daily                           Hospital Assistants

                    Ventilation/extractor                                         Green mop/dust              One clean weekly: deep clean by                Hospital Assistants
                                                                                                              contractor as part of PPM
                                                                                                                                                             All Tasks: Ward Staff
                                                                                                                                                             between cleans.
Staff room/ staff   Floors (hard non-slip) to be brushed and mopped, deck         Green mop, check / change   Dust brush and mop daily + 1            HIGH   Hospital Assistants
Kitchen             scrub to be used weekly                                       head. Green gloves          check clean.
                                                                                                              Deck Scrub weekly

                    Damp dust Low surfaces: sills, skirting, sideboards           Green cloths                1 full clean daily + 1 check clean.            Hospital Assistants

                    Switches, Sockets & Radiators                                 Green cloths.               1 full clean daily.                            Hospital Assistants

                    High surfaces: pipe work, picture frames, shelving, kitchen   Green cloths.               One full clean weekly                          Hospital Assistants
                    cupboards etc

                    Clean sinks and kitchen surrounds. (temperature check to      Green cloths.               1 full clean daily + 1 check clean.            Hospital Assistants
                    be logged on fridge)                                                                      run taps twice weekly (* 1)

                    Wipe down any electrical equipment.                           Green cloths.               1 full clean daily + 1 check clean.            Hospital Assistants


                    Empty and replace bin bags with appropriate coded bags        Green                       1 full clean + 1 check clean daily.            Hospital Assistants
                    and wash inside and out (inc. lid & foot pedal).                                          Deep clean weekly.                             (check clean Nursing
                                                                                                                                                             Staff)

                    Dispensers to be damp dusted and re-stocked                   Green cloths.               1 full clean and restock daily                 Hospital Assistants


                    Water coolers/water boilers                                   Green cloths                1 full clean daily. Water cooler tray          Hospital Assistants
                                                                                                              to be emptied and cleaned weekly.

                    Fridge/Cooker/Microwave/Toaster/Kettle/Dishwasher             Green cloths                Once weekly                                    Nursing staff

                    Kitchen Cupboards                                             Green Cloths                Weekly                                         Nursing staff

                    Tables and chairs                                             Green cloths/Hoover         One full clean daily                           Hospital Assistants



        Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                  Walls                                                    Green Cloths                     One check clean daily                         Hospital Assistants
                                                                                                            One full dust weekly

                  Internal glazing of doors/windows/partitions             Green Cloths                     One check clean daily                         Hospital Assistants

                                                                                                            One full clean daily
                  Doors and frames                                         Green Cloth                                                                    Hospital Assistants

                                                                                                                                                          All Tasks: Ward Staff
                                                                                                                                                          between cleans.
Corridors         Floors (non-slip) to be dusted and mopped;               Blue mop, check / change head.   Brush and mop daily + 1 check          HIGH   Hospital Assistants as
                  Machine clean weekly.                                    Floor cleaning machine.          clean. Machine clean weekly.                  part of their rota.


                  Damp dust Low surfaces: sills, skirting, phones, hand    Blue cloths.                     1 full clean daily + 1 check clean.           Hospital Assistants
                  dispensers etc

                  Switches, Sockets & Radiators                            Blue cloths.                     1 full clean daily                            Hospital Assistants

                  High surfaces: pipe work, picture frames, shelving etc   Blue cloths.                     One full clean weekly                         Hospital Assistants

                  Empty and replace bin bags with appropriate coded bags   Blue Cloths                      1 full clean + 1 check clean daily.           Hospital Assistants
                  and wash inside and out (inc. lid & foot pedal).                                          Deep clean weekly.

                  Walls                                                    Blue Cloths                      One check clean daily                         Hospital Assistants
                                                                                                            One full dust weekly

                                                                                                                                                          All Tasks: Ward Staff
                                                                                                                                                          between cleans.
Staff lockers &   Floors (hard non-slip) to be brushed and mopped, deck    Blue mop, check / change head    Dust brush and mop daily + 1           HIGH   Hospital Assistants
Toilet            scrub to be used weekly                                                                   check clean.
(TOILET TO BE                                                                                               Deck scrub weekly
CLEANED AS
PER               Damp dust Low surfaces: sills and skirting               Blue cloths.                     1 full clean daily + one check clean          Hospital Assistants
BATHROOM/TOI
LET DETAILED      Switches, Sockets & Radiators                            Blue cloths.                     1 full clean daily.                           Hospital Assistants
PREVIOUSLY)
                  High surfaces: pipe work, picture frames, shelving etc   Blue cloths.                     One full clean weekly                         Hospital Assistants

                  Internal glazing of doors/windows/partitions             Blue cloths.                     One check clean daily                         Hospital Assistants


                  Empty and replace bin bags with appropriate coded bags   Blue cloths.                     1 full clean + 1 check clean daily.           Hospital Assistants
                  and wash inside and out (inc. lid & foot pedal).                                          Deep clean weekly.                            (check clean Nursing
                                                                                                                                                          Staff)

                  Ventilation/extractor grills                             Mop/dust                         One clean weekly: deep clean by               Hospital Assistants
                                                                                                            contractor as part of PPM

       Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                 Door and frames                                          Blue Cloths                     One full clean daily                          Hospital Assistants

                 Walls                                                    Blue Cloths                     One check clean daily                         Hospital Assistants
                                                                                                          One full dust weekly

                 Lockers                                                  Blue Cloths                     One full clean daily outside. Inside          Hospital Assistants
                                                                                                          of lockers is users responsibility            outer surface/Nursing
                                                                                                                                                        Staff inside

                                                                                                                                                        All Tasks: Ward Staff
                                                                                                                                                        between cleans.

Cleaning Store   Floors (hard non-slip) to be brushed and mopped, deck    Blue mop, check / change head   Dust brush and mop daily + 1           HIGH   Hospital Assistants
Cupboard         scrub to be used weekly                                                                  check clean.
                                                                                                          Deck scrub weekly

                 Damp dust Low surfaces: sills and skirting               Blue cloths.                    1 full clean daily + one check clean          Hospital Assistants

                 Switches, Sockets & Radiators                            Blue cloths.                    1 full clean daily.                           Hospital Assistants

                 High surfaces: pipe work, picture frames, shelving etc   Blue cloths.                    One full clean weekly                         Hospital Assistants

                 Empty and replace bin bags with appropriate coded bags   Blue cloths.                    1 full clean + 1 check clean daily.           Hospital Assistants
                 and wash inside and out (inc. lid & foot pedal).                                         Deep clean weekly.


                 Ventilation/extractor grills                             Mop/dust                        One clean weekly: deep clean by               Hospital Assistants
                                                                                                          contractor as part of PPM

                 Door and frames                                          Blue Cloths                     One full clean daily                          Hospital Assistants

                 Walls                                                    Blue Cloths                     One check clean daily                         Hospital Assistants
                                                                                                          One full dust weekly

                 Sink                                                     Blue Cloths                     2 cleans daily: at the end of                 Hospital Assistants
                                                                                                          morning and evening shift. run taps
                                                                                                          twice weekly (* 1)

                 Cleaning equipment                                       Blue Cloths                     Full clean after each use                     Hospital Assistants

                                                                                                                                                        All Tasks: Ward Staff
                                                                                                                                                        between cleans.

Laundry Room     Floors (hard non-slip) to be brushed and mopped, deck    Blue mop, check / change head   Dust brush and mop daily + 1           HIGH   Hospital Assistants as
and ALL          scrub to be used weekly                                                                  check clean.                                  part of their rota.
STORES                                                                                                    Deck scrub weekly


       Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
              Damp dust Low surfaces: sills and skirting               Blue cloths.                    1 full clean daily + one check clean          Hospital Assistants

              Switches, Sockets & Radiators                            Blue cloths.                    1 full clean daily.                           Hospital Assistants

              High surfaces: pipe work, picture frames                 Blue cloths.                    One full clean weekly                         Hospital Assistants

              Empty and replace bin bags with appropriate coded bags   Blue cloths.                    1 full clean + 1 check clean daily.
              and wash inside and out (inc. lid & foot pedal).                                         Deep clean weekly.                            Hospital Assistants


              Ventilation/extractor grills                             Mop/Dust                        One clean weekly: deep clean by               Hospital Assistants
                                                                                                       contractor as part of PPM

              Door and frame                                           Blue Cloths                     One full clean daily                          Hospital Assistants

              Walls                                                    Blue Cloths                     One check clean daily                         Hospital Assistants
                                                                                                       One full dust weekly

              Sink                                                     Blue Cloths                     2 cleans daily: at the end of                 Hospital Assistants
                                                                                                       morning and evening shift. run taps
                                                                                                       twice weekly (* 1)

              Electrical Equipment                                     Blue cloths.                    Dust removal daily                            Hospital Assistants

              Washing Machine                                          Blue Cloths                     One full clean daily: check cleans            Hospital Assistants
                                                                                                       between washes                                Check clean to be
                                                                                                                                                     carried out by Nursing
                                                                                                                                                     staff

              Linen trolley                                            Blue Cloths                     Contact point clean daily: One full           Hospital Assistants
                                                                                                       clean weekly
                                                                                                                                                     N.B. This will form
              These areas should be kept accessible and storage                                                                                      part of FMA Linen
              should be off the ground where possible in order for                                                                                   services role but
              the area to be thoroughly cleaned                                                                                                      should be maintained
                                                                                                                                                     by Hospital Assistant
                                                                                                                                                     staff during A/L and
                                                                                                                                                     sickness

                                                                                                                                                     All Tasks: Ward Staff
                                                                                                                                                     between cleans.



Craft Room    Floors (hard non-slip) to be brushed and mopped, deck    Blue mop, check / change head   Dust brush and mop daily + 1           HIGH   Hospital Assistants
              scrub to be used weekly                                                                  check clean.
                                                                                                       Deck scrub weekly


      Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
             Damp dust Low surfaces: sills, skirting and cupboards    Blue cloths.                      1 full clean daily + one check clean          Hospital Assistants
                                                                                                                                                      (check clean Nursing
                                                                                                                                                      Staff)

             Switches, Sockets & Radiators                            Blue cloths.                      1 full clean daily.                           Hospital Assistants

             High surfaces: pipe work, picture frames, shelving etc   Blue cloths.                      One full clean weekly                         Hospital Assistants

             Internal glazing of doors/windows/partitions             Blue cloths.                      One check clean daily                         Hospital Assistants


             Empty and replace bin bags with appropriate coded bags   Blue cloths.                      1 full clean + 1 check clean daily.           Hospital Assistants
             and wash inside and out (inc. lid & foot pedal).                                           Deep clean weekly.                            (check clean Nursing
                                                                                                                                                      Staff)

             Ventilation/extractor grills                             Mop/dust                          One clean weekly: deep clean by               Hospital Assistants
                                                                                                        contractor as part of PPM

             Doors and frame                                          Blue Cloths                       One full clean daily                          Hospital Assistants

             Walls                                                    Blue Cloths                       One check clean daily                         Hospital Assistants
                                                                                                        One dust clean weekly

             Furniture: Tables and chairs                             Blue Cloths/Hoover for non-wipe   One full clean daily and one check            Hospital Assistants
                                                                      able                              clean daily
                                                                                                                                                      All Tasks: Ward Staff
                                                                                                                                                      between cleans.

ALL STORES   Floors (hard non-slip) to be brushed and mopped, deck    Blue mop, check / change head     Dust brush and mop daily + 1           HIGH   Hospital Assistants as
             scrub to be used weekly                                                                    check clean.                                  part of their rota.
                                                                                                        Deck scrub weekly

             Damp dust Low surfaces: sills and skirting               Blue cloths.                      1 full clean daily + one check clean          Hospital Assistants

             Switches, Sockets & Radiators                            Blue cloths.                      1 full clean daily.                           Hospital Assistants

             High surfaces: pipe work, picture frames                 Blue cloths.                      One full clean weekly                         Hospital Assistants

             Empty and replace bin bags with appropriate coded bags   Blue cloths.                      1 full clean + 1 check clean daily.
             and wash inside and out (inc. lid & foot pedal).                                           Deep clean weekly.                            Hospital Assistants


             Ventilation/extractor grills                             Mop/Dust                          One clean weekly: deep clean by               Hospital Assistants
                                                                                                        contractor as part of PPM

             Door and frame                                           Blue Cloths                       One full clean daily                          Hospital Assistants

             Walls                                                    Blue Cloths                       One check clean daily                         Hospital Assistants

     Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                                                                                                          One full dust weekly

               Sink (if present)                                        Blue Cloths                       2 cleans daily: at the end of          Hospital Assistants
                                                                                                          morning and evening shift. run taps
                                                                                                          twice weekly (* 1)

               These areas should be kept accessible and storage                                                                                 All Tasks: Ward Staff
               should be off the ground where possible in order for                                                                              between cleans.
               the area to be thoroughly cleaned


Conservatory   Floors (non-slip) to be dusted and mopped;               Blue mop, check / change head     Dust brush and mop daily + 1
               Machine clean weekly.                                                                      check clean.
                                                                                                          Machine Clean weekly

               Damp dust Low surfaces: sills, skirting, sideboards,     Blue cloths.                      1 full clean daily + one check clean
               media units


               Switches, Sockets & Radiators                            Blue cloths.                      1 full clean daily.

               High surfaces: pipe work, picture frames, shelving etc   Blue cloths.                      One full clean weekly

               Internal glazing of doors/windows/partitions             Blue cloths.                      One check clean daily


               Empty and replace bin bags with appropriate coded bags   Blue cloths.                      1 full clean + 1 check clean daily.
               and wash inside and out (inc. lid & foot pedal).                                           Deep clean weekly.


               Ventilation/extractor grills                             Mop/dust                          One clean weekly: deep clean by
                                                                                                          contractor as part of PPM

               Doors and frames                                         Blue Cloths                       One full clean daily

               Walls                                                    Blue Cloths                       One check clean daily
                                                                                                          One dust clean weekly

               Electrical equipment; TV, HI-FI, DVD player etc          Blue Cloths                       One clean daily(dust removal)
                                                                                                          One full clean monthly

               Furniture: Tables and chairs                             Blue Cloths/Hoover for non-wipe   One full clean daily and one check
                                                                        able                              clean daily

All Areas      Ceilings and walls                                                                         Full washing yearly                    Approved contractor
All Areas      Curtains and Blinds                                                                        Clean, change or replace yearly        Hospital Assistants to
                                                                                                                                                 organise with Ward
                                                                                                          Curtains/blinds should be visibly      manager.
       Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                                                                                                     clean and free from any body
                                                                                                     substances, stains or dirt           All staff to be vigilant.
                                                                                                     (including shower curtains)
All Areas        Mechanical Vents                                                                    To be cleaned quarterly as part of   Approved Contractor
                                                                                                     maintenance contract
All Areas        Windows, internal glazing and external glazing                                      To be cleaned quarterly as per       Approved Contractor
                                                                                                     maintenance contract.
Bathrooms        Shower traps                                                                        To be cleaned as part of             Approved Contractor
                                                                                                     maintenance by approved              (Team Co-ordinator
                                                                                                     contractor-agreed Monthly            to arrange)
All Areas        Fire Extinguisher                                    Blue Cloths                    To be cleaned weekly


       These schedules are subject to change depending upon the needs of the ward occupants
           1 Refers to unused outlets, please refer to your “Register of Unused Outlets and Flushing Schedules”




       Appendix 3.

       A-Z Decontamination of Equipment and Medical Devices.
       Staff must follow the Infection Control Decontamination of Equipment and Medical Devices Guidelines as listed in the following
       section, to ensure that items are decontaminated and that no staff or service user is put at risk.

       The individual indicated in the responsible person column must decontaminate the item as indicated in the method column.

       The term Nurse has been used to describe the professional directly delivering care however in certain areas the individual may
       belong to another discipline e.g. Physiotherapist, Technical Instructor, Occupational Therapist etc.

       Overall accountability for ensuring provision of single use items and appropriate decontamination of reusable items lies with the
       Clinical Area/Ward Manager or Modern Matron, this includes regular audit to ensure compliance with the standards as set out in the
       Medical devices policy.
       Medical Device                         Method                                                            Responsible Person
       Airways                                Single use only.                                                  Nurse
       Ambubag                                Single use only.                                                  Nurse
       Ambu-lift/Hoist                        After each use, wash with neutral detergent. If contaminated with Nurse

       Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                                        body fluids, clean with high level disinfectant.
Auriscope                               Use disposable earpieces if available, or wash in neutral detergent    Nurse
                                        to remove the wax. Rinse and store dry.
Bath                                    Clean between clients                                                  Nurse

                                        Titan may be used to remove stains.                                    Domestic/Housekeeper
                                                                                                               (daily)
Bedding:-                                                                                                      See Linen Policy

Wipe Clean Duvets and Pillows           Clean as for mattress – after each service user use, or when visibly   Nurse
                                        soiled/bodily fluids


Bed frames                              Clean with high level disinfectant                                     On discharge or if
                                                                                                               contaminated with body fluids
                                                                                                               - Nurse

                                                                                                               Weekly - Domestic
Bedpans                                 Disposable single use – empty contents in toilet and dispose of into   Nurse
                                        appropriate waste stream
Bedpan Holders                          Clean with high level disinfectant                                     Nurse

Blood Glucose Monitoring Machine        Clean after every use as per manufacturer’s instructions.              Nurse

Blood Pressure Cuffs                    Wipe with neutral detergent or disinfectant wipe between each          Nurse
                                        service user, Use a dedicated cuff for a known infectious service
                                        user, which can be washed or disposed of at the end of care
                                        episode or use a single use cuff.
Bowls (washing)                         Use disposable wash bowls                                              Nurse
Brushes
Hairbrushes                            Individual use only. Wash in neutral detergent, rinse and leave to      Service user/Nurse
                                       dry.
Lavatory brushes                       Rinse in flushing water and store dry. Toilet brush holder should be    Domestic/Housekeeper
                                       cleaned once a week with high level disinfectant and when visibly
                                       soiled
Nailbrushes                            Individual use only.                                                    Service user/Nurse
Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
Shaving brushes                        Individual use only.                                                   Service user/Nurse
Toothbrushes                           Individual use only.                                                   Service user/Nurse
Buckets                                Wash with neutral detergent (with mop-buckets, ensure that the         Domestic/Housekeeper
                                       wringer removed and is cleaned thoroughly), rinse and dry before
                                       storing inverted.
Carpets                                Vacuum daily, periodically clean by hot water extraction and carpet    Domestic/Housekeeper
                                       shampoo, or following gross spillage with high level disinfectant.
                                                                                                              Following bodily fluid spillage
                                                                                                              - Nurse
Catheters                              Single use – dispose of into appropriate waste stream.                 Nurse


Catheter Stands                        Wash daily with neutral detergent, rinse and dry. If contaminated by   Nurse
                                       body fluid, clean with a solution of high level disinfectant
Chiropody instruments                  Single use instruments to be used                                      Suitably qualified staff
Cleaning Cloths                        Must be disposable.                                                    Domestic/Housekeeper
Combs                                  Individual use. Wash in neutral detergent, rinse and leave to dry      Service user/Nurse
Commodes                               Clean with high level disinfectant between uses. Individual named      Nurse
                                       service user use preferred. (ICT approved wipes may be used)
Cot Sides                              Clean with high level disinfectant.                                    Nurse
Crockery/Cutlery                       Use Dishwasher                                                         Domestic/Housekeeper or
                                                                                                              Nurse
                                                                                                              As per local arrangements
Curtains                               Must be washed/dry cleaned, steam cleaned annually. Must be            Domestic/Housekeeper
                                       washed/dry cleaned, steam cleaned after outbreak of
                                       Norovirus/C. diff as part of terminal cleaning – see policy
Dental Equipment & Instruments         All Medical devices associated with dental care must be                Dental Nurse
                                       decontaminated in line with the local standard operating procedures
Dish Cloths                            Use green disposable dish cloths                                       Domestic/Housekeeper/Nurse
Drainage Bags                          Empty contents into toilet and dispose of bag and tubing into          Nurse
                                       appropriate waste stream.
Dressing Trolley                       Clean with high level disinfectant before and after use.               Nurse
Drip Stands                            Damp dust with neutral detergent if contaminated with body fluids,     Nurse
                                       clean with high level disinfectant
Examination Couches                    Cover with disposable paper roll and change between service            Nurse

Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                                       users. Clean with high level disinfectant or disinfectant wipes after
                                       each session.
Enteral Feeding Pumps/Equipment        Wash with neutral detergent, rinse and dry with paper towels, or        Nurse
                                       follow manufacturer’s instructions.

                                       The feeding tube should be flushed with fresh tap water, before and
                                       after feeding or administrating medication. Enteral feeding tubes for
Enteral Feeding Tube                   service users, who are immunosuppressed, should be flushed with
                                       either cooled freshly boiled water, or sterile water from a freshly     Nurse
                                       opened container.
Feeding cups                           Use dishwasher                                                          Domestic/Housekeeper/Nurse
Floors (dry-Carpet)                    Vacuum clean. (hepa-filtered preferred)                                 Domestic/Housekeeper
Floors (Wet)                           Contain spillage then mop or shampoo.                                   Domestic/Housekeeper
                                       If body fluid spillage use high level disinfectant.
                                                                                                               Bodily Fluids – Nurse
Laryngoscope                           Single use/ handle to be cleaned with Azo wipes between patient         Nurse
                                       uses.

Locker Tops/Tables                     Clean with high level disinfectant.                                     Domestic/Housekeeper

                                                                                                               Lockers cleaned by Nurses
                                                                                                               on Discharge/Transfer
Linen                                  Follow Linen Policy                                                     Nurse
Masks and O2 Tubing                    Individual service user use only, which is changed when dirty and       Nurse
                                       discarded in appropriate waste stream.
Mattresses                             Clean mattress monthly with high level disinfectant and after every     Nurse
                                       episode of incontinence and when a service user is transferred or
                                       discharged.
                                       For special mattresses – follow manufacturer’s instructions.
Medicine Pots                          Single use.                                                             Nurse
Mops (floor)                           Rinse well after each use and store inverted to dry. Change and         Domestic/Housekeeper
                                       launder daily, or use disposable mop heads.
Moving and Handling Board              Clean with high level disinfectant. after each use.                     Nurse
Nail Clippers                          Individual service user use or disposable.                              Nurse
Nebuliser Mask                         Individual use only. Wash in neutral detergent after every use,         Nurse

Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
                                       rinse and leave to dry, cover between therapies.
Acorn and Tubing                       Wash in neutral detergent and rinse and hang tubing to dry after       Nurse
                                       every use.
Ophthalmoscopes                        Wipe with neutral detergent or follow manufacturer’s instructions.     Nurse
Oxygen Cylinder Frames                 Use neutral detergent, and dry with paper towel.                       Nurse
Patella Hammer                         Wipe with neutral detergent after each use.                            Nurse
Peak Flow Meter                        Use single use disposable mouth pieces with filters.                   Nurse
Razors                                 Use disposable or single service user use electric razors. Follow      Nurse
                                       manufacturer’s instructions for cleaning electric razor-heads and
                                       disposable razors to be placed in sharps box.
Scissors                               For clinical procedures, use single use disposable scissors.           Nurse
Shower                                 If not regularly used, flush as per Legionella policy.                 Daily –
                                       Clean between service users’ use.                                      Domestic/Housekeeper

                                                                                                              Between service user - Nurse
Slip Sheets, Hoist Slings (Moving &    Single person use only, mark with client’s name. Send to laundry       Nurse
Handling)                              when soiled.
Sputum Container                       Disposable. Dispose into appropriate waste stream.                     Nurse
Stethoscopes                           Clean diaphragm and ear-pieces with wipe after every use.              Nurse
Stoma bags                             Single use, dispose of via appropriate waste stream.                   Nurse
Syringes                               Single use                                                             Nurse
Suction Units                          Use disposable liners and catheters. Wash bottles with neutral         Nurse
                                       detergent, rinse and dry using paper towel.
Surgical Instruments (Minor surgery)    Single use only, dispose into appropriate waste stream                Nurse

Tablet Cutters                         Wash thoroughly between use with neutral detergent and dry with        Nurse
                                       paper towel
Thermometers                           Use disposable thermometers or those with a disposable sleeve.         Nurse
                                       Digital – use a new sleeve cover for each use. See manufacturer’s
                                       instructions to clean thermometer.
Urine Jugs                             Disposable single use – empty contents in toilet and dispose of into   Nurse
                                       appropriate waste stream
Volumatics                             Single service user use. Wash in neutral detergent monthly, allow to   Nurse
                                       air dry (do not wipe dry)
                                       Rees, J., Kanabar, D. (2007)

Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
Wheelchairs                                   Individual service user use, whenever possible. Wash daily with                Nurse
                                              neutral detergent, rinse and dry. If contaminated with body fluids
                                              clean with a solution of high level disinfectant.
Weighing Scales (seated adult)                Line with disposable paper towels. Clean with neutral detergent                Nurse
                                              daily and keep dry. If contaminated with bodily fluids, clean with
                                              high level disinfectant.
                                              N.B In most areas of the Trust, patient weighing scales are
                                              used to give an approximate weight of the service user- Class
                                              1V scales are therefore acceptable for use where the weight
                                              indication is not to be used for the purpose of monitoring,
                                              diagnosis and medical treatment. Where an exact weight is
                                              required (e.g. to obtain accurate medication dose) then Class
                                              111 scales should be used as a minimum and these should be
                                              subject to servicing and calibration as per manufacturers
                                              instructions.


Appendix 4.

Policy Implementation Plan

POLICY NO: SA16
RATIFYING:
DATE REVIEWED: February 2012
NEXT REVIEW DATE: June 2013

ACCOUNTABLE DIRECTOR: Director Facilities

POLICY AUTHOR:        FACILITIES MANAGER/PEAT LEAD

An implementation plan should be completed for all policies. This will ensure that a systematic approach is taken to the introduction of policies in order to
secure effective working practices.

The following template provides a checklist to be used as a starting point for thinking about implementation in a systematic manner. It is evidenced based
and draws on the work of the Promoting Action on Clinical Effectiveness (PACE) programme (Dunning et al, 1999)



Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
IMPLEMENTATION PLAN                                                                                                                   Time-Scale
                                               Issues identified / Action to be taken
Co-ordination of implementation
 How will the implementation plan be co-      The implementation plan will be co-ordinated by the Director of Estates and           Within 1 month
    ordinated and by whom?                     Facilities. The plan will include distribution of the policy in accordance with the   of ratification
Clear co-ordination is essential to monitor    guidance in Policy and Procedure for the Development, Ratification,
and sustain progress against the               Distribution and Reviewing Policies and Procedures.
implementation plan and resolve any further
issues that may arise.                         The Policy will be distributed by the Infection Prevention and Control
                                               Committee (IPCC) and this forum will be used to evaluate the policies
                                               effectiveness as well as addressing operational issues relating to the
                                               implementation of the Policy.

                                               This committee will also be used as the forum for future reviews and subs
Engaging staff
 Who is affected directly or indirectly by    Infection Prevention and Control Link Nurses                                          Ongoing -
   the policy?                                 Modern Matrons                                                                        Continuous
 Are the most influential staff involved in   Domestic/Facilities Management
   the implementation?                         PEAT Teams
Engaging staff and developing strong           Hospital Assistants
working relationships will provide a solid     Housekeepers
foundation for changes to be made.             FM Assistants
                                               Ward Managers
                                               Consultants and Doctors
                                               Nursing staff
                                               Admin staff

                                               Influential staff are:

                                               Infection Prevention and Control Link Professionals
                                               Modern Matrons
                                               Housekeeping Services
                                               Domestic/Facilities Management
                                               PEAT Teams




Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
IMPLEMENTATION PLAN                                                                                                                   Time-Scale
                                                  Issues identified / Action to be taken
Involving service users and carers                                                                                                   PEAT process
 Is there a need to provide information to       Every service user, their carers and visitors could have a copy of this policy     covers the
    service users and carers regarding this       upon request. However service users will be represented through the Infection      period –
    policy?                                       Prevention and Control Committee and the PEAT Processes.                           January to
 Are there service users, carers,                                                                                                   March each
    representatives or local organisations        Service users and carers are invited to participate within the PEAT Process        year.
    who     could      contribute   to     the    and through the Mersey Care NHS Trust website can view the scores for the
    implementation?                               National Specifications of Cleanliness when they are published.                    Pre PEAT
Involving service users and carers will                                                                                              involvement
ensure that any actions taken are in the                                                                                             cover the
best interest of services users and carers                                                                                           period –
and that they are better informed about their                                                                                        September to
care.                                                                                                                                November
                                                                                                                                     each year.
Communicating
 What are the key messages to                    Key messages are:
    communicate       to     the      different
    stakeholders?                                 This Policy details the principles which underpin the approach to the              Ongoing -
 How       will   these     messages       be    management of cleanliness and duties under the Health and Social Care Act          Continuous
    communicated?                                 2008.
Effective communication will ensure that all
those affected by the policy are kept             Outlines the responsibilities of Managers and staff that keep all areas clean
informed thus smoothing the way for any           and free from infection.
changes. Promoting achievements can also
provide encouragement to those involved.          Messages communicated by Mersey Care website, Mersey Cares magazine
                                                  and Team Brief. Circulation to Trust Managers via e-mail. Staff will receive a
                                                  copy of the procedure if requested.
Training
 What are the training needs related to          Training needs will be identified by the management processes in place and         Ongoing –
     this policy?                                 information will be shared with all stakeholders to include Staff Side with        Continuous
 Are people available with the skills to         regards to the policy.
     deliver the training?
All stakeholders need time to reflect on what     Vocational training is available via the E Café – E Learning and Local Colleges.   Ongoing –
the policy means to their current practice                                                                                           Continuous
and key groups may need specific training         The training will also be delivered in-house by the Housekeeping/Domestic          Annually and
to be able to deliver the policy.                 Management departments and all associated staffs will be included.                 as required

Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
IMPLEMENTATION PLAN                                                                                                                   Time-Scale
                                                   Issues identified / Action to be taken
Resources
 Have the financial impacts of any                Indirect costs associated with re-training of staff.                              Ongoing
     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 e.g.
     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           Current lack of consistency with regard to the implementation of the 13 week      Ongoing -
     realistic ways to overcome them been          review work book – this policy will help to create a consistent framework from    Continuous
     identified?                                   which the whole Trust can work to.
 Who needs to change and how do you
     plan to approach them?                        Current demands for mandatory, statutory and vocational training – this will be
 Have arrangements been made with                 overcome by widening training opportunities to include E Learning and offering
     service managers to enable staff to           support at local sites throughout the Trust.
     attend briefing and training sessions?
 Are arrangements in place to ensure the          Managers involved in this process will be released to attend training sessions.
     induction of new staff reflects the policy?
Initial barriers to implementation need to be      All staff will be made aware of the policy at induction training.
addressed as well as those that may affect
the on-going success of the policy




Corporate Cleaning Standards Policy Version 3 Review Date: June 2013
IMPLEMENTATION PLAN                                                                                                          Time-Scale
                                               Issues identified / Action to be taken
Evaluating
 What are the main changes in practice        The main change should be consistent monitoring and recording for the PEAT   PEAT Periods
    that should be seen from the policy?       Process and ERIC returns.                                                    are: January to
 How        might   these      changes   be                                                                                March each
    evaluated?                                 Lessons from this implementation should focus on the correct standards and   year.
 How will lessons learnt from the             guidelines now in place for everyone to adhere and refer to.
    implementation of this policy be fed                                                                                    Pre PEAT
    back into the organisation?                Feedback is through monitoring and primarily the PEAT process. PEAT          Periods are:
Evaluating and demonstrating the benefits      results, subsequent actions plans and issued found on the ‘inspection’ are   September to
of new policy is essential to promote the      feedback to the relevant CBU Leaders and copies sent to Estates Department   November
achievements of those involved and             and the Infection Prevention Control Team.                                   each year.
justifying changes that have been made.
                                               An annual report is also submitted to the Integrated Governance Committee.   Annual
                                                                                                                            Reporting
           Other considerations




Corporate Cleaning Standards Policy Version 3 Review Date: June 2013

								
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