Document Title: CLEANING POLICY

Document Reference/Register no: 09033 Version 6.0

Number:

Document type: (Policy/ Guideline/ Policy To be followed Domestic Team

SOP) by: (Target Staff)

Ratification Issue Date: 14th December 2018 Review Date: 13th December 2021
(Date document is uploaded onto the
intranet)

Developed in response to: National Guidance/Recommendations

National Specifications for Cleanliness in the NHS
Contributes to HSC Act 2008 (Regulated Activities) Regulations 2014(Part 3);
and CQC Regulations 2009 (Part 4)
CQC Fundamental Standards of Quality and Safety: 15
Issuing Division/Directorate: Estates and Facilities

Author/Contact: (Asset Georgina Sawyer, Estates & Facilities Management

Administrator)

Hospital Sites: MEHT

(tick appropriate box/es to indicate □ BTUH
status of policy review i.e. joint/ □ SUH
independent)
Consultation: (Refer to page 2)

Approval Group / Committee(s): n/a Date: n/a

Professionally Approved by: (Asset Jo Mitchell, Quality Assurance Date: 19th November 2018
Owner) Manager (MSB Group)

Ratification Group(s): Document Ratification Group Date: 3rd December 2018

Executive and Clinical Directors Date: Distribution Method: Trust Intranet/ Internet
(Communication of minutes from December 2018
Document Ratification Group
 Cleaning Policy/09033/6.0

Consulted With: Post/ Approval Committee/ Group: Date:

Maggie Bayley Interim Director of Nursing November 2018
Sian Olivo Interim Associate Director Infection Prevention Control November 2018
Garry Bardsley Estates & Facilities Site Manager November 2018
Andy Wright Domestics Service Manager November 2018
Steve Lewis H&S Manager November 2018

Related Trust Policies (to be read in 04070 Decontamination Policy

conjunction with) 08029 Isolation Policy
04072 Hand Hygiene Policy
04088 Waste Management Policy
08021 Linen & Curtain Policy
04077 Procedure for the Control of an Outbreak of Infection
in Hospital
09047 Cleaning Commodes and Bedpans Policy
09157 Strategic Cleaning Plan
10003 Mattress Policy
11023 COSHH Policy

Document Review History:

Version Authored/Reviewer: Summary of amendments/ Issue Date:
No: Record documents superseded by:
1.0 Ricky Cichon 14/12/09
2.0 Jo Mitchell 04/01/10
3.0 Jo Mitchell Amendment to colour coding, audit chart & 16/03/10
terminal clean check sheet
3.1 Jo Mitchell Amendment to Terminal Clean check-sheet 27/05/10
(Appx E and Colour Coding Appx F)
3.2 Ricky Cichon Amendments in accordance with centralisation May 2011
on Broomfield site
3.5 Vicki Chapman Addition of COSHH and breach of policy Jan 2012
statements
4.0 Vicki Chapman Addition of foul weather plan June 2012
5.0 Vicki Chapman Formal Review August 2014
5.1 Vicki Chapman Amendment to frequency of cleaning reports. Nov 2014
5.2 Jo Mitchell Extended for standardisation and review Nov 2017
process (Success Regime)
5.3 Georgina Sawyer Addendum to policy to updated information on 11 May 2018
curtain changing schedules. Sections 10 & 11
5.4 Georgina Sawyer Addendum to monitoring section point 24 15/102018
6.0 Georgina Sawyer Full Review 14th December 2018

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Contents

1 Introduction ................................................................................................................. 4

2 Scope ........................................................................................................................... 4

3 Definitions ................................................................................................................... 5

4 Roles and Responsibilities ........................................................................................ 6

4.1 Role & Responsibilities within the Trust (Committees) .................................... 6

4.2 Role & Responsibilities of Individuals within the Trust .................................... 6

5 Cleaning Procedure .................................................................................................... 9

6 Training Requirements ............................................................................................. 15

7 Monitoring and Audit ................................................................................................ 16

8 Approval and Implementation ................................................................................. 18

9 References ................................................................................................................ 18

10 Equality Impact Assessment ................................................................................... 19

Appendix 1: Procedure for Routine Cleaning of Bed and Bed Space ......................... 20

Appendix 2: Procedure for Standard Isolation Bed and Bed Space in a Barrier Area
(Bed in Use) ...................................................................................................................... 21

Appendix 3: Terminal Cleaning Procedure for Isolation Bed and Bed Space (between
Admissions) ..................................................................................................................... 22

Appendix 4: National Colour Code ................................................................................. 24

Appendix 5: Cleaning Monitoring and Auditing Process ............................................. 25

Appendix 6: Equality Impact Assessment Form ........................................................... 26

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1 Introduction
1.1 Ensuring hospitals are clean and safe is an essential component in the provision of
effective healthcare. A clean and tidy environment is an outward manifestation of the
health of the NHS and provides the right setting for good patient care practice. It is
fundamental in assisting patients to recover and help in the prevention and/or control
of the spread of healthcare associated infections.

1.2 Cleanliness and infection control are closely linked in the public mind, however there
are important distinctions to be made; whilst cleanliness contributes to infection
control, preventing infections requires more than simple cleanliness.

1.3 There are numerous publications to assist Trusts in ensuring that their cleaning
programmes are properly focussed, effectively resourced and that they consistently
deliver high quality services that are well regarded by patients.

1.4 The cleaning of premises within the Trust is carried out by teams of Domestic
Assistants. The focus on improving hospital cleanliness and reducing healthcare
associated infection has never been more topical and it is important to recognise the
important role that domestic staff plays in ensuring public confidence in the overall
cleanliness of the hospital environment. This is recognised and supported by
management and clinical teams.

2 Scope

2.2 This document sets out the approach of the Trust to deliver a clean and safe
environment for everyone using its facilities and should be read in conjunction with the
Trust’s Strategic Cleaning Plan.

2.3 This Cleaning Policy supported by the Strategic Cleaning Plan will enable the Trust to
comply with all relevant legislation and guidance, in particular the Health and Social
Care Act (2008) and the National Specifications for Cleanliness in the NHS (2007).

2.4 A clean hospital environment is paramount to all staff and patients. Whilst this is
important from an aesthetic perspective, it is also of significance with regard to the
minimisation of risk, including the incidence of healthcare associated infection. There
are many factors that influence the overall impression presented by the organisation,
in addition to those of cleanliness and maintenance and the Trust therefore recognises
its responsibilities to wider environmental issues.

2.5 Maintenance, as well as cleaning, is essential in ensuring a safe and aesthetically

pleasing environment, and it is recognised that as buildings and equipment become
old, they often become more difficult to keep clean. The achievement of this policy will
be through the ongoing application, review and evaluation of the Trusts Cleaning
Schedules and Service Level Agreements. It is stressed however that all employees
have a responsibility for caring for the environment.

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2.6 Recognising that cleanliness is everyone’s responsibility the aim of the cleaning policy
is to:
 Provide direction in maintaining and improving cleanliness standards across all
hospital sites and premises, ensuring a clean, comfortable and safe environment for
patients, clients, visitors, staff and members of the general public
 Increase patient confidence whilst using the hospital facilities in relation to
environmental hygiene and the organisational commitment to reduce the incidence
of healthcare associated infection; and
 Provide the opportunity to improve cleanliness standards in terms of the national
standards of cleanliness and patient environment action teams

2.7 The cleaning policy embraces all cleaning activity within the Trust. This includes all
general scheduled and reactive cleaning activities undertaken by the Trust’s Domestic
Services Department, as well as those traditionally undertaken by the Estates
Department (i.e. wall washing, ceiling vents) , cleaning duties undertaken by nursing
staff (i.e. patient related equipment) and cleaning duties undertaken by catering staff
(i.e. kitchen areas and catering equipment).

2.8 In line with the National Specification of Cleanliness healthcare environments should
pose minimal risks to patients, staff and visitors. However different functional areas
represent different degrees of risk and therefore require different cleaning frequencies
and different levels of monitoring and auditing. All functional areas are assigned to one
of four risk categories:
Risk Category Example of Functional Area

Very High Risk Burns Unit, ITU/HDU, A&E, Neonatal, Theatres, and other areas
Areas where invasive procedures are performed.

High Risk Areas Wards, Sterile Services, Pharmacy, Public toilets and
thoroughfares.

Significant Risks Pathology, Outpatients, laboratories and mortuary.

Low Risk Areas Administrative areas, non-sterile supply areas, healthcare records.

2.9 This policy excludes any cleaning requirements for wards or departments that are
closed either on a temporary or permanent basis.

3 Definitions

TERM DEFINITION
Cleaning A process which physically removes organic matter but does
not necessarily destroy micro-organisms. It is carried out using
detergent to help remove the debris
Disinfection / The removal of micro-organisms to a safe level, carried out
decontamination using either heat or a disinfectant chemical. Disinfection /
decontamination cannot take place on an unclean surface as
organic matter will interfere with the disinfectant. Therefore all
surfaces must be cleaned before they can be disinfected.

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4 Roles and Responsibilities

4.1 Role & Responsibilities within the Trust (Committees)

Infection Prevention and Control Group

The Infection Prevention and Control Group are responsible for:
 Reviewing and supporting the implementing the Strategic Cleaning Plan and
Cleaning Policy;
 Assisting in ensuring the Trust is compliant with decontamination guidance and
Prevention and Control of Healthcare Associated Infections and related guidance;
 Giving assurance that local decontamination practices meet with national
standards; reviewing cleaning standards audit results and cleaning operational
procedures.

4.2 Role & Responsibilities of Individuals within the Trust

4.2.1 Chief Executive

The Chief Executive is responsible for:
 Ensuring that there are effective arrangements for infection control throughout
the Trust;
 Ensuring sufficient resources to comply with this policy.

4.2.2 Chief Estates & Facilities Officer

The Chief Estates & Facilities Officer is responsible for:
 Ensuring hospital cleanliness is high on the corporate agenda;

4.2.3 Estates & Facilities Site Manager

The Estates & Facilities Site Manager is responsible for:
 Ensuring Hospital cleanliness is high on the corporate agenda;
 Ensuring that premises are fit for purpose, maintained and clean;
 Providing professional leadership for cleaning services;
 Providing the operational cleaning framework within which the Domestic teams
operate.

4.2.4 Director of Nursing

The Director of Nursing is responsible for:
 Ensuring that nursing practice is in line with Trust policies and objectives;
 Ensuring that job descriptions and appraisals are in place and reflect the
importance of infection control;
 Ensuring that nurses and midwives are trained effectively in key techniques.

4.2.5 Associate Director of Operations and Clinical Directors

The Associate Director of Operations and Clinical Directors are responsible for:
 Ensuring effective management practice and response is maintained in relation to
infection control to effectively contribute to a reduction in hospital acquired
infection and achievement of the MRSA and Clostridium difficile trajectories;
 Ensuring all staff in their areas are aware of and understand this Policy that it is
embedded into practice locally and within their areas of responsibility;

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 Investigating failures to comply with this Policy and ensure corrective action is
taken to prevent a recurrence.

4.2.6 Associate Directors of Nursing

The Associate Directors of Nursing are responsible for:
 Supporting the performance and delivery of access targets within an environment
that does not compromise clinical practice but maximises the opportunity to ensure
delivery with infection free environments;
 Supporting discussion at speciality and Directorate meetings to make sure that
there is a routine review of infection data and take action to maintain compliance
with the Directorates;
 Ensuring that all nurses and midwives are suitable trained and that job
descriptions, objectives and appraisals reflect the importance of infection control;
 Holding Lead Nurses to account for nursing/midwifery practice in their area;

4.2.7 Matrons
The Matrons are responsible for:
 Delivering a safe and clean care environment with direct responsibility for Ensuring
that cleanliness standards are maintained throughout the shift;
 Ensuring all staff are familiar with escalation procedures for additional cleaning;
 Ensuring that all patient equipment is cleaned between patient use to standards as
outlined within the National Specification for Cleanliness, April 2007;
 Ensuring that correct documentation is completed to evidence that cleaning
practices have been undertaken;
 Working closely with the ward/departmental domestic staff.

4.2.8 Nursing & Housekeeping staff

Nurses and Ward Housekeepers are responsible for:
 Delivering a safe and clean care environment with direct responsibility for Ensuring
that cleanliness standards are maintained throughout the shift;
 Ensuring familiarisation with escalation procedures for additional cleaning;
 Ensuring that all patient equipment is cleaned between patient use to standards as
outlined within the National Specification for Cleanliness, April 2007;
 Ensuring that correct documentation is completed to evidence that cleaning
practices have been undertaken;
 Working closely with the ward/departmental domestic staff.

4.2.9 Infection Prevention Team

The Infection Prevention Team will work closely with the Domestic Services
department to:
 Provide technical advice on specialised cleaning agents, equipment and
methodology of cleaning;
 Provide advice and be consulted on all matters related to cleaning contracts and
cleaning frequencies; provide appropriate infection prevention training to Trust
staff.

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4.2.10 Quality and Assurance Team

The Quality and Assurance Team are responsible for:
 Delivering and ensuring compliance against the cleaning auditing programme;
 Providing audit results and actions, and weekly and monthly cleaning reports to
senior management (Chief Executive, Chief Estates & Facilities Officer and Site
Manager, Director of Nursing, ANDs, ADO’s, Matrons and Sisters) ;
 Escalating issues related to cleanliness to Senior Management.

4.2.11 Domestic Services Manager

The Domestic Services Manager is responsible for:
 Managing the day to day service delivery of the Domestic cleaning service
within the Trust. Responsibilities include:
 Setting standards;
 Selecting equipment, products, methods of cleaning;
 Compiling work schedules and outcomes;
 Setting staffing levels within budget;
 Establishment and ongoing review of Strategic Cleaning Plan and Cleaning
Policy;
 Quarterly Cleaning Report on cleaning standards.

4.2.12 Domestic Team Leaders

The Domestic Team Leaders are responsible for:
 Working with the ward/department and undertaking cleaning monitoring of the
ward/department in accordance with the national specifications;
 Leading a team of Domestic Staff and ensuring that the day to day cleaning
duties are completed in accordance with the service specifications determined
within the ward/department.

4.2.13 Domestic Staff/Team

The Domestic staff are responsible for:
 Working with the ward/department and undertaking cleaning duties in
accordance with service specifications determined within the ward/department.

4.2.14 Catering Staff/Team

The Catering Staff are responsible for:
 Working with the ward/department and undertaking cleaning duties involving
ward/zonal kitchen areas, beverage rooms and all kitchen equipment in
accordance with the service specifications determined within the
ward/department.

4.2.15 All staff

All staff have a duty to maintain a clean environment. Cleaning is everyone’s
responsibility and staff should ensure their work does not have a negative impact on
the work of the housekeeping teams.

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5 Cleaning Procedure
5.1 Cleaning Folder - a cleaning folder has been developed and implemented whereby
all cleaning information and records relating to a ward/department are centrally
located, clearly identifying cleaning responsibilities for domestic, nursing and estates

5.1.2 The Cleaning Folder should be easily accessible to all staff working in a
ward/department, e.g. nurse’s station.

5.1.3 Results from cleaning audits and subsequent action plans are emailed to the
ward/department senior lead by the Quality and Assurance Team to monitor progress
and highlight any outstanding issues.

5.1.4 The checklists used within the Cleaning Folder are those developed within the
Cleaning and Decontamination policies which are also included within the folder.

5.2 Procedure of Cleaning

5.2.1 All clinical areas must be cleaned daily using an approved product.

5.2.2 Infected areas such as isolation rooms must been cleaned daily using an approved
product and a Terminal Clean completed upon the patient’s discharge.

5.2.3 Appropriate cleaning of each patient bed and bed space should occur on a daily
basis and between every patient admission in accordance with guidelines. A
breakdown of which methods of cleaning should be followed in accordance with the
Trust’s Isolation Policy. These include:

 Procedure for Routine Cleaning of Bed and Bed Space Appendix 1;

 Procedure for Standard Isolation Cleaning of Bed and Bed Space in a Barrier Area
(bed in use) – Appendix 2;
 Terminal Cleaning Procedure for Isolation Bed and Bed Space (between
admissions) – Appendix 3.

5.2.4 The Trust pledges that patients will be admitted to both a bed and bed space
thoroughly cleaned after the last patient. It is unacceptable to admit a patient into a
bed space until this has been completed. The use of a signed and dated green
ribbon indicates that a bed space and equipment have been cleaned.

5.2.5 Ward Sisters or their deputy will undertake a risk assessment in the event of internal
patient transfers within the ward environment due to clinical necessity.

5.2.6 The cleaning agents to be used are as follows:

Detergent = 1% neutral detergent = Clinnell or detergent wipes or combined

detergent / disinfectant wipes
Tristel Fuse = mix with 5litres of cold water

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5.2.7 The national colour coding scheme is adopted within the Trust in accordance with
the National Specification of Cleanliness.
(Refer to Appendix 4)

5.2.8 Mattresses should be cleaned between each patient following discharge as outlined
in Bed Space procedures in Appendix 1 and D and as set out in the Mattress Policy.
Nursing staff are responsible for checking the integrity of the mattress cover and
foam core during this process. Nursing staff must complete the procedures
regarding cleaning and returning mattresses as outlined in the Mattress policy.

5.3 Hydrogen Peroxide Vapour (HPV) Decontamination Technology

5.3.1 This method of decontamination, also known as ‘fogging’, is ideally suited for use in
healthcare facilities due to its rapid, flexible and 'residue-free' nature. HPV has
extensive, proven biological efficacy against a wide range of environmentally
associated pathogens. This procedure must only be carried out by trained domestic
staff in accordance the HPV policy.

5.3.2 HPV decontamination can be applied safely even where expensive electronic
equipment is situated. HPV decontamination has proven material compatibility so all
equipment can be safely decontaminated in situ with no detrimental effect on
performance or aesthetics. This is critical during the "deep clean" process where
these areas have traditionally been hard to reach or where the decontaminants are
incompatible with sensitive electronics, particularly chlorine-based products
(including bleach). This process is also used following clearance from Infection
Prevention Team over Clostridium difficile (C diff) patients.

5.4 Standard for Curtain Changing

5.4.1 In accordance with the national specifications for cleanliness in the NHS,
curtains/blinds should be visibly clean with no blood and body substances, dust,
dirt, debris, stains or spillages. Curtains must be changed immediately when visibly
soiled and during a terminal clean, or as part of the Curtain Change Programme as
outlined below:
Very High Risk Areas Change four monthly
High Risk Areas Change six-monthly
Significant Risks and Low Risk Change 12-monthly
Areas
Shower curtains are changed monthly.

5.4.2 Curtain changes are recorded on a Log held in the Domestic Team Leaders office
and the change is indicated as either an ad hoc or a programmed change.

5.5 Standard for Radiator Cleaning

5.5.1 Radiators must be cleaned following the discharge of a patient who has been
symptomatic and confirmed to have C diff or norovirus.

5.5.2 Estates & Facilities will remove the radiator covers for the retained estate – request
to be placed via the Facilities Helpdesk ext 6000.

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5.5.3 Nurses to request radiator cleaning by the Facilities Helpdesk ext 6000.

5.5.4 A ward based radiator cleaning programme is carried out throughout the year as
part of the Radiator Cleaning Programme as outlined below:
Very High Risk Areas 5 times per year
High Risk Areas 4 times per year
Significant Risks 2 times per year
Low Risk Areas 1 times per year

5.6 Steam Cleaning

5.6.1 Steam cleaning is becoming an essential part of our cleaning systems and
methods. The Trust uses an environmentally friendly, easy to use system that is
beneficial in helping to lower health care associated infections. It is a dry steam
system that can instantly clean and dry surfaces without leaving any unhygienic
residue. Each ward is provided with a steam cleaner that both nursing and domestic
staff can use. Steam cleaning will enable the Trust to achieve higher standards of
cleanliness and hygiene.

5.7 Cleaning Schedules

5.7.1 Within the Trust, the Cleaning Services are provided in house. The cleaning service
has been developed in accordance with the National Patient Safety Agency (NPSA)
National Specifications for Cleanliness in the NHS April 2007. Each functional area
is assigned one of four risk categories according to its functionality:

Risk
Clinical Areas
Level
Burns Unit, ITU/HDU, A&E, Neonatal, Theatres, and other areas
Very High
where invasive procedures are performed.
High Wards, Sterile Services, Pharmacy, Public toilets and thoroughfares.
Significant Pathology, Outpatients, laboratories and mortuary.
Low Administrative areas, non-sterile supply areas, healthcare records.
5.7.2 The Trust has a terminal clean resource operating an ‘out of hour’ service.
Terminal cleans are operating on a 24/7 basis. If additional support is required,
then the domestic services department has a mechanism in place to divert other
resources from their current task. All terminal cleans should be requested directly
by the ward/department using the approved designated system. The Domestic
Services department is contactable through this process.

5.7.3 Service level agreements are produced for each ward and clinical department.
They identify all cleaning requirements for these areas detailing the risk categories
for each cleaning task. They include cleaning frequencies and standards to be
achieved. They are monitored by audits and inspections which are at agreed
frequencies depending on the risk level as identified.

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5.7.4 Domestic assistance is available 24/7 via the following processes:

 07:00 – 20:00: Domestic Team Leaders are available via the Bleep #6555
2800/2805.
 20:00 – 07:00: All cleaning requests are to be made via the Bed Office. This
includes spillages and any other ad-hoc requests across the site.

5.8 Cleaning Responsibilities

5.8.1 Reference is made to the fact that not all parts of healthcare facilities and
equipment are always cleaned by the Domestic Services department. Cleaning
may involve the Domestic, Nurse, Housekeeper, HCA, Estates department and it is
important that there is clear distinction around who is responsible for which
component, including the frequency of cleaning & method of cleaning.

5.8.2 Checklists are established for all cleaning tasks that Domestic and Nursing staff are
required to complete. These are held centrally in each ward within the Cleaning
Folder.

5.8.3 Nursing cleaning responsibilities are determined within the Decontamination Policy.

5.9 Good Practice Measures for Infection Prevention

5.9.1 The Domestic Services Department works in close partnership with the Infection
Prevention Team and are involved in the development and implementation of local
standard precaution protocols and procedures following any outbreak of infection.

5.9.2 A colour coding system is used to prevent cross contamination and forms part of
the cleaning services induction programme and relates to all cleaning equipment
and cloths.
(Refer to Appendix 4)

5.9.3 The cleaning schedules, frequency of cleaning and cleaning responsibilities used by
the Trust are all agreed with the Infection Prevention Team, Ward Sisters or
Departmental Managers.

5.9.4 All Cleaning staff including Managers and Team Leaders are trained in the use of
appropriate infection prevention procedures.

5.9.5 In the event of an outbreak there are defined protocols to follow and clear lines of
communication between cleaning services, ward managers and the Infection
Prevention Team. A request will be made for an increase in frequency of cleaning of
frequently touched areas. Any members of staff receiving antibiotic treatment must
refrain from working in these areas. Members of staff must wear scrubs at all times
in accordance to policy and guidelines. Strict hand hygiene to be carried out at all
times.

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5.10 Bodily Fluids

5.10.1 A spillage is contamination of the environment by blood, body fluid or excreta.

5.10.2 All spillages of blood or body fluid should be considered as potentially infectious.
The person witnessing the event should deal with spillages immediately. This will
reduce the risk of exposure to infectious agents or further contamination.

5.10.3 Infectious agents can survive for long periods of time in spillages. It is essential,
therefore, that all staff receive training in spillage management and, where possible,
appropriate equipment is readily available.

5.10.4 For the effective management of spillages in healthcare facilities, surfaces such as
walls, floors and upholstery should be smooth, continuous and moisture repellent.
Carpets should be avoided in all areas where patients are managed. All surfaces
should be able to withstand frequent cleaning including cleaning with chlorine-
based agents.

5.10.5 A chlorine-releasing agent is an agent recommended for the safe disinfection of all
spillages except urine and vomit, prior to cleaning.

5.10.6 Spillages of blood and bodily fluids in clinical areas must be decontaminated
promptly - this is usually undertaken by the nursing team caring for the patient.

5.10.7 However, trained domestic staff can undertake this task in non-clinical areas, and
external areas of the hospital.

5.10.8 Chemical spills must be managed according to COSHH/Risk assessment.

5.11 Control of Substances Hazardous to Health (COSHH)

5.11.1 The Trust has issued a COSHH policy and associated procedures as a means of
achieving a safe environment in respect of the storage, use, handling and disposal
of hazardous substances.

5.11.2 The Domestic Services Manager and Senior Team Leader are responsible for
ensuring that all chemicals used for cleaning purposes have a current Safety Data
Sheet logged in the department. Copies are also be kept in Ward cleaning folders.
Risk Assessment Forms for all new products must be completed and copies issued
to the H&S Manager.

5.11.3 The Domestic Services Manager and Senior Team Leader are responsible for
ensuring compliance with the Trust’s COSHH Policy including providing any
necessary training for the safe use and storage of chemicals.

5.11.4 A training record is kept within the Domestics Department of all staff that have
received generic COSHH awareness training, which should be renewed annually.
Further records are kept for identified staff who deal with specific products in
specific areas and require additional training.

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5.11.5 Only staff who have received COSHH awareness or specific COSHH training are
permitted to use those products.

5.12 Public Area

5.12.1 A dedicated team is resourced to clean public corridor floors, waste bins, lifts and
stairs, public toilets external entrances and external stairwells. This includes
reactive cleaning of these areas, and support from the Grounds & Gardens team
and contracted providers for clearing internal and external entrances and pathways.

5.12.2 During foul weather conditions, additional cleaning of entrances is undertaken to

reduce the risk of slips and trips attributable to wet floors.

5.13 Key Stakeholders

5.13.1 It is recognised that the cleanliness of the Trust is the responsibility of various
stakeholders.

5.13.2 The Domestic Services department work closely with the following to ensure a
cohesive approach to cleanliness is provided.

 Patient representation: assist in auditing ;

 Ward Sisters: assist in review of cleaning schedules, monitor cleaning standards
locally with Domestic Team Leaders;
 Infection Prevention: assist in the development and implementation of local
standard precaution protocols and procedures following any outbreak of
infection.
 Quality Assurance Team: monitoring and reporting cleaning standards.

5.14 Reporting Cleanliness Issues

5.14.1 Reporting arrangements are crucial to improving cleaning standards.

5.14.2 Patients and visitors are encouraged to report problems or concerns via notices
displayed in toilet areas.

5.14.3 Domestic staff have a mechanism in place to report all issues to their immediate
supervisor, manager or ward sister.

5.14.4 Supervisory teams currently use pagers to ensure a speedy response to spillages
and other requests.

5.14.5 Domestic assistance is available 24/7 via the following processes:

 07:00 – 20:00: Domestic Team Leaders are available via the Bleep #6555
2800/2805.
 20:00 – 07:00: All cleaning requests are to be made via the Bed Office. This
includes spillages and any other ad-hoc requests across the site.

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5.15 Tagging System for Equipment Cleanliness

5.15.1 A tagging system is used within the Trust to identify when equipment (such as
commodes, drip stands, nursing equipment etc.) and bed spaces have been
cleaned. A green tag is signed and dated and then left attached to the cleaned
commode or across the cleaned bed.

5.15.2 A yellow tag is used to identify when an item of patient equipment has been
decontaminated prior to its return to the Medical Equipment Library or BME for
repair. All the tags must be filled in completely after every clean has been
completed in accordance with the Trust Decontamination Policy.

5.16 Breaches, risk events, serious incidents etc

5.16.1 All breaches of this policy must be reported to either a Team Leader, the Senior
Team Leader or the Domestic Services Manager. All matters will then be
investigated and remedial action taken to rectify the issues. Any further training
requirements or necessary disciplinary action will be taken in accordance with Trust
Policy.

5.16.2 All risk events or serious incidents must be reported to either a Team Leader, the
Senior Team Leader of the Domestic Services Manager. These will be escalated
via the DatixWeb system and the H&S Manager informed. An investigation will be
conducted as per Trust Policy.

6 Training Requirements
6.1 All staff with responsibility for cleaning must be adequately trained and made aware
of the importance of high standards of cleanliness, this is essential for both service
excellence and staff safety. Training programmes are systematically applied and
include both “classroom” and “on-the-job” training; and refresher training should be
routinely provided as and when appropriate. Refresher training would be given
where a specific area does not maintain the expected standard of cleanliness.
Monthly observations are undertaken by Domestic Team Leaders to ensure that
staff continue to adhere to the correct standards and practices.

6.2 A comprehensive local induction programme ensures that domestic staff are fully
aware of appropriate policies and procedures, which include COSHH, Health &
Safety, Infection Control and colour coding.

6.3 It is important to ensure that staff responsible for cleanliness has the ability and
support to do a good job through:
 Induction training;
 On-the-job support;
 Customer service training;
 Supervisory, managerial and leadership development training;
 Infection Prevention Training

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6.4 Nurses receive training in relation to cleaning via Infection Prevention training
sessions, local induction and bespoke training on wards.

7 Monitoring and Audit

7.1 Each document must outline the Trust’s process of monitoring compliance with, and
the effectiveness of the document’s main points.
The monitoring of cleaning standards is key to ensuring that standards of comfort and
cleanliness remain high and that the right level of feedback is provided to cleaning
stakeholders to identify any slippage. The following methods of auditing cleanliness
standards are undertaken:

7.2 NHS Specification for Cleanliness Audits, April 2007 (49 elements)

7.2.1 The Trust operates a robust monitoring system based on the National Standards of
Cleanliness (a framework in which to measure performance outcomes), this provides a
comparative framework within which hospitals can assess “technical” cleanliness
along with the option for peer review.

7.2.2 All areas are monitored by Domestic Team Leaders and Ward Sisters/Departmental
Managers in accordance with the national auditing tool and an action plan is produced
to correct any areas falling below the required standard of cleanliness. Below is a table
explaining the targets and Trust thresholds. If an area falls below the threshold then
this will be re-audited as required until it reaches the threshold target and re-audited as
set out below.

Please refer to Appendix 5 for flowchart of the cleaning audit procedure

Functional Very
High Significant Low
Area High
Target
98% 95% 85% 75%
Score
Tolerance 93%- 90%-
80% 70%
Level 97% 95%
Re-Audit 48 1 1
1 week
within: hours week week
Further re-audit required to escalate to below:
Fail <93% <90% <80% <70%
Escalate to
Quality
Audit 24 3 3
3 days
Team to hours days days
re-audit
within:
*Additional Escalation to EFM Site Manager and
relevant Chief Nurse and where re-audits fail more than
twice.

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7.2.3 The Quality Assurance Team also monitor and audits the process of the domestic
cleaning service. The cleaning audit results are presented as a Domestic Weekly
and Monthly Dashboard and a report submitted to the Infection Prevention and
Control Group.

7.3 High Impact Intervention Number 8

7.3.1 The High Impact Intervention No. 8 is a care bundle to improve the cleaning and
decontamination of clinical equipment. The aim is to:
 Improve the cleanliness and decontamination of near-patient equipment;
 Help reduce the risk of healthcare-associated infection (HCAI) cross-
contamination;
 Embed the importance of cleaning into the everyday work routine of the ward;
 Improve patient confidence.

7.3.2 This High Impact Intervention will help trusts to achieve compliance under criterion
2 of the Code of Practice by providing a focus for activity and a method for
measuring the implementation of policies and procedures for reducing reservoirs of
infection. As such, it complements the auditing framework set out in the 2007
National Specifications for Cleanliness and provides nurses with an easy-to-use
protocol for assessing cleanliness, as outlined in standard 3 of the Royal College of
Nursing’s Infection prevention and control: Minimum standards.

7.4 Patient Led Assessment of the Care Environment (PLACE)

PLACE assessments are undertaken on an annual basis in accordance with NHSI.
The audit includes a wide range of environmental issues including cleanliness and
infection prevention. The results of the PLACE assessment are monitored by the
Infection Prevention and Control Group.

7.5 Patient Surveys

Internal and National patient surveys are carried out within the Trust which include
cleaning issues.

7.6 Complaints
Complaints regarding cleanliness issued are investigated by the Domestic Services
Manager and necessary corrective actions put in place as required. All complaints are
scrutinised by the Patient Advise and Liaison Group.

7.7 Governance Standards

The delivery of the cleaning service has a direct impact to the compliance of the Care
Quality Commission (CQC) and NHS England standards as listed below:
 Regulation 15 - The intention of this regulation is to make sure that the
premises and equipment utilised to deliver care and treatment are clean,
suitable for the intended purpose, maintained, stored securely, used properly
and where required, appropriately located. Premises and equipment must
maintain standards of hygiene appropriate for the purposes for which they are
being used in clinical and non-clinical areas and ensure that the premises and
equipment meet the national specification for cleanliness.
 Hygiene Code Criterion 2 - Provide and maintain a clean and appropriate
environment in managed premises that facilitates the prevention and control of

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 Cleaning Policy/09033/6.0

infections. This includes a specific requirement for effective arrangements for

the appropriate decontamination of environment, fixtures and fittings,
decontamination of reusable medical devices and other equipment.

Aspect of Monitoring Individual Frequency of Group / Committee / Committee /

compliance or Method department the monitoring forum which will individual
effectiveness responsible activity receive the responsible for
being for the findings/monitoring ensuring the
monitored monitoring report actions are
completed
Standard of Technical Domestic In accordance Ward/ Department Ward/ Department
Cleanliness Audit Team with the Matrons, Sisters and Matrons, Sisters
Leaders National Domestic staff; and Domestic
Specifications Infection Prevention staff;
for Cleanliness Control Group;
and risk Domestic Service
category Manager
frequency
(Auditing
schedule
implemented)
Standard of Managerial Quality In accordance Ward/ Department Ward/ Department
Cleanliness Audit Assurance with the Matrons, Sisters and Matrons, Sisters
Team National Domestic staff; and Domestic
Specifications Infection Prevention staff;
for Cleanliness Control Group;
and risk Domestic Service
category Manager
frequency
(Auditing
schedule
implemented)

8 Approval and Implementation

8.1 The policy will be made available on the Trust’s intranet and website.

8.2 The Domestic Services Manager will be responsible for issuing copies to senior
operational managers for them to disseminate within their wards and departments.

8.3 The Domestic Services Manager will be responsible for ensuring all Domestic staff
read and fully understand the policy and is read in conjunction with the Cleaning
Policy.

8.4 The approved policy will be notified in the Trust’s Staff Focus that is sent via e-mail
to all staff.

9 References
National Specifications for Cleanliness in the NHS:
https://www.rdehospital.nhs.uk/docs/patients/services/housekeeping_services/2007
%20National%20Spec%20for%20cleanliness%20in%20the%20NHS.pdf

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10 Equality Impact Assessment

The Trust is committed to the provision of a service that is fair, accessible and
meets the needs of all individuals. Each procedural must go through an Equality
Impact Assessment (EIA).
(Refer to Appendix 6)

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 Cleaning Policy/09033/6.0

Appendix 1: Procedure for Routine Cleaning of Bed and Bed Space

NURSING DUTIES
Description/Task
1 Tidy and ensure all surfaces are clear before cleaning.
2 Use blue colour coded equipment and blue disposable cloths for cleaning. White should be used for
bodily fluids.
Between patient/discharge:
3 Inform (patient entertainment) of discharge on ext. 6765
4 Discard all disposable equipment (including patient entertainment headsets) via clinical waste.
5 Dispose of bed linen according to Trust Linen & Curtain Policy.
6 Clean mattress (both sides) and plastic pillowcases, whole bed-frame, locker, bed table and patient
chair, with Tristel Fuse. Mattresses must be thoroughly dried prior to remaking bed. NOTE: The
mattress must be unzipped and checked. If a mattress is found to be stained, torn, the foam
core is visibly soiled or heavily indented then the mattress must be deemed unfit for purpose
and condemned.
7 Clean all reusable clinical equipment according to manufacturers guidelines and refer to the
Decontamination Policy. Tristel Fuse may be suitable for some equipment such as commode chairs,
drip stands but not some electrical equipment.
8 Check that the bed is working (it should pump up and down, brakes should work and bed should tilt).
9 Certificate of cleaning to be placed across the bed (green tape system) once bed linen is in place.
The name of the nurse in charge cleaning the bed space must print their name and date at
point of fitting tape across the bed.
DOMESTIC DUTIES
Description/Task
1 High dusting should be undertaken prior to cleaning the bed space.
2 Use blue colour-coded equipment as per national colour coding scheme
3 Put on gloves and apron as per national colour coding scheme
4 Discard all rubbish appropriately in accordance with the Trust’s Waste Management Policy.
5 Clean ALL horizontal surfaces including the light fitting, patient entertainment screen, box and arm,
and grey sill behind the bed and all ledges with Tristel Fuse and allow to air dry. Tristel Fuse must be
rinsed off with water only on stainless steel. Pay particular attention to door handles, light switches,
patient call bell.
6 Where bed space is a side room with en-suite the toilet and hand basin must be cleaned with Tristel
Fuse and allowed to air dry. Tristel Fuse must be rinsed off with water only on stainless steel.
Particular attention to be given to taps, handrails, toilet roll holders, door handles, toilet flush and light
switch. Use red colour-coded equipment for toilets and bathrooms as per national colour coding
scheme.
7 Floor must be vacuumed and damp mopped with Tristel Fuse.
8 Open windows to allow room to dry if appropriate.
9 Empty the bucket into the sluice sink in the cleaning room. Clean bucket with Tristel Fuse, dry
thoroughly and store inverted.
10 Remove mop head, place in clear plastic bag and return to the domestic laundry. Clean mop handle
with Tristel Fuse and dry thoroughly.
11 Remove gloves and aprons and dispose of via Domestic waste. Hands must be washed and dried
thoroughly.
12 The room/ bed space may be used when dry.
PATIENT ENTERTAINMENT DUTIES
Description/Task - Between patient/discharge:
1 Headphones to be replaced with new set.

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Appendix 2: Procedure for Standard Isolation Bed and Bed Space in a

Barrier Area (Bed in Use)

NURSING DUTIES
Description/Task
1 Put on gloves and apron.
2 Tidy and ensure all surfaces are clear before cleaning.
DOMESTIC DUTIES
Description/Task
Note Barrier Bed in Bay: Clean this bed space after other bed spaces have been cleaned in the bay.
1 High dusting should be undertaken prior to cleaning the bed space.
2 Use yellow colour-coded equipment as per national colour coding scheme.
3 Put on gloves and apron. Put on a fresh apron for each bed space.
4 Clean the barrier area horizontal surfaces after the other bed spaces
5 Use a new cloth and fresh cleaning solution for each bed space.
6 Clean ALL horizontal surfaces: the bed frame including underneath, table, locker, patient
entertainment screen, box and arm, light fitting and grey sill behind the bed with Tristel Fuse, these
can be allowed to air dry. Tristel Fuse must be rinsed off with water only on stainless steel.
7 Where bed space is a side room with en-suite the toilet and hand basin must be cleaned with Tristel
Fuse and allowed to air dry. Tristel Fuse must be rinsed off with water only on stainless steel.
Particular attention to be given to taps, handrails, toilet roll holders, door handles, toilet flush and light
switch. Use yellow colour-coded equipment for toilets and bathrooms as per national colour coding
scheme.
8 Do not vacuum any area within the bay, the bed space or side room. Dust control and damp
mop the whole area in one go. Damp mop with Difficil S.
9 Empty the bucket into the sluice sink in the cleaning room, clean it with Tristel Fuse, dry thoroughly
and store inverted.
10 Remove mop head from handle, place in clear plastic bag and send to the domestic laundry. Clean
the mop handle with Tristel Fuse and dry thoroughly. Any disposal mops used must be disposed of
via clinical waste.
11 Remove gloves and aprons and dispose of via clinical waste. Hands must be washed and dried
thoroughly.
PATIENT ENTERTAINMENT DUTIES
Description/Task - Between patient/discharge:
1 Headphones to be replaced with new set.

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Appendix 3: Terminal Cleaning Procedure for Isolation Bed and Bed

Space (between Admissions)

Terminal Clean checklists must be followed, signed by Nursing and Domestic staff and kept
within the Cleaning Folder.

Ward: Room/Bay: Date:

Description/Task Duty Tick

Box
1 Replace Isolation Sign on door with “DO NOT ENTER - Isolation Cleaning in Progress” N
2 Use yellow colour coded equipment as per national colour coding scheme. Put on N
disposable gloves and yellow apron.
3 Discard all disposable equipment (including patient entertainment headsets) via clinical N
waste.
4 Strip Bed. Bed linen is placed in a pink soluble liner, double knotted, ensuring the bag is N
no more than two thirds full. Linen must be bagged inside the room and then placed in a
white outer bag outside the room.
MATTRESSES NOTE:
The mattress must be unzipped and checked. If a mattress is found to be stained,
torn, the foam core is visibly soiled or heavily indented then the mattress must be
deemed unfit for purpose and condemned. Any replacement mattress should be
fitted following domestic clean.
Static Foam Mattress: replace via porters
Air Mattresses: clean, bag and use yellow tag to declare as decontaminated and
return to Medical Equipment Library.
5 Clean all reusable clinical equipment according to manufacturers guidelines and refer to N
Decontamination Policy. Tristel Fuse may be suitable for some equipment i.e. commode
chairs, drip stands.
6 Move cleaned equipment outside the room to allow for curtain change and domestic N
clean. (Note: do not remove equipment from room following the clean if the room is to
be fogged after clean).
7 Empty bowl into the sluice and clean bowl with Tristel Fuse and dry thoroughly and N
store inverted.

8 Dispose of apron and gloves as clinical waste. Hands must be washed and dried N
thoroughly.

9 Request Terminal clean via Bed Office N

10 Use yellow colour coded equipment as per national colour coding scheme. Put on D
disposable gloves and yellow apron.
11 1. Take down curtains and place in pink soluble liner, double knotted, ensuring the D
bag is no more than two thirds full. Curtains must be bagged inside the room and then
placed in a purple outer bag outside the room. Complete a personal bundle tag to
accompany each bag. This needs to be done prior to any cleaning.
12 2. Clean mattress (both sides) and plastic pillowcases, whole bed-frame, locker, D
bed table and patient chair, with Tristel Fuse. Mattresses must be thoroughly dried prior
to remaking bed.
13 3. Clean ALL horizontal surfaces including the patient entertainment screen, box D
and arm, light fitting and grey sill behind the bed and all ledges with Tristel Fuse and
allow to air dry. Tristel Fuse must be rinsed off with water only on stainless steel. Pay
particular attention to door handles and light switches, patient call bell.
14 4. Where bed space is a side room with en-suite the toilet and hand basin must be D
cleaned with Tristel Fuse and allowed to air dry. Tristel Fuse must be rinsed off with

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water only on stainless steel. The shower curtain must be removed, placed in clear
plastic bag and return to the domestic laundry. A clean shower curtain must then be
fitted. Particular attention to be given to taps, handrails, toilet roll holders, door handles,
toilet flush and light switch. Discard all rubbish appropriately.
15 5. Do not vacuum any area within the bay, the bed space or side room. Dust D
control and damp mop the floor with Tristel Fuse.
16 Wall washing is only necessary if there is visible soiling with bodily fluids and as part of D
a pre-planned maintenance programme. Bodily fluids to be initially cleaned by nursing
staff.

17 6. Open windows to allow room to dry if appropriate. D

18 7. Empty the bucket into the sluice sink in the cleaning room, clean it with D
Tristel Fuse, dry thoroughly and store inverted.
19 Remove mop head, place in clear plastic bag and return to the domestic laundry. D
8. Any disposal mops used must be disposed of via clinical waste.
20 Clean the mop handle with Tristel Fuse and dry thoroughly. Return to Sluice Room for D
storage.

21 Remove gloves and aprons and dispose of via clinical waste. Hands must be washed D
and dried thoroughly

22 Hang clean curtains when floor is dry. D

23 The room may be used when dry. D

24 Fit replacement mattress (if required), make bed. N

25 Remove Cleaning In Progress Sign and clean with Tristel Fuse. N

26 Replace patient entertainment headphones from ward stock. Certificate of cleaning to N

be placed across the bed (green tape system) once bed linen is in place. The name of
the nurse in charge cleaning the bed space must print their name and date at
point of fitting tape across the bed.

COMPLETION SIGN OFF

DATE
________________________________________________________________________________
__

NURSING Print Name

__________________________________________________________________

Signature
___________________________________________________________________

DOMESTICS Print Name

__________________________________________________________________

Signature
___________________________________________________________________

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Appendix 4: National Colour Code

THE GOLDEN RULE: WORK FROM THE CLEANEST AREA TOWARD THE DIRTIEST
AREA. THIS GREATLY REDUCES THE RISK OF CROSS CONTAMINATION.

The aim of a colour coding system is to prevent cross contamination.

Mop heads MUST be laundered prior to use – do not reuse between patients.
Additional mop heads and plastic bags for disposing of dirty mop heads can be
obtained– contact Domestics on Bleep #6555 2800 or on Ex.

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Appendix 5: Cleaning Monitoring and Auditing Process

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Appendix 6: Preliminary Equality Analysis
This assessment relates to: (please tick all that apply)

A change in a service to patients A change to an existing policy X A change to the way staff work

A new policy Something else

(please give details)
Questions Answers

1. What are you proposing to change? This is a formal review of the Cleaning Policy. This policy has also been transferred from the MEHT
template to the MSB template.
a. There are changes in the scope of the document to include general and reactive cleaning
activities undertaken by Estates, Nursing and Catering Staff.
b. The area risk categories have been included.
c. Changes to the roles and responsibilities have been included to highlight structure changes.
d. Information has been included in the Procedure of Cleaning (5.2) regarding mattresses.
e. Information has been updated regarding cleaning service availability out of hours under
Cleaning schedules (5.7)
f. Responsibilities for cleaning bodily fluids (5.10) has been updated to include the
decontamination process and include trained domestic staff as responsible for non-clinical
areas
g. Public areas (5.12) has been updated to include the team responsible for cleaning external
areas and include Grounds & Gardens Team for clearing pathways.
h. Equipment Cleanliness (5.15) has been updated to include all equipment.
i. The Governance Standards (7.6) has been updated to reflect the most recent information
relating to CQC outcomes and regulations.
 Cleaning Policy/09033/6.0

2. Why are you making this change? These changes are required in order to ensure the document is reflective of the current services
(What will the change achieve?) provided, ensure the services and areas provided are within scope and all staff are aware of their
responsibilities to the policy. Services provided alongside cleaning services are identified within the
policy, such as mattress services as this will have an impact on the service delivery, and out of
hours services. These changes have also been made to ensure that the standards of cleanliness
and the correct CQC regulations are maintained.

3. Who benefits from this change and how? The policy is mainly providing benefit to Domestic Staff and staff with responsibility for cleaning,
such as catering and nursing staff. The policy clearly outlines the aims and objectives for staff
groups involved with hospital cleanliness.

4. Is anyone likely to suffer any negative impact No- there is no negative impact sustained from these changes. The changes are highlighting
as a result of this change? If no, please record responsibility changes due to staff structures, and includes further details regarding the standards
reasons here and sign and date this assessment. for hospital cleanliness .
If yes, please complete a full EIA.

5. a) Will you be undertaking any consultation as Yes- consultation will be completed with the following individuals
part of this change? Maggie Bayley Interim Director of Nursing
b) If so, with whom? Sian Olivo Interim Associate Director Infection Prevention Control
Garry Bardsley Estates & Facilities Site Manager
Andy Wright Domestics Service Manager
Jo Mitchell Quality Assurance Manager
Steve Lewis H&S Manager
Preliminary analysis completed by:

Name Georgina Sawyer Job Title Domestic Service Manager Trainee Date 22/11/2018

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